Techniques for placing implant in extraction site #7?
I extracted #7 [maxillary right lateral incisor; 12] 7 days prior and I would like to install the implant. The dimensions of the extraction socket are 5mm buccolingual by 4mm mesiodistal. The walls of the extraction socket are intact. The interproximal bone is 2mm coronal to the buccolingual bone height. Should I plane down the interproximal bone so that it is at the same height as the buccolingual bone so that I have a flat site for installation of the implant? I do not want to have the rough surface of the implant exposed. Should I install the implant so that the platform head is below the buccolingual bone height? Should I graft the socket and then go back in later after the graft osseointegrates? If I do that, what graft material and membrane should I use? How much later can I go back in?
16 Comments on Techniques for placing implant in extraction site #7?
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CRS
4/15/2013
Lateral incisors although seeming simple, can be very challenging in the esthetic zone. There has to be enough buccal plate and soft tissue thickness, otherwise you will have a dark line. Whatever you do don't even think of "flattening out' the interproximal bone, you will lose your papilla. The best time to graft is at the extraction with primary closure or a Bio-coll technique. Based on your questions, this may not be an ideal case to learn on. I would have to see a film to judge what size implant to place. The socket dimensions seem fine for a 3.5-3.0 width, placing the tip of the implant in nascent palatal bone. The screw access should be to the cingulum.. Perhaps referring and watching the surgery would be a great way to learn while avoiding pitfalls. Good luck
Pynadath
4/16/2013
5mm by 4mm bone? Have you enough bone to even place a implant?
Not to sound harsh, we all start somewhere, but the questions asked are basic knowledge. You definitely shouldn't flatten out the bone. Why not refer this case and watch to get more experience. Especially as its a anterior tooth.
Marc
4/16/2013
You are wise to ask questions before. Hope you stay wise and follow the previous advices.
Adam
4/16/2013
Ideally, place the implant immediately post extraction to maintain bone height in this area.
Do NOT flatten out the bone; tissue follow bone and you will lose your papilla as pointed out in earlier response.
This part depends on the type of implant you are using; since you did not specify, place the implant at the lowest contour of bone and make sure the buccal plate is sufficiently thick that it will not resorb after your placement.
Sounds like this is a first time case for you. Graft the socket, wait for it to heal; evaluate the tissue and bone (ideally CT or tomo).
I agree with the previous post. If you need to ask what type of of bone graft and material, you may want to reassess whether this is a good case for you. Socket grafting is the first step to easy implant placement. Upper lateral incisors are not easy.
Good luck, whatever you decide.
Dry
4/16/2013
Why did you not consider an immediate placement? If you are familiar with the basic principles of implant placement then I would suggest placing a subcrestal implant (about 1-2 mm below the line of the adjacent CEJ's), such as an ankylos or bicon implant. Before doing so please read through the risk factors involved in placing implants in the aesthetic zone and consider involving a more experienced colleague to mentor you.
charles schlesinger
4/16/2013
If I understand you correctly, you only have 4mm between the teeth at crestal level? If so, you do not have room for an implant larger than maybe 2mm in diameter. if you go wider, you will increase the chances of losing your crestal bone.
You would be better off long term grafting the area, and then doing orthoto increase M-D width or plan to use a small diameter implant(1.8 or 2.2 ) in the healed site. You could try and squeeze a 3mm implant in there, but then you only have .5mm on either side. I guarantee you that you will lose bone and subsequently the papillary support.
dr nehal sheth
4/16/2013
i guess 4 mm is socket size. not the dimention between two teeth
Drdave
4/16/2013
I would agree that you should enlist a local experienced mentor for this case. You certainly can get some "mentoring" in this forum and there are going to be a lot of helpful suggestions and thankfully fewer less than helpful(chastising) ones. At this point wait until you have 3mos minimal healing before you proceed. Do not subject your patient to a needless second surgery to get what nature will give you in the end with a properly placed implant. You never said why the tooth had to come out. is infection present. Of course for this forum a radiograph is necessary and possibly a ct. Many surgeons consider a ct overtreatment for a simple single tooth implant. I would gather your measurements may be off. while waitingbfor healing, with the help of a colleague select a bone level implant from the system you prefer. I like Straumann and Astra. After good training fly solo on a mandibular molar and watch out for the maxillary premolars. Good luck
Dr shyam mahajan Aurangab
4/16/2013
Extraction & immediate implant. Or else wait for 8-10 weeks. IOPA then will tell bone formation. Agree with all that implant should be 1-2 mm. subcrestal. & no flattening of bone.As Drdave says let nature do its work now for next 8 weeks. What temporary prosthesis is patient using ? If if its RPD , relieve it at socket site.
Angle of osteotomy drill is important. Go palatal , beyond apical level. I would prefer 3mm Adin Narrow platform.
Peter Cabrera
4/16/2013
In the maxillary anteriors managing the biotype is the ball game. Techniques are irrelevant and materials are of minimal importance. Once you understand the biotype you can address the technical issues.
For meaningful advice you should include photos, probing depth of adjacent teeth , position of the adjacent teeth.
Brett Murphey
4/16/2013
I have to agree with the advice given above. I definitely would place the implant subcrestal at least 2 mm. Remember that bone height from contact point of interproximal teeth must be at least 5 mm to preserve papilla. Symmetry of contralateral lateral is important in this issue because it may be okay for you to lose bone height depending on the type of contralateral symmetry.
Something to point out in this situation is the bone grafting material. I recommend using something like cadaver bone, not synthetic anything.
Always remember that if you don't feel like you can accomplish what you want at the first appointment, tell the patient that "we will do one miracle at a time".
Theodore M Grossman DMD
4/16/2013
Let this forum assist you. Pre-op pictures, smile line, FMXR digital p.a. or CBCT and a dental history(ie. perio.,caries) on the reason for extraction. Then do the planning. We need the big picture to guide you.
Dr. Numier
4/17/2013
dear dr
we need to know
1st the reason for ext. of lateral ...
2nd how much baccal bone plate there is
3rd bone available from socket floor to nasal floor
if infection then curette socket v.good ,graft , close and wait 16 weeks.
if all is good at time of ext. then place a longer implant >3 than socket depth as palattal as possible and 2mm below crestal bone margine.. graft labially
if torque during implant placement was >50Ncm then immediate loading is pssible..
if not then go for 2 stage surgery
Sam Jain
4/18/2013
Send the Px to somebody who can do immediate implant with screw retained temporary today.
Sam Jain, DMD
Center for Implant Dentistry
Fremont CA
CRS
4/18/2013
I would advise against placing an immediate with a screw retained temporary. This is an advanced technique and the temporary has to be out if occlusion, the screw hole needs to be lined up with the cingulum and there has to be adequate bone without any labial dehescence. One cannot place implants as technicians there are biological principles which one needs to respect to avoid trouble. These popular techniques just help the doctors egos and allow bragging vs really helping the patient long term . The most important thing is knowing how the body heals. I see this on a daily basis, I graft extraction sites, regraft poorly grafted sites and treat peri implantitis. The only one who suffers is the patient. I just struggle with this even though it provides my practice with more cases to fix, it is hard to see the trusting patients reactions to this type of care. The posts so far assume a certain level of experience and technique. Take a look at the most recent case posted on the cases section. If the implant you place in the esthetic area has to be removed it is not a good thing. Be wise and honestly evaluate where you are clinically instead of listening to bravado. Sorry if I offended just my opinion thanks for reading.
Gregg Weinstein
5/3/2013
Dont do the first case with an immediate extractions and avoid he immediate temp. Never remove ANY bone from an anterior extraction site. If you want to be safe follow one of two approaches. Dr Numier sounds great but the only proble in alot of these immediate anterior cases is patient compliance. I have seen this happen and it is not pretty . They forget that is is a temp and go to town using it and implant removal is a nightmare and you wind up being the victim. Safest is graft the socket and pull over a palatal circular pedicle graft for closure and wait it out for 12 - 14 weeks to place the fixture.. Then insert and temporize. Imagine the esthetic disaster if the immediate fails.. Play it safe!
