Placing an Immediate Implant in a Molar Site

Last week I placed an immediate dental implant in a molar site, and about a year ago, I would not have had the confidence to do this!

Lets look at a section in the CBCT Scan.

As you can see, its a pretty bad situation. 

The distal root has fractured, and there is a big radiolucency between the apices. 

One other thing that you should know, is that this lady is having another dental implant somewhere else, but that's an easy delayed placement. 

Other things to note here are that there is about 2mm of cortical bone around the tooth, separating the tooth from the sinus, which looks okay, there is very mild inflammation of the membrane, but that's about all. 

If we took this out, then chances are that the floor of the sinus would drop, and that would commit us to a sinus lift treatment. 

I am guessing here, but its not hard to imagine that the current roots are supporting the lower border of the sinus. 

But if we are to place an immediate implant, we have the issue of dealing with the infected site, and lack of bone. 

To cut a long story short, the reasons I chose to do an immediate implant here were:

1. The patient is already in for the other implant, so there is less stress for her to have 2 implants in one sitting, rather than two appointments. 
2. By placing an implant immediately after the extraction, there is less risk of the sinus floor dropping, and commitment to a sinus lift procedure
3. Its quicker for the patient, and less surgery overall (if it works). 
4. It is more efficient in clinical time. 

But there are risks, I think the biggest are: 

1. Infection and early loss of the implant. 
2. Lack of primary stability of the dental implant.

So how can we minimise these risks? 

Apart from the antibiotics that all implant patients get, removing the granulation tissue after removing the tooth is critical. 

I like to leave a safe margin around the sulcus of the tooth. 

The above photo shows the incision line, and I am about 0.5mm from the sulcus. This is because I want to remove the internal aspect of the pocket, where the tissue will be very inflamed. 

The blade is also quite upright, almost parallel to the buccal bone. I ideally want to hit the crest of the bone, and not fall into the pocket. 

There is also a vertical release incision, because I want to fully close this after the placement. 

Removal of the granulation tissue takes time, but once you have it all out of there, the site doesn't bleed so much, and you can clearly see the internal aspect of the socket. 

Needless to say, you need to be using high mag loupes and lighting for something like this. 

How I got Stability

For this case, I got about 20ncm of insertion torque. 

I think the implant selection is very important, and what you need for high torque, is a strong taper, and fairly aggressive thread pattern. 

I used a Southern Max implant, as its designed for immediate molar replacement, but most systems have an implant with a strong taper to help with insertion torque. (I mean, every implant company wants to have an All on 4 Implant these days!)

The process was similar to an internal sinus lift, I made a tiny hole where the head of the implant was going to go, and then lifted the membrane a little. 

The end of the implant is round, this again is important, as it can gently lift the membrane as its being inserted. 

This is quite a fat implant, so it fills out the extraction socket nicely. 

I still placed a little Bioss around the implant to fill the gap. 

In the end, there was a 4 walled defect (buccal wall in tack) and the implant filled most of this extraction socket. 

This means that the bone does not need to grow that far, and as it grows about 1mm a month, time to loading can be reduced. 

Remember, bone makes bone, so having 4 walls is very beneficial. 

The drilling is also important, I only went as wide as the apical width of the implant, not the full body width. 

Apart from the first drill, the rest were used in reverse, this helps to condense the bone.

I could have used the Versah drills, but I didn't have them with me. They are still in the shop, waiting to be bought. 

I put a healing cap on it, but as the implant is so deep, I even covered the healing cap! 

I did a periosteal release incision, and was able to close the whole thing by primary intention. 

By closing like this, I am able to again reduce the chance that oral bacteria enter the grafted area, and tip the scales of success in my favour. 

What if it doesn't work?

This is a possibility, but here, if we delayed the placement, then we would have to perform another surgery to do sinus work and place the implant anyway. 

If it fails, the implant can be removed in 10 minutes, and all we have lost is the few weeks it took us to realise the implant was not integrated.

What's the compromise? 

The biggest issue that I can see here is that by pulling the gum to close the wound, we may not have any buccal keratinised tissue.

This will likely mean that we need to do some type of tissue graft later. 

If the healing cap remains submerged, then we can do a buccal rolled flap to thicken the buccal tissue. 

If it does become exposed, then we may need to do a normal CTG. 

But either way, the number of surgeries is not increased. 

Please let me know what you think, you can connect with me on social media by using the links at the bottom of this page. 

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