Contraindications to Immediate Placement?

Dr. D, Most implant company courses start out with the standard, complication-free placement instruction and later get into the more 'esoteric' cases which require some experience and judgement at the outset as well as during the placement itself. You may benefit from some more second level courses by experienced surgeons and perhaps you could present this case with some good records and detailed history/ medical and dental. As for here and now, the lack of the simplest x-ray is bothersome. I'd want at least 4-3 different angles on such a questionable site as you discuss. Infection has to go somewhere... maybe the sinus? Assuming you have a case without serious contraindicaions to implant placement, here are some thoughts: 1 - The nature of the infection and bone quality are key factors in deciding whether to do an immediate placement. A diffuse radiolucent area would surely be a strong warning sign. 2 - It is nice to have at least 1/2 the Buccal plate in place although I've done some with about 1/4 bone height on the Buccal or Labial. 3 - A bone graft can quickly become a submerged agar plate, ready to support the wild growth of any pathogen present. How healthy is the patient? Is there adequate circulation all around the graft? what can be done to minimize the volume of the graft? (smaller grafts are closer to the cirulation) 4 - What type of implant are you considering for the site? Some require intimate contact with healthy bone while others only require they be held still inside a healthy blood clot (e.g., Bicon). Note that placing an implant of the type supportive of blood supply paths, e.g. less solid diameter, would help to reduce the volume of the bone graft while allowing circulation. I am only posting this to avoid your considering an all or nothing answer to your question. The answer lies in judgement from experience and good surgical courses. My final advice is to either refer this patient to a highly experienced operator, or delay any treatment (if that's possible without harm to the patient) until you've had some upper level courses under your belt. But, keep on developing and asking! That will benefit you, the profession and your patients. John

Dr. D, Also, I remember Dr. Terry Tanaka, the pathologist, stating that he'd never found a fractured tooth which did not have a portion of the root fused to the bone somewhere. So, some thoughts about how well you are going to be able to remove this tooth "atraumatically" need reviewing. I just did a first bi area which looked simple at the outset, but ended up being a marathon of small, crazed fractures which had to be worked out one at a time to keep the surrounding bone. John

IF you have enough bone for primary stability then there should be no issue with immediate placement. Placing bone around the gaps of the implant might be a good thing and make sure the patient is aware that it might be necessary. Research has shown that 2mm or less of a gap doesn't need grafting. However, premolars are normally oval shape and implants are smaller and rounder.

Very good comments proceeding mine! I should start by saying that a complete response could easily fill a chapter in a book dedicated to this topic. I am long winded but not willing to go that far. I have been doing implants in my practice for over 25 years and I believe that no matter how well you pre-plan a case, you will occasionally be surprised. I also believe that not being prepared to handle the most commonly found complications is the single most important contraindication to doing an immediate placement after extraction. Due to maxillary bicuspid root morphology, you have to expect voids between the socket and implant on the buccal and lingual when immediately placing implants here. Grafting is not always required but guidelines and experience will help you choose when that is indicated as well as the type of material to use. You need to know how you will isolate the graft from the oral cavity (healing cap, barrier, primary closure and/or etc.) How will you handle bone defects due to infection, sinus perforation, missing or fractured buccal plate. What will you do if you can't provide good primary stabilization and how do you assess that? Not an inclusive list but these should certainly be part of the mental process that you should go through prior to the surgery and dictate what materials (and techniques) you need to have at hand. Also consider that immediate placement has, at least in my hands, a slightly lower integration rate. I think this makes sense in that we are often placing implants in compromised bone and have challenges in providing adequate closure leading to a rapid biologic seal. This is a contraindication if the patient is not willing to accept that as a consequence. Along these lines, you may occasionally have to abort implant placement and the patient needs to be aware of and accept this as well. Lastly, there is some peace of mind in knowing that if the situation is not adequate for immediate placement that you can back off, preserve the socket with a graft and the site revisited again later for insertion of the implant. Immediate placement provides the patient with a significantly reduced treatment time (and often cost) but it should be done only when conditions are right. An implant that fails to integrate generally will significantly extend treatment time (as well as the number of procedures) often beyond delaying implant placement to a second surgery. Good luck! Dr No

Wow , you really are learning to place implants on the net! Damn , I'm a fool. I had to go to school for 14 years, and am still learning. Bv

Is your patient getting the best possible care, in this scenario? Your still gonna make money on the restoration if you let an experienced surgeon remove the tooth and place the implant. The surgery will be faster and safer and the patient will most likely be sedated. Let's keep our implant pt's happy, please . Bv

You have also consider about atravmatic extraction.Because sometimes ıt's been much more complicated to put an implant.So you have to protect the buccal wall during the extraction..extract first than decide what to do...and also how much bone volume beyond the apex?This is also important for proper primary fixation.. good luck

Dr. Manuel, a pathologist that makes a statement like that,shows a gross lack of experience. I know who dr. Tannaka is and his work has lots of credibility, but that statement holds absolutely no water. What about the tooth that was fx in an accident. The majority of fractured teeth that I have removed are in that exact scenario. In my 20 short years I have seen very few ankylosed premolars,even fractured ones. I, on the other hand have seen a multitude of ankylosed upper molars,especially in the African american population. Bv

I would agree that I have taken out thousand of fractured teeth and very rarely seen ankylosed or fused teeth to the bone. However those fractured teeth are usually more difficult to remove, often fracture further and make the residual bone less appropriate for an immediate implant. Immediate implant have greater success with no infection, excellent primary stability, stable intact buccal bone, no communication to the sinus, and thick tissue biotype. You need to be cautious especially if this tooth #4 is in esthetic zone or if any of the above are not present. I get more predictable buccal tissue if this tissue is not reflected and there is stable buccal plate of bone. It is not adequate to just get the implant to integrate. The tissue and restoration also have to esthetically pleasing. Also I usually place the implant toward the buccal which creates a better emergence profile but also leaves a larger defect along the palatal aspect that you have to manage. As you can see there are multiple consideration and I would agree could fill a text book.

great comments from john manuel and Dr No, Not much to add, but you need to always assess the case on its merits at the time of surgery always be prepared to STOP AND DO NOTHING. My immediate patients know going in that unless I am fully satisfied that all of the conditions are met, they are going to walk out with a socket preservation or indeed just an extraction. Don't paint yourself into a corner from a pt management perspective and promise the implant will be placed there and then. Immediate placement, and to a greater extent immediate placement and loading are common place BUT they are still pushing the envelope and should always be considered as such. Even though they often look very quick and simple if you are observing, these procedures really require a great deal of experience to judge. In my opinion you need to have just done lots of implants and extractions and grafts and CE to look at a site and decide. All the best, Mike

BV, did you have to repeat each year of your residency? Because all of us here we have learnt at least 8 years (if not more) to do what we are doing!