Extra Wide Implants for Immediate Placement: Any Experience with These?

I am Prof.Dr Tarek Mahmoud Prof. Of Oral &Maxillofacial Surgery Faculty Of Dentistry Alexandria University and Founder Dean Of Faculty of Dentistry Pharos University In Alexandria. My point of view is that it is extremely difficult to gain primary stability during implantation of upper or lower molars,and putting wider implants will reduce the success rate of the dental implants. My opinion is to wait for healing then putting the ideal diameter 3.5-3.75 implants without grafting.

Professor, do you think that narrow implants like 3.75 pr 3.5 are ideal for the molars?I have attended an interesting lecture recently about maxi extra diameter implants, which are meant to be ideal for immediate post-extraction placement in the molar areas. Their width range is 7-9mm! We were shown photos ad radiographs of these implants literally filling the big xla sockets of molar teeth.

I use both techniques(graft and delayed implant and the inmediate placing of a very wide implant) and have to say that there is not a single point of view. Mine is that: if after the extraction(usually segment the mollar to preserve the inter radicular bone) I have more than 1,5 mm of vestibluar and pallatal bone I will probably place a very wide implant and graft to complete., if there is not enough vestibular or pallatal bone i will graft and place an implant at a later date. just be safe in terms of final aesthetic results.

I agree with the concept "the largest the best"for Implants in Molar Regions,whenever possible ,and mainly in case of post-extractive sites to avoid atrophy of bone:and think about the possibility to avoid too major surgery in sites where Sinus Floor is just neighbouring. The maximum I've already put in these situations as Implant of the largest diameter is a 7.2 diam. Implant:but sinply because I had not something larger.

I have had good success with wide diam. implants. They work very well in immediate placements in conical molar sites.I have only used 5.6mm bodies but would not hesitate to use larger if the restorative person was comfortable. there is little doubt in my mind that the larger the implant the greater the surface area to intergrate. This is especially a factor of the diam. more the the length. Therefore, it seems logical the in upper posterior areas where there is ltttle room below the sinus to use as wide a diam. implant as possible. The use of a 3.3 3.7 implant as a molar is questionable. I believe that there is some question as to whether narrow implants such as 3.3, 3.5 should even be used a bicuspids. What you get with a narrow (smaller) implant as a molar is what looks like a toad stool.

I have been using for around 5 years Endure Implants with a very good success, does anybody know if there is zirconia abutments for it?

i have done several very select cases using the osstem/hiossen ultra large fixtures (6-7mm diameter) for immediate molar placement and they have worked out well. the comments of previous posters are correct though. a lot of graft material, difficult to get primary stability. case selection is extremely important. gary

extra large extra short: bicon 6.0x5.0 and good success.

If you have that much room I don't see why you wouldn't graft first and then place a combination of 2 implants. Say a 4.1 & 3.5.etc.. Those teeth have multiple roots for a purpose and with more than 1 implant you significantly increase the bone to implant surface contact.

One must not forget the original anatomical structure of a maxillary and mandibular molar in the first place. Moreover, those teeth are meant for chewing purposes and i believe a wide diameter implant is more suitable in this area. However, this also depends on situation and time of implantation. I also believe that we have to visualised the design of the molar before selecting the size of the implant and to the extent patient's occlusion will be have to be considered as well.

I recently started using wide diameter implants but only in the mandibular molar areas.In one unique case it was for a delayed placement and all others were immediate placement situations. All implants were Hiossen/Osstem implants 6mm diameter and 11.5 mm long. I perform a Cone beam CT scan to analyse and assess bone anatomy from the apex to the cervical areas of the tooth to be extracted and replaced. Sometimes the lingual curvature of the mandibular bone especially in molar areas can increase the risk of lingual perforation with wide implants(below mylohyoid line). Another observation is that with wide diameter implants you do not have to engage the socket all the way to the apex or get to close to it but you will still achieve good primary stability. the amount of peri-implant graft needed material is much reduced. Finally, as Dr Dennis suggested we should keep prosthetics in mind with regards to biomechanics and emergence profile. Therefore in the majority of cases implants replacing mandibular molars I prefer no less than 5.0 in diameter whenever possible.

In molar cases, I like to place a 3.5 mm diameter implant in each of the root socket. If a maxillary molar has three roots, then I will place three implants. In mandibular molar situations, I will usually place two implants into the two root sockets. My rationale is: 1. Original molar teeth have multiple roots, so why not restore back to what nature had intended in the first place. 2. By placing multiple implants, I am able to charge more for the procedure, making more economical sense. I have done hundreds of cases without any failure so I think that this should be the new standard of care. Has anyone else out there tried my technique ? I will be offering courses on this in 2010 so please keep an eye out for my courses.

wow dr cho, i'm sure your patients would love to read that statement. unbelievable. just goes to show you, anyone can be an expert... yikes

dr cho, thank you for being so honest.apologies for being direct but you would be the last one I would like to see to have my implants done

Dr Cho, you have made my day, thank you. Can you give us a link to your website so we can see your work? I really can't wait to see it! Kind Regards, Bill Schaeffer

it can be not easy to place the implant transfer in the fixtures in that case... it will be not able to clean betwean the implants, so you create a furcation affected tooth .

why would you need three 3.5mm implants for restoration of one molar? have you tried to extract an ankylosed premolars or incisors? You basically have to remove entire buccal bone or leave some root alone if you don't want to destroy too much vital structure around. Implant works as ankylosed root tip. Im sure dr cho's technique works but I think it's just a vast overkill. Once osteointegration takes place( once it gets ankylosed,), it will stay.

Dr. Cho and Sergio, I can understand placing multiple root forms to replace a molar inorger to combat the M-D cantilevers and the B-L cantilevers. However one cannot always use certain sockets due to various issues. You also have to address the OH issues.

In case of implant loss- You will have a huge defect by using large diameter implants- 3mm around the implant will be therefore 3mm mesial+ 8mm impl.diameter + 3mm distal= 14 mm defect mesio- disataly. Regarding oro-vestibular I don`t even like to think about it ! I guess the number of companys providing large diameter implant is greater then the number of patients having that much bone in oro-vestibular dimension witout grafting in before.

Prof.Tarek Mahmoud and Sammy Noumbissi DDS MS have described the reasonable range of implant diameter beeing suitable. 3,5 could even be to big for a lateral incisor and 5 mm absolute maximum for a molar. Bone adopts far better to implant then all of us would think. It is very arrogant to pretend we knew how to influence bone biomechanics. Actualy its exatly the other way round. Bone adopts over dentitions, prosthetics and age. Biomechanics is changed all the time even by alterations in function/use. The ankylosation can be even understood as a mortification - making compartments in bone with far reaching consequences. Bone stiffens out arond the implant site. Biomechanical we change the elasticity in function of the whole jaw because other regions have to compensate. Diametermeganomania is deffinitively wrong- even if it works. Did anybody of you specialists see a elongation of an implant ? I didn`t!

I agree with Professor Tarek from that ancient city of knowledge, Alexandria. Its got the largest library in the ancient world. His approach is very sensible because it allows the bone and mucosa to heal and any infection to disappear. A 3.5mm diameter implant is reasonable as it allows plenty of marginal bone around it. I believe that the learned Professor will place implants that are at least 10mm long or more, based on the quality and quantity of the bone available. The assumption that the fixtures used should at least match the size of the roots of the teeth that it is replacing is fallacious or to say it simply, incorrect. The natural tooth is attached to the bone via a highly sophisticated biological structure called the periodontal apparatus. The dental implant is attached via osseointegration, a form of ankylosis. This normally pathologic occurence is now being used to attach all our much vaunted titanium screw implants. The surface area for effective ankylosis for the implant is much less than is required by the natural tooth for the periodontal apparatus[as we all know]. Briefly, it means the titanium fixture can be smaller in surface area than the tooth that it is replacing....probably only half is enough! Folks, it means that we need not copy Branemark's original assumption, which is reasonable at the time. But now with hindsight and understanding of osseointegation, we can use smaller-than-the-root implants and therefore Professor Tarek is right. As for the wide diameter implants, I use them too for immediate extraction of molar cases. It gives good primary stability, cuts down on bone graft and gives good emergence profile....and of course faster turnaround for the patient and faster cashflow..sic. But I am a bit worried about the extra large iatrogenic pocket that will result. The pocket will not only be vertical but horizontal since the surface of the larrrrge diameter implant will not be covered with bone but connective tissue which...err...does not integrate to titanium..what.?. Got to shut up now before I decide to stop messing around with implants.**@@!

dr. Chow's explanation is exactly what I think. Attachment of tooth to bone via PDL is different from that via ankylosis, hence you do not need multiple implants to replace one molar.

Just a few points for this discussion, an implant is not a tooth and uses different stress parameters.Implants bio-mechanical stress management depends on the modus of elasticity of the Ti thus "flexing" at its individual stresss riser ( System variable). This may be the issue in the future with Maxi type implants leading to crestal bone loss. An implant is merely a screw and you do not necessarily place the biggest possible one in a block of wood to the deteriment of the wood. Just a thought as many collegues place maxis (Southern) and seem to be happy.

There is no fixed technique in treatment planning,otherwise we should only apply without the need for planning. successful planning = successful doctor.what I have learned for planning decide your goal ,collect all information ,make a rational,put steps,apply.if we think this way then ask our self why immediate? seconed question,what size of implant do I need for my successful prosthetic planning? First why immediate? for esthetic (it is the posterior region)saving time & money(what is the peecentage of failuer in such cases)ok we come to the point ,if my treatment plan based on wide implant diameter,assuming that the I have a patient with heavy bit or bruxism,in this case we can not put reguler implant diameter,graft the extraction site & then put the implant later,doing this we preserved the ridge & implantaton well be more in solid ground .

Back to Dr. C's original question. Yes I have used the 8 & 9mm diameter implants (Southern Implants) out of South Africa. You are essentially grafting the extraction site with titanium rather than bone. The head of the implants cone down to 6mm diameter with options of a Nobel Replace Select tribobe, Branemark ex-hex or a Straumann internal octagon. Intact buccal and lingual cortical plates are essential for primary stabilization. Just another option for those who don't want to wait 4-6 months for the extraction site to heal prior to implant placement. Dr. Stuart Graves in Washington D.C has placed a large volume of these implants. Can't say I agree with Dr. Tarek or Dr. Cho.

I can't believe the nature of some of the statements made.Three implants for Maxillary molar. Where is the research to support this. What about periodontal health. Should we also build in furcation problems to duplicate an actual molar. What is this nonsence about large iatrogenic pockets with larger molar implants. The whole idea of well intergrated implants is to have no pockets. If you have pockets when your implant is healed you have a problem. 100% of your implants are intergrated? I suspect you are not evaluating them correctly. Perhaps we would be better off speaking in generic terms instead of touting a particular system. How about more evidence based pronouncements.

OSURG, i AGREE.

Dr Cho just a point of information. The library at Alexandria burned down during ancient times. It is no longer a valid refrence source.I am sure The University is a great center of learning,but for books try the library of Congress in D.C.

Dear osurg, Chow is not Cho. Notice the difference in spelling even in the English alphabet? In Chinese, it may be the written in the same character or pictorial script. But rest assured, I am not Dr. Cho. I am Dr. Chow not Dr. Cho. Though I disagree with Dr. Cho replacing a three rooted molar with three implants joined together, I admire his courage or is it guilessness?.....in saying it?...without a care or awareness of the consternation and wisecrack responses that he is bound to get. A respectful bow to all your individualities. Oh, by the way, in the East a bow does not mean surrender, it just means respect for the other individual.

3 implants for a molar replacement is just absurd!I hope you can still get your impression out in one piece. And a 3.5 mm implant to replace a molar tooth could be an ancient surgical ingenuity of replacing a tooth with an umbrella! are there any prosthodontists around!!

I would definitely like to see a picture of the impression taken of that 3 implants for molar replacement. It has to be a open tray impression right?

Don't hate...learn to appreciate !! It is a good technique that has been used for many years by many great implant surgeons. It is also very easy to take an impression of the 3 implants if you slightly diverge the angulation of the implant placement. This achieves 2 goals: 1. more stability of the final prosthesis by offering a tripod effect 2. restores the natural form of the missing tooth as god originally intended. I have done thousands of these cases with no failures. That's right...I said no failures, because even if one of the implants fail, then there is still two others that can be used to support the final prosthesis. I will be publishing this new concept soon.

Dr Cho, As I requested previously, could you please direct me to your website so that I can see this interesting technique in action? Kind Regards, Bill Schaeffer

It's amazing that so much of what we do actually works. The body is so forgiving. Anyway, back to the topic at hand. Misch addresses extra wide implants in his book. Unlike most of us, his statements are, for the most part, based on facts/research. In fact, at one of his lectures, someone asked him what he though...he said "who cares what I think...ask me what I know because that is based on research" - paraphrased of course. His book says that extra wide implants had a higher failure rate when originally introduced...I think it was attributed to the crestal bone not being stimulated enough resulting in crestal bone loss. When the implant becomes too large, very little force is transmitted to the surrounding bone...while it's bad if too much force is transmitted, it's also bad if no force is transmitted...after all, that's why bone continues to resorb when a tooth is extracted - there's no force to stimulate it. So, I'm leary of extra wide (e.g. 8mm or more) implants based on this premise. That being said, some of the newer extra wide implants have a different design than the original extra wide implants and may stimulate the crestal bone better. My advice is to proceed with caution.

Paul, This is one of the best literature reviews on implant width (and length) and I have pasted part of the results in "" below; Clin Oral Implants Res. 2006 Oct;17 Suppl 2:35-51. Impact of implant length and diameter on survival rates. Renouard F, Nisand D. "Considering implant diameter, a few publications on wide-diameter implants have reported an increased failure rate, which was mainly associated with the operators' learning curves, poor bone density, implant design and site preparation, and the use of a wide implant when primary stability had not been achieved with a standard-diameter implant. More recent publications with an adapted surgical preparation, new implant designs and adequate indications have demonstrated that implant survival rate and diameter have no relationship."

Dear osurg, "Iatrogenic", according to Webster's is defined as, "induced inadvertently by a physician". When we insert a dental implant into the bone and gums, we create a pocket around the neck of the implant as it traverses through the gum and into the oral cavity. This pocket is different from the normal gingival sulcus that is found around a normal tooth. When the gingival sulcus become diseased due to infection, trauma or abnormal immune response......it becomes inflamed and deeper and the diseased state is then called a pocket. I call the corresponding sulcus around the dental implant as it emerges into the mouth a pocket because it is not normal but a pathology. In this case the pathology is physician-induced and therefore iatrogenic! If we examine the pocket around the implant histologically, it is a vast difference from that of a normal gingival sulcus. There are no true fibrous attachment like on a real tooth, only a pseudo-attachment and connective tissue that contains a higher number of defense cells than normal. Yea, everytime we place a dental implant, we create a pocket..... a pathology...yep.....a diseased state. It is a fact that we must recognise so that we will use dental implants judiciously....only when we are convinced that the new pathology is better than the pathology it is replacing....to put it bluntly. Remember the first maxim of the Hippocratic Oath....first do not make it worse...err to paraphrase "do no harm". All well integrated dental implants possess pockets... thus what you say is true, "If you have pockets when your implant is healed you have a problem." Every dentist who places implants should recognise that they have created problematic pockets that they must check regularly and maintain at status quo as far as possible. It is not nonsense, it is a histologic fact that we self enthroned "implantologists" should accept and therefore treat responsibly. The alternative would be neglect with the accompanying consequences.

With regard to immediate implant placement on molar sites, I would like to recommend the Maxi implants. These are made by Southern Implants. There are diameters of 7, 8, or 9 mm. It is really possible to achieve great primary stability.

i have been placing 5.5. - 6.0mm D implants at time of molar exo surgery on a regular basis.....my instinct regarding choice of implant diameter is that a generous accommodation for circumferential vascularity and contiguous bone regeneration must be respected. big screws to fill big holes may result in infarcted tissues and dehissence over time; appositional bone grafting may produce organic volume outside of the physiologic envelope and can be the first tissues to resorb.....on the other hand, small diameter implants to support molar loads may tend to fracture.....it happens. it is not all about implant:bone interface 'square footage' ...best, klm

I always use the interdental septa to engage the Implants immediately after extraction.I think the septa would be lost for placing extrawide Implants and the primary stability would be derived from apical area alone.The only advantage I think of using extra wide Implants would be to avoid grafts.

I have placed a few of the Megagen Implants into wide molar spaces below the sinus and they have worked well. Also in combination with an internal sinus lift procedure. Should be careful though about initial stability as short implants tend to offer less initial stability for early or immediate loading protocols. Other than shortening treatment time in certain cases I see no other benefit at this time.

DR. SALAMA: GOOD POINTS MADE!

Wide body implants and immidiate placement need to be treatment planned carefully like any other implant placement..some points to note a)That nice solid inter dental septum of bone that provides the vascularity for bone fill into the root sockets is being totally cut out with immediate placement making a massive socket..so if the walls of the socket are not properly engaged then we have some potential problems and possibly voids that need to be catered to (depending on extent)by grafting. b)Some molars can be huge A 12mm mesio distal width for a molar with a single say 6mm implant creates cantelevers and space of 3mm ALL round the implant(horizontally)..not including the distance of contact point to CEJ of adjacent tooth. Not so easy to clean either .. c) While I have to disagree with 3 implants for a single molar... 2 can occasionally be very useful and superior biomechanically to a single wide body implant particularly if they are placed slightly diverging creating internal tripodisation. These decisions relate to the space available and of coarse the condition of the socket that we are inserting the fixtures into. I have in the past compromised ideal position placement(thus compromising aesthetics and biomechanics) due to the poor placement of immidiate implants into a molar site because the socket was damaged..it would have been far better to graft and wait ..in the long term the additional 8 weeks waiting for graft to heal seems silly to allow that to be a factor c) 2 X 3.5 in a large molar area molar area have proven to be very succesful in my hands over the years, yes the artificial furcation is potentially an issue but in an 11mm mesio distal space 2mm between the adjacent implants and a good lab tech can create a very cleansable area.This is no big deal After all when we do multiple unit bridge work on implants we have the same "furcations". d) I also have a tendancy to "premolarise" the restorations in the molar areas Reduce occlusal table size and still maintain stable occlusion..this will reduce cantelever and lateral stress in the molar areas. When you have implant cases in your office coming back many years latter ,where you wish you had taken a little more time to graft or get a more ideal implant position rather than saving 2 months on the treatment plan..you feel rather foolish!!

The problem of using wider implant in mandibular molar area is perforation of lingual plate because of balcony area in the molar area.but i use it in selected case with a slightly lingual inclination of the shaft of drilling bur to avoid perforation in the lingual plate. Dr.hajiheshmati implantologist

Having placed some 8 and 9 mm wide implants ,i have found them to be very technique sensitive and un forgiving ,concerning depth of placement and thickness of bone and soft tissue biotype. They need more scientific validation and prospective clinical studies ( at least 3 years results).On the other hand they are Great to have when your 6 mm implant doesn't have adequate initial stability.

I can't believe some of these comments.....there are some very intelligent people on here and there are some that I question everything.... In molar cases, I like to place a 3.5 mm diameter implant in each of the root socket. If a maxillary molar has three roots, then I will place three implants. In mandibular molar situations, I will usually place two implants into the two root sockets. My rationale is: 1. Original molar teeth have multiple roots, so why not restore back to what nature had intended in the first place. 2. By placing multiple implants, I am able to charge more for the procedure, making more economical sense. I have done hundreds of cases without any failure so I think that this should be the new standard of care. Has anyone else out there tried my technique ? I will be offering courses on this in 2010 so please keep an eye out for my courses." Unfreaking believable!!!!

Dear Dr. Cho, As a Sales Rep. in the Dental Implant industry I would just like to say thank you. I think you are on to something!! Take care. MJK