Extracting Tooth 18: How long should I wait before placing implant?

This is a Root canal treated teeth, mostly the exo will be a bit traumatic, if this is my pt i would leave it for at least 3 months, then if I'm happy with the tissue/bone condition i'll place my baby with no drama. Thanks for sharing your case..

I am with Dr. Ben

delayed immediate implant is the best mean 6 weeks after extraction,regarding socket preservation it depend on the residual thickness of buccal plate which usually is good at the posterior mandibular area as long as a trumatic extraction with roots separation is done

waiting time depends on: - The diameter of the socket after extraction. - Patient's age, general health - with or without socket preservation technique. In my opinion, at least I wait 04 months and prefer to use allobone for socket preservation. I ask patient to take a conebeam CT to check the bone healing before placing implant.

I routinely place the Bicon short implants in similar cases. You must thouroughly debride and decontaminate the socket. Rinsing with sterile water rapidly kills bacteria without much bone damage, or you could dab some monocycline and then rinse with steril saline. I cut a wedge out of the interradicular bone section with rongeurs to keep that from kicking the reamers out, then proceed with normal prep techniques using the spreading bone plugs on between the last size. You want to rely upon the implant being held securely by the Buccal and Lingual sides of that bone, so usually do not use the final full size diameter reamer. Then place the Synthograt/blood mixture and top off with a Collaplug and inverted x suture to keep the plug below the socket edge. Most of the collagen is lost by the two week visit, leaving a smooth layer of epithelial tissue to cover the socket. This will look like a hole, but no problems since once the implant s placed 3 mm below the crest and the final abutment undersurface is a titanium sphere. Sometimes a titanium healing abutment has been placed at the initial immediated implant placement, but this adds possible problems from movement or tissue/bacteria invasion. Both surgeries maybe viewed on the Bicon webcast replay menu. Lots of very healthy bone and great prognosis for placement at extraction. John

I should add that any bone area touched by a 1,000 rpm bit or above will have to be trimmed away so as to not contact the implant. You can leave areas of fast burr contact if they are several mm away from the implant and that assumes you used proper saline coolant on your sections, channels, etc. E.g, if you section the tooth with a high speed, then the bone cut by that action needs to be removed at a very low speed or by hand. Also, special attention and a large round burr or currette are needed around that apical cyst area.

I do a lot of immediate implants but I do not do immediate molar implants. If you do a delayed implant in good bone you are assured of a great result. If you do an immediate in a molar region you may likely have remaining osseous defects that will cause failure in the future. Socket Graft Putty is approved by the FDA for implant placement 2 months after grafting and our FDA submission study showed 100% success rate with 100 implants after 3 years. Greg Steiner Steiner Laboratories

As to grafting the entire socket - that's not needed. You mainly need to ensure no epithelial tissue dives down to the side of the implant. Look at post op healing on extractions and note no problems if the initial clot stays undisturbed. We do not always place Synthograft on immediate molar Bicon implant placement and usually only put 1/4 gram atop and immediately around the implant (note that we put bone harvested from the prep directly atop the implant first), leaving the peripheral socket volume open to the top against the Collaplug, which is paced to delay epithelial/bacterial invasion. NOTE that other implant designs may require intimate bone contact and/or prohibit any open areas contacting the implant surface.

Greg, Good socket cleaning pretty much prevents defects in implant integration in the Bicon implants which are submerged 3 mm below the boneyard ridge crest. That three mm submersion allows rapid tissue growth over the top of the implant and reduces the tendency of tissue to grow up against the the implant top and then to proceed downward along the interface.

Dr. John Manuel, I agree with you. I mostly use Bicon Implants for posterior mandibular sites for immediate placement. I just remove all the soft tissue and decorticitate the socket and tap in the implant. Many times I do not use an osteotomy bur. I smother the socket with Osteogen, place a collagen membrane and cover with Coe Pak. MANY TIMES THERE IS TOO GREAT A RISK OF BAGGING THE NERVE, so the use of the Bicon the way I suggest helps to avoid this issue. If to close to the IAN, graft and give it time.

This patient has natural antagonists, therefore mastication force is supposed to be powerful. So, short Bicon type of implant is less desirable. The wider and longer the implant is the better the future prosthetic prognosis is.

Dr Alex, What you say is simply false, and shows you have not availed yourself of the years of research demonstrating that Bicon Short implants are equal to and in some cases, superior to longer cylindrical implant designs. Bicon Short implants reduce or eliminate the dead spots in bone loading which increase in proportion to the length of the implant. Finite stress analyses show lateral force on a Bicon short Implant goes down one side and back up the other side, across the bottom, and across the top of the implant. Studies show Bicon Short Implants stimulate bone growth over the top of the implant consistently for years after insertion. While short threaded implants may show weaknesses, the Bicon is a "finned" implant, not threaded, and has more bone surface contact area in a 6 mm implant than many 11mm or longer implants. Long cylindrical implants are threaded in place with pressure which stimulates a primary bone restorative phase of over 2 weeks, followed by medullary bone formation. Bicon Finned Implants go to place almost passively and skip that resorption phase, spaces being immediately invaded by the stonger Haversion type ( cortical-like ) bone.

Dr. Manuel, While your insights are good, do you receive some form of compensation from Bicon? Every comment of yours now reads like an advertisement for Bicon. Some disclosure would be appropriate, I think.

In this area you have several issues. The first is relative close proximity to the IAN. The second is the undercut from the submandibular fossa. I would graft and revisit and place the implant when the lamina dura is absent.

Drmf, Disclosure of names would be a good start. I posted a lengthy answer to your request, but it did not show up. I have no vested interest or ties to Bicon other than being a user. I use other systems at times, but there is already plenty of posting about those options. I mainly only post when the answers do not consider all the current , viable options, or when gross misstatement of fact appears. Just as dentists are obligated to explain the implant option to other prosthetic choices, dentists should also know about and explain less traumatic options for cases.

Hi, i need some help. We have a patient in Belarus, from Canada. We made a first step, but now patient cannot came for next steps. May be someone working with MIS system in Toronto, and can take her?

I'd advise lay a flap section the tooth preserving the buccal plate, graft with allosorb or cadaver cortico-cancellous bone. Primary closure, leave sutures in 7-10 days. place implant at 16weeks, also measure root lengths with perioprobe for implant length. Have fun!

I'm still a novice at implants but I have a few suggestions. You have several issues that are red flags as to not place an immediate. One. The patient is older, the bone is dense, the tooth is brittle. The extraction will be a surgical extraction as you will have to split the roots in order to take out this tooth atraumatically. Two.The S/M fossa area is in that vicinity and can be easily perforated .Three.The IAN is also in that vicinity. Your best bet is to wait 4 months before placing the implant and use the length of the distal root of the first molar (#36) as a guide to your maximum depth.Waiting a bit longer gives the bone a chance to ossify and improves your chances of obtaining primary stability.

There is plenty of room for a 5-6 mm long implant without going near the IANerve. The fossa can be easily felt with hand reaming after the initial pilot drilled short of final length. Sectioned and channeled areas can be freshened with ultra slow or hand instrumentation. We perform this procedure routinely with no problems. John

4 months after ridge preservation assuming everything goes right with the extraction. That's what works in my hands

You can also feel the lingual fossa bottom with a finger upside down. It is not hidden, and the variation in density on an x-ray can give you an approximate location. Gentle hand preparation will prevent violation of the socket boundaries.

By your question you aren't well experienced in dental implants so I would strongly advise you to proceed one step at a time and don't rush this case.

ray makes a good point. And while you are waiting for this patient's bone to fill in, you can check out webcasts, read research, and take courses to learn as much as possible about the different implant systems out there.

Take the tooth out as atraumatically as possible, see what you have left to work with and go from there. Use the implant system(s) you feel most comfortable with, and or graft materials. Simply let the patient know you will decide what to do once the tooth is out. Go from there based on your experience.

Dear Dr Young and all respected Doctors out there, Taking care of the above mentioned vital structrues is a must and I tend to do as dr young oms says, unfortunately patients have a hard time understanding why i'm going to decide after the tooth is out. If i explain and do delay at times, the delayed patients tend not to get the implant done at all. as i've lost quite a few patients this way. So best is to learn to optomize atrumatic extraction techniques, as patients get discouraged by the undecided (may or may not place implant) approach of dentists. Good luck with the case.

Pretty standard immediate case . All extractions should be atraumatic. Place the implant in the mesial most canal, while allowing an adequate amount of bone between the tooth and implant. The bone quality and quantity will never be as good as it is at the time of extraction . Graft the distal sockets and perform standard GTR. Bv

Dr ryoungoms absolutely right

Thank you all for responding to my case. Ray, you are sort of correct that I lack the experience of having placed hundreds of implants. I have about 30 under my belt over the past three years. Training, though, is over 250 hours. There just never seems to be a standard agreement on even the most straight forward of questions. Just look at the variety of answers to my question that people posted on this thread. If I try to summarize the consensus of answers above I would say that the safest advice would be to take the tooth out and wait 4 months before placing the implant no longer than the original tooth's root. This should keep things safe and avoid the SMF as well as the IAN. I don't sense any agreement on the whole grafting/socket preservation idea, so I will decide that as long as my buccal and lingual walls are intact then the need to graft is debatable. My question then is: Since after 4 months the bone will not be solidly filled into all of the socket spaces, do I just gently screw the implant to place in the still immature bone without any regard to initial stability? Isn't it true that it would take closer to a year to have dense bone fill where I could expect to have the 35 NCM insertion torque that I would like?

John Manuel, I appreciate all of your information about the Bicon system. I will view some of their videos as they seem quite extensive. While I haven't looked at Bicon in a while, my problem with the system in the past wasn't that it failed to integrate or have enough support. My problem was with the strange restorative interface. But I hesitate to post that comment because for all I know they may have improved on that.

I routinely wait 2 months post EXT for fixure placement and achieve both good stability and good torque. Obviously it depends on how easy/hard the EXT is....

Dear Doc, Sorry for digressing from the question asked. As for looking for the right time to place. Depending on how atraumatic your extraction is A good reference is Type of placement I,II,III,IV in SAC Classification in implant dentistry, Chen, Buser. Quintessice publishing.

John Sackman, I suppose there's good and bad to any system, but, with reasonable planning that Bicon Morse taper connection is reliable and bacteria proof to the point we often see bone growing over the abutment/implant interface. Over the years I've tired of having to maintain and repair the dozens of different screw abutment configurations, and enjoy the versatility of a rotatable connection. This helps a lot with alignment of the Trinia full arch on four or five short implants, since the abutments self align before we set them. I placed them in the 80's when fewer size and length options were available. You can still get the same 2 or 3 mm tapered connection, however, for anteriors a fairly recent 2.5 mm, more parallel taper is used to avoid knocking the connection loose. It has taken some time to learn a gentler preparation and insertion technique, but I'm now addicted to feeling the bone and structures in the prep. In spite of all the tapping shown on videos, we mainly tap on the expansion plugs which I use like an endodontic test file before gently positioning the implant. You can actually alter the implant angle after insertion using the alignment pins.

As for restoring the Bicon's, I mainly put PFG, Zirconium, or E Max (ant), all of which are easily done directly on the Stealth Shoulderd abutments. We take implant level impressions without the need door the screws and send the abutments to the lab with little or mostly no trimming needed.

I have placed many implants in this position but in this case has anyone actually said "does this patient need this tooth replacing". It sounds to me like a lot of people are making sure they get their money, e.g. don't do delayed as the patient might not come back, we know there is a risk but we can miss all the vital structures. Would it not be better to extract the tooth and review the patient in three months, which I think is about the right length of time for healing to take place, and let the patient decide if he can manage without it. If he says he can then monitor over eruption of the opposing tooth and only recommend an implant if this occurs. This might go against the ethos of many dentists who want (or have to) get as much money out of every patient that walks through the door but in my view this is the ethical way to treat this case

The patient is unlikely to be knowledgeable enough to foresee all the problems stimulated by removal and non replacement of this tooth. For example, the extrusion of #15 is inevitable, the increased loading on #19 is inevitable, etc.. Even dentists as patients cannot "feel" the long term consequences of lost teeth until significant damage has taken place. e.g.,Who can feel the bone ridge resorption as it occurs? The patient deserves to be informed of the risks and benefits of the major choices in treatment available before proceeding. There are clear advantages to being able to place an implant at the time of extraction, but this is not always possible. As far as seeking money goes, the placement of a removable chrome/acrylic partial denture or a cantilevered fixed bridge are close to the cost of the implant body placement, but condemn the site to future problems. Just be knowledgeable of the options, and be ABLE to perform or to refer whatever informed choice the patient makes.

I agree. By the way what is the age of patient and why is the tooth to be extracted?

Here is the key question. What is the rush? As far as your experience level, 30 while something is minimal especially over 3 years. Not to brag but me being an average periodontist in my community I'm placing 30-40 per month. With that said minimizing risk is the benchmark goal. Do yourself a favor take out that brittle, hollow, ice cream cone of a root carefully. Fill in the hole with your favorite graft, (mine is still cortico-cancellous mix 70/30 from zimmer) and then enjoy a risk free simple 20 minute implant in 3 months.

Anupam: The patient is 44. The buccal wall of tooth originally fractured below the gingival attachment. Now there is furcal decay. Drag: I would like to do more, but I have been cherry picking the easy cases and referring the nasty ones to my experienced local periodontist who like you does ~30/mo. You suggest I should graft the socket and wait 3 months. I use Mineross which is a 50/50 cortico-cancellous mix by osteotech/Biohorizons. But if all the walls of bone are intact is the bone graft necessary? Or will others on this site suggest that I am just lining my pocket while I unnecessarily place grafting material into a site that will fill in by itself. and I will repeat my earlier question which is: Isn’t it true that it would take closer to a year to have dense bone fill where I could expect to have the 35 NCM insertion torque that I would like? so do I expect a three month old extraction to be too soft to give strong initial stability?

Hi All, According to the x-ray the tooth have sound structure and no periapical pathosis good bone and periodontal structure, the most suitable treatment plan in such case is crowning to guard against crown fracture due to masticatory load i dont recomment extraction and placing implant in this case

This very straight forward. Remove the tooth atraumatically sparing the buccal plate. The tooth will need to be sectioned. Take a perio probe in the socket to measure or measure the extracted root with an endo ruler. Graft, allograft with primary closure or collaplug. I wait 14-16 weaks for healing. Place an implant wait 3-4 months for osteointegration. All these immmediate techniques and short implants compromise the final result, you need to allow for proper healing the implant will be there 20years. Also this is NOT an esthetic area so an immediate is not indicated, it drops the success rate. Be honest with your patient.Be conservative.

Crs, show me one scientific study that suggest immediate placement is compromised care. What is the hurry? The bone begins to resorb the minute you lift the periosteum. Don't we want as much bone as possible? Again suggesting that you must have primary closure, is antiquated medicine. We were certain that this was necessary 20 plus years ago. Now we know it is not. I never attempt to obtain primary closure on simple cases and our success is proof enough. Aside from my silly anecdote, there are some strong scientific studies that suggest the same. "It's the same old story, same old song and dance, my friends ". Ibid zep. Bv

Baker, I agree with you. I do suggest immediate grafting and delayed placement when there is a chance of bagging the nerve. Even experienced operators can have a bad day.

CRS, is there research showing that "...short implants compromise the result."? ALL Short Implants, SOME Short Implants? What I have read and heard and experienced is that SOME short Implants actually Improve results in this type of case.

Easy! Atraumatic extraction!!! No augmentation!!! Wait 3 months:implant,wait two month:crown.

Greg Steiner, Re: your statements that you do not perform immediate molar implantation and that you do not consider short implants equal to longer implants, please note: 1- While you may not feel comfortable placing the immediate molar implants, the procedure is a common, highly successful choice for many implant designs. The fact that you do not choose to do so doesn't override the the supporting studies and stable success rate. Perhaps it is not very successful with the systems you choose to use. 2- Your judgement that longer implants are "proper" and that shorter implants are experimental and "not proper" could stem from that being the case with the implant systems you use. However, research has shown that, even within the Bicon system, 6 mm long implants are equal to or superior to 8 mm long implants. 3- With the above in mind, I feel the "proper" implant for most tight space situations would be the Shortest implant capable of providing the needed support. John

Uli, I do not consider dollar bills, when planning surgery. If I did, I would do the extraction and graft and come back later and do the implant. The removal of this tooth, is a three minute procedure for me and with cone beam technology I can place a 5.0 to 5.7 mm implant, that is 10 to 13 mm long. The amount of graft material required is small and yes, I use autogenous bone 90% of the time. Of the 7 to 8 failures I have had in 20 years, none have been in immediate sites. Yes, this treatment may seem absurd to you, but If you were to watch a double jaw osteotomy, you may not be able to keep your balance. Some of us will move forward with the latest advancements in medicine and others choose to " hang out " in their comfortable little niche. I do not concern myself with patient attrition. If the patient leaves your care, then they probably are not very compliant to start with. I hope this clears up any misconception you may have about my philosophy. Have a pleasant day. B Vinci

Dr BV, The current philosophy from the big boys of oms is getting away from immediate placement since the shape of the extraction socket dictates the implant placement, why not place it ideally it will be there a long time.The success rate does drop with immediate vs delayed. I like doing primary closure, it is a solid, not antiquated technique and I can control the result. The information that you share does not indicate that it is current. Oh and I have never lost my balance during a double jaw osteotomy and don't see the relevance of that statement. Is there anything else that you can complete in 3 min????

CRS, The shape of the molar socket does not need to dictate the placement of an implant which will integrate as long as it is held still in a stable blood clot. The interradicular bone can usually easily anchor a Bicon short implant. Sectioning of roots during removal is not detrimental if all of the drill damaged bone is gently removed to avoid contact with the implant. Sockets fill with bone in most extraction sites without special intervention. An implant can help to fill and maintain socket bone if the design has a narrow center and a configuration allowing almost straight through vertical and horizontal circulation as well as a nearly passive contact area with the native bone.

In summary, IF the big boys only use implants which require intimate contact with bone, then they will have better success with either following the existing root space, or waiting until the extraction site fills with healed bone. However, IF the big boys expand their knowledge of other implant types, they will likely find greater choice range and higher immediate success rates. Not all implants are the same. Research which does not include other types of implants may have little or no bearing upon the successful use of the alternate designs not evaluated.