Immediate implant placed: leave it or remove it?

Did you take a pre op CT scan? From your post op scan it appears that there was inadequate B-Li dimpension for any implant. What would you do if this were in your mouth? In mine I would get it out ASAP with GBR

If you saw 4 walls, can you say how you then say that the implant seems to have no bone around the palatal: is this what you are describing? If the implant was deeper, would that have solved the problem?

Have you done a hand wrist film? One year apart Cephs? Why would you place an implant on an 18 year old woman? She still has growth occurring and implants are not indicated until all evidence of growth is completed. You should remove the implant, perform a Maryland bridge and wait until you are assured her growth is complete. It would be ashamed to ruin her lifetime smile by being too eager to place an implant and watch as the teeth move, the implant doesn't and her smile is less than ideal with completion of facial growth and development.

Dear Dr. I don't like posting negative comments, we have all made mistakes and we all have our own learning curve but, I am afraid, yours maybe a little steeper. Why didn't you take a pre-op ct scan but decided to take one post op? How did you assess "visible circumferential bone"? Simple probing should have revealed no palatal bone!! You need to: 1) inform patient 2) removed implant asap 3) gbr with FULLY RESORBABLE material as this site will require a graft; there's no way enough bone width can be achieved only with gbr 4) refer for bone graft after 3-4 months, 5) new fixture after 4-6 months. 6) wold strongly recommend more training Good Luck ST

Hi. Take implant out. Graft. 6-9 month another CBCT. Another implant . At least she will be almost 19. Good luck

1. With pre op CBCT could prevent this type of problems. 2. In younger patients with perforation we will expect more resorption. 3.Even a little asymmetry in palate causes tonge activity and more problems. 4. I prefer to remove Fixture, GBR and after 4 months very long, narrow implant.

I agree with most of the comments. A pre-op CT would have been beneficial in assessing the true B-P ridge width. At this point, I would refer the patient to an OS or Periodontist and let them decide on the best course of action, to remove and GBR or consider a block graft at the time of removal. Given it is #6 that is being replaced, I would not consider a longer, narrow implant just because the bone is narrow.

Wow, what great feedback. So much to address. I should have pointed out that we had a pre-op CT, here it is. There are a lot of things that could have been done differently that I will take into consideration for future reference and it seems there is a consensus to get it out, graft and wait, that's what I will do. Thanks! J

Take the implant out. Honestly, don't feel bad, if we are honest in self evaluation, we have all been there.

Please note that for those asking for a pre-op, the original poster added one in the comments. We have also now added this pre-op to the original set of post images for easier reference. Thanks.

Out of curiosity, what was the temporary tooth replacement, a flipper? If so, is it possible the flipper was putting pressure on the palatal area? I had an implant as part of a locator denture that had that problem as it was healing, too much pressure on the tissue, and the whole lingual became exposed, similar to this presentation. In this case single tooth #6 I would extract implant and graft with a titanium reinforced PTFE membrane with screw retention on the palatal apical to the defect.

Most women are done growing between 13 to 15 years. I would not worry about placing an implant on an 18 year old woman.

To all of you that have made a comment about female growth being done at 18.5 years or younger, please review the findings of Dr. Oded Bahat. At the AO national meeting he showed research of Mx and Mn skeletal growth that occurs well into the twenties. The premaxilla after the age of 18 will change an average of about 3.5 mm if I remember correctly. Creating an ankylosed implant 3 mm below the occlusal plane. Also, it is almost impossible to tell who will be done with this skeletal growth at 18 and who at 25 or later. The heaviest of hitters on the distinguished panel all said that they would all change their approach to doing implants on patients in the 18-24 age range. Relying on some on growth plates in other areas of the body would clearly be a mistake.

Thanks for posting. Good case to discuss. I would agree I would remove and graft and after 6-9 months reassess and start again. The other option to consider is giving her an adhesive bridge as a temporary instead of the denture to help avoid any pressure on the area whilst it is all healing. I personally ask patients to leave dentures out for up to 1-2 weeks after implants especially if grafting is done to help risk of pressure on implant / graft. The fact the patient is without a tooth is obviously very important for most people so has to be timed well for patients circumstances, i.e. No important events etc. The alternative to consider is to give an adhesive bridge for a longer term temporary (even for a couple of years). I have done this for some younger patients when they have favourable occlusion / enamel etc and have had patients with bridge for some years before then having an implant . Best of luck.

I despise the guy who criticized you for your inadvertent error in placement. We have all walked in your shoes and shame on anyone putting you through more stress! Get the implant out, GBR, and you Amy still need a block graft down the road.

How soon did you figure the defect on the palatal wall? If there was a decent palatal wall to begin with , after removal of the C , and you saw the 4 walls, how did it get to where the CT shows in the post op? I wonder if the palatal wall , after surgical removal of the 3/adult canine, wasn't just tissue paper, and fooled you from the start...you mention it might have given way as the osteotomy proceeded...? I think this is a great problem to show colleagues, as it can only help, so thanks for showing it ...there are many people who present with this exact bone set up, and anything that helps colleagues is to be welcomed with open arms. Who ever learned from getting it right? As to growth and 18 year olds....I do a lot of ortho, and late adolescent growth is common.

Thank you for the reference to Oded Bahat’s research, i read a paper on the following address: odedbahat.com. The paper “Lifelong craniofacial growth and the implications for osseointegrated implants” I recommend it. I could not find support however to the statement that craniofacial growth on 18 year old women differ from women older than 25 years. My take from the study is that changes are lifelong. Does anyone know any research that shows that the problems we can encountered when placing an implant in an 18 year old woman can be avoided by waiting after 25 years? This has been a great discussion and i have learned a lot.

Welcome to the most difficult implant scenario. These must be grafted preoperatively since the alveolar bone does not develop fully when the canine does not erupt.Now you have a compromised site. Refer it to someone with experience. I'm fixing one of these now, it is not easy.

I an a member of other Implant lists, I have been placing implants probably before must of you graduated from dental school, I have trained many doctors in the field of Oral Implantology, I was Co-Director with Dr. C Misch in a CE MaxiResidency Course at Pittsburgh School of Dentistry, I have a Hospital based Residency or Oral-Cranial and Maxillofacial Implant, and I am Fellow and Diplomate of both the ICOI and the AAID. Almost every time that someone asks for an advice or post a mistake, on this someone always comes to the attack. There is no reason to tell anyone that he is ignorant, no one should be ashamed of asking for a solution to a problem. Yes you can refer the patient to an Oral Surgeon, a Periodontist, or to a Dental Implant Specialist, but you can also repair it yourself and if your partner is a Diplomate of the ICOI he can also assist you with this case. Regarding Dr. Oded Bahat’s research and presentation, it has no place and very little relevance in how the profession should perform dental treatment. As far as age I totally disagree with the timing of implant placement. If properly placed, implants can be placed on teenagers, to prevent bone resorption. Treatment should be properly planed and with the right implant and abutment design, so the case can be prosthetically retreated. Simple distraction osteogenesis if necessary can be performed later on to adjust for any discrepancy in bone growth. Doing so is easier and less problematic than bone grafting at a later age and also prevent some psychological problems for having a missing tooth at an early age. Smart and knowledgeable professionals are humble and carrying with their colleagues.

Dr Mena, thank you for your response about Dr Bahat's information. In your estimation why does it have so little relevance? Is it that research shows difficulty in predicting who has continued skeletal growth, you are unsure of the verifiability of the research, you find it not particularly difficult to treat the Mx anterior area with DO? In most cases with teenagers we are not really preventing bone resorption, it is already an issue and would appear fairly static into the 20s, at least in congenital cases. What is the proper implant and abutment design. I have many late teenagers coming in with missing laterals and I would really love to know if implants there are viable. Thank you for your time, expertise and considered response.

Nice Post Raul ...... there are a number of factors to taken into account , you have summed it up perfectly Peter

I am also in full agreement with Dr. Mena's opinion. With regards to Dr Bahat's research, have everyone commenting on it actually read the paper? The paper is actually not very relevant to the discussion at hand. Why? First, the paper does not investigate 18 year old women. In fact, we do not know what population was investigated. There is no average age or range if ages in the study (please see the M&M section). It does not specify how many patients were investigated or followed? There are 4 cases presented in pictures. Not enough for any relevant conclusions. Second, there was no statistics done, zero. Third, the paper talks about lifelong changes, are we to assume that we can not restore missing teeth with implants because the occlusion sre going to change throughout the patient's lives. Of course not. So i agree We can not use this research to set up guidelines on how to treat our patients. as far as i am concerned both Dr Mena's and Dr bahat's opinions should be given equal value.

I don't believe CBCT's are absolutely accurate. I often see burnout around Titanium and other metal objects. If you felt bone on the lingual before placing the implant, there's a good chance the bone is still there. It usually gets defected towards the buccal and not through the thicker buccal bone.