Immediate Placement of Implants: Graft First or Only After Placement?

I would recommend the book from Straumann/ITI "Implant therapy in the estetic zone". In the book there is a "risk factor analysis" which will help You a lot. If used properly it will keep You out of trouble. I do a lot of the cases You are describing and there are so many factors to sort out before and during the surgery that You need to adress; Bone volume? Soft tissue volume? Biotype? Infection control? Sourrounding teeth? Shape of teeth (risk of black triangles)? Lipline? Smoking habits? Deep bite? Forces on the provisional? Oral hygien? Type of implant? Type of grafting material? Positioning of the implant? Implant stability? Patient expectations? Etc. Etc. In my hands, there are no surgery more sensitive to small details than implant placement in the estetic zone especially when done in a immediate manner. The first couple of cases of immediate implant placement in the estetic zone should be a patient presented with a low lip line and a "low risk case" (ITI/Straumann). Fill the void with a non resorbable graft material like Biooss Collagen. I spoke to Prof. Jan Lindhe a couple of weeks ago and in his recent studies the most predictible results came from extraction, socket preservation (including Biooss Collagen, Biogide and a soft tissue graft), healing 9 mounth and then implant placement. The bundle bone "always belongs to the root", if the root is lost You will always loose the bundle bone! Thin biotype = more bundle bone = higher risk! I wish I had more time, but surgery waits. I wish You all the best! / Erik Lennartsson

Place the Implant first then graft the spaces as if you do not get graft material further down the implant it is not important.The graft material aids in preventing soft tissue ingrowth and any small spaces more apically are generally narrow and the bone will form.

If you graft the socket before implant,graft particles will hinder accuracy of implant placement.

Place the implant, the close the implant(primary screw), then graft. Although there are some studies that show that grafting the space between the implant and the alveolar bone, delayes osseointegration.... I do it regularly. After grafting you can place a healing screw and or take the impression for the temp(or do it yourself) remember to correctly determine the primary stability best of luck

It may be best to build the foundation of bone for the implant and the place the implant in an ideal position after regeneration of the bone. It is asking a lot of the body to heal an extraction site, regenerate bone, accept an implant and load the implant into function in one surgical procedure.

I routinely place implants into extraction sockets and immediately temporise if there is sufficient primary stability. I use Dr Joseph Kan's technique (published in the International Journal of Oral and Maxillofacial Implants a few years ago) where self cure acrylic is flowed around the abutment and the abutment seated in the socket. Sounds weird but works and achieves several things: 1. The soft tissue is supported so you lose NO height, contour or papillae whatsoever. 2. There is no need to graft as the socket is occluded and endosteal blood will provide all the precursors for new bone formation. I routinely use 3.5mm diameter parallel sided threaded implants and even in upper central incisor sockets do not graft and in the 4+ years of using this technique have achieved wonderful results. (Perhaps 50 cases). To achieve good primary stability it is necessary to place the implant apex palatally and you will have to drill through the palatal socket wall about mid way down. Do this by using a round drill to make a ledge in the sloping socket wall to enable the pilot drill to bite into the palatal bone and not run into the socket apex. If you just drill through the socket apex, in most cases you will perforate into the labial fossa. I have lectured on the technique all over Australia and in England and yet my audiences often do not believe you do not need to graft if the socket is occluded. If you graft and re-enter later, you lose the papillae and have to use techniques to re-form them, and often the results are mediocre. If you support the soft tissue after extraction and implant placement, you will keep the papillae and the gingival height, even in cases of thin biotype. Trust me, it works.

A few comments. As always, I agree with my mentor, Don Callan. If you want to place implants in BONE, you need to use a graft material that is resorbable or re-ossifying into BONE. You can't use an inert, non-resorbable biomaterial and expect the same results. If you look at the literature from Europe, they have to use BioOss or synthetic materials, as human products are not available in most of the EU. You can look at articles by David Anson and John Sottosanti to see their outstanding techniques with DFDBA and Calcium Sulfate. As far as immediate placement, what are you trying to accomplish? If you place immediate socket implants, the literature tells us that there is still bucco-palatal collapse in the socket. The studies show up to almost 5mm bucco-lingual loss of hard tissue from implant placement to uncovering. If you want to preserve the papillae, that is a different story. Also, consider the downside risk. If you place and immediate socket implant and end up with a deep pocket where the gap was, how do you treat it? I agree with looking at the Straumann guide. More importantly, think biologically. Many of us want to, scientifically need to, end up with bone. After all, it is the osteoblasts in bone that deposit the osteoid and give you osseointegration.

I agree almost totally with Tony Collins, except I am unsure about bone infilling so I always fill the void round the implant just in case. I have carried out over three hundred immediate implants into extraction sockets and lost 4. Don't belive the people who say this system does not work and you have to rebuild the socket first then place the implant, it works brilliantly. Also immediate implants with immediate temporary restorations on are a massive practice builder (as long as you chose your cases correctly so they don't fail) and the patients are really thankful they do not have to wear a temporary prosthesis.

I, too, agree with the position that immediate implants and immediate temporization are a predictable and safe treatment modality. I would also like add that BioOss is a great product when used properly. Whether you use it in a layered technique or mix it, BioOss has properties that are helpful when space maintenance is of utmost importance. I use it with great success and have never regretted its inclusion in my grafts. A long history with evidence based success cannot be overlooked and indicates it as another material we may use.

Poor guy is asking simple question.Should I graft the socket, before or after implant?????????????? I do not see the need of lecturing him with all the knowledge and technique of immediate implant in socket,merits and demerits of the same,arguments for what graft material is superior (what ever commercial interests are involved),etc.............

THANK YOU FOR YOUR QUESTION AND MANY THANKS ROF THE BENEFIT COMMENTS. I TRY BOTH WAYS MANY TIMES AND THY WORK

Satish is absolutely correct. Place the implant first then graft. Otherwise the implant may not fit the osteotomy as you planned or thought it might.

Mike Heads, Your point is well taken. I ues to do the same. Except now I will graft and place the implant later in the following situations: mand molar areas, patients with rheumatoid arthritis, occlusal parafunction and people 50 yrs. and over.

Dear Colleagues, It is always very enticing to read all your revered comments. In my clinic it is always is a practice that we place 1/3rd to 1/2 of the implant first into the socket and then place graft along with the implant screwing it together graft of choice is individual. Well I have tried gimmicks in a non infected socket but buccal dehiscence results in a few cases atleast 20%. I would like to get some idea about it. Dr. Ambrish Maniar

First, I finish my drilling process.I engage the fixture into the osteotomy site.After three or four threads are inside the bone, I add some fine particles of autogenous cancellous bone around the fixture and screw it down to the bone.I repeat this process for every two or three threads entering the bone until the fixture is fully seated.The remenants of grafting bone is then placed around the platform and the soft tissue is finally closed over the implant. By the way,I don't understand what all these lectures about the biomaterials have to do with the original question.

We all love to lecture others.Isn't is true?

When I do place implants in sockets, I usually do the following: first detox the socket if necessary with a tetracycline slury for 3 min. and irrigate, prepare the osteotomy and place a loose mix of Osteogen into the osteotomy and socket, now place the root form, now top off with the Osteogen in a thick mix. I also decorticitate the socket after the osteotomy. I try to take advantage of the RAP as much as possable. This is not a lecture, just a suggestion.

I have done hundreds of immediate implants over many years. I do immediate molars routinely. I rarely do any concurrant grafting. As has been suggested, graft material can delay bone formation. Sometime I will put a narrow lonf bolus of Bioss Collagen down the direct buccal aspect of a thin biotype. I do this to keep the ridge from dishing in. Basically we know BioOss will not resorb so it stays there and holds the shape and some bone grows around it. THe implant will integate on the palatal and proximal primarily. I don't try to cover the socket usually with argylic or graft or other wise. A good clot is what you want. In some case where I think the site is vulnerable or there is insufficient bleding I will cover with a perio pak.

i have placed only one immediete implant in the place of #12, i drilled pallatally longer drill than the socket to achieve primary stability and to place the implant deeper than the ridge,and i didnt put anything to leave space for blood clot ant therefore bone to grow.i didnt clean socket, implant was with healing abutment, i placed the crown 3 months after operation, no resorbtion apeared at all 18 months now. I intent to do this again except for molars. there i will put bioss anad membrane in the 2nd empty socket. u always will need little things along with strict surgical rules and biology thinking.

Is it done flapped or flapless?

it was done with raise of flap just 3-4 mm bucally to guide me better

with smal flap buccally

I dont think it is black or white. You have to evaluate several things with probably the most important being the integrity and thickness of your buccal wall. If it has sufficient thickness you probably wont need to graft the site. However the graft material no matter how big or small the space is between your implant body and facial wall seems to add not only to hard tissue but also to soft tissue stability as research shows. I can recall a study that showed more recession when graft was not used. However they did not corelate their results with soft tissue biotype or buccal wall thickness.

I agree but when in doubt, give it tincture of time.

Place the dental implant first, then place the graft to fill the dead space and achieve more stablity by wedging effect.

Im a student and i want to know, if its not possible to place a provisional because of a low stability, how do you suture if you dont have tissue. whatif you grafted,,,infections??

Dear Dr R, I know there have been numerous answers highlighting various aspects of the philosophy of Immediate extraction Implants in response to your question.. I wish to put things in a more generic perspective. The extraction socket is predominantly constituted by the cortical (Bundle) bone that re-inforces the socket walls and offers attachment to the PDL. Given our understanding that all forms of bone grafting involve two main principles - 1. Resorption of the graft (irrespective of whether it is an Allograft / Alloplast / Autogenous graft) 2. Osteogenesis at the graft site to have the native (recipient) bone unite with the donor bone (or substitute) with a bio-mechanical bond. This apart, the process of "Osseointegration" being an entirely independent process (from "Osteogenesis"),there is the need to look at Immediate extraction Implant healing (with graft) at the interface of the recipient bone and the Implant. The Interface (quite unlike conventional osseointegration), has to contend with the graft material's presence, its resorption activity and thereafter 'conversion' into new bone... and then only then Osteoblastic activity towards the accomplsihment of Osseointegration with the Titanium Implant. It would therefore make biologic sense to avoid the graft completely (if the gap left behind... mostly in the coronal aspect of the socket into which the Implant has been inserted)as it would then enhance the possibility of direct Osseointegration without the sequence of Osteogenesis, as this would anyway be accomplished satisfactorily by the jumping distance of the Osteoblasts in the 'gap' left after Implant placement. I have, in other words,staked my claim with the group of "Implant philosophers" who would go the Non-graft way! PS: I think primary closure (with or without an immediate crown) would go a good distance to ensure good healthy bone around the Implant coronally as well.