Implant placement: two stage or one?

60 yr old white female, ASA II, recently fractured tooth #11 (UL canine) and is need of a permanent restoration. Patient has a low to moderate smile line and is not concerned about non visible esthetics ( a long tooth is OK). Loss of vertical dimension due to bruxism. Complete dentition is present, PAN does not show implants on UL. After discussing all treatment options the patient elected to place an implant. My question involves immediate implant placement and the lost buccal plate of bone. Would you do it 1 or 2 stage and how?

![]PAN dated 7,13 (before implants)](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/04/fl-713-1024x768-e1428072398758.jpg)PAN dated 7,13 (before implants)
![]lateral view](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/04/fl-2.jpg)lateral view
![]pa](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/04/fl-1024x729-3-e1428072454200.jpg)pa
![] occlusal view](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/04/fl3.jpg)occlusal view

13 Comments on Implant placement: two stage or one?

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btcdentist

4/3/2015

if no buccal plate in maxillary. rec 2 staging this one.

4/3/2015

Do you expect I will need a CT graft as well?

btcdentist

4/13/2015

No. Just extract then wait 4 to 6 months. I'm always cautious when it comes to immed placement in socket sites of root canaled teeth. Ive had failures. The socket site isn't the same as an extracted site of a vital tooth. Just extract. if buccal plate is gone then do your best to graft. Wait for bone to remodel. Then go ahead and place. I think better option in this case. No ct graft.

Richard Hughes, DDS, FAAI

4/14/2015

Btcdentist, You bring up an excellent point. We should exercise caution when implanting sites that had prior endodontic treatment. Bacteria can lie dormant for decades in these sites. CRS in the past mentioned using a laser to decontaminate these sites. She is on to something.

Peter Fairbairn

4/4/2015

Always 1 stage to save the patient the devastating effects of bone modelling and the extensive subsequent grafting. After over 2,500 cases in a ten year period my protocol is remove the root and allow for a 3 week soft tissue healing period for closure then raise site specific flap curette the granulous tissue , place Implant in the correct position ( slightly palatally ) , graft with a fully bio absorbable synthetic graft material load at ten weeks . Simple , predictable , work with the body to heal . Peter

CRS

4/5/2015

Actually Peter I think we are doing the same thing, your's is a two step procedure allowing the soft tissue to heal as a natural CT graft with a delayed placement and bone graft using the implant to maintain it. I used to place implants this way until I got my primary closure with release technique established. What I really like is that you use the implant to stabilize the bone graft to prevent collapse I sometimes add an onlay at placement. I try to regenerate what was lost, each case is different if there is good soft tissue and bone with a decent soctet then I'll place immediately. I like to modify the technique to suit the clinical situation but I see wisdom in a standard technique, SOP, which is great.

WBH

4/4/2015

The length of your clinical crown might be unexpectedly high if you immediately place your implant . Even if the patient accepts it now . Extract , wait 3 months and place your implant in 1 stage and you will have a predictable outcome

CRSt

4/5/2015

I would atraumatically extract, graft, since I like buccal plate/bone and soft tissue regenerated. I allow more healing time prior to loading. I don't like the tissue line on this failed endo tooth and allowing the site to dictate the poor placement. It is really difficult and expensive to chase a poor placement. Site preparation is best in my practice and I have some niche techniques for optimal results. I could not get away with immediate placement on this case nor would I choose to, I'm not that good! Also as a specialist I get the more difficult cases and the expectations are different so I am not criticizing others protocol just my humble opinion, love to learn from others! One tip I try to imagine how this implant will look down the line with a good buccal plate profile and healthy attached tissue that a patient can maintain.

Peter Fairbairn

4/7/2015

Hi CRS , yes we both understand the role of host healing and needing to work in its timescale for optimal outcomes ........ protocols may vary a small amount but core principles remain .. Regards Peter

John Walker

4/10/2015

Peter, which "fully bio absorbable synthetic graft material" are you using?

PeterFairbairn

4/12/2015

BTcp and CaSO4 , done just under 3,000 grafts with Vital and now EthOss can send case studies and Animal studies of look on Pubmed REgards Peter

Navdeep Saini

4/14/2015

First of all assessment of occlusion and lateral excursion is most important in deciding whether to place & load an implant in maxillary canine region immediately after extraction. One may carry out an atraumatic extraction, but, here the second most important factor is that the labial plate of bone in maxillary canine region is extremely thin & sometimes may be missing at some places. I generally prefer pack the socket with a 40:60 mixture of Synthetic Hydroxyapatite & Beta Tri Calcium Phosphate & place implant after 03 months. There is no risk in placing and provisionally loading an implant immediately after extracting a Root Canal Treated Canine with no associated peri radicular lesion, provided that the occlusion is favorable & the labial bone is intact.

dr nasim

4/15/2015

Why abutment of some implants loose after some time usally of large lower six?