Lack of Bone on Distal after Immediate Implant Placement: Best Options?

It's impossible to exactly diagnosis the problem, but with immediate implant placement and immediate temporization, one should not remove the crown until the implant is integrated (at least two to three months, depending on the size of the socket and the type of implant used. I would refer back to the periodontist as good communication, especially with a complex technique, is critical.

Yes, I agree . With immediate implant or even conventional implant procedure, the implant should be left quiet, undisturbed for at lease 2 months. ...and yes reffer back to the periodontist for follow up.

If the patient has a high lip line, I would anticipate the possible gum loss on distal #9 implant down the road. Dr. T

The criteria for immediate loading is high primary stability, atleast 40 Ncm. The loading should be done within 5-7 days of the placement at the latest, earlier is better. the temp should be out of occlusion in any excursive movements, in centric the contacts should be light too. The temp should not be messed with there after for a minimum of 10- 12 weeks. Distal bone loss can mean a lot of things, absolutely refer back to the Periodontist

Dear Dr. DW Your explanation show you didn't merge enough implant in the bone. What's the fundamental implantology said you have to place implants in hard tissue(with enough supporting bone) not soft tissue.However,while you place the implant actually you place implant in hard and soft tissue, this was your first mistake. Your second mistake was using rasin composite which penetrate to palatal aspect of implant and the most important reason for recision it was your second mistake. Placed immediately temporary crown on implant with condition was your third mistake. Bone graft by periodontist on messy implant is same as doing surgery without glove. Please note that don't do horrible mistake again.let the patient know, remove implant, bone grafted and waite for at least six week meanwhile study "Southern Dental Implants" text book or what ever and place NEW implant. Good luck to you Dr. Vazir-Iran

I agree with sending back to the periodontist and how he/she explained about it. Immediate provisionalization is very difficult to work with 2 clinicians. Surgical part and prosthetic part is well integrated and cannot be apart. This time, if PA is available, show it and worst case is removing and GRB and NEW implant. Hope everything would be okay with the patient.

The bottom line is you have a problem implant that will likely continue to be so. I think your problems came from messing with an implant far to early in the healing phase. The provisional placement on an immediate implant is very technique sensitive. You likely broke more then one of the rules of the procedure. You removed the crown,took impressions ect. You must tell the patient that there is a problem. Failure to do so can lead to big problems. Patients who are informed and part of the process tend to be forgiving and understanding. Patients who are not informed are the more likely to sue. There is also an ethical and moral need to tell your patient what is going on. I am suprised that you would even ask this question. As they say you need to "man Up",send the patient back take out the implant repair the damage and place a new implant.

First, change periodontist. The implant will be a problem untill it is lost, no matter where the lip line is located.

The fundamentals of immediate loading are: primary stability, fast provisionalization, undisturbed healing for at least 2 months. You have violated the third by removing repeatedly the crown. I believe that you have to inform the patient and refer him to the periodontist.

You may have to have the implant removed, do some house cleaning of the site, regraft and place another implant (unloaded). Give it tincture of time.

I think both periodontist and restorative dentist do not have proper understanding of immediate implant,immediate restoration,grafting a no walled distal site in presumption of filling a defect. Patient would be better off with another clinician. Only solution is to remove implant,regraft site and place new implant-off course by another dentist.

As a periodontist, trained by one of those early responders and working closely with 2 others, we all jump to conclusions quickly. It sounds like there were a number of "errors" made during the healing time. The crown should NEVER be removed until the implant is integrated as Dr. Anson pointed out. Doing this puts macro not micro strain on the hopefully integrating implant surface. Additionally, you will lose any epithelial seal you had on the soft tissue. As Lindhe's research has shown in dogs, you probably accellerated the apical migration of the biologic width. You should consider what Dr. Callan has implied and have the implant removed, site grafted and then start from a stable base.