Mobile implant after extraction, immediate placement/temporization: best treatment option?

Remove and Graft at this time.

1. Removing the implant at the earliest, 2. Curette the socket targeting it's conversion into a " FRESH SURGICAL SITE" , 3. Via, removal of most practically possible contaminated organic materials 4. along with all possible debris sourced from the fabrication of provisional crown. 5. Graft the site with any graft material of choice 6. Use a barrier membrane to contain the grafted material 7. Administer a suitable antibiotic of choice for 10 days + palliatives for comfort. 8. Periodically evaluate for resolution of grafted material and 9. Upon finding the grafted site being suitable for receiving an implant, 10. Place an implant of suitable dimensions...width/length.

Your clinical history is telling. I see two things, when immediately extracting and placement then doing a third thing, immediately temporization extends the risk. I think the temp needs to be very short with no interproximal contact or contact of any kind. However it is moot since the patient chewed on it anyway. So now that you need to do more work I assume for free, remove the implant graft the site and cover it to protect it either primary closure or membrane. With this patient allow it to heal 16 weeks. The bridge has been burned for primary stability here. Now if it were an edentulous site with implant placement then a short "chicklet" crown with no contact whatsoever would have been an acceptable risk not all three factors that's my rule of thumb. Now you can charge for the removal and essix your call. Clinical situation always rules over other advice that's why we are the doctors!

I agree with the former comments insofar as I would not have performed an immediate temporization on an extraction site and immediate placement of an implant. However, in the absence of any signs or symptoms of infection, (ie: pain, exudate, redness, swelling), I would, after thoroughly debriding the socket and cutting a few small holes in the mesial and distal cortical plates to get it bleeding nicely, reinsert another implant. I would put a 3.75 mm x 13 fixture in and make sure there is bone grafting material sticking to and coating the entire outer surface of the implant before placing it into the socket. After driving it down the full distance, place your cover screw and then make sure that all remaining voids around the implant are filled with bone graft material. Next, you want to take a large surgical spoon and insert it and create a pocket about 3 mm deep between the labial gingiva and the labial bone and the palatal gingiva and the palatal bone. Then, after overfilling the site with additional bone graft, trim and tuck into those pockets, a strip of nonresorbable PTFE membrane (Osteogenics sells this) Make sure that the membrane does not touch any adjacent tooth roots and then suture the membrane into place with a criss cross suture made of 4-0 or 3-0 PTFE. (Also sold by Osteogenics) Leave the sutures and membrane in place for 4 weeks and then have the patient back to remove the sutures and membrane. Make sure to place the patient on antibiotics for 14 days to prevent any infection. Now, your patient should be well on their way to osseointegrating their implant and saving you and them a bundle of time.

The most predicatable thing to do at this stage would be to extract the implant, curette the socket well and make sure you have good bleeding, place bone graft, place osteogenics ptfe membrane over the site with ptfe sutures. Remove the membrane at 4 weeks and let things heal for 3 more mos. Then place the same size implant again. Good luck.

Thats why I live them always buried at first stage . The patients sometimes have their own rules ! I agree with others .. remove . Good luck ! ps : I would charge him only for not listening to the advice you have him :)

Thank you all for your input, I really appreciate it. I will post some follow up xrays and photos. Cheers!

Are you sure the implant is mobile and not just the abutment/temporary crown? With 30 N cm on a front lateral incisor, how much load can a patient actually put on this fixture to make it move? If I were you, I would anaesthetise, then, remove the provisional crown and PEEK abutment, put a healing cap and position it in final position and wait for osseointegration. Somehow, I don't think an immediate torqued to 30 N Cm can move that easily. Please check again.

Yes this can happen with men , most / possibly all of my immediately loaded single tooth cases are women , they listen and care more ...... Guys once they get through the door forget everything you told them.. Peter

There is no any clinical substantiation to the initial root extraction based on the posted X ray.

Just a quick questions - are you sure it is the implant moving, and not the temporary coming loose?

I wrote my first article on immediate load in 1998. This technique is nothing new and it is well documented. I've done it with many different brands of implants. What disturbs me about this case is the outcome was 100% predictable. Less than 20% of the threads are engaging bone. If not for the apical curvature of the root 0% of the threads would be fully engaged. Judging from the radiograph the coronal 2/3rds of the lateral had less than 1.0mm of bone between it and the root of the central. The implant would have to show less space if it were engaging bone. It shows a great deal more. So the implant was engaging air. The distal situation is not much better. I understand those who say there must be at least 1.5mm a bone between the implant and the adjacent tooth (I'm not sure I agree BTW). I assume that was the reason for the narrow implant that did not even equal the diameter of the root it was replacing. I also agree that placing an implant in this extraction site was a prudent thing to do. As long as the implant has primary stability its success rate is equal to any other. But immediate load was implant suicide. In over 17 years of doing immediate loads I have had 2 failures. I guess that equals a 99.99% success rate My rules are simple: No smokers Patients mean well but they will break the rules 2/3 of the implant fully engaging bone Implants withstands 35ncm of torque without moving Temporary completely out of occlusion: centric, protrusive, lateral excursions I give the following speech to the patient: "For the next 6 weeks your tooth is made of glass. Would you bite down on a piece of glass? Ok then. Cut all of your food into small pieces and chew it in the back of your mouth. Don't bite anything with your front teeth. Nothing. Don't use your front teeth to pull food off a fork. Not a piece of banana, not soft cheese, nothing. If you've ever wanted to go on a smoothie diet now is the time. If anything does feel loose it could just be the temporary but call me immediately. Otherwise I will see you in 6 weeks."

I try not to put a crown on a fresh implant passed 1st premolar. The trick is to bond the tooth . Make .020 clear vac stint. Now use your bonding of choice for material you are bonding to . In this case I would have used hydrofluoric etch, silane and xtr. Put whatever bis gma temp you use and seat the tray. let cure and trim. I have used this for Bicons which have 0 torque value. We all are idiots some times in our lives so we will screw up our best intentions. This is a "wonder bread tooth" if it is harder than that don't use that tooth, is usually understood but not always followed. XTR is your best bond with saliva and blood in the way; how I know: I like to seal crown preps dry tooth paint the prime and adhesive, each get a few seconds(not following directions) . Now I would barley blow the spit or blood off cement with etc(parkell). I quit because I would have to cut 3/4 of my temps off.

Have to agree with Alex that based on the x-ray that it doesn't appear to have been necessitated in the first place

I agree with Ashwath M Gowda. DDS. comment on the steps in regards to the implant. Best of luck with your patient.