Most Favorable Place for Drilling the Osteotomy Site?

i'm going to cut you off early, sorry. Why are you attempting immediate molar implants as a beginner?? I have placed thousands of these things and I still avoid this as much possible. Let the site heal, graft if necessary. Have the lab do a wax up, then you will know exactly where to place it. You wont have any bone constraints or complex socket anatomy to deal with. Regarding "correct implant placement", every case is different. If you are a beginner, get a wax up for your cases. Look at the models from cases you have done. Do as many implant work ups as you can until you start to get a feel for things. AT this point it sounds like you need a review of basic principals.

Perfect answer

Let me second the previous comments. There is rarely need to place immediate implants in the molar dentition. I rarely place immediate implants in the molar dentition and I own a bone graft company that makes a product specifically for grafting around immediate implants. Extract, graft and wait a bit and get a perfect result.

My advice is to get some more implant training. Can you imagine your orthopedic surgeon asking similar questions? This is elementary implant knowledge and, if you have to ask, you need more education. An online forum will not replace good ce. In the US, consider maxi course, Garg and Misch. An excellent book is Misch's Contemporary Implant Dentistry. At the least, read it. Your patients will be better for it. Sorry if this comes across brash - it's hard to dictate tone in this format. Best of luck.

Immediate placement in molar regions will always be a compromise. In some lower molars the compromised angulation is minor and it will work well. This may only be 5-10% of your cases, but it can be done. As you gain experiance you will know when it will work.

perfectlly commented by every one.i will also support the same adcise.im also a beginer but always avoid immediate placements specially in molars.when u can wait and place better why rush.secondly,for implant placements,knowledge means a lot.contemporary implant dentistry by carl misch is a helpful matter in this regard.good luck

Southern Dental Impalnts has a implant specifically for this. I think it is an interesting concept and I watched the video. I have not tried it. If you plan to do this, do it on a "friend" or relative that likes you. Ha!

Good forum to discuss this subject, and a lot of good advice. I would like to add another parameter, in that the dentist did not tell why the natural molar tooth had to be extracted. Was it an infected area, was there damage to the alveolar bone causing formation of granulomatous tissue in the area? The best advice is to wait a few weeks after extraction, and let the healing process begin, and allow the gingival tissues to close the hole created from the extraction. The granulation tissue (if prsent) will no longer have an infected host to hang on to,and will probably begin to slough off on its own. The site should be washed with citric acid, throughly curretted, washed again with the citric acid and a third wash with antibiiotic disolved in saline. Draw blood, for PRP, mix particulate grafting materials,drill holes in the host bone for blood to irrigate the site, place the mixture in the hole, and cover with a membrane before suturing......wait 4-6 months. When returning to place the implant, the osteotomy can be placed in the most ideal position you choose, and not have to be dictated by a previous angulated root

If you have an intact buccal plate and lingual plate, there is no infection and the roots come out easy, it is possible to drill the osteotomy in the ideal location for that tooth, usually in the septum between the roots. You also need plenty of room for an implant, longer than the molars original roots to insure good primary stabilization. The implant needs to be in its ideal location with primary retention in excess of 30 Ncm. With a little luck and good technique, an immediate placement can be achieved. This procedure is not for the novice or the faint hearted. You’ll still need to wait at least 4 months to restore this tooth. As always, grafting and healing first is the best way to achieve the ultimate results you and the patient want. Don’t let the patients impatience force you into a compromise you may be sorry for later. Make the patient happier 5 years from now than they might be right now.

I agree with sb oral surgeon, you are walking on very thin ice.

Hey Dr B, I guess, there's been more replies to your post than you expected! Understandable as many of us already believe we have set the benchmarks for the rest of the field to follow..! While it is true to suggest that several of the community that replied to your posts are extremely knowledgeable and "experienced" folks, it may also be appropriate to note that your question was one that everyone has trampled upon and gone past to get to the stage where we would now ask "beginners" to tread with caution! Found Dr Ben Eby's post most pertinent, am sure you got several of the answers you were looking for from there! Even so, let's look at "WHY" one is better off not attempting an immediate extraction implant in the maxillary Molar site. 1) The Maxillary bone is largely comprised of Trabecular, cancellous bone that is not as dense as the more cortical bone of the Mandible. This makes it more susceptible to resorption in the immediate post extraction period. If you were to follow - the 'Time Sequence for healing' graph published by Cruess and Dumont (Lippincott, 1975), and put in place M H Amler's "Extraction socket healing" Journal of Oral Path, Oral Med & Oral Surg , 1969.. in perspective, you would know that there exists a differential in the healing rates between apical and coronal areas of an extraction socket..(Look up "Jumping distance" of Osteoblasts.. Daniel Buser et al will help). This causes much of the coronal height of an extraction socket to be lost in the early post extraction period, almost upto 30 -40% in the first 11 months (Wang & Kiyanobu) This being the case, the imediate extraction implant would necessarily have to be placed considerably deep within the socket to thereafter continue to be subcrestal after the bone loss has taken place after the extraction -implant procedure. The protocols for immediate implant placement dictate that the platform of the implant should be ideally a couple of mm inferior to the crest (or the Gingival zenith, depending on the gingival biotype). The Maxillary molar tooth often does not help the cause by virtue of its proximity to the antral (Sinus) floor. You would require to engage the implant in a minimum of 1.5 to 3mm of bone beyond the apex of the tooth(socket) in order to gain a Primary Stability that would be required to help facilitate osseointegration. This maybe difficult in most cases (particularly if there was a pre-existing peri-apical pathology that may have taken some of that vital bone away already)of First Maxillary molars. The Crown that would eventually be placed on the implant would definitely not be Prosthetically Loaded differently from a Crown that would be placed on a Delayed Implant (in a healed extraction site) in the same region. Hence, no reason why a change in angulation or position should be sought if the implant were to be placed at the time of extraction. The Septum between the three roots or slightly more at the expense of the inter-radicular bone between the Mesio-buccal and disto-buccal roots would be the preferred position. Aside from these considerations, gaining primary closure in the region after extraction even without implant placement can be quite an enterprise by itself... and to have an immediate extraction implant in the Molar region be exposed to the elements from lack of closure or from a gaping wound in the early days of post-implant healing, would just make the whole process more unpredictable. In a nut shell, as almost all of us who have done it before and prefer not to do it now, you may be wont to try it out (use Bruce's advice and find a relative or someone who will keep your practice out of harm's way if things don't turn out as expected!) It is a fun learning experience (after "EXPERIENCE" was famously defined as "THE CUMULATIVE RESULT OF FAILURES" !!! If its a patient that's going to get you referrals, just go the graft way and do a delayed implant placement! Cheers

Well, I had my master’s in oral Implantology on the topic of immediate implantation at the extraction site in the posterior area (success rate more than 98%, for 3 years), Placing an implant at an extraction socket in my opinion is not for beginners you must have a well knowledge about the basics of oral Implantology and what do I recommend to master the system you are using and specially surgically and then try to train on and on to do such a technique, and you have chosen the most difficult area to , and that due to its anatomical structure, but as a concept I do not believe within no limitation for implant placement, to leave the socket without an implant, healing will be there and if you are not going to have healing around the implant you will never have healing, I admit there will be always limitations so immediate placement, on the other hand to have optimum results in the anterior area is another issue.

hmmm . i agree with the frst contemporary view- adhering to misch principles.. interestingly ihave tried both things- first case tho beginner- i extracted and curretted and grfted socket pushing a correct size (6mm d X 10mmL) in the site floating in without any drilling and closed with a membrane with primary closure.. reason fr hurry- young patient was leaving as student to US and wouldnt afford there nor be able to come back soon.... we successfullly loaded her after 1 and half year later christmas break when she returned and how she was glad to eat paani puri! but now yest, tho now well experiencd yet i did a 26 extraction but just tapped condensor indirect lift filled graft and did a forced primary closure.. implant will wait for 4 months in my inventory. patient is here and well informd.. life is different under circustances :)

Dr. Goneim: Very well stated!

I too, am still a neophyte and would suggest that if you want to attempt more "complex" cases you should try to place a couple of implants adjacent to each other to begin with, and then branch out from there. Get the proper placement with adequate bone between each implant and proper vertical alignment.Preferably in the lower 1st molar and bicuspid area is good to begin with. I think one of the problems that you will run into with immediate placements in the lower molar area is that by the time you have enlarged the osteotomy to the proper size, you will have to graft the implant circumferentially,and the only area you will have any fixation will be in the apical area.

Always ask your lab to perform a wax-up and a surgical guide to help you drilling in the right place. Always consider that the implant is a support for the artificial crown, not only a surgical act. Elie Warde DDS

Hi dear dr, In maxillary first molar u don.t have good quality boe enouph length and u have maximum forces, for this never place immediate except u have enouph wide for placing wider fixture in septum region

After extraction of maxillary first molar DON'T COMPRESS the socket.Place gauze and allow some time to heal.After a month take CT scan then plan to place an implant of clinical indication. Don't be in a hurry.

As my mentor Don Callan has stated, be very careful. You have minimal to no human histologic evidence to back up your decision. What is the rush to place immediate molar implants? What are the reasons? IF you believe that you are preserving bucco-lingual socket width, the literature is totally against you. If you think you will get as high a percentage of bone-to-implant contact as with "conventional" placement, I would like to see the documentation. You would, and your patients as well, benefit from learning predictable socket augmentation and then placing the ideal implant in the proper location and angulation.