Placing Immediate Implant in the Palatal Root Space: Below Standard of Care?

why, you thinking standart of care.....? if you, are obtaining good retention,and you bone graft properly, use adecuate implant with and orientation, to achieve proper occlusion and sthetics,....was the problem...I, dont get what you trying to get at....Many colleagues, are placing implants in any which way with the all on four, and zygomatic implants ect....If you can find bone and manage it great..!!!

Standard of care is defined as to what most prudent DDS in that geographic area would do. Placement of an implant into the palatal root is within the standard of care and has been done successfully for years. Problem is if the palatal root is angled toward the medial then you can have issues restoring as the prosthetic angle may be great and even with a custom abutment not an ideal result will occur. This can be handled by using the Southern Implants Co-Axis implant which has either a 12 or 24 degree axis correction built into the fixture. if the palatal root is fairly vertical then not much of an issue but you may wish to use ostetomes and expand the area to allow a 5mm fixture to be placed so you have a better emergence profile then with a 4.0mm diam. Other options in these cases are use of Super wide body implants (7.0 and greater in diam) and these will get good primary fixation in the socket then smaller diam

MY question is what is your hurry? You do not have any immeadiate esthetic considerations with the maxillary first molar, really. Just slow it down, put in your graft material at time of extraction and then come back in 3-4 months and make an ideal preparation for a wide based/necked implant. My feeling is that you compromise the function of the implant long term as you now have a crown functioning on an angled abutment, the masticatory forces arent directed "up and down" but rather along an implant that goes off divergent from perpendicular. You are replacing 3 roots with one, and I would want the largest diameter implant supporting that molar bite force, rather than the once you could torque into the palatal socket. In my mind it isnt ideal so you could argue deviation from standard of care. What do you lose by waiting? The implant placement is pretty atraumtic. What you gain in immeadiate placement you lose in potential issues later.

Multirooted teeth are not ideal for immediate placement. Immediate placement can be achieved, but it requires more finesse and the right circumstances. The drill bit will tend to track and follow the closest socket. If you are not willing to graft and wait and would like to place the implant immediately, you should strive to get good implant stabilization and the correct emergence for the placement of a good restoration. Plan how you want to restore it and then see if the surgery you are planning will give you that result. If not, don't do it immediately and do it right.

I like Dr. Beckman's comments. As a doc that has restored implants since 1985 and placed since 2000, I believe we should still think restoratively, not surgically. Sure it would integrate, but would you build a house in the corner of your lot when the plan calls for the center? The crown should be in the long axis of the implant and 2-3 mm distal to the 2nd bicuspid in order not to have a food trap. If there is a 2nd molar, then a centered implant would create a food trap distal and mesial, but that's the compromise. Like Dr. Beckman said, what's the rush? Cut and fill soil for your home lot and wait a year. Extract and wait to heal for your implant so the implant goes where it should go.

While in agreement with all the other comments may I suggest "informed consent". Yes it will work. It is a compromise, inform the patient of the pros and cons of immediate placement. In my practice 85% would graft and wait, conversly 15% want it done "now" with only one surgery. I would want to be part of the decision process in my mouth.

Placing an implant in the palatal root space is not below the standard of care. However, be careful. I have lost a root form in the sinus and had to retreive it, which made for an interesting time. Another alternative and if one needs more vertical bome, is to perform a socket lift and graft and place the root form later in a wonderful site, without complications.

Dr. Nelson is correct, the patient should be the one to make the choice based on a detailed consent. Many times I have offered a solution that is more economical, but after explaining pros and cons they sometimes go with the more complex.

The implant insertion totally depends on the angulation of the root as well as the distance from the sinus wall. If u can put implant of wider diameter without much angulation then u can go 4 it. But do follow the standard protocol of loading the implant as per Misch.

Hi, why why why are we still doing immediates??? is it our ego? we should not be doing them look at your patients! Look at the literature it is wrong. Let me know if you want some of teh literature! Even when i did do them why would you go for the palatl root (unfavourable occlusal loading) why not if you have to do it go in the interradicular space? Extract periotomes sharp luxators carefullly collagen block wait 6/12 implant if the spae mesiodistally is more than 12-13mm consider x2 narrow platform implants.

I just love your sense of humor, Tom! One has to agree, even if osseointegration were to be successful, the prosthesis is bound to fail due to misdirected occlusal loading. Try to stick to the basics. Prosthodontic requirements dictate the surgical procedure, not the other way around.

in the last few years i did many immediate implants after any extraction, but the tecnique is rather complicated expecially with three roots molars. the advantage is that you can solve two problems in one. the difficulties are different: the dimention of implant (for this purpose i use one piece implant with large coils, from 4,5 to 8,5 mm, i drill more or less exactly in the midle of furcation to find the best occlusal relation. i use a graft like biocoral or shepore, during the implant screwing, filling all the empty spaces. all this, very simply described. But so you and the patient can spare time and money and useless pain.

I see no advantage to placing an immediate implant in that region, other than completing care for that patient ASAP. Far better to graft, give it 3-4 months, and place in idealized location/angulation. As surgeons, we don't have the advantage of a long-term relationship with most of our patients, but I have had patients return later for additional implants after the bone graft/waiting period/implant placement time frame allowed more patient interaction and thus built up a relationship of trust.

The standard of care, in legal terms is the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances. This would be the average standard of care. I presume that we may want to look more closely at the highest standard of care and then come to a compromise with the peculiar circumstances of each case. Thus if the standard of care is to restore the extracted tooth as quickly as possible so that it will bite well, look good and last long at reasonable cost in a safe and simple manner...... then I would not do an immediate placement into the palatal root socket. This is because it will then require an angulated abutment that will increase the costs and also the chances of failure. If I have to use a conventional, I would drill a small hole into the inter-radicular bone, bone spread with an osteotome to the appropriate size and screw in the implant. Bone spreading may obviate the need to graft because the bone sockets will be reduced in size. Place a large healing abutment and suture round it as tightly as possible. The alternative may be to screw in two minis, one into the palatal socket, and the other into one of the buccal sockets, and restore it with a pfm crown.

The question is where do you want the tooth? The ideal placement of the crown should dictate the treatment plan for you.

Consider sink depth when placing implants in the palatal root. If not the abutments may be to lingual.

Like all questions, the answer is "it depends". Why was the tooth extracted? length of crest to apex of roots? width of intra-radicular bone? Occlusal scheme in total? Bone quality? It really depends on surgical conditions for the implant success and prosthetic conditions for the total success (which is really what matters). I have had much success with upper first and second molar extraction and implant placement in appropriate prostethic directed anglulation. If the intra-radicular bone is wide enough to hold a 5 or 6mm implant I will undersize the osteotomy, bump the sinus, membrane and allograft, and increase the length for the implant from, maybe an 8mm crest to sinus depth, to a 11-13 length, cover screw, graft sockets,resorbable membrane, close primarily via scoring periosteum. I will not place a 4.0 implant in a molar site, the prosthetics will not be appealing to the patient. That is when you graft and wait. This is not to say that 4.0 implants should not be placed in molar sites, "it just depends".

You can certainly utilize the palatal socket for placing an implant . I have done so successfully in a case where an implant supported bridge from right upper first premolar to second molar was placed . Lack of vertical bone in the first molar area led me to place a bendable one piece implant in the palatal socket after about 2.5 months of extraction of this tooth .You need an implant with which an angulated abutment can be placed,in case you are not using a bendable one piece implant . Well it is important to know whether sound / firm teeth or implants are already present mesial & distal to your planned site or you intend to place implants in these regions also . I agree with some of other respondents that a single implant in the region of a tri rooted tooth is insufficient . If possible do place minimum one implant in mesiobuccal or distobuccal root socket in addtion to the implant in the palatal socket.

Now we are getting a bit silly. There is no credible evidence that we need more than one implant to replace a molar, provided that implant is well aligned and of reasonable width and length. Placing 2 implants in the sockets of an upper molar would both present unfavourable angulations and create a bifurcation with limited access for oral hygiene. Since the main wearness of upper molars is furcation problems why would w want to reproduce this in the final prosthesis. Extract and graft, wait; place implant; wait; restore. The rush to complete everything rapidly is largely company generated. Do you prefer a slow gourmet meal or fast food?

Wow lots of ideas and plans - some relatively simple and some rather complex.Is there a rush to get the implant in? Whats the inter radicular bone quantity? Whats the alveolar ridge height and width? Patient risk factors. If you really want to go for immediate placement in the palatal socket consider the angled implant from Southern implants and ensure the central screw access is in the correct prosthetic position - good to have inter-radicular bone for this and I dont really see the need to graft the other sockets - they will heal! If there is good bone available you can even you a straight or tapered implant but try and go for a wider diameter say 4.5mm and up.Avoid a narrow implant. If you are going to delay the placement (as I would prefer) why graft initially? Rather let it heal and asses at placement time .I often find a lot less bone loss with a careful removal technique and at most add a small amount of graft material on the buccal aspect when the implant is placed and there is adequate SOFT tissue. Remember to give your patient the various options each with ad and disadvantages and what will work best in YOUR hands according to your experience. I would not advise adventurous procedures in inexperienced hands. Just some of my thoughts. Good luck and hope you have success and a happy patient.

Dr. Cason: RIGHT ON.

Dr. Cason: Excellent points to consider.