Prosthesis for deep implants after immediate extraction: comments?

I am sure there will be those that disagree, but personally I would have either put in a slightly wider implant (like 4.8 to 5) if possible for more “grab” or if not an option, wait. Graft the site, allow to heal and then place an implant. Although if not loaded, 20 N/cm is not terrible and if left alone, integration is likely, so the low torque to me is not the big issue. I am a bit concerned about how far sub osseous the implant is...for 2 reasons. One being the implant to crown ratio and the challenge to restore an implant that is so far sub osseous. The second is the proximity to the mental nerve. Now I realize this was not mentioned and I guess not an issue in this particular case. But this area is tricky and as practitioners, we need to be careful. That nerve can loop and this is something we need to be completely on the ball with. Neil Zachs Periodontist, Scottsdale AZ

I don’t want to give you wrong information to try this or that. The end story is Take the implant out, and replace later 2-3 months after it heals. If you will restore this implant that deep, you will get bone loss on adjacent tooth, you will also develop large gingival pocket. Dont waist your time, just remove it and replace later. I also don’t think you will be able to find healing cap that high. Besides all that your Xray’s showing penetration into mandibular and mental nerve. Of course 2 D image will not provide proper information and I am not sure if you were using CT scan to check that issue.

The second mandibular premolar seems to be a problematic spot for immediate extraction-implant placement for the reason sited above by Dr. Zachs. The implant is placed too deep to be useful and healthy. It's better to graft and place the implant later to achieve better bone-implant contact as well as soft tissue health. Check for persistent paresthesia. The problem here is remedied by implant removal, grafting and replacement.

That's not a problem at all since there's no paraesthesia and I was carefull to be lingual enough to place it.there r no paraesthesia issues whatsoever

I cannot fault the dentist in this case......the person to blame for the problems is the patient, for the complete disregard of the condition of his mouth....this problem started many years ago, and with the patient not changing his habits, the implants will not help him.....he needs a complete re-education of his oral cavity.....and yes, remove those implants, and after the patient has changed his ways, graft the sockets, and later on place implants into more suitable sites.

Is the radiograph provided at time of surgery or second stage? Doesn’t look integrated and will need to be extracted. Your distal implant is too close to a periodontal defect and will need to be extracted as well. I would extract the last tooth, remove both implants, bone graft and reassess in 4-6 months with cone beam. No room for error, your sitting on the IAN and would need a steady hand removing these implants. You will most likely need to remove lots of bone to get a good grip of the implants. Invest in a cone beam and back to basics.

It's unclear if you are referring to the # 29 implant or the # 31 implant in regards to diameter and torque. Based on the radiograph, it looks like you may have had the option to go to a larger diameter implant in either case, maybe 4.5-4.8 depending upon the situation. I am assuming you will do a bridge here. Either way, my pros colleagues are not as concerned implant/crown ratios as they are crown/root ratios. I concur that you may have some bone remodeling issues that could affect the adjacent teeth; only time will tell. I probably would have counselled the patient to remove # 32 at the time so I could place the molar implant in a more favorable position for prosthetic restoration.

A wider diameter implant is not the solution. You cannot use the same solution for every situation, and in this case, trying to make the correct diameter implant fit by driving it deeper was the wrong thing to do. Follow the advise of the consensus which shows everyone in agreement as to what to do. Good luck.

Many implant problems are the inevitable outcome of inadequate case planning. The depth of the implant should be determined prior to surgery case upon the desired gingival architecture. To place an implant deeper just to gain primary stability without any regard to the vertical position of the prosthetic platform is an act of negligence on the part of the surgeon. Why not reschedule the patient after ordering a longer implant in order to properly position the prosthetic platform? Surgical compromises do occur, but the clinician is aware of the steps that will be necessary to mitigate the detour. In this case, we are being asked what should have been asked by the surgeon prior to, or at the least, during surgery, not after the fact. Is this how you want surgeries performed on you and your loved ones performed? By restoring the implants in these compromised positions, you are condemning the adjacent natural teeth, and creating an environment that is at increased risk for future problems. Is this fair to the patient who may have never agreed to this procedure had they known they will be adding a substantial cost to their future dental needs? In this day and age of guided surgery and 3 dimensional planning, compromised implant positions should have a solid rationale, and should be the exception instead of the norm. Also, proper surgical planning requires you to stock longer and wider fixtures to avoid these type of “deeper” problems. Having said all that, the implants are restorable, but please use longer, narrower CAD/CAM, titanium abutments with margins that will promote hygiene. That is, no more than 1 mm subgingival on the facial and mesiofacial, equigingival on the dis Todack always, and smoothly transitioning to a supragingival lingual margin, which slows for the bulk of then excess cement to be expressed lingually, and allows the clinician to visually confirm complete seating at a glance. Alternatively, a screw retained solution, likely to a screw receiving intermediate abutment, would work, being mindful that the shape of the abutment and emergence profile of the teeth encourage excellent hygiene.

Your best move at this point is to offer to remove the implants because of poor ridge width. Explain the problems with margins that are not only too far sub gingival BUT much too far below the alveolar ridge. This will most likely resorb over a relatively short time until the bone is comfortable with the margin But then you have a lot of bone loss which affects your adjacent teeth, weakens your restoration, and probably causes chronic soreness in the adjacent gingavae This is not going to be successful I would remove AND graft at NO charge to patient then reevaluate in 4-6 months for a better start over AND a better case. When faced with this again , you might consider adding graft to the socket as you place the implant in the ideal position and not worry so much about torque and stability. Often , we get great osseointegration using this approach since it is a two-stage procedure

Of course can only make comment based on given information. If width ext site is 6.4 how thick is the buccal and lingual plate. Most bone in that area is 7mm or so....meaning the cortical wall above the 29 implant is very thin. Without grafting it will collapse. I agree with removal and grafting. Also, I do not know health and oral history if pt, but pan indicates poor oral health including periodontal disease. Not a good case for implants, at this stage anyway.

Clearly you intended to place the implant immediately and were reluctant to pull back on the reign. When I first finished my perio residency 13 years ago I was raring to go and wanted to place every implant immediately after the extraction. Fortunately I outgrew that phase and now use more sound clinical judgement. While I still place a lot of immediate implants I proceed with caution in the mandibular molar/premolar for reasons previously mentioned (I did actually place an immediate #20 about 2 hours ago but the clinical situation was favorable for it). You mentioned that you only had approx 6.5mm which limited you to a 4.2mm fixture yet you later said that you were able to stay lingual to the mental nerve thus suggesting that you had "wiggle room" in the apical area. I suspect that you only measured at the crest and did not factor in the geometry of your tapered fixture, if in fact you are even aware of the amount of taper and apical dimensions of your chosen system. Basically get over the tendency to place every implant immediate and exercise some patience....... it has worked well for me.

I understand the problems associated with the positional problems of the implants in question. It appears by the Xray that this patient's Dentition is failing. I would remove the implants and step back and do a thorough examination with Articulated Diagnostic models. I believe a treatment plan addressing his entire Mouth will entail a more comprehensive treatment plan like an all-on-4. Just a thought!

I feel the general advice given here is excellent. It has been implied but not mentioned that this is not a well planned case BUT it is a good learning experience and if handled properly from here on then valuable experience will be gained without much pain and suffering or financial loss. In fairness to the dentist, we have not been informed about the desires and demands of the patient or the discussions of the dentist and advice given. So it may be that the dentists who are offering comment are not correct. We just do not know, but those who have offered advice are essentially making suggestions of how they would have handled the case. If this was a case I was handling, I would inform the patient of all the oral problems and I would explain that if he/she wanted to retain most of the remaining teeth for a life time then things need to change. I would then proceed (with patient consent) to complete what I call “Phase 1” treatment. This is where I remove all pathology and restore broken fillings and teeth. In other words I aim to establish a disease/trouble free base line. Sometimes this takes 1-2 years (depending on patient priority and finances). I would further explain that once Phase 1 is completed there will be an elective “Phase 2” required whereby (over time) more complex and expensive rehab will be performed but on an elective basis (ie - as needed and can be afforded). By doing this, there can be no accusation of negligence and I can be confident that I am doing well by the patient. Further, there is time for healing to occur and for the patient to develop a relationship with me and understand that the objective is for him/her to retain all teeth possible for a lifetime. Evaluation of required change of habits can also be done. In this particular case, by putting implants as a higher priority, there have been surgical/prosthetic consequences which have complicated what could have been easy. Further, by neglecting other pathology, blame could be laid at the dentist. However most obvious, is the fact that these implants were rushed when there was no real need to “jam” them in. Extractions and grafting would have been easy and delayed implanting would have avoided all the comments above (albeit that I am aware the IAN may have been a reason immediate implants were placed). The reason I have taken time to discuss this is to help this dentist and others to understand that treatment plans need to be carefully thought out with a view to short and long term consequences. Simply put, all the issues presented in this case are due to rushing to do implants rather taking a longer term approach and prioritising treatment sequencing better. As best I can see, there appears to be no reason for implants to be immediately placed. If there was a reason, then wider implants should have been selected – these are available but it seems that perhaps the dentist did not have any in his surgery when he extracted (again poor planning if this was the case). There is other pathology which requires much more urgent attention that implants. Having said this, as mentioned I have not been informed of pre-treatment discussions and demands – so I may be completely wrong. However if this is the case I would point out that it is the dentist who determines what treatment is done and when, irrespective of the desires of the patient. In other words, while the patient obviously has rights, the dentist has an obligation to not perform treatment which is contrary to proper standards. So it requires considerable pre-treatment discussion to come up with an agreed agreement between both parties in cases such as this. Hopefully this case will end up with a required result – especially if some of the above advice is followed.

I can’t believe the commentators are not being honest with you. Sometimes one has to modify the surgical plan in this case an immediate placement had to be aborted due to surgical conditions. So now this implant needs to be removed it is not restorable. That’s surgical judgement in the moment.

The problem I see here is actually systemic within dentistry. The individual who posted this most likely just recently completed an "Implant Course" that taught a level of competency. These courses are usually sponsored by a manufacturer and teach the basics of drill hole-place screw-increase production. All of the discussion on case selection/planning is irrelevant as long as manufactures are allowed to spread their propaganda and people pay to listen. Bottom line is there are way too many "Implant Courses" and the level of treatment is suffering along with patient care and confidence.

Very good discussion about a man iatrogenic problem created all too often (and designed into the implant design of implants like Bicon with Morse tapered connections. My suggestion is to unscrew it ASAP and immediately replace with an implant that is slightly wider for stability and 3mm longer

If no parathes is there it's surprising 1. Can place 1 more implant in between as good amount of healthy bone seen in 46 region. 2. Do Crestotomy around implant for proper abutment n healing cap adjustment. 3. Customize abutment will be the choice for prosthesis

There is a lot going on in that pano so I’m going to keep it short. There are questionable teeth opposing those deeply placed implants Missing teeth on the contralateral side Crooked and rotated teeth all over with potential for periodontists if not already infected Implants that appear to be in the IAN canal and mental foramen Remove implants, remove all teeth, alveoloplasty X4, 6 max. Implants, 6 mand implants and implant supported prosthesis. This is a patient I would have a long conversation with about having multiple surgeries as teeth fail one by one, or just take the one surgery and put it all behind them.

am i the only one who sees them massive periodontal defect on the molar just distal to the posterior implant? you need to help this patient walk before they can fly remove hopeless teeth interim partials treatment plan accordingly what i see here - "new windshield wipers on a broken windshield"

Why not unscrew fixture till the platform is flush with the crest, primary closure for a 2-stage surgery?

Youve gotten the proper answer to your question. Ive only been placing implants for 3 years and live by this rule. ...get rid of everything bad in the mouth. broken teeth, infections, failing Root canals, defective restorations, perio disease, inflammation, etc... If the patient refuses that, then I decline. My success depends greatly on the patient and if theyre not interested in doing all they can do to achieve the greatest possibility of success, then theyll lose interest later. Ive had to turn patients away but i feel like Id be coming ahead in the long run. Bite the bullet on this one, remove the implants, bone graft, clean up the mouth and give yourself and the patient the greatest chance for success.