Socket Preservation: Do I Need it for this Implant Retained Overdenture Case?

If patient finances are adequate best to do a fixed prosth on 5-6 implants with implant placement at time of extraction and load with a biotemp. If not implant placement at time of extraction immediate temporary denture unloaded and then conventional overdenture post healing. CT scan not bad idea for new implant surgeon.

Why do you have to remove #20 and 21? Just asking...

You have lots of depth of bone to place a few implants to hold an over denture. Extract, let heal naturally to allow natural bone just like your previous extraction. Wait 3 months. Scan is indicated to show mostly the angulation of the mandible. If you are placing intra foraminally there will be no nerve involvement.. So a scan will not give a lot of usefull information. Place into hard natural bone and you can't go wrong ( hopefully!)

The implants you place will integrate as a result of osteoblasts depositing bone on the surface of the implant. The more osteoblasts you have in the bone the higher the vitality of the bone which then results in higher integration rates and more implant to bone contact. In addition to high vitality you want bone that can adapt to changes in load placed on the implant during the life of the implant. If the bone is sclerotic it cannot adapt which can lead to failure. So you want normal bone with normal bone architecture and a lot of osteoblasts. If you don't graft you get bone that has poor mineralization, poor architecture, reduced vitality and hence lower integration rates. I will not go into what bone graft to use because I am biased as a bone graft manufacturer. Back to your case. I graft all sockets. I would place the implants at the time of extraction and graft any areas where bone does not contact implant with a material that has been shown to result in integration at the graft site. Greg Steiner Steiner Laboratories

Thanks for your input Dr Al. It was along the same lines i was thinking. To OMS resident- the OPG is a few years old, and teeth 34/35 (20/21) have since become mobile, and in opinion they will only complicate treatment now and in the future if i decide to keep them. What do you think?

Greg, As a manufacturer I am curious what your thought(s) are about DBM putty material for these type of situations.

If you are placing an immediate full denture in the interim after extracting the teeth, be aware that instead of socket preservation you may need to do some alveolarectomy if the denture cannot be full adjusted.

What type of "implant retained overdenture" are you planning? A great deal of interarch space is required for the hardware in Hader bar or screw retained dentures. Less for snap retention, but still, as mentioned, you may already be looking at alveoloplasty to remove undercuts and allow attachment space. John

John Manuel- looking at placing 2 implants (possibly 4?) and using locators to retain the denture.

I think your conservative approach is great based upon your experience. What's the rush? Immediate denture with some metal reinforcement...Bone graft or don't. Both will work. I'd socket graft with Mineross or Oragraft or Puros or something of that nature, stick a little collatape over it and suture(maybe a little alveoloplasty while you are at it to level) Get a CT in a couple of months. You have no idea about width at this point. This is a perfect case and your approach is responsible. Make a clear dup of that denture to help position the implants. Let them heal before exposing for 4 months before engaging. Guaranteed success. Love to see the end result. Best,t

Bone graft? Why? This patient has great bone, possibly too much! You will need space in the denture for both the male and female retainer components, not to mention a sufficient thickness of denture base for strength. If he is a heavy bruxer you may need to reinforce with a metal frame or mesh. He might do well with an interim denture post extraction and not even need the implants. At any rate, the IP can give time to develop an optimal solution.

At the time of the extraction of the remaining 2 teeth of the lower left area, I would evaluate the socket. If there are good 4 walls of the socket, I don't think you need a bone graft in the sockets. Just let them heal, and evaluate in 4-6 months for Implant placement. If you can place a total of 4 Implants, I would plan on the posterior implants to be in the terminal tooth position of the denture. If it is in the 1st molar area, I will make the denture with 1st molar occlusion and no 2nd molars set in the denture. You want to avoid having heavy functional occlusion posterior to the last implant, or you may make that posterior implant a fulcrum point, and posterior chewing can potentially unseat/un-snap the anterior implants. Overall...looks like a good case with good vertical volume of bone. By the way...I like the Locator system, have had good results with them.

I think that you do not need to graft at all in this case. if anything is valid, it is that in fact you may have too much bone. I am a prosthodontist and can tell you that in some mandibular overdenture cases, less bone is better as this give me and the technician more room to work with for the necessary attachments required for retention. if you are using 2 implants, you would want them in the canine area and even if you place 4 implants, I think you have more than plenty of bone to work with. A tomogram is always a good idea as you would like to have an accurate idea as to what the buccolingual width of bone is like. I think the use of tomography applies for any implant planned and should be part of your diagnostic phase

flap open, extract, do an alveolectomy, probe the lingual bone for lingual fossae, put implants in the canine sites, cover implant dehiscences with milled bone, put on an membrane, close flap, uncover after 2 months and put on locators. can't go wrong.

All good comment especially Dr.O and Gary OMS I would do immediate implants and remove bone horizontally to provide adequate restorative space. The space required is less that if your placed a bar. I personally prefer 4 implants. You might want to look at Biohorizon's maximus system which is easy and less likely to perforate plates. The worst thing that could happen to you is not remove enough bone and have too little restorative space resulting in chronic denture fracture. Generally I find that patients who already have teeth prefer fixed prosthesis and patients with existing loose Complete dentures are grateful for implant retained dentures. I would place the implants to allow you to add more if the patient wants to go fixed in the future.

Please do not use unresorbable cow with proteins! We are a lot of damaged patients.

Are you farmers? They do a honest job.

Hi Dr. L, Keep it simple and predictable, you will learn plenty on this case. This patient looks like he has great bone, if #27 area healed well, and the other areas where he had extractions without bone grafting did too, then you can expect good healing. You didn't ask this, but take impressions and make a wax rim with teeth. Plan where you want your implants, make sure you have room for the implant housings in the denture. You may not have lots of room so probably best to place locator attachments, not a bar (needs too much room). This patient looks young and has a long time to live without teeth. You can place two or four implants to retain his lower denture, but I would encourage him to get more as time goes by. Maybe he can afford one per year or so. Try to get some in the posterior mandible to help preserve his bone. You don't have to use the implants anytime soon, just bury them. This way in five years or so he'll have enough implants to save his mandibular bone and then you can make him an hybrid denture. So many patients present like this, just get them to add an implant here and there as time goes by, he'll thank you in the future.

why don't you place an implant in the socket of # 21? It would be easy to check to make sure the buccal and lingual walls are intact. make sure you go past the lengh of the natural root. allow for some overall ridge resorbtion, graft # 20 with whatever works for you. place a cover screw leave it submerged (2 stage it) same with 28/27 area. 4 months ready for locators

Dear Dr.Lask, Socket preservation has been demonstrated well and with excellent results in other indications .But please be careful with comments like the Dr.J, that apparently place allograft materials only. You forgot to mention Diagnostic before you conduct any procedure Best

Socket grafting has great benefits and the best socket graft is an IMPLANT , so if you can always place and peri-implant graft if you cannot get primary stability or the is an infection issue then graft with a bacterio-static , bio-absorbable material . Do not wait for the loss of the bone due to re-modelling and modelling.