Sutures opened on Immediate Implant in molar: what should be done?
I had placed an immediate implant in the mandibular molar extraction site. The implant had excellent primary stability. On the second day post-operative the sutures had opened up, in a manner that there is no way I could close them back to achieve primary closure. It was my mistake to close the wound site flaps under tension and so the flap opened. Now the condition is that the cover screw was exposed and I replaced it with a transmucosal healing abutment. This allowed closure of the surgical flaps around the healing abutment distally, bucally and lingually, but there is a wide gap on the mesial you can see into the extraction socket and oral fluids can go in. I can even see the implant threads from there, without manipulating the tissue and a little of the buccal bone is also exposed. I understand that the exposed bone will die, but my implant is still a little deeper.
As I am encountering these complications for the first time I would like to hear from the more experienced clinicians -what should be done? The implant is not mobile at all, no sign of infection. I have asked the patient to keep the area clean and do warm saline rinses 3-4 times a day, be on semi-solid diet and the patient is under my constant observation. What are the chances of the bone forming on the mesial area that is exposed to oral fluids? Should this be left alone for 3-4 weeks and then re-evaluate? Or should I remove the implant now and graft the area?
Its a learning case for me. Your advice will be highly appreciated.
Immediate post op
32 Comments on Sutures opened on Immediate Implant in molar: what should be done?
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CRS
5/26/2013
At this early point in the game, non intergrated, remove it graft the site rotate the flap and close it primarily. Take that three months of watching an iffy placement and watch a sure thing heal, then place the implant in the correct place, the interseptal healed bone and an implant with the occlusal forces down the long axis.the body is giving you an opportunity for a second chance to do it over. I would rather watch an implant heal covered with bone on all sides vs hoping things ill fill in. At six weeks you will be able to tell since this is when the primary stability from the mechanics will be lost and osteointegration takes over. It's not a typodont it's a human with healing necessary for this to integrate
Dr Charles Sutera III
5/26/2013
I agree with CRS. Bone grafting this case and waiting for 3-4 months for healing would be the most predictable option for a more novice provider in implant placement. I'm not sure if this is your final post op PA, but I also notice that the implant was not bone grafted in this PA film. To increase the predictability of healing this case should have an allograft placed into the vertical defects. An alternative to the previous suggestion by CRS would be to further score the periosteum to advance the flap to achieve more primary closure, graft the site with 50/50 dFDB/FBD, place a resorbable/acellular membrane (ie Epiguide, perioderm, or alloderm), and resuture the site without tension using ideally nonresorbable Teflon sutures, or Vicryl as a secondary alternative suture choice. Followup at 1 week to eval site, then followup at 3 weeks to take a PA and remove sutures.
greg steiner
5/26/2013
Dr. Sutera
Even Urist -who discovered BMP's- advised against grafting titanium surfaces with allograft. See Histologic findings after implantation and evaluation of different grafting materials and titanium screws into extraction sites. I don't understand why immediate implants are placed in molar extraction sites. If you extract, graft and then place your implant in a few months you will approach a 100% success rate long term without these complications. Greg Steiner Steiner Laboratories
Baker Vinci
5/29/2013
We do this, because it works and saves the patient time and money. Success rates In my facility for these, are close to 100 percent . Bv
Pynadath
5/26/2013
Agreed with CRS!
Jon
5/27/2013
Perhaps you should read this regarding socket healing.
Int J Periodontics Restorative Dent. 2011 Sep-Oct;31(5):515-21.
Human histologic verification of osseointegration of an immediate implant placed into a fresh extraction socket with excessive gap distance without primary flap closure, graft, or membrane: a case report.
Tarnow DP, Chu SJ.
CRS
5/27/2013
Why not hedge your healing bet and raise the quality of your surgery, however I will read the article. And yes I know about the "gap"and "spinners " integrate. It is just from a practical standpoint, that three extra months of graft healing for optimal implant placement is always accepted by my patients when I explain it to them and guide them They hear the confidence, caring and do trust. If they get impatient, it is forgotten once the implant is restored. I use the OB Gyn analogy the three months bed rest in the life of a twenty year implant is worth a healthy result (baby) or I place no implant before its time. I don't want to have to nurse a sick result once it is integrated.
lyle
5/28/2013
Dr. Jon,
You are correct. I grafted the gap in my first 2 cases and both got infected so for the last 12yrs, I have not grafted an immediate implant in the posterior provided I have intact bony walls. I don't close the flap over the site either, often no sutures. For me it has been predictable and no failures with proper case selection. Tarnow's article just reinforced what I have been doing. I do BG the anteriors for other reasons. Understanding socket healing and how the sockets of different areas heal is key to understanding immediate implants.
Santosh kumari
5/28/2013
Dr Jon can u sent a link for dr tarnow article you have mention
Regards
Dr santosh
Leal
5/27/2013
Well if I saw that huge gap I would probably just use Calcium Sulphate no primary closure, no membrane, nothing. I mean at the time of implant placement of course.
Jon, that excessive gap is very subjective. In this particular case the gap must have been "over-excessive" and I do agree very much with Tarnow regarding that the blood is a good graft for the gap but it truly depends on the gap type.
Thanks
CRS
5/27/2013
Blood is a good graft, however micro movement and oral flora will prevent osteointegration vs a fibrous union. Blood provides the precursors but cannot maintain space.That is how fractures heal. Also from a business model can you charge for all those careful watching post op appointments vs knowing that the properly grafted site with primary closure will heal more predictably requiring less reparative procedures, do you charge for those as well? I suspect that often failure is due to the fact that the patient will incur additional expense and time due to cutting corners at the get go. I only place immediately when the socket morphology is near perfect and I obtain primary closure. The molar area is not well suited for this.
Leal
5/27/2013
Sorry to disagree but if the implant is between 4 walls calcium sulphate will act just fine with no primarily closure and no membrane.
vk
5/27/2013
This implant has been removed. I will wait for 4-6 months now. Thank you for all the expertise. Now I can sleep soundly. Thank you all respected - CRS, Greg Steiner, Dr. Charles, John and Leal. This forum is a great way to learn.
Charles Sutera
5/27/2013
Glad you made the decision to create a more predictable prognosis. Its impressive to see a fellow colleague reaching out for advice to ensure the best clinical outcome for the patient. Good luck with the case and best wishes.
greg steiner
5/27/2013
Dr. Jon If you base your clinical therapy on a case report then Tarnow had one success and VK had one failure. Does that indicate you can expect a 50% failure rate? Just giving you a hard time in fun. I can show that you can float an immediate implant in graft material with no bone contact and it integrates up to the platform but that does not indicate it is predictable 95% of the time. Greg Steiner Steiner Laboratories
CRS
5/28/2013
Dear Greg, I'm really glad you said that. It seems to me that sometimes a poster will just state one thing to have an opposite viewpoint based on an article or an anecdote. I think that only confuses the poster to the more conservative approach with bravado. I personally would rather be brave and redo the implant vs getting lucky especially when the reasonable opportunity exists to start over. I guess it depends on ones understanding if biology and healing although it is is not always possible to predict with 100% accuracy. I feel that you consistently give good honest advice based on experience and I hope that I come off that way also. I find I learn from that. Than for reading
greg steiner
5/28/2013
Thanks CRS. Coming from you it is a much appreciated complement. Greg
Vipul G Shukla
5/28/2013
Dear poster,
You have two things going against you. First, no primary closure. Second, the angulation and positioning. I don't know if this will receive a crown or a bridge or an overdenture, but don't you think this is angled in? You need to catch the inter-radicular bone septum between mesial and distal roots and place it such that the platform is parallel to occlusal, then, pack in your favorite grafting material around the fixture, and suture best you can, WITHOUT tension. Immediates do have high success rates, if done right, and you can get at least a 35 Ncm torque on it.
Lastly, the general rule for immediates is at least 2mm beyond the apex into solid bone for primary stability.
I don't see that either.
My advice, go back in, torque this one out, new osteotomy in correct angulation, place a longer implant, pack graft and post a new peri apical X-ray for all of us to see.
Good Luck!
Pedro Guitian
5/28/2013
Let mother nature works by itself. Blood cloth is the best graft material and do not disturb the new bone regenaration with anything else than blood if you have good alveolar walls and good gum (if those conditions are not there do not place the implant)...
I am totally agree with Tarnow´s work.
I do that everyday since more than ten years ago, and the success rate is higher than 95%, even doing immediate loading when is possible if there is good primary stability.
Regards to everybody from Spain.
Mustafa galal
10/6/2013
Dr bedro what about the critical jumping gap which present in all immediate in molars can we ignore it or leave it to blood also to fill it
Baker Vinci
5/29/2013
I didn't read the other responses, but this really isn't a "learning" type case. I always encourage grafting and placing a membrane in these cases, with no primary closure. The membranes tend to stick around for about a month. In this case, I would remove the implant and replace it with a slightly wider fixture and graft as described above. It has worked well for me, over the last two decades. You seem to appreciate the fact that wounds can not heal under tension, so don't forget to apply the obvious principles. Bvinci
Fredrick Shaw
5/29/2013
I agree with BV, not a learning case, and when considering the patient not that much additional time to the patient to extract, augment and come back to a much more ideal and predictable outcome for your patient. Additionally, if you could have placed that implant in septal bone between where the mesial and distal roots normally reside, a much more ideal restorative presentation can be achieved and in proportionately greeter integrated surface area of native bone from day one of the integration process.
Dr G
5/29/2013
Incidently, this type of immediate molar case is perfect for a MAX implant. used to be southern implants now owned by keystone. They recommed no grafting (i agree) and they come in sizes 7,8,9 mm wide.
Baker Vinci
5/29/2013
My other concern is; I don't see a tooth next to the implant. This typically results in an inadequate embrasure design. I agree that anytime you can, you should engage the more dense bone, but the product dictates the position. In many cases the apical bone is your best bone, mandating a ct scan and a good understanding of the result. With the exception of the purulent infection, I am placing the implant in the fresh molar extraction site every time. B Vinci
Baker Vinci
5/30/2013
I don't want people to think I am " harping " on this issue, but when is the bony anatomy going to match the natural contours best? At the time of extraction, in my opinion, especially in the anterior region. An implant that is torque stable( my goal is greater than 40 ncm ), grafted with autogenous bone and a good membrane gives the patient an arguably better result. The fact that it is in less time and less expensive is just a coincidental bonus. I find myself removing bone at the second stage in 25% of the cases. I don't encourage this technique for the neophyte. I also believe that if you are extracting and waiting four months, with the rare exception of the maxillary molar region, the site will do find without a graft. B Vinci
CRS
5/31/2013
I have been burned with absorption of the labial/buccal plate when I don't graft. Often It is not present at extraction since many of these cases are referred late or the generalist does the extraction no graft or a poor graft which needs to redone. However your insight is much appreciated and I will be on the lookout for more immediate cases since even with grafting I have lost bone. Probably some anatomical or patient factors also.thanks
Baker Vinci
6/6/2013
CRS, I agree. However if the buccal and lingual walls are intact, we can get away without a graft, in my opinion. With that being said, I almost always graft on a delayed case. Patients that change their minds about implants after the extraction, tend to have good bone, without the graft. Bvinci
Peter Fairbairn
5/31/2013
Totally agree BV and have been lecturing so for many years now preservation always a better solution to later GBR .
CRS the key I suspect lies as in the next case here with the disaterous loss of bone and soft tissue in the bundle bone which as you know is a. thin and b. dependant more so on the PDL blood supply , hence removal of tooth can lead to issues hence I always pack a graft ( I use Synthetic materials that set ) material between the Implant and this bone .
Seems to work well , with a 99 % sucess and yes I do raise flaps sometimes to have a look .
This case can work very well with this type of proocol but best not to place immediately but after 3 weeks to get soft tissue closure . I have been doing a fair bit of research on ridge preservation and the procedure has great benefits not merely in hard tissue preservation BUT preserving to all important attached gingiva which is vital in the lower 6 area for long term success .
Regards
Peter
CRS
6/2/2013
Maybe I'm special or handle the tissue delicately but I don't have the soft tissue loss with an undermined flap or loss of vestibule. Perhaps it's the way I rotate the flap. Anyway I am looking into generating an immediate clot with my laser and packing the bone at the same time since the clot will seal it. I know that the wider buccal plate is difficult to close primarily and I do rely on teflon guided regeneration.Thanks for your feedback, always appreciated!
Baker Vinci
6/3/2013
I'm not practiced in using the laser for this, but CRS expresses an appropriate understanding of the limits of getting primary closure. Most of the cases on this blog, do not need "it". We are robbing Paul to pay Peter, when we strip away the nutrient supply with over zealous raising of flaps. My goal, is to raise the flap enough to contain the membrane, with loose sutures, that are taken out at two weeks. Bv
Fredrick Shaw
6/4/2013
Here Hear! Good sound surgical principles! Learning the basics facilitates a treatment platform based on science and clinical outcome which is consistent, something the patient appreciates and deserves.
Sam Jain
6/14/2013
Immediate molar implant is my work horse. Flap less exo. I love using my trephine and place screw plus 6.5x5.7x13 tissue level with 5mm healing collar. Never a cover screw. Cover screw and bone level implant make it a concave defect in which things fall. So always a tissue level with 5mm collar that occupies 75 percent of the socket defect. The bone harvested from trephine is split and grafted into buccal space along with mfdba mixed with clinda metro prf etc etc. prf held by collar and tucked in at the periphery of socket and figure 8 suture. $3k
If u make a temp crown like the way it is done for upper front tooth, nothing like that.
We have been doing more and more of that.
Only one surgery, always.
flap-less always
The cosmetics, buccal bone, soft tissue is unsurpassable with immediate implants.
Px comes with a broken tooth or missing tooth, leaves with a screw retained tooth,
Temporary used to make customized impression coping and screw retained crown made using pfm and stock abutment.
Sam Jain, DMD
Center For Implant Dentitry
We image, we plan, we place, we restore, and we teach
