Treatment plan for 37: Immediate placement or delayed placement?

It's not common for a molar to be immediately replaced by an implant, but it is quite possible. You hit on the problem, its a matter of establishing good initial stability. In this situation the diameter of the molar will almost invariably be less than that of the tooth being replaced. You would be able to get apical stability in the floor of the socket, providing you stay clear of the mandibular nerve. That is often sufficient. Once the implant is placed, it needs to be surrounded by a regenerative bone graft such as Bio-Oss® Collagen. We bring this up and around a 4.0mm gingivaformer placed in the implant instead of a cover screw. The socket is closed over with a good Membrane. We do not ever consider placing a restoration at the time of placement because it would mean the implant would quickly lose initial stability. We generally place a 5.0mm x 11mm implant. This allows the implant to integrate while the socket is regenerating. It's a single rather than a multi-stage drawn out procedure. It has proven to be very successful and much appreciated by both patients and referring dentists.

Sorry, I meant to say " the diameter of the implant will almost invariably be less that that of the tooth being replaced."

The grafting material is a matter of personal choice....I would extract the root, wait a few weeks for the gingival tissues to close and the bone to begin the healing process, as well a sloughing off unwanted cells. ...place the graft, wait several months for the graft to mature and remineralize. It would be good to bone a piece of wire to the upper molars to keep the #27 from drifting down......when the graft gas matured, place the implant..... and wait for full osseointgration.

Consider not replacing a second molar because the load is excessive and there is a risk for over-load (use a 4.7mm diameter implant), the patients function will probably not be diminished with the loss of the second molar. It may be best to extract and graft and wait and allow the patient to decide if there is a need.

Interesting varied comments: I've been immediately placing molar implants for 6 years. 95% of maxillary and 70% of mandibular sites. It is more challenging to stay out of the root defects yet careful osteotomy solves that. Dr Rudick, I see little value in delaying the socket bone regeneration as a separate procedure. The socket will be smaller, more surgeries, more post ops, more wasted time from the patients job and life. If the buccal plate is thin then I use a xenograft. More often I use 50/50 allograft/xenograft mixed with a mulched L-PRF membrane as the socket bone material and then use a PRF membrane over the whole thing to be sure the particles stay in place and stimulate crestal bone formation. this works very well. I routinely replace second molars. Countless people have told me they chew on the side with second molars avoiding the side without second molars. I've also noted that the first molars take a beating when the seconds are gone, esp if one of the first molars has had endo. My 2 cents worth.

My strong advice would be to do follow the most predictable and safe journey , that you can do today giving the patient the best result. Remember when you place immediate fixtures it’s not only the primary stability it’s also the trajectory and spacing of the fixture You also have to control the pilot drill itself from chattering in a bloody , uneven socket and keep it in the right position ,also Keeping in mind the IA nerve could be 3- 4 mm away ....not easy even for seasoned clinicians. You also have to have many sizes of implants in your tool box , not just the one that you have to make do with . And then protecting your fixture with good primary closure or use ptfe, prf Or custom healing collar with resin .Then you have to worry that the patient is careful enough to protect your site. Lots Of things can go wrong if any of the above are not done properly...and then you will have an Implant with greater exposed threads and not an ideal outcome but it will integrate . Nonetheless, if you gain experience start with upper premolars much more easy, try flap less , Become comfortable with understanding bone quality , manipulating the tissue , improve suturing skills, drill angulation ,then in time the outcome becomes predictable . Anteriors are also important to learn as important protocols like drill engaging the palatal wall (CBCT I always use today) I am also very selective with the patients that I place immediates on , Avoid smokers diabetics anybody w immune compromise disease. Imediate placement techniques have improved w/ socket shields (PET) , even on posterior molars now as expert Chuck Scwimmer DDS does in Pittsburgh routinely. Wider, shorter diameter 6-7 mm are available, some implants expand with a second screw ( Sargon Implant)to create stability , using densah burs to create stability ( my choice), it goes on and in. My advice, ask your self what will be best outcome route in your hands , today, for the patient. Ultimately you have to give the patient an outcome that will last decades , and If it takes a few months more that it’s OK. Good luck, if you do immediate also use CBCT ,as 2D image can be off ... or constantly take X-rays during osteotomy to check for vital areas . Any particle bone will work . I prefer allograft, but xenograft will work too..I would use ptfe and full closure of socket with cover screw, don’t expose implant with healing cap and pancho membrane technique ,unless you are experienced. Best of luck

I have found the best graft material for an intact posterior socket to be a stable clot. Remove the tooth and wait 6-8 weeks then place the fixture. Anything else according to Becker qualifies as "osseoinhibition".

As with many cases discussed previously, there is not enough information given for appropriate, conclusive comments to be made. A 3D radiograph is required before an informed decision can be made. A review of the entire dentition is required also. It seems to me from the OPG that 27 is probably ever erupted which means proper restoration of 37 could be tricky (models required to evaluate). Further the 47 seems to be unsatisfactory and likely needs retreatment or extraction. So with just these two issues (are there more?) there needs to be more thought about the whole treatment plan not just a “smash and grab” for the 37. What does the patient want – once they know there is more work (and consequent cost) required? All comments made above are relevant but I agree that the necessity for a 37 implant is dependent on circumstances which have not been presented. Most particularly I like Dr Gangji’s comments, not just because he has given you a very comprehensive outline of the methods to use, but because he has prompted you to realise that implant placement in this case may not be as simple as you think.

I think that the issue here is not when to place the fixture but if you can restore it at all. It seems you'll be very limited in height and you may better consider from the start a screw-retained crown. Having this in mind, in my opinion , you'll have less space for angulation errors and therefore I would choose to work with enough bone than with the lack of it. If you are unsure about gaining stability I think it's safer for you and the patient to go in 2 steps( asses the width too and if necessary go with socket preservation first). Good luck!

easy peeesy first immediate implant case. Insert it NOW! Extract seamlessly and just drill the socket. I prefer immediate installation when two condition meets my standard: 1. good initial stability 2. no residual infection in the socket.

i think it is better to take a para sagital cross sectional image from the interest site and pay attention to diameter of intra radicular crest and the apical bone