Immediate placement with marginal discrepencies: A problem I need answered??????

Tue, 04/20/2010 - 11:41 — njp207

If a patient comes in with a root fracture on #9, and the gingival margin of #8 is apical to that of #9, how would you proceed with treatment, assuming this is a socket type two classification where soft tissue and bone augmentation would be necessary at time of implant placement if an immediate implant were to be placed?
Thank you for your help.

Comments

Tue, 04/27/2010 - 08:02 — Mental Foramen

I would not place an immediate implant in this case

I would not place an immediate implant in this particular case. First, many in the profession are getting away from immediates in the maxillary anterior due to esthetic issues that develop years down the road. Second, and this is super critical with this case, if you need hard AND soft tissue augmentation at this site, you are setting yourself up for failure in my opinion. On top of all of this, you have the issue with the #8 margin.

I would remove 9 and perform GBR. Also do the CTG on 8. You will be coronally advancing the flap at site 9 to cover the GBR, so you can accomplish coverage on site 8 at the same time with a CTG or allograft material.

Once that heals, you will have bone at site 9, you will have no more gingival discrepencies, and you will have set yourself up for a nice result. Why risk a long term esthetic nightmare to save a few months of time?

Tue, 04/27/2010 - 21:00 — sinuslifter

nip207, I have to agree with MF. Why the rush in this case?

This case sounds interesting. It would be nice if JIACD would allow us to post pictures so we can see the cases.

This case appears to have many issues. Rushing the case with an immediate implant is the wrong way to go. Take time to get the recipient site to optimal conditions and the patient will thank you for it in the end. Doing an immediate may make the patient happy in the short term, but if the final result is poor, all of that goodwill will be forgotten and you will end up as the bad guy who now has a problem to fix.

Wed, 04/28/2010 - 09:11 — HEATHERRICHARDS...

In agree....No rushing here.

I absolutely agree that this case needs to be performed in 2 stages. Augment the bone and tissue then come back and place the implant. We all want to make our patients happy but I prefer to make them happy for as many years as possible and not just at the moment.

I used to be much more aggressive with augmentation and implant placement simultaneously. I have been burned early in my career and had some messes to clean up. I now have much more success and enjoy my career much more.

It is not to say that you cannot get lucky and have it all work out. However, I think we need to respect that our patients TRUST us and our judgements to make the best decisions on what is most predictable long-term. I have found that when I tell a patient that it will take X amount of time because it is the most predictable that they accept my treatment plan. I always let them know that others will do things much quicker but in my experience and opinion....it comes with a higher risk. What is a few more months for something that can last many years or even a life-time?

On the other hand maybe it just does not work in my hands this way.

Wed, 04/28/2010 - 12:37 — SamBusich

What extraction site classification is being utilized?

The post refers to the extraction site as a Class 2?
According to what classification? Also, it is in your favor that the adjacent root has recession from an esthetic standpoint.
I refer you to a recent article on this subject from Funato, A & Salama, M IJPRD Volume 27, No. 4 2007
See a below excerpt from their article;

Classification of Immediate Implant Placement

Table 2: Categorizing the Potential Implant Site . This classification is based on both the osseous and soft tissue levels of the potential site at the time of extraction.

Class 1: The buccal bone is intact with a thick flap gingival biotype.
“Incisionless” implant placement without flat reflection is viable (Figure 2).

Class 2: The buccal bone is intact with a thin, more scalloped gingival biotype.
Incisionless implant placement is viable but in combination with a connective tissue graft or a subsequent secondary connective tissue graft (staged) (Figure 1).

Class 3: The buccal bone is lost, but the implant can still be placed immediately within the remaining alveolar housing of the extraction socket, providing the necessary osseous support through regeneration utilizing a membrane with guided bone regeneration (GBR) and incorporating a simultaneous connective tissue graft (CTG). Depending on the degree of compromise to the buccal plate, the case may alternatively be handled in a staged approach utilizing a socket augmentation procedure with subsequent implant placement. In many instances, especially in thin biotypes, this method provides a more predictable and safer outcome.

Class 4: The buccal bone is severely compromised, and implant placement within the remaining palatal bone results in a significantly off axis implant position. In these cases, following extraction, implant placement should be delayed. If performed immediately, the long axis of the fixture inclines toward the buccal and will result in a significant esthetic compromise of the final restoration. In these situations, the delayed approach should be utilized with subsequent three dimensional (3-D) bone & soft tissue augmentation of the deficient ridge followed by optimal implant positioning.

Wed, 04/28/2010 - 13:48 — leopold

max done

i am absolutly agree with You...,no rush...,everyone have to understand what max shoud be done in each situation

Wed, 04/28/2010 - 13:55 — leopold

max done

i am absolutly agree with You,...no rush, everyone have to understand what max should be done in each situation to make cases more predictable.

Mon, 05/03/2010 - 05:50 — Logan MD DMD

Sam: I love that extraction site classification article.

I read that article a while ago and I use that as the protocol in my practice. Anyone starting implant placement or doing extractions should read that article.

Sat, 09/11/2010 - 09:15 — Mental Foramen

Another Implant 2nd Opinion came in yesterday...WOW!

Ok, so I had yet ANOTHER (this is like the 6th person in the past 2 months) come into my office for a 2nd opinion on the dental implant treatment proposal they recieved from a nationwide big implant chain center (I won't say who it is, but everyone knows exactly who I am talking about).

So, this person has rampant moderate to severe periodontitis. Teeth 7-11 and 22-26 are hopeless, but the remaining teeth had good bone levels, only class 1 mobility, and could easily be saved with some standard perio therapy. My recommendation was to extract 7-11 and 22-26, perform initial therapy on all remaining teeth, and re-eval in 6 weeks. After this initial treatment, she will likely need a few bone grafts and will probably opt for a max and man partial denture. There is no way this person can afford implants on top of this.

Guess what choice the big chain center gave to this person? You guessed it! Let's pull all of your teeth and do an All-on-4. You will have teeth in a day and it will only cost $40,000! Needless to say, the patient did not choose that option.

It is really unbeleivable! As I mentioned, I have had about 6 patients come from this particlur chain of treatment centers in the past 3 months for 2nd opinions. All were told that they needed All-on-4's for $40,000. It did not matter what the condition of their mouth was...they were all told they needed All-on-4's. Not one of these patients went through with the chain center's recommended course of treatment.

Thu, 09/16/2010 - 13:48 — sydney2008

Temporisation if the anterior maxilla after grafting procedures

Thank you for the IJPRD reference...I will certainly read it.It seems that there is avery mixed bag of opinions of the subject of immediate placement and immediate provisionalisation;some will do and some will not.Does anyone with alot of experience have a "golden rule" with respect to ideal criteria when they can guarantee success with immediate implant placement and immediate provisionalisation? Like thick biotype; class 1 implant site only;complete absence of occlusal contact (although there will always be contact on the provisional from a food bolus and the lips and the tongue;non-buxer;
Also if you are dealing with a class 2,3 and 4 implant site which needs soft/hard tissue grafting what is the best way to temporize the missing tooth if you are not preparing the teeth on either side for crowns which could support a fixed provisonal FPD?
I have heard some clinicians use an Essex type retainer with a tooth placed in the gap but I would think these would be poorly tolerated by patients.Adhesive resin bonded bridges can debond readily especially if there is not a shallow incisal relationship and an acrylic flipper will apply pressure to the grafted site...What has experience led you to chose an ideal esthetic temporisation method??

Thank you