Upper Molar Immediate Implants
In this section, three topics are discussed. Where to place implant? Bone graft is necessary? CT is mandatory?
To answer the first question, we need to know which molar to receive implant, whether the septum is present or not, and the size of the septum. When the first molar has three widely separated roots, the implant should be placed in the septum. Osteotomy is initiated in the septum either before or after extraction. In the second scenario, the septum can be expanded so that a large implant is placed to obliterate the whole socket. Or a smaller bone-level implant is placed within the confinement of the septum. The opening of the socket is sealed by placing a large healing abutment with or without membrane. If the buccal wall is defective or a long implant is expected, the implant can be placed in the palatal socket. Due to oblique orientation of the palatal socket, the coronal end of the implant placed in the socket is more or less in the center of the whole socket. Since the septum is longer buccolingually than mesiodistally, an implant can be dropped into the buccal socket, slightly occupying the buccal aspect of the septum. When the septum is destroyed by lesions, the largest implant is placed in the socket. The second molar usually have fused roots. The largest Implant is a choice. No matter how big the implant is placed, the socket opening cannot be closed. Raising flap is associated with pain. Placement of the largest healing abutment may not solve the problem completely, since the socket is oval instead of being rounded (1). The remaining space can be closed by using membrane, which may be dissolved quickly. Bone graft may be dislodged if placed. A more secure method to close the socket opening is to use a temporary abutment and fabricate an immediate provisional around the former. The occlusion of the provisional should be low to avoid micromotion of the implant. The methods mentioned above are non-surgical ones to close the remaining sockets following immediate implant. Here is a surgical modality.
When socket walls are intact and a large implant basically obliterate the three sockets, bone graft is not mandatory. Otherwise, bone graft is placed where the defect is, to cover exposed threads of the implant and along the root of the neighboring tooth.
Since the anatomic structure in the maxilla (the sinus) is less than critical than the lower counterpart (the inferior alveolar nerve), CT is not so necessary for an upper molar immediate implant. Anatomy of the upper molars is a critical step.
Since peri implantitis in the molars appears more common than that of the premolars and anterior teeth, new protocols are proposed to reduce the incidence (2016_06_26). Buccal Root Exposure Subcrestal Placement
Molar | Features | Plan | Surgery | F-U | Features | Plan | Surgery | F-U | Features | Plan | Surgery | F-U | ||
1st | Septum | Expansion | 1 2 | 1 2 3 4 5 | 4 | Perio, Bruxism | Emdogain Sub CT | Wide Septum | Fractured Molar | Sequence | #1 sensor | |||
Drilling | 1 1' | 1 2 3 4 | 2nd molar Septum | Buccal Roots Exposed | Palatal Socket | Cantilever FPD | Bruxism | Drill/Expander | ||||||
Palatal Socket | 1 | 1 2 3 4 4' | Thread Exposure | Incision | Root Fracture Post RCT | Bone Loss | Compaction | Worst Next | ||||||
Buccal Socket | 2 3 3' 4 | Sinus Lower than Root Tip | Septum Exp/Sinus Lift | Non-Immediate: Same Pt | Limited Height | Difficult | ||||||||
Single Large Socket | 1 | Largely Furcated Molar | Bone-level Implant | Unknown Pain Post RCT | Short Septum | |||||||||
Sinus Lift | 1 2 2' 3 3' 4 | Narrow Mesiodistal Space | Limited Ortho | Non-Immediate Implant | Limited Height | Why Perforates | ||||||||
2nd | Buccal | 1 | Bone Loss: 2nd Molar | M-D Trajectory | B-P Trajectory | Exfoliate | Non-Immediate Implant | Ortho modality | ||||||
Septum | Expansion | 1 | Sinus Septum | Primary Stability | Early Implant | Osteotomes | Easy Placement | |||||||
Drilling | 1 | Why Large Implant | Can't be Placed | Ortho | Implant at Healed Site #15 | Expander | Thick Gingigva | |||||||
Combined | 1 2 2' 3 4 | From Extraction to | Immediate Implant | Adjacent Immediate Implant | Reamers | Septum | ||||||||
Single large socket | 3 | 1 2 3 4 5 6 7 | 1 | Residual Roots | Septum | Buccal | When not Place Immediate Implant | Delayed Implant |
1st Molar | 2nd Molar | ||||||
Features | Plan | Surgery | F-U | Features | Plan | Surgery | F-U |
14 | Bicon >7 Year Follow Up | 2 | Bicon | Plateau Coverage | 5y4m Post Cem | ||
#3 | Sinus Lift | Without Bone Graft | |||||
Can Shorter Implant | Achieve | Primary Stability? | 3-Unit Bridge | Plan | Immediate, Delayed | ||
Buccal Root Exposure | Smoker Palatal Socket | Grafts Threads Expose 2nd Redo | Thick | UL Failed FPD | Conversion | Drill Osteotomy | |
Healed Site | Condensation | Trephine Bur | Crack Tooth #15 | Post RCT | Complete Socket Seal | ||
2 Residual Roots | Parallelism | No Prep Temp | Perio, Bruxism | Drill with Stopper | Septal Slope | Early Periimp | |
Long Term Edentulism | Initial Depth | Bone Condensation | Lesion Higher Than Sinus Floor | Osteotomes or Taps | Cylindrical Implant | ||
Crack Tooth | UF | RCT instead | Fused Roots | Single Socket | Largest Implant | ||
Sudden change in Plan | No drill Osteotomy | Osteotomy Between Pathological Lesions | PA Angulation | ||||
Residual Roots | UF in Septum | Pointed Sinus Floor | Osteotomes | ||||
Severe Buccal Atrophy | Bone Expansion | Expand Dense Bone | 3rd Molar Immediate Implant | 2nd molar Periimplantitis | Limited Space | ||
Furca Lesion | Graft from #15 | Abnormal Bone Loss at #14 | Reduced Bone Height Post Ext | Sinus Lift | Immediate Impression | ||
Porous Bone | Condensation | Periodontitis | Bone Loss | ||||
Palatal Recession | Buccomesial, 2nd Try | Bilateral Pneumotization | UL, UR | ||||
Severe Bone Loss | Emdogain | Change in Trajectory | Periodontitis, Occlusal Trauma | Largest, Longest Implant | Executed as Planned Flap Surgery | ||
Low Bone Density | Expanders | CAS Kit | Perio, Severe Bone Loss | 3-Wall Contact | Perio Surgery with Graft | Redo 2 | |
Residual Roots | Septum or Not | Not Palatal Enough | Distal Caries | Implant Placement Level | |||
Bicon Implant | Tripod | Long-Termed Follow-Up | Two Adjacent Loose Molars | Threads Covered by Bone | |||
MB Root Fracture | Repair Defect | Graft Materials | Mesial Bone Loss | Post Bone Graft Failure | |||
Uneven Bone Loss | Bone-Level Implant | Placed as Deep as Possible | Ortho | Proximal Root Caries | Keep 3rd Molar As Reference | 4 Rounds of Bone Grafting | |
Palatal Cusp Fracture | 4.5 mm Implant | 1-2 mm Allograft Closes Ext Gaps | From FPD to 1 or 2 Implants? | Implant Sizes not Matter for Bruxer | |||
Implant across Arches | UF Long | Supraerupted Opposing Tooth | Low Bone Density | Sinus Perforation | Rescue | ||
Mesial Tilt | Anchorage | Heavy Bruxism | Splint or Not | Bone-level Implant | |||
2 Layers of Sinus Floor | Sinus Master Kit | Short Implant Placed Deep | Crown Fracture with Partial | Large Implant Small Temp | Magic Osteotomes | ||
Extensive Bone Loss | Medium Sized Implant | Complete Fill of Defect | Crack Tooth: Crestal Approach | with Membrane Control | Overprep | Extrusion | |
#14 Narrow M-D Space | Small Implant | #3 Limited Height | #15 Large Defect | Sinus Lifter | Hard Sinus Floor | ||
Crack Tooth (Bruxism) & | Periodontitis Coexit | Extensive Crack Line | Protect Buccal Plate | Socket Shield | Vertical Height | ||
Crack | Septal Expansion | Dense Septal Bone | Perio, Endo, Bruxism | Long Implant, Tap | Palatally Placed | ||
From Flipper to Implants | Wide Implant | Not Invade Sinus | Advanced Periodontitis | Implant Protection | Sinus Lift with PRF | ||
Multiple Missing Teeth | #14,15 Soft Bone | Dual Modes | Cantilever Bridge | Largest Implant | Change Trajectory Early | ||
Bone Loss, Low Density | Osteotomes | And Drill | Control Upper 2nd Molar | Osteotomy M-D Spacing | Executed as Planned | ||
#14 Palatal Defect | Buccal Placement | Tap Drills | Soft Bone at #2 | Bone Condensation | Magic Expanders | ||
Perio, Sufficient Bone | Long Implant | Abutment Diameter and Cuff | #2 Close to Sinus (WP) | PRF | 7 mm Implant | ||
Implant Fails with Sinus | Progressive Loading | 1st Case of CMC | 10Y | Immediate Loading Bridge | Osteotomy in Septum | Engage Sinus Floor | |
#3 Sufficient Bone | Long, Large Implant | Large Septum | #15 Sufficient Height | Thick Gingiva | Bone Expander | ||
#3 Large Septum | Provisional Margin | Repair Sinus Membrane Perforation | #2 Crack Tooth | Implant Fills Socket | 8x17 mm Implant | ||
Establish Correct Implant | Position & Trajectory | Avoid Sinus Membrane Perforation | #15 Thin Bone Before #14 Impl | Prevent Implant into Sinus | Sinus Floor Thickens | ||
#14 Severe Bony Defect | Long Implant Locks | into Mesiodistal Bone (LJH) | #2 4 Months Post Ext | PRF/Graft Pre-dum | Wide Ridge, Wide Implant | ||
MB Root Fracture | Extraction, Implant or | Root Amputation | #15 Vertical Clearance | Control Initial Depth | Soft Bone not Underprep | ||
From FPD to Implant | Bone Expanders | 3-Year Follow Up | #2 Trifurcated Roots | Septum Resection | Mesial Slope | ||
Failing FPD 2-4 | Dual Modes | Osteotomy Depth | #2 PARL,Crack, 2 Fistulae | Severe Bone Loss | 6.5x11 mm, Control Depth | ||
#14 2 layers of | Sinus Floor | PRF with Sinus Lift | #2,3,5 perio, bruxism | 5 mm Cuff | Mill Abutments | ||
#14 Paper Thin Sinus Floor | Magic Lifter | Simultaneous Implant Placement | #2 Long-Termed Residual | Roots | 1st Magicore for Immediate | ||
#14 Endo-Perio Disease | Single Drill Bone Core | Type II Bone | #15 Fistula post RCT | Mesial Slope | Avoid Extracting #16 | ||
#14 Low Density | Place Deep | Bone Graft Where Needed | #15 Place Implant | Not So Deep | Septum Shorter than CT Indicates | ||
#14 Endo Perio Dz | IBS Tap | Bone Height | #15 Severe MB Bone Loss | Distopalatal Placement | 1 mm Sinus Floor | ||
#14 BEB through | Residual Root Socket | Flap Transfer | #15Residual Roots with | Reduced M-D Space | Bone Graft Should be 1st | ||
#3 4 mm Bone Height | 6 mm Gingiva | Buccal Socket Placement | #2 Fractures | Dense Bone | Osteotomy Depth Landmark | ||
#15 Mesial Shift | Pre-implant Ortho | #14 Narrow Ridge (IBS) | IS | 14,15 Root Caries | Plavix | Ortho or Not | |
#14 No Sinus Floor | 6 mm Cuff | Failed Placement | 2 Possible Root,6 Bone Height | Larger Implant in Slope | More Thread Exposure | ||
#3 Thick Gingiva | Mill Abutment | Bone Expansion | 15 Bone Height Decreases | as Residual Roots Expelled | Sinus Lift | ||
Halt Perio | to Periimplantitis | Septal Slope: Sequential Osteotomy | 2,3 Guided Surgery with Sinus Lift | ||||
#4 Extraction | For A Molar Implant | Executed as Planned | 14,15 Sinus Lift with Guided Surgery | 12 mm Offset | Close to Neighboring Curved Root | ||
#14 Severe Bone Loss | Sinus Lifter & IBS Fin | Retrieve Implant from Sinus | Redo | 15 Palatal Bone Loss | Buccal Placement | Middle of Socket | |
#3-5 Extraction for | Provisional FPD | Control Osteotomy Depth | #2 Severe Bone Loss, #3 Exfoliation | IS Drill Stopper | Parallel Pins | ||
Cantilever FPD | Largest Implant | Change Trajectory Redo Design Surg | 15 Crack | PRF for Sinus Lift | Tatum Screw Implant | ||
#3 Residual Roots | BEB with Implant | Sinus Lift with Implant | 15 Crack | Short & Fat Implant with PRF | Not So Short | ||
#14 Crack | Control Depth | 8.5 mm Depth | 15 Palatal Root Fracture | Guide for Better Trajectory | Less Screw Loosening | ||
#14 PARL Post RCT | Osteotomy Shifting | Hard Bone Shorter Implant | 2 Immediate | 13,14 Guide | Short Implants | ||
#3 Used as Surgical Guide | Prior to Extraction | Septal Undercut | 15 Palatal Root Fracture | Guided | Immediate Implant II | ||
#14 Crown Fractures | Osteotomy Landmarks | Use Implant for Sinus Lift | 2,13,14 Short Implants | Free Hand Immediate Implant | |||
2 4 UF | Guide for Tatum | ||||||
#14 Severe Recession | Implant Within Septum | Study Septal Dimension Before Drill | 2,3 Vertical Fracture | Severe Bone Loss | 8 Months Post Socket Preservation | ||
2 Residual Root | Mucocele | Buccal Socket Placement | |||||
#3 Atrophic Buccal Plate | Bone Expander Kit | 3 Year Follow Up | 13 Narrow Space 15 Immediate | ||||
#14 Root Exposure | Mill Abutment | 5.5x7(5) mm | 13-15 No More FPD | ||||
#13-15 FPD to be Removed | Overloaded? | 4 Q Molar Implant Reconstruction | |||||
#14 Palatal Root Fracture | Shy of Sinus Floor | Buccal Placement | #2 Severe MB Bone Loss | Distopalatal Placement | |||
#3 Plenty Bone Height | Insufficient Clearance | Short Implant | 3-4 mm Bone Height at #14,15 | Magic Lift | |||
3,14 Implant/Crown Ratio | Septal Gingiva; Short Implant | 1-4 mm at #3,14,15 | Sinus Lifter | ||||
#14 Crack | Socket Preservation | Magicore | 1 mm Bone Height at #2 | Sinus Lifter | |||
#14 Narrow Space | Thick Gingiva | Tissue Punch | #2 Single Long Socket | Tap Drills | |||
3 Narrow Ridge | Bone Graft Post Guide | Undersized Drilling | 2 Limited Bone Height, Low Density | Magic Lifter with Guide | |||
3 Bruxism | No Sinus Lift or Tap | Clearance from Curved Root | #15 Severe Bone Loss Around | Buccal Roots | |||
14 Immediate (UF) | 2nd Placement (IBS) Flapless | 3rd Placement (IS) | #2-5 Failing FPD | Exploratory Procedure | |||
11-14 Dislodged FPD | Various Bone Width & Height | And Density | 14,15 Socket Preservation with | Osteogen Plug | |||
3 Redo with | Sinus Membrane Perforation | 31, 15 Immediate or Not | Palatal Root Fracture | ||||
3 Sinus Lift with | Bone Expanders | Dr. Gao | Fracture | Socket Preservation | |||
14 Mesiodistal Crack | Septal Height Control | Thin Septum: Osteotomy Deviation | |||||
2 Buccal Plate Resorption | Sinus Lift with PRF | Difficult without Guide | 2 Redo | No Sinus Floor No Sinus Lift | |||
3 Crack; | No Sinus Lift | 5x10 mm Implant | 2,3 Short, Hard Bone | ||||
3,4 Loose Bone | Guide Underprep | Offset: No Fixture Anchor Pin Engagement | 2 | Guide Post SRP and Extraction | |||
14,19 Under-Prep, -Size | Class I Occlusion | Surgical Precision | |||||
3 Free-Hand Osteotomy | 1-3 FPD Dislodges; Avoid damaging | Neighboring Root | |||||
3 Short Bone | Long Bone Trimmer | Immediate Provisional | 15/18 Ortho | Short Implants | |||
Upright UL7 | Before Implant | 15 Vertical Fracture, Large Socket | Socket Preservation | ||||
14 Emergency | Prevent Screw Loosening | Tissue Level Implant | 15 Hidden Crack | ||||
14 Severe Palatal Resorption | Buccal Plate | Palatal Bone Graft | |||||
13 Immed,14 Delayed | Deviation of Trajectory | 15 Single Large Socket 1 cc Allograft | |||||
13 Immed | 15 Delayed | 14,15,29 One Appt | Increase Implant Length | with Guide | |||
3,4 Severe | Buccal | Recession | |||||
3 Residual Root | 2-3 mm Bone | ||||||
14 19 Short Narrow | 13 Immediate 15 Delayed Implants | ||||||
14 Thick Sinus Membrane | No Sinus Lift | ||||||
14 ~6 mm Bone Height | |||||||
14 Sinus Lift | for Neighboring Site Later | #2,4 FPD Dislodges | Sinus Lift Master Kit | ||||
14,30 Guided Surg: | Dentophobic Patient | 30 | |||||
14,19,31 Guided Surgery | CT (#3) | #2-4 FPD Fails | Implants Avoid Sinus | ||||
14 Mesiodistal Crack | Septal Height Control | ||||||
14 Establish | 1st Molar Occlusion 14/19 Guide | ||||||
3 2 mm Bone | 2 Root Fracture | Mesial Slope Osteotomy | |||||
14 Periimplantitis | Lingual Defect | ||||||
14 Internal Resorption | 14,15 Guided Surgery | with Sinus Lift | |||||
14 Sinus Lift for | Neighboring Site Later | ||||||
14 Septum Lower than Crests | Socket Preservation | ||||||
3 Advanced Periodontitis | |||||||
12-14, 18,19 | Limited Bone | ||||||
#3 Crack, Possible Bruxism | Tissue-level Implant | ||||||
#2 4 Months Post Ext | PRF/Graft Pre-dummy | UL Quadrant | Treatment Options | ||||
#3,4 Residual Roots DC | Underprep, No Prep | ||||||
Change FPD to Implant | #3 with 7 mm Height | ||||||
Soft, Long Bone, Perio | Implant/Bone Ratio | Section Bridge | |||||
Tooth Shift: Post-impl | Ortho (Restorative) | #15 Palatal Root Split | Buccal Placement | ||||
#3 Buccal Roots Expose | 6 mm Cuff | 2 or 3 Implants? | |||||
14 After Upright | #15 | #14,15 Root Caries | Ortho or Not | ||||
3 Narrow Mesiodistal Space |
Immediate Implants Molar
Crown Materials for
Bruxer
Xin Wei, DDS, PhD, MS 1st edition 01/21/2014, last revision 06/06/2020