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          
#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 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   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  
#14 Severe Recession Implant Within Septum Study Septal Dimension Before Drill   2 Guide Post SRP and Extraction    
#3 Atrophic Buccal Plate Bone Expander Kit 3 Year Follow Up   15 Vertical Fracture, Large Socket Socket Preservation    
#14 Root Exposure Mill Abutment 5.5x7(5) mm   15 Hidden Crack      
#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            
3 Sinus Lift with Bone Expanders Dr. Gao   2,3 Severe Bone Loss, Vertical 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          
3,4 Loose Bone Guide Underprep Offset: No Fixture Anchor Pin Engagement          
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          
Upright UL7   Before Implant          
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 12/30/2018