Immediate placement of a large diameter implant in a maxillary first-molar site: a case study

Dr. Charles D. Schlesinger discusses reduced healing time after extraction and immediate placement

Introduction
In today’s competitive dental market, patients are always looking for a differentiating factor when choosing a dentist. Today, implants are the fastest growing procedure category of the general practitioner’s practice.

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You cannot walk down a street in America or look online without seeing an advertisement for dental implants. So, with all this competition, what is a practitioner to do? The key, in my opinion, is patient satisfaction. To me, that means providing sound treatment that will last a lifetime and doing it in an expedient manner.

With modern implant protocols, the healing time has been shortened dramatically,² but when faced with a patient that presents with a tooth that must be extracted first, the clinician must decide which treatment path to follow. Do you extract, wait 3-4 months for bone regeneration, and then place the implant; or do you extract the tooth and immediately place the dental implant? In this article, I will not go into the protocols that revolve around immediate loading. I am just speaking of extraction and immediate placement where we can save the patient 3 to 4 months of healing time, thereby cutting treatment time by half.

Clinical case
A 63 year-old-male patient presented to the office with a non-restorable tooth No. 3. The tooth exhibited buccal recession with concomitant abfraction lesions and recurrent decay (Figure 1). Radiographs showed furcal involvement (Figure 2). The patient’s medical history was non-contributory, and the decision to extract the tooth and place a dental implant was decided upon after all options were discussed with the patient. A CBCT study was done and revealed that there would be sufficient bone between the three roots to immediately place a dental implant at the time of extraction (Figure 3). Using inter-radicular bone to stabilize an implant is well documented³ and will allow the implant to be stabilized and in bony contact all along its length from apex to crest.

After profound anesthesia was attained using 2% lidocaine with 1:100K epinephrine, a spade proximator was utilized to create a space between the alveolus and the tooth roots. The tooth was then extracted with a 301 elevator and a 150 forceps. Careful attention was taken to prevent any damage to the potentially fragile buccal plate and crucially needed inter-radicular bone (Figure 4). The sockets were debrided with a serrated curette to remove any periodontal ligament remnants and induce sufficient bleeding to encourage bone growth and regeneration. The extraction site was then irrigated with sterile saline to flush out any debris.

A high-speed handpiece with a long-shanked 703 surgical-carbide bur was used to create a purchase point for the initial pilot drill (Figure 5). A 1.5 mm pilot drill was used to a depth of 8 mm (Figure 6). This will put the tip of the pilot within 1 mm of the sinus floor, thus allowing the implant to “bump” the sinus floor when seated to its final position. Next, a 1.5/2.4 mm pilot drill followed the initial trajectory of the 1.5 mm pilot to open the osteotomy (Figure 7) allowing the use of a 3.0 mm twist drill (Figure 8). Following the surgical protocol outlined for the Hahn Tapered Implant system, the osteotomy was serially opened up to a diameter of 7 mm using the length-specific drills (Figures 9-11). The incorporation of length-specific drills into the system negates the need for drill stops and makes depth assessment easy. The final osteotomy can be seen with some communication with the remaining root sockets (Figure 12). As stated earlier, the implant will be stabilized apically and at the point where it comes in contact with bone within the site.

A 7 mm x 8 mm Hahn™ Tapered Implant (Glidewell Direct) (Figure 13) was delivered to the osteotomy using an implant handpiece set at 25 rpm and maximal torque. The Aseptico^® AEU-6000 drilling unit has a top end torque limit of 55 N/cm, and the implant attained approximately 50 N/cm at placement (Figure 14). Since the implant restoration will be platform-switched, the final position, approximately 1 mm below the buccal crest, was done by hand with a torque wrench, making sure to position the flat of the long tapered internal hex toward the buccal (Figure 15). This normally does not matter unless you are using a stock angled abutment or a multi-unit abutment, but I prefer to place all my implants this way for consistency. It also makes it easier to line up impression copings and abutments when you cannot directly visualize the internal connection position. The internal connection on these implants is color-coded to correspond to platform restorative size for easy recognition at either the impression or restoration phases of treatment.

A 3 mm concave-sided healing abutment was placed (Figure 16), and approximately  0.5 cc of particulate allograft (Newport Biologics™) mixed with blood was placed into the sockets and the gaps between the implant body and the buccal-palatal bone (Figure 18). The use of this wide-body implant minimized the amount of material necessary to graft the site. The 7 mm x 8 mm implant body provides a tremendous amount of surface area for osseointegration and ultimately contributes greatly to long-term resistance of occlusal loads.

The soft tissue was sutured with a 4.0 PTFE suture (Figure 19). The spaces between the approximated tissue will granulate in by secondary intention, thereby producing keratinized tissue around the abutment. The final radiograph shows an implant in excellent position to facilitate a cosmetically pleasing and well-functioning final restoration (Figure 20). The patient returned to the office for a 10-day postoperative check and suture removal. The site is healing as expected (Figure 21), and impressions for the final restoration will be taken in 2.5 months.

Conclusion
As treating doctors, every step we can take to decrease treatment time, increase long-term success, and satisfy our patients will go a long way toward assuring our own success as practitioners. The use of a wide body implant immediately placed in conjunction with extraction is a viable and predictable treatment option to help you stand out in a competitive dental world.

Charles Schlesinger, DDS, FICOI, is the founder and CEO of The C.D. Schlesinger Group, a dental implant consulting company.

For the past 10 years, he has been an internationally renowned implant educator, teaching implantology based upon his years in private practice and his work as an implant company executive.

1. Specialty care in the general dental practice. Decisions™ in Dentistry. Dec 2015. https://decisionsindentistry.com/article/specialty-care-in-the-general-dental-practice/. Accessed November 18, 2016.

2. Dichter D. Loading Protocols for Dental Implants. Spear® Education. April 26, 2016. https://www.speareducation.com/spear-review/2016/04/loading-protocols-for-dental-implants-1. Accessed November 18, 2016.

3. Schlesinger C. Immediate implant Placement: cutting treatment time in half. Implant Practice US. 2015;8(5): 20-24.

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