Immediate implant placement is the process of placing the endosseous implant immediately after tooth/root removal. Delayed implant placement allows for healing of the extraction site with or without grafting for a period of four to six months. Clinicians should consider immediate implant placement when faced with the overwhelming need to address certain clinical problems. The instances include but are not limited to:

• A failing endodontic treatment
• A hopeless periodontal condition
• A non‐restorable tooth
• Tooth loss or severe damage due to trauma.

Some typical emergencies that merit immediate implants can be seen in Fig. 11.1.

Table 11.1 outlines the rationale(s) underlying the decision by both clinician and patient to undertake immediate implant placement in order to address the clinical problems indicated above:

Nevertheless, certain criteria must be satisfied if the case in question is to be satisfactorily resolved and the following requirements are recommended for predictable success:

• Atraumatic extraction of the affected tooth
• Intact buccal and palatal/lingual plates
• Absence of purulence and active infection
• Satisfactory oral and systemic health
• Initial implant stability of 30 N.cm insertion torque

If the case does not satisfy any of these requirements, then placement should be delayed until remedial action has taken effect, as noted above in footnote (a).

Two examples of the need for an implant to treat a failed endodontic restoration and periodontally‐involved tooth with severe bone loss [1] are shown in Fig. 11.2 and Fig. 11.3.

In both cases, the size of the bony defects necessitated bone grafting to heal the defects. Consequently, immediate implant placement should not be performed until the defect sites had healed following bone grafting and bony restoration was complete.

There are, of course, several factors that will impact the success (or failure) of the immediately placed implant even when the above criteria are satisfied. The same factors and surgical considerations also apply to delayed placement implants, as discussed elsewhere in this book (Chapters 4, 6–8). Two of the most important of these success‐determining factors are the absence of purulence and infection, together with the need for enough sound bone surrounding the osteotomy site in which the implant will be placed. Another important facet of successful immediate implant placement is to ensure primary stability.

It is also important during preparation of the implant cavity that there is minimal trauma to the surrounding bone which, at least in part, depends on avoiding excessive heat generation during surgical drilling. Achieving this means that there must be careful control of the force applied and the rotational speed of the osteotomy drill, the design of the drill bit, the drill‐bone contact area during the osteotomy and there must be effective saline irrigation throughout the surgical procedure.

Steps in placing an immediate implant are as follows:

1. Raise a flap if necessary
2. Create a purchase point with a sharp‐end cutting drill slightly favoring the palatal/lingual to compensate for increased buccal bone loss
3. Undersize the osteotomy by 1 drill size to achieve primary stability
4. Place the implant palatal/lingual of center, avoiding contact with the buccal plate
   

   

5. Place implant at 1–2 mm below the bone crest
6. Graft the gap with demineralized cortico/cancellous particulate bone
7. Do not attempt primary closure

Raising a flap after extraction is discouraged only if the plates can be inspected from the extraction socket. Raising a flap will lead to an increase in bone loss with a thin buccal plate. A purchase point is created to allow subsequent drills to remain centered. Drills will generally take the path of least resistance which can lead to improper positioning. Since immediate implant placement rarely results in the implant being completed encompassed in bone, it is recommended to undersize the osteotomy to increase torque of insertion and improve primary stability. For example: if placing a 4.7 mm diameter implant, one would use the 4.2 mm drill as the final drill in the osteotomy sequence. If the implant does not easily follow the intended insertion path and falls into the extraction socket, it may be necessary to upsize at least the upper half of the implant osteotomy.