I just received this written question from a patient who is trying to figure out what he should do.

“I don’t understand why some places claim they can do all the work in one visit, Dr. Young says I have to wait to heal after that 1st step.”

This individual lost a lower first molar a while back and would like to replace it with a dental implant. The area is now healthy, having been grafted with bone months ago. In the spirit of good due-diligence he is reading things on the Internet and talking with friends. Evidently some are saying that he should be able to have the tooth placed on the implant the same day the implant is placed.

I don’t advertise this option for a reason, it is not predictable enough.

There are situations where this can work, but there are just as many, if not more, where it will not. The reason has to do with how bone heals to the surface of a dental implant.

When dental implants are placed they must be in intimate contact with the surrounding bone. Bone cells do not travel long distances. They replicate and grow into open spaces not inhabited by other cells of the body. When dental implants are placed immediately following the extraction of teeth, sometimes the socket left behind by the tooth is larger or a different shape compared with the diameter of the implant. This results in a gap between the implant and the bone. It still may be possible to place the dental implant in this situation as long as there remains enough native-bone contact to stabilize the implant. If the implant wiggles at all, bone cells will not grow and mineralize (harden) to its surface.

There are still other situations where putting a dental implant under stress by immediately placing a tooth and chewing food with it will cause the implant-bone connection to fail. For example, sometimes bone is soft. The placement of the dental implant in this type of bone can strengthen the bone because it will have to remodel, but this will take some time. Think of it like slow setting cement. Another reason to delay loading the implant by putting a tooth on it has to do with there being a less than ideal quantity of bone around it at time of placement. Sometimes this requires widening the area either before or at the time of the surgical placement of the implant. When these become necessary, loading the stand-alone implant is not recommended.

Ultimately, for a dental implant to be successful (and being successful includes having enough strength to resist chewing forces, not to mention looking good and being pain free) the bone, made up of living bone cells, must attach to the surface of the implant. Touching the surface is not the same as attaching to the surface. There is a phase of healing that must take place after placement and the localized injury to tissues this necessarily causes. During this healing phase the initial response of bone is to briefly demineralize (get softer). In this initial phase, wounded and dying bone cells are removed by other cells nearby and new bones cells are formed to replace them. The final step of bone cell maturation is remineralization. Again, think of this as bone hardening.

Sometimes the initial resistance of the implant as it is seated into the bone is greater than the weakest remineralization step. In this case, it is possible to place a tooth onto the dental implant immediately, however, this is always a temporary tooth (or I think should be) and it is always kept from direct contact from the opposing teeth. In other words, it is possible to place a tooth on a dental implant at the time it is placed, but it is usually a temporary tooth and it is designed to not take a direct hit by touching the opposing tooth or teeth.

Now, I like to make sure dental implants work the first time because the ultimate objective is for the implant (the artificial root portion placed into bone) is to last and work for the rest of your life. Replacing implants that did not integrate (meaning achieve this hardened bone attachment that makes them ten times stronger than teeth) results in more time spent and potential discomfort by you, the patient.

Dr. Young’s Recommendations:

Ask the following questions when offered the possibility of immediate tooth placement at time of dental implant placement.

  1. Are we talking about a temporary tooth or a permanent tooth?
  2. Does the placement of this temporary tooth cost more than other methods of temporary tooth replacement? Sometimes back teeth do not require a temporary replacement at all during the healing phase.
  3. What happens if the implant must be replaced due to early loading? Do I pay more or is this covered in the initial procedure? (Whose money are we risking here, yours or mine?)

In fairness to dentists who have not placed many dental implants, some implant companies and dentists conducting weekend courses are marketing the idea that most dental implants today are being restored immediately. This is not the case. Just remember, in the end, biology always wins.

2 Responses

  1. Excellent article Dr. young. The second question is a little sneaky and might embarrass some operators. I understand the the importance of giving tissues time to heal but I would like to see strong evidence that immediate loading is successful in anterior teeth because it would help a lot people who can’t afford to be edentulous when they smile. I made a flipper for a patient replacing #9; immediate placement of Nobel active and embedded it. 2 weeks later, the patient lost it and already hated it that’s why he kept taking it off till he lost it. Would be good for immediate loading concept to be successful.

    1. Thanks Tarek,
      I have seen case reports where immediate loading of an anterior implant was successful, however, this is a far cry from having a highly predictable system. Usually with a strong enough initial torque and a good sized implant (not narrow diameter or too short a length) it is possible to go to immediate provisionalization. Always the temporary crown is out of occlusion so it does not hit in any excursions. Then the patient is told to baby the implant and that any blow might cause it to fail in integrating. There should be an additional fee for the work of delivering the provisional. Adding to the challenges, often these implants are placed at time of extraction of the failed tooth. Now the amount of native bone in contact with the implant for stability is critical.

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