7 Fugazzotto

Case Series

Implant Placement at the Time of Maxillary Molar Extraction:Technique and Report of Preliminary Results of 83 Sites

Paul A. Fugazzotto*

Background: The purpose of this study was toevaluate the predictability of implant placement atthe time of maxillary molar extraction using a modi-fied insertion technique and implant design.

Methods:At the time of maxillary molar extraction,83 tapered-end implants with an apical diameter of4.1 mm and a neck diameter of 6.5 mm were placedin maxillary first or second molar sites, following ma-nipulation of the remaining interradicular bone withosteotomes. Regenerative materials, consisting ofdemineralized freeze-dried bone allograft (DFDBA)and/or osseous coagulum, and bioabsorbable ornon-resorbable membranes were placed, and passivesoft-tissue primary closure was attained in all cases.

Results: Soft-tissue closure was maintained untilthe time of clinical reentry 6 months after implant in-sertion in 81 of 83 sites. Loss of primary soft-tissue clo-sure in the other two areas did not result in completeuncovering of the cover screwand implant top. All im-plants were clinically immobile at the time of implantuncovery 6 months after insertion and were restoredwith single crowns. All implants were functioningsuccessfully for up to 18months (mean: 12.4 months).

Conclusion: The combination of atraumatic re-moval of hopelessmaxillarymolars, controlledmanip-ulation of the residual interradicular bone, insertion ofimplants of the aforementioned design, and use of ap-propriate regenerative materials at the time of implantinsertion predictably afforded a stable implant forrestoration with a single crown. J Periodontol 2006;77:302-309.

KEY WORDS

Bone regeneration; implants.

The predictability of implant insertion at thetime of tooth removal and subsequent resto-ration is well documented in a variety of clin-

ical situations. Depending upon the residual extractionsocket morphology, regenerative materials are notalways placed around immediately inserted implants.However, the ability to regenerate the alveolar bonesurrounding an immediately inserted implant throughthe use of sundry autogenous and non-autogenousmaterials beneath various covering membranes is wellaccepted. Such a treatment approach helps lessen thealveolar remodeling and atrophy which would occurfollowing tooth removal in the absence of implantplacement and/or regenerative therapy.1

Caldwell-Luc sinus augmentation therapy has beenshown to be highly effective in regenerating adequatealveolar bone for implant placement in the atrophicposterior maxilla and in regenerating alveolar bonearound implants inserted at the time of sinus augmen-tation therapy.2-7 Summers8 and Rosen et al.9 intro-duced a more conservative therapeutic approach toeffect limited sinus augmentation therapy and imme-diate implant placement by osteotome elevation ofthe sinus membrane through the implant osteotomysite and placement of autogenous or non-autogenousparticulate regenerativematerial in the osteotomy siteprior to implant insertion. This technique has beenreported upon by a number of authors,1-16 albeit withminor modifications by various authors. A review ofthese papers has been published.17 Modifications tothis technique have been published,18,19 as has a pro-posed hierarchy of treatment selection in an attemptto elucidate when best to employ various approachesto sinus augmentation therapy.1

Immediate implant insertion in maxillary molar ex-traction sockets poses a number of unique challengesto the conscientious clinician including the needto preserve the interradicular bone at the time oftooth removal, the often problematic position of themaxillary sinus around the roots of the tooth to beextracted, the compromised nature of the residualinterradicular bone when faced with periodontally

* Private pratice, Milton, MA. doi: 10.1902/jop.2006.050055

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hopeless maxillary molars, and the difficulty in plac-ingand ideally positioning the implant to accept futureprosthetics as a result of the position of the residualinterradicular bone.20 Placement of an implant inone of the three existing root sockets following max-illary molar removal will result in a less-than-idealimplant emergence profile, significant off-angle load-ing, and the creation of a cantilever effect eitherbuccally, mesially, or distally, depending upon whichextraction socket is chosen to accept the implant.

This article documents a technique to help facilitateimplant placement in an ideal position at the time ofmaxillarymolarextractionandexaminespreliminaryre-sults following employment of this treatment approach.

MATERIALS AND METHODS

Eighty-three adult patients (39 men and 44 women)aged 38 to 68 years presented with either periodon-tally or restoratively hopeless or fractured maxillaryfirst or second molars. All patients were non-smokerswith non-contributory medical histories. None of thepatients had undergone chemotherapy or radiationat any time. The study was conducted from June2002 to June 2005 in accordance with the HelsinkiDeclaration of 1975, as revised in 2000. Subjects pro-vided informed consent to participate in the study.

A complete examination of oral hard and soft tis-sues was conducted for each patient, and an overalldental treatment plan was formulated in conjunctionwith the treating restorative dentists. Panoramic radio-graphs were taken of all patients, as were formattedcomputed tomography (CT) scans, when they weredeemed clinically necessary. Diagnostic casts, wax-ups, and surgical templates were also used as needed.

Thepresenceorabsenceofperiodontal orperiapicalpathology had no bearing on patient selection. Fifty-three teethwere removeddue to theextentofperiodon-tal destruction; four teeth were removed due to cariousbreakdown; and 26 teeth were removed as a result oftooth fracture (Table 1). Eight teeth presented priorto removal with radiographic evidence of periapicalpathology. Eleven teeth demonstrated clinical evi-dence of exudate prior to removal.

Description of TechniqueFollowing administration of local anesthetic, a sulcu-lar buccal incision was made around the tooth to beextracted. Mesial and distal vertical releasing inci-sions were placed on the mesial aspect of the mesialpapilla and the distal aspect of the distal papilla andextended past the mucogingival junction well intothe buccal fold. Horizontal releasing incisions wereplaced at themost apical extents of the buccal verticalreleasing incisions and extended;6 to 7mmhorizon-tally as described previously.21 A full-thickness mu-coperiosteal buccal flap was reflected, and a lingualsulcular incision was placed on the tooth to be re-moved and the adjacent teeth. A mesial vertical re-leasing incision was placed on the mesial aspect ofthe toothmesial to the tooth to be removed, and a dis-tal vertical releasing incision was placed on the distalaspect of the tooth distal to the tooth to be removed.A full-thickness palatal mucoperiosteal flap wasreflected. If the tooth to be removed was a secondmolar, the flap design was modified so that a distalwedge incision was placed on the distal aspect ofthe secondmolar, which extended over the tuberosityinto the mucosa, with a buccal and palatal releasingincision. The distal wedge tissue was reflected in afull-thickness manner buccally and palatally.

The tooth to be removed was trisected and eachroot was removed individually, unless three distinctroots were not evident. In such a situation, any distinctroots were separated and removed. The socket wascarefully debrided to remove any granulation tissueand any periapical lesion that was evident.

Clinical and radiographic assessment was carriedout to determinewhether adequate heightwaspresentcrestal to the sinus floor to allowplacement of an11.8-mm long implant (10mm of a roughened surface and1.8 mm of a polished collar) so that the 10 mm of theroughened surface of the body of the implant would beat or below the level of the anticipated regenerated al-veolar bone following regeneration. A round bur wasused at 550 rpm under copious irrigation with sterilewater to make a notch in the most crestal aspect ofthe residual interradicular bone. A tapered-end osteo-tome with a maximum diameter of 2.2 mm was uti-lized to compress and implode the interradicularbone beneath the tip of the osteotome and to spreadthe interradicular bone lateral to the osteotome. If ad-ditional height was not needed to ensure placement ofthe complete roughened surface of the implant withinthe confines of the expected regenerated bone, the os-teotome was malleted to a depth that allowed place-ment in the aforementioned position. If additionallength was required to place the implant at the desiredposition, the osteotome wasmalleted to the appropri-ate depth, lifting the floor of the sinus (Figs. 1 through3). In no instances did the osteotome extend beyond

Table 1.

Reason for Extraction

Teeth Extracted Periodontal Disease Caries Fracture Total

First molars 44 2 24 70

Second molars 9 2 2 13

Total 53 4 26 83

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the original floor of the sinus for a distance greaterthan 2· x, with x being the height of the residual in-terradicular bone (Table 2). Osteotomes of 2.8- and3.5-mm maximum diameters were used sequentiallywith gentle malleting to broaden the osteotomy site inthe interradicular bone. When additional length wasrequired, 2.8- and 3.5-mm wide osteotomes weremalleted to a depth equal to the depth attained origi-nally with the 2.2-mm wide osteotome.

A tapered-end implant† with an apical diameter of4.1 mm and a neck diameter of 6.5 mm was insertedinto the prepared osteotomy site using a handpiece at

30rpmwithcopiousirrigation.Theimplantwasinsertedtosuchadepthastoensurethatthe10mmoftherough-ened surface of the implant were at or below the ex-pected height of the alveolar bone to be regenerated.

Osseous coagulumwas packed around the implantwhen available. If osseous coagulum was not avail-able, demineralized bone matrix paste‡ was flowedaround the implant to fill the residual extractionsocket defect. Either a bioabsorbable membrane or atitanium-reinforced expanded polytetrafluoroethy-lene (ePTFE) membrane§ was trimmed to size andsecured with two buccal titanium tacksk at its mostapical extent. If the residual extraction socket mor-phology was deemed capable of supporting an over-lying membrane without collapse, a bioabsorbablemembrane was used (Figs. 4 through 13). If the

Figure 1.The most crestal aspect of the interradicular bone was notched witha round bur after trisection and extraction of a maxillary molar.

Figure 3.Following further spreading of the interradicular bone with 2.8- and3.5-mm wide osteotomes, respectively, an implant was inserted withan apical diameter of 4.1 mm and a neck diameter of 6.5 mm.

Figure 2.A 2.2-mm wide tapered osteotome was used to spread theinterradicular bone and lift the floor of the sinus if necessary.

Table 2.

Extension of Implant Beyond OriginalSinus Floor Position (in mm)

Implant Position 0 <3 3 to 5 >5 Total

First molar 34 31 4 1 70

Second molar 8 4 1 0 13

Total 42 35 5 1 83

† Straumann, Andover, MA.‡ Exactech, Delaware, MD.§ W.L. Gore & Associates, Flagstaff, AZ.k Ace Surgical Supply, Brockton, MA.

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residual extraction socket morphology could notsupport an overlying membrane without collapse, atitanium-reinforced membrane was employed, asoutlined previously.22

The mucoperiosteal flaps were tested for their abil-ity to attain passive primary closure following sutur-ing. The horizontal extensions of the buccal verticalreleasing incisions were extended as necessary, inconjunction with the aforementioned full-thicknessreflection, to provide greater flap mobility. A rotatedpalatal pedicle flap was used to help enhance the at-tainment of passive primary closure in seven cases.23

When treating second molar sites, the buccal aspectof the distal wedge was rotatedmesially and crestally,in conjunction with a rotated palatal pedicle flap fromthe palatal aspect of the distal wedge, to help ensureattainment of passive primary closure.

Postoperative ManagementPatients were placed on 500 mg amoxicillin threetimes a day for 10 days and 400 mg etodolac three

Figure 4.A maxillary molar was trisected and extracted, as were the first andsecond bicuspids.

Figure 5.A 2.2-mm wide osteotome was used to begin preparing andspreading the interradicular bone.

Figure 6.A view of the interradicular bone after using the 2.2-mm wideosteotome.

Figure 7.A view of the interradicular bone after using the 2.8- and 3.5-mmwide osteotomes.

Figure 8.The implant was inserted at 30 rpm with copious irrigation.


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times a day for 5 days. In cases of patient allergies,333 mg erythromycin three times a day for 10 dayswas substituted for amoxicillin. Hydrocodone wasused as necessary for pain. No removable prostheseswereworn at the sites of tooth removal, implant place-ment, and regeneration until the time of implant un-covering 6months after therapy had been performed.

RESULTS

Eighty-three implants were placed in 83 patients. Inno instance was the attempt to place an implant inthe interradicular area at the time of tooth extractionunsuccessful. Primary soft-tissue closure was main-tained until the time of 6-month implant uncoveringin 81 of 83 sites. The two sites that exhibited loss ofprimary closure demonstrated partial exposure ofthe implant healing screws. No full exposure of theimplant healing screw or implant neck was noted inany site.

Prior to implant uncovering, radiographswere takento assess bone regeneration and maturity. Following

Figure 10.Osseous coagulum was packed around the implant to fill theresidual extraction socket defect. A bioabsorbable membranewas subsequently placed.

Figure 11.A radiograph of the implants in place 5 months postoperative.

Figure 12.A radiograph of the restored implants after 18 months in function.

Figure 13.A buccal view of the restored implants.

Figure 9.A view of the implant in place in the manipulated interradicular bone.


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implant uncovering, all implants were clinicallyimmobile and seemed on course to fulfill the clinicaldefinition of osseointegration.

All implants were restored with single porcelain-fused-to-precious metal crowns. The implants werefunctioning for 12 to 18 months, with a mean func-tional time of 12.4 months. All implants were func-tioning successfully at this early stage according tothe criteria of Albrektsson et al.24

DISCUSSION

Use of osteotomes as described by Summers9 to ef-fect localized sinus augmentation presents significantadvantages over conventional Caldwell-Luc sinusaugmentation therapy with regard to invasiveness ofthe procedure, postoperative morbidity, and thelength of the course of therapy. It is not uncommontowait 6 to 9months from the timeof lateral-approachCaldwell-Luc sinus augmentation surgery to implantinsertion. The implants are usually uncovered 2 to 6months after insertion depending upon the specific in-vestigator’s protocol. When implants have beenplaced at the time of lateral-approach Caldwell-Lucaugmentation surgery, investigators report waiting 6to 8 months before implant uncovering and loadingdepending upon the regenerative materials used andthe specific investigator’s protocol.2-8,25-35

The treatment approach described in the presentarticle offers a number of advantages including theless invasive nature of the surgical procedure and ashorter course of therapy than that of lateral-approachCaldwell-Luc augmentation surgerywith simultaneousimplant placement. The need for only one surgicalsession offers an additional advantage over Caldwell-Luc surgery with second-stage implant placement.In comparison to tooth extraction and augmentationto regain ideal ridge form, followed by implant place-ment with or without osteotome use, the reportedtechnique offers two advantages. The most obviousis the need for one surgical entry as opposed to twosurgical sessions. In addition, the course of therapy,including significant regeneration of the alveolar ridgefollowingmaxillarymolar extraction, is only 6monthsfrom surgical entry to implant uncovering and loadingthe area. Although it is sometimes possible to extracta maxillary molar and reenter the area ;3 monthslater for implant placement, such rapid reentry isnot ideal or is impractical if significant ridge augmen-tation and regeneration of prepathologic ridge mor-phologies are desired. In such a case, the tooth isextracted, and ridge augmentation therapy is per-formed. The area is reentered 6 months later for im-plant placement. The implant is then uncovered 2 to6 months after insertion depending upon preferredclinical protocols. Therefore, the advantages to theapproach described in this article are the need for only

one surgical visit and the shorter course of therapycompared to other treatment approaches.

Amodification of the Summers’ technique to affordthe ability to effect such localized augmentation at thetime of maxillary molar extraction has previouslydemonstrated a high degree of predictability.20

Now, a technique has been presented that demon-strated further modifications of these therapies toallow placement of implants in ideal prosthetic posi-tions at the time of the removal of maxillary molars,with or without localized sinus augmentation therapyas required.

Using a specifically designed implant with a4.1-mm wide apex and a 6.5-mm wide neck helpsminimize the amount of spreading of the residualinterradicular bone required for implant placementand stabilization, thus lessening the chance of interra-dicular bone fracture and loss of a key componentnecessary for attainment of initial primary stabilityof the implant.

This technique is highly effective not only in in-stances where a broad interradicular septum is evidentradiographically but also in situations that seem to in-dicate radiographically a paucity of interradicular bonefor manipulation and eventual stabilization of the im-plant. The unique configuration of the implant de-scribed allows its effective placement in thin, residualinterradicular septa (Figs. 14 through 16).

Using flap designmodifications and innovations af-fords the opportunity to predictably attain and main-tain passive primary closure over first and secondmolar extraction sockets following placement of im-plants and regenerative materials.21 It is importantto note that the covering membrane is chosen notas a function of the ability or inability to attain andmaintain passive primary closure but as a function

Figure 14.The maxillary first molar was fractured and hopeless. Despite theradiographic appearance of insufficient interradicular bone for implantstabilization, this area was amenable to immediate implant insertionfollowing appropriate osseous manipulation.


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of the residual alveolar ridge morphology.36 If the re-sidual ridge defect is not space maintaining, a tita-nium-reinforced membrane is used. The buccalwalls of the extraction sockets of the buccal rootsare not routinely removed and compressed to narrowthe buccal palatal width of the alveolar ridge in an ef-fort to aid the attainment of passive primary closure.Rather, the goal is to regenerate an ideal prepatho-logic alveolar ridge morphology. Although such anapproach places significant demands upon the clini-cian in the quest to attain and maintain passive soft-tissue primary closure, there is no doubt that suchsoft-tissuemanagementmay be realistically expected.

CONCLUSIONS

Using the outlined treatment approach helps elimi-nate many clinical compromises often encounteredwhen placing implants at the time of maxillary molarextraction. These compromises include non-idealimplant positioning in one of the three extractionsockets, loss of ideal alveolar ridge morphology in

an effort to attain soft tissue closure, compromisesin regenerative material selection due to the afore-mentioned soft-tissue concerns, and a high degreeof exposure of regenerative materials in the earlystages of healing. The result is the compromisingof the hard- and soft-tissue treatment outcomessurrounding the implant. Through the use of the tech-niques described here, all such therapeutic compro-mises may, at worst, be significantly minimized and,at best, be predictably avoided.

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rooted tooth removal: A literature review and proposedhierarchy of treatment selection. J Periodontol 2005;76:821-831.

2. Jensen OT, Shulman LB, Block MS, Iacono VJ. Reportof the Sinus Consensus Conference of 1996. Int J OralMaxillofac Implants 1998;13(Suppl.)11-45.

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Figure 16.A radiograph of the restored implant in function for 16 months.

Figure 15.A radiographic view after the first molar was trisected and extracted,the interradicular bone manipulated, and the implant placed.


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16. Winter AA, Pollack AS, Odrich RB. Placement ofimplants in the severely atrophic posterior maxillausing localized management of the sinus floor: Apreliminary study. Int J Oral Maxillofac Implants 2002;17:687-695.

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27. Fugazzotto PA, Vlassis J. Long term success of sinusaugmentation using various surgical approaches andgrafting material. Int J Oral Maxillofac Implants 1998;13:52-58.

28. Khoury F. Augmentation of the sinus floor with man-dibular bone block and simultaneous implantation:A six year clinical investigation. Int J Oral MaxillofacImplants 1999;14:557-564.

29. Mazor Z, Peleg M, Gross M. Sinus augmentation forsingle tooth replacement in the posterior maxilla: Athree-year follow-up clinical report. Int J Oral Maxillo-fac Implants 1999;14:55-60.

30. Peleg M, Mazor Z, Garg AK. Augmentation grafting ofthe maxillary sinus and simultaneous implant place-ment in patients with three to five millimeters ofresidual alveolar bone height. Int J Oral MaxillofacImplants 1999;14:549-556.

31. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus flooraugmentation with simultaneous implant placement inthe severely atrophic maxilla. J Periodontol 1998;69:1397-1403.

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33. van den Bergh JPA, ten Bruggenkate CM, Krekeler G,Tuinzing DB. Sinus floor elevation and grafting withautogenous iliac crest bone. Clin Oral Implants Res1998;9:429-435.

34. Raghoebar GM, Brouwer TJ, Reintsema H, van Oort RP.Augmentation of the maxillary sinus floor with autog-enous bone for the placement of endosseous implants:A preliminary report. J Oral Maxillofac Surg 1993;51:1198-1203.

35. Block MS, Kent JN. Sinus augmentation for dentalimplants: The use of autogenous bone. J Oral Max-illofac Surg 1997;55:1281-1286.

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Correspondence: Dr. Paul A. Fugazzotto, 25 High St.,Milton, MA 02186. Fax: 617/696-6635.

Accepted for publication July 21, 2005.


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7 Fugazzotto