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Understanding Immediate Implants

‘How long should I wait after extracting my tooth to get implants?’

‘Can I get implants immediately after extracting my tooth?’‘

There are so many clinics out there saying I can get my implants on the SAME DAY after extracting me teeth! Is it too good to be true?’

If you have ever asked yourself these questions, this article is for you!

Google the word ‘implants’ and you will be met with a bevy of dental clinics offering ‘SAME DAY IMPLANTS’ or ‘IMMEDIATE IMPLANTS’ with the implied promise that you will be able to get your implants immediately after extraction.

This plays into the immediate gratification that we millenials are used to nowadays. Want something? You can always get it now, now, now!

Firstly, the term ‘immediate implants’ is a slight misnomer. You usually cannot get fully functional implants within a single visit. At the maximum, temporary implant which is not in occlusion. You will still have to return at a later date for the permanent crown.

*insert pic: immediate implant with temporary to final crown*  

Can immediate implants be done? Yes, in carefully selected cases only.

Are these clinics promising too much of a good thing? Probably.

Scenario 1: You lost your tooth a while ago. It has affected your chewing occasionally but has never bothered you enough to want to get something done about it.

Your friend recently had an implant done and was just telling you how great it feels.  You are thinking about getting implants now. How soon can you get it?

Implants are classically done in a 2 stage procedure. This was and always has been the gold standard in terms of success. Numerous studies have shown that this 2 stage procedure had the greatest amount of success, and hence, it became widely followed.

The drawback, however, was that the entire process would take up to 6 months. Yes, 6 months before you could get a fully functioning implant!

In the first stage, only the implant screw is sunk into the bone. The area is then stitched up, and left alone to heal for several months. This was due to the traditional idea that the bone and implant needed time to integrate and form a union.

Of course, newer studies have challenged that notion, hence explaining why dentists have been hastening the process of implants. This is not without its risks, but we will get to it later.

Implants replacing back teeth are usually left alone to heal for a longer period of time. This is because the bone at the back of the jaws are softer, and may take anywhere between 4-6 months to fully heal.

For implants replacing front teeth, the implant screws were left for around 2-3 months.

The second stage of implant placement involves doing a second surgery to expose the buried implant. At this stage, X-rays are taken to ensure that the implant has fully integrated with the bone and is stable.

Once the implant screw is deemed stable, healing abutment is placed in.

After another few weeks, the final crown portion of the implant is placed in.

In total may be about 6 months before can get final implant. To shorten the waiting time to please impatient patients, dentists have experimented with shortening the waiting time between first and second stage.

Early loading refers to waiting 3-4 months for posterior implants
Immediate loading refers to less than a week.

There are generally few studies done on immediate implants. One well known study shows that immediate implants can work predictably completely edentulous mandible, when multiple immediately loaded implants were used but they had to be restored with splinted crowns or a denture.

Immediate implants replacing a single tooth have been shown to work, but we are unable to definitively say so.

Scenario 2: You are experiencing problems with a tooth. Your dentist tells you that the tooth needs to be extracted. You are thinking about getting an implant after extracting your tooth. Can you get your implant immediately after extracting your tooth?

The Ministry of Health, in conjunction with the Academy of Medicine, have laid out a few guidelines for practicing dentists to follow in their treatment. (click here for the full guidelines)

After a tooth is extracted, what is left behind is a space called the extraction socket. Over time, this socket heals.

*insert pic of healed socket *

The recommendation by MOH is that implants placed after extraction sockets have healed is the treatment of choice. This means that although you can get implants done immediately after extracting your tooth, it is best to wait for the extraction socket to heal before getting an implant.

MOH goes on to further state that ‘implants may be placed in fresh extraction sockets… with the patient’s understanding that survival rate is lower than those placed in healed sockets’.

They continue to state that ‘Although implants placed into fresh extraction sockets do survive,there is a slightly lower survival rate as compared to implants placed into healed alveolus. The survival rate of implants is also reduced when they are immediately loaded as compared to loading after a healing period.’

Based on the MOH guidelines, what would be the recommended treatment for my case?

Let the extraction site completely heal first. This will take anywhere between 3-4 months. Why does it take so long? Although the extraction site may seem to heal after 2 weeks, it usually takes much longer for the underlying bone to heal.

After that, a one- stage or two-stage implant procedure is done. The entire procedure will take another 6 months before you can finally get your crown (click here for a comprehensive guide to the implant process)

In this day and age however, this practice is considered arcane and outdated.

Of course, these are just recommended guidelines based on studies that have been done. There have been many reported cases of successful outcomes of immediate implants. In fact, many dentists now routinely offer it as their first line of treatment.

You just have to be aware of the risks and consequences

What do clinics mean by immediate implants? Do I get the whole implant AND the crown immediately?

This is where things get tricky. ‘Immediate implants’ are usually a misnomer. Let us step back for a second and define the terms. An implant is basically made up of 2 parts: the implant screw, and the crown.

*insert pic*

When clinics say ‘immediate implants’ after an extraction, they could mean 2 things:

- Immediately placing only the screw in after the implant.

- Immediately placing the screw AND the crown after the implant

Scenario 2 rarely happens, yet that is what most patients think will happen! And that is some misinformation that I hope to correct.
You will almost never get a fully functioning implant and crown on the day of your extraction.

What usually happens is Scenario 1 - where only the screw is sunk in on the day of your extraction. A temporary crown can be used in the meantime to allow the tissues to heal.

However, you will still have to wait for a period of a few months before the final crown can be done.

However, the benefit is that you will have shaved off a few months of the whole implant procedure, when compared if you had fully waited for the extraction socket to heal before placing in the implant screw. (again, click here for an in depth explanation of the implant procedure!)

What is the procedure for immediate implants?

At the first visit, a thorough examination is done and X-rays will be taken. You will have a consultation with your dentist to determine if your case is suitable for an immediate implant. After your tooth is extracted, the extraction socket will be thoroughly cleaned out.

Bone is then drilled beyond the depth of the extraction socket. This is to allow a site for the implant to be placed in.

What you have now is implant surrounded by empty space, Bone grafting material in place, Depending on situation - the area is sutured up, OR healing abutment immediately with temporary crown.

The extraction socket is then filled up with bone grafting material. Temporary prosthesis is then screwed on. You will be instructed to avoid chewing on the area so as to let the socket heal and also to let the implant stabilise.

After 2-3 months, the final implant will be screw on.

What are the disadvantages of doing immediate implants?

It is important to note that implants are considered a relatively new field in dentistry. Although they started in ____ and have been practiced for many years, there are few scientific studies in many areas of implants. Immediate implants are one area where there have been a lack of studies done.

If you were to decide to do immediate implants, do note that it is a highly selective procedure which should not be done without due diligence, appropriate investigations, and discussions with your dentist.

Not everyone is suitable for the procedure.

The following requirements generally have to be met:

- Implants must be placed 4-5mm beyond the apex, means that there has to be enough bone for implant to engage in the extraction site. If hole is too big, implant will not be stable

- Placed as close to alveolar crest level

Dentistry is evidence based practice:
Current studies do not meet strict criteria - number of cases too small, not randomised enough etc
More studies are needed before immediate implants can be scientifically recommended

So should I get immediate implants or wait out the normal procedure?

This depends on how much of a risk you want to take, and it also depends if your case is suitable for an immediate implant.

Depends if it is anterior teeth- posterior can usually wait. Also usually covered by bone grafting material.

Some people present with infected tooth, infected socket, gum disease, should not do immediate implants.

If the tooth to be extracted is tilted, implant cannot fit in. If the extraction socket is not favourable for implant placement, also cannot do.

Explain conventional loading - how many months

Early loading Immediate loading - most advertised

Usually use immediate denture first

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