Lately I have been placing a lot of immediates (especially now since I’m also placing implants for Western Dental).
I want to share a trick I picked up a little while back.
I am getting better at extracting root tips. Especially now that I’ve gotten a few new tools for fishing those suckers out. (spade elevators & periotome + mallet) But every now and then I get a root tip that just won’t come out. Especially for anterior teeth, I don’t want to damage the bone getting the root out.
I’m going to show you how to prepare your implant site and make it easier to extract that root tip all in one fell swoop. Sound good? Read on.
What I do is just straight up drill through the remaining root tip. Make sure to drill a little lingual and at the angle that you want your implant to end up.
Then I take an x ray to make sure that the drill is past the apex of the tooth. That way I know that the tooth will easily split apart with some elevators, rather than breaking and leaving an even smaller root tip to fish out.
X ray looks solid. You can see that I am past the apex of the tooth by a couple of millimeters.
I can then finish splitting the root tips apart with a spade and straight elevator and I deliver each piece individually. You still have to be careful not to damage the buccal plate. In this case, I actually fractured the plate when I delivered the roots (Damn ironic that I happened to fracture the buccal plate while trying to teach you how NOT to fracture it. Whatever. This is still a damn good technique)
It wasn’t a huge fracture.
In situations like these, I like to sink my implants a little deeper. The reason is that my priority number one is to avoid threads from showing on the buccal. If sinking the implant a bit will help prevent this, I’ll do so. Second, If I am worried about the gum level, I will completely submerge the implant with a cover screw and then pull tissue from the lingual aspect during my uncovery procedure.
In molar sites, I’ll submerge immediates like 3mm. Its because I’ve seen a lot of resorption at these sites. For anterior sites, you have to be much more careful with how deep you place the implants because esthetics play a major role in defining success for these sites. [I’ve updated this paragraph in response to questions about bone loss when submerging immediate implants below bone level. Thanks for bringing this up, Ronald! This is a great topic. I’ll make that my next lit review blog post.]
This following x ray shows my final drill.
Note that I drilled near the floor of the nose. I didn’t have to, but I like to drill a little deeper than I intend to end up. This helps avoid any annoying “bottoming out” or spinning of the implant.
Check out my preparation in the picture below. Yea…you can also see the buccal wall fracture :( Don’t you appreciate that I show my mistakes too?
Anyway, I kept the preparation lingual and it is VERY distinct. A common mistake is to not make your preparation distinct enough from the socket. If that’s the case, the implant can slip out of your preparation and slide into the socket. This will lead to an off angle implant or an implant just sitting in the base of the tooth socket not engaged to anything — both situations are to be avoided!
Here’s the final x ray. Note that I didn’t sink the implant as deep as my deepest drill. The most important decider of depth, is your future emergence profile. That is what guides me for how deep to sink my implants. Usually I end up within 1-2 mm of my final drill depth. In this case I ended up about 3mm away.
Anyway, I’m just nitpicking so that you can hopefully take away something useful.
Also, I like to add the healing abutment. It’s especially handy because when I sink the implants below bone level, bone often ends up covering the cover screw. This makes the uncovery a little tricky.
When the cover screw is covered in bone, I have to use my bone profiling burs to grind away bone around the implant at my uncovery appointment and it is sometimes difficult to seat the impression coping. Using a healing abutment allows me to make the restorative phase pain-free for the patient and easy for me to take the impression.
Hope that helps!
PS: Yes in this case socket shield is a good alternative (although more technique sensitive). However, this is still a great technique to be familiar with. It works well for every single situation in which you have a root tip stuck and are hoping for immediate placement. Good luck!