Articles - Forum Implantologicum

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Feature Article

Aug 27, 2025 // 17 min read

Single Tooth Immediate Implant Placement in Molar Sites

Emilio Couso-Queiruga

DOI: 10.63580/ITI.FI.45757

dental implants immediate implant grafts bone substitutes alveolar ridge augmentation cone-beam computed tomography

Abstract

Immediate implant placement (IIP) in molar regions has emerged as a viable treatment option that can shorten rehabilitation time and reduce surgical interventions. However, posterior sites present anatomical and biomechanical challenges, such as complex socket morphology and high functional loading, which may compromise primary stability and subsequent osseointegration. Meticulous treatment planning during the clinical decision-making process is essential, including a thorough assessment of the patient's medical condition, site-specific characteristics, alveolar bone quantity and quality, periodontal status, occlusal factors, anticipated implant-supported prosthesis and proximity to critical structures, among others.

Advancements in customized implant designs and surgical techniques, including minimally invasive extractions, tailored osteotomies, computer-assisted implant surgery, and phenotype modification therapies, have expanded the potential for successful IIP in molar sites. Although favorable outcomes with survival rates comparable to delayed placement protocols have been reported, concerns persist regarding potential intra- and post-operative complications that may affect implant success, including 3D implant malposition, violation of anatomical structures, postoperative infections, early implant failure, and significant alveolar ridge remodeling.

A definitive consensus on the optimal protocol for molar IIP is still lacking due to heterogeneity in clinical approaches and reported outcomes. Therefore, this narrative review aims to explore critical factors influencing treatment success in molar IIP and to support appropriate case selection.

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Introduction

Patients are increasingly interested in shortening treatment duration and minimizing the number of surgical and clinical procedures, while clinicians should ensure long-term successful outcomes (Lilet et al. 2022). In the context of tooth-replacement therapies, immediate implant placement (IIP), with or without immediate loading, has become an attractive treatment alternative, supported by a steadily growing body of evidence (Sabri et al. 2024).

Although IIP could be considered a suitable protocol for single-tooth replacement in the anterior region based on the phenotypical and local anatomical characteristics of the site, its success has also sparked growing attention toward its application in posterior regions (Stefanini et al. 2023). This interest is driven by its predictable outcomes regarding high survival and success rates and minimal marginal bone loss in selected case scenarios (Ragucci et al. 2020). However, IIP in molar sites remains less documented, largely due to the inherent complexities of these regions and their comparatively lower esthetic needs (Meijer & Raghoebar 2020). The challenges arise from the complex socket morphology features of molar extraction sockets, which can impact proper implant positioning and consequently affect primary stability as well as lead to future biological and mechanical complications (Meijer & Raghoebar 2020). Additionally, the expected higher functional load and other occlusal factors in the posterior regions necessitate special attention during evaluation when considering potential loading protocols.

Despite these and other challenges, studies suggest that the survival rates of IIP in the posterior region may be comparable to those of delayed implant placement protocols (Atieh et al. 2010; Ketabi et al. 2016; Ragucci et al. 2020). However, the heterogeneity between study designs across available publications hinders the establishment of a clear consensus on the optimal surgical strategy and prosthetic loading protocol for IIP in molar sites (Meijer & Raghoebar 2020). Hence, this narrative review aims to explore the key clinically relevant considerations to favor successful therapeutic outcomes for IIP at molar sites.

Fig. 1: Factors contributing (green) or limiting (red) the predictability of immediate implant placement in posterior sites of the upper and lower jaw: apical and interradicular alveolar bone volume, thickness of the alveolar bone walls, morphology and divergence of the molar roots, presence of a lingual undercut or acute apical pathosis, proximity of the maxillary sinus or the mandibular canal

Fig. 2: Classification of molar extraction sites for immediate implant placement according to Smith & Tarnow 2013

Fig. 3: To prevent positional deviations during IIP, a pre-extractive implant osteotomy, in which the remaining tooth roots guide the surgical drill’s orientation, might be considered (Rebele et al. 2013). Initial situation with root remnants (a). Minimal flap elevation and implant osteotomy with the tooth roots in place (b). Intraoperative radiograph involving a depth gauge to verify the positional orientation of the implant osteotomy (c)

Fig. 4: Multipanel illustrating the sequence of immediate implant placement in conjunction with alveolar ridge preservation therapy. Initial clinical and radiological presentation of a 53-year-old female patient with a hopeless maxillary first molar (#16) (a, b). Minimally invasive extraction performed with root separation to preserve soft and hard tissues and maintain the integrity of the interradicular septum (c, d). The implant osteotomy followed the manufacturer’s recommendations, and a tissue-level implant was placed (TLX, 4.5. × 10 mm, RT, Straumann, Switzerland) (e, f, g). Note that the implant shifted toward the palatal aspect during insertion, following the path of least resistance toward the palatal alveolus. However, due to the limited bone availability, repositioning was considered challenging and potentially detrimental to primary implant stability. As the final position was deemed suitable for the subsequent procedure by the surgeon, the implant was accepted in its position as placed. Alveolar ridge preservation was performed via socket grafting using a xenograft (Bio-Oss, Geistlich, Switzerland) and socket sealing using a collagen matrix (Mucograft Seal, Geistlich, Switzerland) (i). Postoperative radiograph (j). Clinical follow-up at 12 days (k), 3 months (l), and 6 months (m). Clinical and radiographic situation at the 1-y follow-up shows stable and healthy peri-implant tissues (n, o). (Surgery: Dr. Geoffrey Lecloux, Prosthodontist: Dr. Tanaïs Dony, Lab: Mirko Piccone)