Same-Day Extraction Immediate Lower Molar Dental Implants And Nerve Injury Discussion

Immediate Extraction and Implant Planning –deeply placed nerve.

It is not every day I see a case like this. This patient is going to lose her lower first molar which is the one that is second from the back typically if you are missing your wisdom teeth. It is the most common tooth to be pulled mostly because it has been in your mouth since you were 6 years old. In her case, the tooth is not savable because of severe root decay on an existing crown with a root canal. (Remember that you can get a cavity on a crown which typically happens at the edge or “margin” which is where the tooth meets the crown near the gum line.)

Decay in first lower molar root canal

Usually the lower molars require a “staged” procedure. This means that the tooth is usually extracted first in the implant is placed at a later date.

Most often, a socket preservation bone graft is done to prevent the bone from shrinking after the tooth extraction.

Because the procedure is done in stages, it typically takes 6-12 months to complete often based on how hard or soft your bone is or how fast or slow your bone heals.

What is so unique about her case is the depth of her nerve!! It is DEEP in the jaw! Most of the time, an immediate lower dental implant is not able to be done because this nerve is too close to the surface. Typically I like to place the implant a minimum of 1-2 mm away from the nerve. So if the nerve is high, your oftentimes limited to a short implant or an implant that cannot get enough stability when it is placed into a socket. This nerve gives sensation typically to the lip and chin. There are other branches of the third division of the trigeminal nerve that give sensation to the cheek and tongue.

The nerve is like an electrical cable which carries sensation back to your brain. If you’ve ever gone to the dentist and gotten your lower jaw numbed up, this is the nerve responsible for this.

By keeping a safe distance away from the nerve, an altered sensation or nerve injury complication can be reduced…. But not completely eliminated.  Complications can still occur with either method.

The nerve has several “tributaries” that are like in the fine fibers of a plant root system that you pull out. There is usually one main root and then thousands of little small rootlets. Most of the time as long as the main nerve is avoided, a nerve injury does not occur.

Plant roots —one main one and many tiny extra roots

If the nerve is bruised, you may feel like the numbness and last longer than normal. This is called a paresthesia. The numbness may last an additional 3 days, 3 weeks, 3 months or may become permanent.

It can be a feeling of slight tingling all the way to feeling fully numb. Most are temporary and return within about a month to full sensation.

It is my belief that this procedure should really only be done by a very experienced dental implant provider.

The advantages of same-day extraction/ lower molar dental implant:

  1. Decreased cost
  2. Single visit procedure
  3. Time savings of 4-8 months
  4. No need for socket preservation bone graft ( usually still need a “void” bone graft though which is much more minor)
  5. One time on antibiotics
  6. One sedation
  7. Virtually eliminates bone loss from disuse atrophy
  8. Ability to place a very wide diameter implant

The disadvantage of same-day extraction/ lower molar dental implant:

  1. Slight increased risk of nerve injury
  2. Lack of implant to be able to achieve primary stability
  3. Often the implant needs to be buried and later and covered with a minor surgical/laser procedure
  4. The tooth extraction must go smoothly
  5. Centering of the implant can be more difficult if not impossible

Nerve injuries can be prevented by a skilled/experienced dentist, intravenous/intramuscular steroids, L PRF/PRP blood product, a 3-D scan planned procedure.

This patient’s case is really cool because her nerve is a mile away! The implant is one of the largest available… A 7.0 x 13 mm which obliterates most of the socket. Obliteration of most of the socket works well to gain stability of the implant, reducing the need for bone grafting, and gives molars a hefty base for a good emergence from the gum line. It also helps carry the high bite force is the back teeth which is important to prevent bone loss around an implant-peri-implantitis.

Obliteration of the socket is not a good idea in other areas of the mouth such as the upper front where the implant should be placed closer to your tongue and the implant ideally be smaller diameter. The rules are very different from each area of the mouth to another… what applies in one area of the mouth can be disastrous and other areas of the mouth!

In some extreme cases that I treat, the nerve is so shallow that I have to move it out of the way in order to put implants in the jaw. This is called a nerve repositioning/lateralization

Plan for immediate extraction and implant. Deep nerve position.

After Immediate Implant –DEEP nerve.

Regular nerve position with dental implant

Same day extraction and implant of lower molars is a wonderful procedure. In my hands, it is very predictable and I have been doing this for about 20 years now as of 2017. It is only intended for probably about 10% of molars. It can be done on the upper jaw as well as the lower jaw. During the surgery, if I feel like there is any increased risk, I will generally abandon the implant and only extract the tooth with a bone graft. You have to be flexible and change if needed for safety and predictability.

The red lines drawn into the 3-D scan indicates the placement of the nerve.

I hope this helps you understand this procedure. The images showed the 3-D scan before extraction and implant placement and another limited field 3-D scan taken after the implant.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

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15 thoughts on “Same-Day Extraction Immediate Lower Molar Dental Implants And Nerve Injury Discussion

  1. jon singleton

    In general, how long will it be if you have a broken tooth that must be removed before the implant can be installed. I have two broken teeth in the front (upper jaw).

    1. RamseyAminDDS Post author

      Most of the upper front teeth I do are immediate dental implants with immediate temporaries. This helps hold the gum contours and prevents the gum triangles from opening and having a poor aesthetic result. Be sure to see a high level provider especially for front teeth dental implants.

  2. Christa Schmitt

    I am a 70 year old woman, who is on oxygen. In 1991, I had the blade type implants, Allen top and all but 4 front on the bottom. I am starting to lose bone in the upper, and my periodontist said it would be useless to keep replacing it because one whole side behind my front, upper tooth is gone. I have several sharp edges on the bottom near my caps. It is aggravating my tongue, so I am needing a drastic procedure to remedy my problems. I am in Lexington, Ky. I don’t know what type of expeet to look for. What would you recommend that I do, and do you think I have enough gum to support dentures?

    1. RamseyAminDDS Post author

      For your upper, the zygomatic implant can almost always be done. Your lung function will need to be discussed, but the zygomatic cheekbone implants I do on a weekly basis don’t cause anymore issues than regular implants. It can likely be done on the same day of removal of your blade implants.

  3. Jen

    Is it possible to have hit a nerve when placing an implant in a lower front tooth? I had tooth #26 extracted and bone grafted due to a root canal infection in the tooth. 5 months later, I had the implant placed. About 10 days after the placement of the implant I started to get severe throbbing pain. I was living on ibuprofen around the clock. My oral surgeon said he saw no signs of infection but gave me more antibiotics and stronger painkillers, but the pain did not subside and I could barely sleep at night. Finally four days later I had him remove the implant (so 2 weeks after placement) and I immediately felt better. He said while removing the implant, he saw no infection. I am at a loss of what the problem could have been, but the only other thing I can think of is the implant hitting a nerve. Is it likely with a lower front tooth? My oral surgeon would like to place the implant in again once I am healed, but I’m hesitant because of the pain I was in.

    1. RamseyAminDDS Post author

      This is very possible although unusual. There is an extra branch of the nerve and some people call the incisive nerve that travels through the chin area. It is difficult to detect by your surgeon or radiologist and often cannot be seen. Your surgeon did the right thing by removing it. I would try a second one may be a little bit shorter although longer implants are generally better. this is no fault of your dentist or of you. Probably the only thing you can do is take a high resolution 3-D scan prior and maybe have a radiologists read to see if a branch is present. It is a routine in doing a full mouth replacement to go right through this nerve as it is not a main nerve and typically does not give sensation to anywhere on the face. Single teeth are different story though..

  4. L.T. Phan

    Dear Dr. Amin,

    It’s a God sent to find your blog and read all your advices! Thank you so much for being there and available practically at all times!!!
    I recently had an extraction of my tooth #30 (lower right molar? Don’t know the term very well!). My DR. said she did not want me to wear a temporary (bridge/crown?) and just come back in 2 weeks to have the permanent bridge done. My question is:
    Is that the right procedure? I’ve had bridge and crowns done before and ALWAYS had to wear some temporary piece while waiting for the extraction area to heal. She said her permanent bridge will take only 1 week to be ready. BTW, when I come back in 2 weeks, I will need to spend 3 hours in the office. All that drilling all at once in one sitting???…My mouth will probably be sore for at least one week!
    Thanks again for your guidance. Please get some sleep!!!!

  5. Michael

    In 2017, how long do the crowns on the implants last? I know this varies and the implant itself if done correctly will last a lifetime, but what about the crowns?

    1. RamseyAminDDS Post author

      Dental implants nor their crowns are permanent. Some do last a lifetime but if you get 20-30 years out of it many would call it a success. The crown and or the implant can be replaced if needed.
      The best advice I can give you would be to see somebody who is very experienced in this field.
      Unfortunately nothing lasts forever…not even us!!

  6. Wil chavez

    My Periodontist told me that because of my history of periodontal disease, I might not be a good candidate for all on 4/6/8 implants and full arches. I am 63 yr old male with 26 teeth and an average of 50% bone loss in my jaws. I have 2 molars that need to be pulled (one is abscesses) and 4 bottom front teeth are Very mobile with at least 70% bone loss. No history of any diseases including diabetes, I do not smoke or drink and have always been athletic. Based on this info, what do you think? I am torn but have been leaning towards all on 4 implants. I have been diligent with my oral hygiene for the past 34 years. My hygiene as an adolescent and hygiene was not good. I also wore braces in high school. My email address I I have been exploring your website and also Dr Golpa in Las Vegas and have been to Clear Choice for a 3d ct scan and full consult.

    1. RamseyAminDDS Post author

      I believe you contacted my office and spoke to Sophia already. Just because you had/have gum disease does NOT make you a bad candidate! It does mean that your case has to be handled differently during surgery and during tooth fabrication. Don’t be fooled by marketing.
      I look forward to meeting you to discuss further. 🙂

  7. bill

    It was really a rare case which you have done it. Her upper molar is looking very sensitive due to bone grafting.
    You have very beautifully explained here same day teeth extraction. I have also noted down some points. Thanks for sharing it here!

  8. Bruce

    Son just had uppermolar removed and had bone graft what should he expect for healing process to look like and swelling how long and how long before he can start eating starting to panic he is getting scared

    1. RamseyAminDDS Post author

      Having treatment only on one side makes it easy. Just chew on the opposite side during the duration of the few months that treatment is being done. Swelling and pain should be very minimal