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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

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

  1. Dr. Amin, Thank you for your very informative website. I am 64 years old, female. In July 2016, I suffered nerve damage during a dental visit, followed by an infection, followed by endo in 20, followed by extraction of 20 a few days later and 18 about a week later. 19 was a pontic and 21 had been removed for orthodontia when I was a child. Augmentation surgery at 20-21 in Jan 2107, followed by full braces to turn 22 more front-facing. Augmentation surgery with donor bone did not work. My periodontist said the nerve at 20 is looping into 21 space. In addition, he says that he does not feel comfortable placing implants in 18 and 19 because I don’t have a lot of bone marrow there and he does not think augmentation will help. My general dentist does not want to do anything to the canine as it was stressed during the year of braces to turn it. I feel so discouraged and hopeless about all of this. Do you think I could be a candidate for bone leveling? I have good bone height, but not good width. Thank you for reading this.

  2. Dear Dr. Amin,

    What method/test would allow you to identify the location of the nerve in the jaw, as you described in your example above? My son had a root canal done on #30 that resulted in severe nerve damage and #30 extraction later on. We have been dealing with the consequences of that procedure for over a year now coming to the point of having a spinal cord simulator installed to reduce this facial pain. But none of the dentists has ever mentioned or offered to us any tests that could possibly show the location of a TN branch in the jaw. Thank you very much in advance!

    1. I am sorry about your son. This nerve is very visible on traditional in office dental scanners. I don’t think there is a a way to test it since we all have it.

  3. I am 63, female, had root canal on tooth 30 in 2010 by endodontist. He said I had 4 roots, instead of normal 3. Lost all wisdom teeth in my 20’s. I had a crown put on within a few weeks. Crown fell off in 2011, never fit right. I never replaced crown. Now dentist says I need an extraction. He did 3-D scan. Says I have 40% bone loss. I worked for Board of Dentistry in Florida for 3 years. Why do I need an extraction? I have no pain, am retired and widowed, live alone, but do have good insurance Cigna HMO and my cost is $600. Expert Maxio-Facial Doctor says implant $2000. Dentist said maybe a bridge instead as I have rear tooth. What is my best option or options here? Can I just get another crown? Please help me with this issue. I live on a very fixed budget, but my teeth are important to me. I had one previous root canal with eye tooth and temporary tooth that lasted 5 years. It cracked and permanent tooth put in. No problems. I live in SW Georgia. Thank you

    1. Also, the dentist that made my crown in his office that fell off one year later said he would not see me again when I asked for my $1,200 refund. Thanks again

    2. It sounds like you had a tooth saved that was on the fence of extraction instead. That would bother me also. I tried to guide patients not to try to do heroics on a tooth that has a poor long-term prognosis. Without seeing you of course there is no way that I could be certain.

      Getting another crown may end up with the same problem and more lost money. Have a second opinion but likely just remove it and have the implant done which has a very high success rate compared to a tooth that is being salvaged at all cost.

      sorry about your troubles

  4. 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. 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!!

  5. 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 southpaw123@cox.net. 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. 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. 🙂

  6. 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. 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

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About Ramsey A. Amin, DDS

Dr. Ramsey Amin has extensive experience in surgical and restorative implant dentistry. As one of only less than 400 Diplomates of the American Board of Oral Implantology/ Implant Dentistry (ABOI/ID) he is considered an expert, and board-certified in dental implants. He is a former instructor at the UCLA School of Dentistry.