The endodontist performing exploratory or endodontic surgery should inform the patient about the possibility of finding a vertical root fracture (VRF) or other situation that will necessitate extraction. Although implant surgery is not easy, if the endo specialist has the required knowledge, training and skill, an immediate implant is an option that should be presented to the patient.
In general, the implant needs to be placed in a way that satisfies restorative, esthetic, biomechanical, and functional concerns. Prosthetics must guide the direction and inclination of the implant in a top-down direction. Getting the right bone and soft tissue framework is done in a down-top direction.
Clinical and radiographic examinations are critical in implant placement. Imaging must be used to determine the status of the anatomy in the implant site and to optimize the placement considering the prosthetic needs and anatomic constraints.
Extraction of a tooth with no pathology and placement of an immediate implant is normally an easy task, because the hard and soft tissue profiles will have been maintained by the neighboring teeth, and the intra- and inter-jaw relationships will not have been altered.
The difficulties start when there is a bone defect arising from earlier endodontic pathology and treatment. The bone topography, and bone quality, will dictate whether the implant will be inserted immediately or delayed. Bone quality was classified by Lekholm and Zarb3 according to the degree of corticalization and the trabecular bone morphology. In this classification, bone quality increases with thicker cortical density (grades I, II); while thinner cortical bone (grade III), and larger trabecular spaces and thinner cancellous bone (grade IV), offer less suitable conditions for implant support.
The clinical examination must include esthetic parameters like the orientation of the occlusal plane, lip support, symmetry, gingival scaffold, and the smile line4. Also important is an assessment of the interarch and interdental spaces to see whether there is accessibility for instruments as well as for the future prosthetic construction.
The local health of the edentulous area considered for an implant must be studied too. No pathology in the soft or hard tissues of the jaws can be accepted at the time of implant placement.
A periodontal exam under anesthesia is compulsory. It provides the clinician with a close idea of the bone crest profile, and the presence of an infrabony or dehiscence bone defect on the tooth to be extracted.
After tooth extraction, a close examination of the alveolus under the micoscope is necessary in order to check for the presence of bone defects left by the endodontic history of the tooth extracted.