The Tooth Came Out and the Implant Went In Twenty Minutes Later

Quick answer: An implant can sometimes be placed in the socket at the moment the tooth is removed, saving months and a second surgery. It works only when five specific conditions are met, and placing one where they are not is how implants end up with visible recession years later.

The call

He had read about it and wanted to know why it had not been offered to his brother, who had waited nine months for the same thing.

Eli, 44, from RBS Alef, had an upper premolar with a vertical root fracture. Not restorable, not painful yet, and due to come out.

The difference between his case and his brother's was not the practice. It was the socket.

What we found

Upper right second premolar, fractured, with the fracture line running below the bone level. Unrestorable, as expected.

The five conditions for immediate placement, assessed on the CBCT scan and clinically. All five have to hold; four out of five is not enough.

An intact bone plate on the lip side. This is the decisive one. That plate is thin — often under a millimetre — and if it has been destroyed by infection or fracture, there is nothing to support the gum and the site will recede. His was intact and measured 1.4mm, which is comparatively generous.

No active infection. Chronic granulation tissue can be curetted out. Acute suppuration means waiting. His had a small chronic lesion and no pus.

Enough bone beyond the socket for stability. An immediate implant does not get its initial grip from the socket walls — those are the shape of the old root. It has to engage bone beyond the socket, usually 3 to 4mm past the root tip. He had that.

Thick gum tissue. Thin tissue over an immediate implant recedes. His was thick, which is partly genetic and is assessed by looking.

A cooperative patient. Soft diet, no loading, exact aftercare. Immediate placement is less forgiving than delayed.

His brother's case, for contrast: a molar lost to a long-standing abscess that had destroyed the cheek-side plate. No plate, active infection. Delayed placement was correct, and it was not a difference in what was offered.

What we did

Atraumatic extraction, which is the whole procedure in miniature. Fine periotomes to sever the ligament, the tooth sectioned into two pieces so neither fragment had to be levered against the lip-side plate, and each piece removed along its own axis.

Levering against that plate fractures it, and fracturing it converts an immediate case into a delayed one — which is a decision that gets made in the first three minutes of the extraction.

Socket debridement, removing the chronic lesion completely.

The implant placed towards the palatal wall, deliberately, not centred in the socket. An implant centred in the socket sits too far towards the lip, and the bone in front of it resorbs, exposing the metal collar. Placing it against the palatal wall leaves a gap on the lip side, which is intentional.

That gap grafted with slow-resorbing bone material, which is what maintains the ridge contour over the years.

A connective tissue graft on the lip side to thicken the tissue.

An immediate provisional crown, shaped out of function so nothing bit on it, to support the gum and papillae during healing.

Four months to integration, then the definitive crown.

The outcome

One surgery instead of two. Four months instead of nine.

At three years the gum margin matches the neighbouring tooth and the ridge contour has held.

The honest caveat, which was explained beforehand: immediate placement in the right case does very well, and it is less forgiving than delayed placement. Success rates in properly selected cases are comparable to delayed placement; success rates in poorly selected cases are not. The selection is the treatment.

Had the plate fractured during extraction, the plan would have changed on the spot — graft the socket, close it, and return in four months. He was consented for both, which is how these appointments should be arranged.

What to do if this happens to you

1. Ask whether immediate placement is possible for your specific tooth, and if not, ask which condition fails.
2. Ask about the bone plate on the lip side. It is usually the deciding factor.
3. Ask about the extraction technique. Atraumatic removal is what preserves the option.
4. Expect to be consented for both plans, in case the socket does not permit it on the day.
5. Ask whether the gap will be grafted. Placing the implant without grafting the gap is a common shortcut.
6. Follow the aftercare precisely. Immediate cases are less tolerant of loading.

Facing an extraction and considering an implant? Ask Ramat Beit Shemesh Urgent Dental Care before the tooth comes out. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.