1. Clinical Challenge Posterior molar extractions lead to unpredictable buccal ridge resorption (30–50 % within 6 months).
Conventional (delayed) protocol → two surgeries, 6–9 months, often requires GBR/CTG.
Socket preservation reduces bone loss but adds cost, morbidity, and can compromise soft tissue.
2. Immediate Implant Placement & Loading (Dr. Gary Finelle) Socket‑Seal Abutment (SSA): custom, anatomically shaped healing abutment placed at extraction→implant; rigid closure preserves clot & soft‑tissue scaffold without flaps or membranes.
Workflow: atraumatic extraction → intraseptal osteotomy & implant placement → gap grafting as needed → seat SSA + “spider‑web” composite seal → interim scan at 3 months → final crown.
Outcomes: in > 300 cases (9 yr follow‑up) horizontal bone loss < 2 % vs. 10–25 % with socket grafting; one surgery, 3–4 mo to final crown; improved comfort & function.
Cautions: requires primary stability, adequate septal bone; operator experience crucial; more RCTs needed for immediate placement + immediate loading.
3. Evidence on Immediate Loading (Prof. Stefan Vandeweghe) Literature Gaps: abundant anterior data; posterior region under‑studied—especially true immediate placement + immediate loading.
Survival Rates: immediate‑loaded posterior implants (single/partial) ≈ 95 % at 2–5 yrs, on par with conventional protocols.
Short Implants: 6.5–8 mm under immediate loading show no higher failure risk; splinting reduces micromotion.
Implant Design: tapered implants yield higher insertion torque but may exhibit greater lateral micromotion; choose diameter/length to balance: primary stability vs. bone preservation.
Biology & Mechanics: primary stability ≥ 30 N·cm (20 N·cm if splinted); moderately rough, screw‑thread surfaces accelerate osseointegration; ≤ 150 µm micromotion tolerated.
4. Decision‑Making in Practice Immediate Placement: robust septal bone, minimal GBR, assured primary stability, experienced operator.
Immediate Loading: when rapid function is desired and you can control provisional occlusion and micromotion; overall treatment 3–4 months vs. 6–9 months.
Protocol Combinations:
Immediate placement + delayed loading: safest, well documented for posterior.
Delayed placement + immediate loading: predictable in healed ridges.
Immediate placement + immediate loading: promising (especially with SSA), but needs more high‑level evidence before broad adoption.
5. Take‑Home Messages Preserve socket volume & contour at implant placement—SSA, provisional‑guided closure, or socket graft + membrane.
Aim for high primary stability, but recognize implant geometry, surface, and splinted provisionals also govern micromotion and osseointegration.
Tailor timing & loading to each posterior case—balancing patient desire for speed with surgical risk and current evidence.
Further RCTs needed on immediate placement + immediate loading in molar regions before widespread adoption.