Guidelines for the MAX Implant

Ten Commandments of the MAX Implant

1. Select for purpose
The original intended purpose of the MAX was to facilitate immediate placement in a molar socket. 
It was not designed for delayed placement, as a rescue implant, or any other tooth site. Although they have been used successfully by some of these applications, it is not recommended. 
2. Never use in thin biotypes
This is “generally recommended for all implant types, but is especially important in the MAX. Classification of biotypes as “thin” or “thick” is, however, subjective. 
The socket should be intact in all four directions. If not, it is best to augment and delay placement. 
3. Never attempt a conventional extraction
This is especially true for molars with divergent roots. 
Forceps should only be used to assist with initial loosening. 
The recommended protocol is to decoronize the tooth separate the roots without removing any interradicular bone, and elevate the fragments. 
4. Prepare the site incrementally
Step 1: If there is a sharp intraradicular crest, use a carbide burr to flatten the center to create a wider V-shaped profiel, with the surface lying 4-5mm above the socket apex (depth can be confirmed with a probe).
Step 2: The pilot hole should be offset toward the lingual/palatal and the mesial. the pilot hole is easier to start accurately with a harpoon drill. The location must be accurate before moving to the next drill as it cannot be revised later in the drilling sequence. 
Step 3: Decoronize and drill through the tooth roots with 1.2mm diameter twist up to 5-6mm depth. Depth must be correct before moving to the next drill as it cannot be revised later in the drilling sequence. 
Step 4: Elevate the roots. The drilling sequence after elevation is:
- 2mm twist drill
- 3.5mm tapered drill
- 4mm spade
- 5mm spade
- 6mm dedicated MAX drill
- appropriate dedicated MAX final drill or tap
5. NEVER engage the buccal wall
Where possible, retain the buccal strut to maintain distance from the buccal face and give the correct implant position. Filling the socket with the implant should be avoided - there should be a jump gap of 1-2mm. For this reason, 6, 7 and 8mm MAX have become more popular and 9 and 10mm MAX are rarely ever used. 
With the narrower MAX it is also more feasible to place two adjacent implants
6. Place to sufficient depth
Platform of the implant must lie at least 1-2mm beneath the lowest point of the buccal wall. Depth must be preplanned and established right at the start of site preparation, as subsequent drills are designed only to widen the site and cannot increase the depth. 
7. Verify position before placement
this must be done clinically and radiographically. Using a tap to verify placement gives the added advantage of assessing insertion torque. 
8. You will encounter a high resistance torque
Mathematically, torque is proportional to the square of the diameter, so increases exponentially as implant gets wider. Therefore high insertion torques with MAX implants are inevitable and not unsafe. A current study observing the effects of high insertion torques in MAX implants on necrosis has shown excellent clinical and radiographic results at 2-year follow-up with insertion torques of up to 250 Ncm.
9. Close voids and support soft tissue
Use a wide healing abutment and suture to ensure soft tissue support. If there are particularly large voids, these can be filled with e.g. haemostatic collagen sponge, but leaving the clot is preferred by some and equally acceptable. 
10. Follow up
Post operative instructions include no rinsing for one week. Follow-up is important not only for the patient but also to contribute to the data and protocol development. 


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