IMMEDIATE IMPLANT PLACEMENT

- DR. KAPIL ARORA

CONTENTS

• INTRODUCTION• HEALING OF EXTRACTION SOCKET• TRADITIONAL PROTOCOLS• TIMING OF IMPLANT PLACEMENT• IMMEDIATE IMPLANT PLACEMENT• ADVANTAGES• INDICATIONS • CONTRAINDICATIONS

• CLASSIFICATION OF EXTRACTION SITES• TREATMENT SEQUENCE• SURGICAL PROCEDURE• DIFFERENT TREATMENT PROTOCOLS• SOFT TISSUE MANAGEMENT• POST-OP MANAGEMENT • DISADVANTAGES• CLINICAL TRIALS• CLINICAL FACTORS TO BE CONSIDERED!!• CONCLUSION

INTRODUCTION

• Following an extraction there is a 25% decrese in the width of the alveolar boneduring first year and an average 4mm decrease in height during the first year following multiple extractions (Carlson 1967)

• Tatum and Misch have observed a 40%-60% decrease in alveolar bone width after the first 2-3 years post extraction.

• Christensen reports an annual resorption rate of at least 0.5% to 1% during the remainder for the rest of a patients lifes

• Schropp et al (2003) most of the bone gain in the socket occurred in the first 3 months.

Traditional Branemark protocols

12-month healing period after tooth extraction

healing period of 3 to 6 months

start of treatment to completion of the restoration extends for 1-2 years

Leaves the patient with a missing tooth or teeth for an extended period of time

Adell R, Lekholm U, Rockler B, et al: A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416

Hammerle 2004

KEY ASPECTS OF THIS CLASSIFICATION

• In clinical practice the decision to place an implant following tooth extraction is usually determined by:

- The attainment of specific soft and hard tissue characteristics of the healing socket

- These events do not necessarily follow rigid time frames and may vary according to the site and patients factors

• To avoid time based descriptions, this classification uses numeric descriptors

Type 1 is chosen- when an implant is placed immediately following extractionType 2 is preferred- when advanced soft tissue healing is desiredType 4 – hard tissue healing is desired

SOFT TISSUE CHANGES AFTER EXTRACTION

HARD TISSUE CHANGES AFTER EXTRACTION

HEALING OF EXTRACTION SOCKETOHTA 1993

AMLER 1969

LINDHE 2005

Theory of bundle bone:

The bundle bone delineates the alveolar socket- Thickness aprox 0.8mm- It’s a tooth related bone structure- Blood supply through blood vessels in pdl

CLINICAL SITUATION AT EXTRACTION OF ANTERIOR TEETH IN MAXILLA

Attempts to shorten the overall length of treatment have focused on

Shortened or immediate loading subsequent to implant placement

Alteration of the surface of the implant fixture to promote faster healing

Immediate placement of the implant after extraction of the natural tooth

Immediate implantation is defined as placement of implant into alveolus of the extracted teeth immediately after extraction.

IMMEDIATE IMPLANT PLACEMENT

Placing an implant

Most edentulous sites are atrophic

Result of inadequate mechanical loading

Time dependant and localised healing

response

Controlled by cytokines

• Placement of implants into fresh extraction sites offer a no. of advantages to both the patients and the clinicians

• Without the support provided by functioning dental units, the bony receptor sites soon undergo a catabolic phase

• Varying amounts of atrophy occur after tooth removal.

• Which later leads to difficulty in achieving superior aesthetic outcome in aesthetic zone of anterior maxilla.

ADVANTAGES

Patients acceptability

Reduces treatment time

Socket as a guide for determination of parallelism and alignment

Surgeon can position the implant more favourably than the original position

Facilitates final restoration and minimizes need for severly angled abutments

Implants in extraction sites can be placed in th same position as the extracted teeth

INDICATIONS

• The ideal extraction site for immediate implant placement

little or no periodontal bone loss on the tooth that is to be extracted, such as a tooth being extracted due to

endodontic involvement

root fracture, root resorption

periapical pathology

root perforation,

unfavorable crown-to-root ratio

CONTRAINDICATIONS

Presence of pusLack of bone beyond the

apex

Close proximity to anatomical vital structures

Clinical conditions preventing

primary closure

CLASSIFICATION OF EXTRACTION SITES

Type 1•ideal for immediate implantation, •3 to 4 wall sockets with minimal bone resorption, •sufficient bone beyond the apex,•manageable gingival recession and•esthetics is not essential.

Type 2• requiring orthodontic extrusive augmentation, •significant recession and esthetics is essential.

Type 3•not suitable owing to inadequate vertical and buccolingual dimensions, recession and•severe circumferential and angular defects.

J periodontol 1997;68;915-923

TREATMENT SEQUENCE AND PLANNING PROTOCOL

Clinical examination

Radiographic examination

Fabrication of surgical guide

Surgical and prosthetic phase

Maintenance

CLINICAL EXAMINATION

• PRE-SURGICAL

• Most researchers recommend

at least 3 to 5 mm of bone beyond the apex and

a bony length of 10 mm or greater for stability when placing immediate implants.

• Evaluation of the potential implant site.

• Residual extraction socket morphology may complicate ideal implant positioning in fresh extraction sockets.

The slope of the axial walls,

The root curvature of the extracted tooth, and

The final position of the apex of the extracted tooth in the alveolar housing

• Therefore, immediate implant placement should be limited to those defects that have three or four walled sockets, sufficient bone to stabilize the implant, and minimal circumferential defects.

• Wilson et al showed that the horizontal or circumferential component of the peri-implant defect was a critical factor and that the horizontal defects of less than 1.5 mm do not need membranes to obtain histologic osseointegration.

Wilson TG, Jr, Schenk R, Buser D, et al: Implants placed in immediate extraction sites: a report of histologic and histometric analyses of human biopsies. Int J Oral Maxillofac Implants 1998;13:333-341

RADIOGRAPHIC EXAMINATIONThe radiographic examination indispensable for determining the volume & density of the bone

BONE VOLUME

Available Necessary Useful

Surgical evaluation Prosthetic evaluationSurgical + prosthetic evaluation

CT

Scanora

• Good evaluation of bone density allows the surgeon to do the following:

- Select proper implant diameter- Decide about optimal drilling - Determine the length of healing period- Evaluate the occlusal load capacity

CLASSIFICATION OF BONE QUALITY

LEKHOLM & ZARB (1985)

Mechanical aspect (bone density)

Type I- essentially cortical bone

Type II- dense corticocancellous bone

Type III- sparse corticocancellous bone

Type IV- thin cortical and very sparse medullary bone

Healing stand point (bone biology)

BHP 1- normal healing potential

BHP 2- moderately reduced healing potential

BHP 3- substantially reduced healing potential

SURGICAL GUIDE

SURGICAL PROCEDURE

• Atraumatic extraction using mini surgical blade or a periotome

• Maintain most of the alveolar housing of the tooth to be

extracted.

careful inspection of the extraction socket

walls are thoroughly curetted to remove all remnants of the periodontal ligament

Irrigated with normal saline

IMPLANT OSTEOTOMY

• The next step is the preparation of the extraction area and the apical bone for the placement of the implant.

• If the site is a maxillary anterior tooth, the osteotomy must be kept on the palatal aspect of the alveolus to prevent perforation of the buccal plate

• Once the osteotomy is prepared to the desired depth with at least 3 to 5 mm of intimate implant-to-bone contact, an implant is placed.

• The implant must be stable within, with no mobility.

• The ideal situation would be for the implant to be in contact with the socket without putting undue pressure on the socket walls unless the alveolus is very thick, leaving no gap between the head or neck of the implant and surrounding socket walls.

• In other words, the radiographic appearance of an ideal immediate implant placement would look the same as a standard implant placement

IMPLANT TO SOCKET WALL SPACE

• Studies have shown that close adaptation of the implant to the socket wall promotes greater osseointegration.

• When a gap exists .. a bone graft and/or membrane can be used to prevent epithelial migration into the space and aid in healing.

• If all four walls are intact after tooth extraction and the circumferential defect is less than 1.5 mm, an implant may be placed without the need for bone grafting or augmentation.

• Presence of three or more walls or a circumferential defect greater than 1.5 mm can support an immediate implant, but bone grafting and protection of the socket with a membrane is recommended.

temporary prosthesis,

removable or fixed,

Studies have shown that close adaptation of the implant to the socket wall promotes greater osseointegration.

Bone healing in an implant osteotomy proceeds apical to coronal, much like that of an extraction socket;therefore, the coronal aspect becomes the most critical in the healing. Current research favors the use of an occlusive barrier membrane to protect the healing socket area.

• While immediate implant loading has been shown to be as successful as delayed loading, excessive loading can cause fibrous encapsulation around implants and subsequent failure.

DIFFERENT TREATMENT PROTOCOLS

Standard Protocol (option 1)

One-stage surgery (option 2)

Option 1 + impression at stage

1(option 3)

Immediate loading

(option 5)

One stage surgery + impression at stage 1 surgery

(option 4)

STANDARD PROTOCOL (OPTION 1)

Implant insertion

•Stage 1 surgeryHealing phase •3-6 months

Stage 2 surgery •Placement of healing abutmentFinal abutment

placement

Impression for final prosthesis

ONE STAGE SURGERY (OPTION 2)

Stage 1 surgery + placement of

healing abutment

Healing phase + provisionalization

•3-6 months

Final abutment placement

Impressions for final prosthesis

OPTION 3Implant

insertion + impression

•Stage 1 surgery

Healing phase + provisionalizati

on

•3-6 months

Stage 2 surgery + final abutment placement + provisional acrylic

resin prosthesis

Impression for final prosthesis

OPTION 4

Implant insertion + impression

Placement of healing abutment

•Stage 1 surgery

Healing phase + provisionalizatio

n

•3-6 months

Final abutment placement +

provisional acrylic resin prosthesis

Impression for final prosthesis

IMMEDIATE LOADING (OPTION 5)

Stage 1 surgery + placement of final

abutments

Gingival healing

Impression for final prosthesis

SOFT TISSUE MANAGEMENT

• One of the most critical factors in implant restorative esthetics is the gingival form.

• can be shaped and managed by the provisional prosthesis and by the provisional crown.

• The use of anatomic gingival formers or single stage implants and the placement of impIants without elevating a flap have significantly improved the clinician's ability to readily achieve excellent peri-implant gingival form.

POST-OP MANAGEMENT

• Antibiotics and analgesics• Oral hygiene and Chlorhexidene mouth wash

recommended

• Covani, Cornelini and Barone (2003)

Study concluded that the coronal bone remodeling around immediate showed a healing pattern with new bone apposition around the necks of the implants and, at the same time, bone resorption with horizontal width reduction of the bone ridge.

• Schropp, Kostopoulo and Wenzel (2003)conducted a study to compare bone healing and crestal bone changes following immediate (Im) versus delayed (De) placement of titanium dental implants

It was concluded that new bone formation occurs in infrabony defects associated with immediately placed implants in extraction sockets.

• Rosa, Rosa, Francischone and Maior (2014)conducted a study to evaluate the stability of esthetic treatment after single tooth replacement in compromised sockets using the immediate dentoalveolar restoration (IDR) concept

The mean mesial and distal papillary heights increased slightly over time. Stable periimplant soft tissues and satisfactory esthetic outcomes were achieved.

DISADVANTAGES

• Additional cost if membranes and grafts are used

• Sometimes may not be able to place implants, tooth ankylosis, fracture of the buccal plate, socket expansion during extraction, or extensive infection(patient should be imformed previosly)

• Difficulty obtaining primary stability

• Inadequate soft tissue coverage

• Difficulty in preparing the osteotomy due to bur movement (chatter) on the walls of the extraction site

Clinical trials • MOST REPORTS ON IIP DESCRIBES:

- Small peri-implant osseous defects result in a gap measurable from the wall of the socket to the surface of the implant

- Horizontal defect dimension (HDD)/ jumping distance

- If HDD is 2mm or less no augmentation is required

- HDD more than 2mm to achieve bone healing, use collagen barrier membrane & implants with a sand blasted & acid etched surface.

• Botticelli et al (2004) strongly indicated that immediate implant placment does not prevent the physiologic modeling/remodeling that occurs in ridge following extraction

The reduction in of the buccal dimension was 1.9mm after 4 months

• Araujo and Lindhe (2005)

After 3 months of healing

• Amount of resorption in edentulous sites was 2.2mm at the end of the study

• Of that of implants was around 2.4mm

• Araujo et al (2006) in 4 weeks of healing :- The buccal and lingual wall had undergone

substantial resorption- Height of the thin buccal wall was also

reduced After 4 – 12 weeks of healing the bone level was more than 2mm apical to the marginal border of the rough implant surface.

CLINICAL FACTORS TO BE CONSIDERED!!

• Primary stability• Adequate implant splinting where appropriate• Provisional restorations that promote splinting and

reduce or control the mechanical load applied to the implant

• Prevention of provisional restoration removal during the recommended period of implant healing

• Incorporation of team approachs and the use of surgical templates

CONCLUSION…..

REFERENCES

• Wilson TG, Buser D, et al. Implants placed in immediate extraction sockets. Int J Oral Maxillofac Implants 1998;13:333-41

• Lazzara RJ. Immediate implant placed into extraction sites – surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:333-343

• Parel SM, Triplett RG. Immediate fixture placement. A treatment planning alternative. Int J Oral Maxillofac Implants 1990;5:337-45

• Becker W and Becker BE. Flap designs for minimization of recession adjacent to maxillary anterior implant sites: a clinical study. Int J Oral Maxillofac Implants 1996;11:46-54.

• Villa R and Rangert B. Early loading of inerforaminal implants immediately installed after extraction of teeth presenting endodontic and periodontal lesions. Clin Imp Dent and Related Res 2005;7:S28-S35.

• Langer B and Sullivan DY. Osseointegration: its impact on the interrelationship of periodontics and restorative dentistry. Part 3. Periodontal prosthesis redefined. Int J Periodont Rest Dent 1989;9:240-261.

• Carlsson L, Rostlund T, Albrektsson B and Albrektsson T. Implant fixation improved by close fit. Cylindrical implant-bone interface studied in rabbits. Acta Orthop Scand 1988;59:272-275.

• Botticelli D. The jumping distance revisited. An experimental study in the dog. Clin Oral Implants Res 2003;14:35-42