Immediate Dental Implant: an overview with two case reports

Dr. Anthopia Nameirakpam
guide- W. Robindro Singh

Implant placement - timing
Immediate implant placement (IIP) – Type 1 procedure
Early placement with soft tissue healing (6-8 weeks) – Type 2 procedure
Early placement with partial bone healing (12-16 weeks) –Type 3 procedure
Late placement after healing is complete (After 6months) – Type 4 procedure

advantages & disadvantages of IIP
postulated
non-conclusive
based on case reports

Immediate Esthetics &
Socio-psychological wellbeing

preservation of alveolar bone
profile & overlying soft tissue
contour
A catabolic phase of atrophy of
bone & recession of the overlying
soft tissue following loss of tooth
support – immediate implant
maintains this structural and
functional support
Better Esthetics

guide the final position of the implant - whether
you want the original tooth position or an
alteration based on esthetic & occlusal demand
multiple implants simultaneously after
multiple extractions – sockets gives an idea
of the arch form and occlusion
Socket acts as guide (not determine)
for the drill and the final position of
the implant- prosthesis

No second surgery…
Treatment time is reduced
Patients are deterred from traditional implant
procedures because of prolonged treatment time

Higher chance of error (technique sensitive)
and clinically more demanding
case selection
drilling
extraction
socket management
grafting
temporary crown

Graft for filling the residual space
is prone to infection..
adequate antibiotics and hygiene
High chance of contamination of the graft by
the oral microbes without proper seal
Residual space because the socket anatomy is
not compatible with implant shape n size

IIP done in 2 patients
helped us evaluate

CASE 1
- non-smoker, healthy, young medico
- carious broken 25 with repeated episodes
of pulpitis
- wants an immediate prosthesis after
extraction
- does not want RCT or surgical endodontic
CASE 2
- non-smoker, tourist from Florida in his
early forties
- root stump 25 with gutta perch remnants
which he wanted to restore
Branemark’s 1st patient : Gosta Larsson

Allfit implant, IHDE DENTAL, Switzerland; single-unit, taper and threaded : Case1
Diameter 3mm; length 11mm,excluding the abutment
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case1 case2
MATERIALS

case1 case2
MATERIALS
Indident Implant System; Defense Research Development Organization(DRDO),
Ministry of Defense; 2-unit, cylindrical and threaded : Case2
Diameter 4.2mm; length 9mm

case1 case2
MATERIALS
Bone repair material : BioGraft in CASE 1 OstIN in CASE 2

1
2
3
4
case1
Fig 1
Grossly carious 25 with
apical periodontitis
The tooth could
have been
preserved with
RCT & Post-
crown
Adventurous
mindset and
was adamant
on immediate
implant

1
2
3
4
case1
Fig 2
The socket was
well preserved
with a thick
gingival
covering
Periodontal ligament
remnants were curreted

1
2
3
4
case1
Fig 3
The implant was
initially inserted
manually in a
clockwise rotation… it
was tightened to its
final position with a
wrench
Drilling was done upto
11mm ie, approx.
3mm beyond the apex
of socket. The final
drill size was 2.75mm
diameter

1
2
3
4
case1
Fig 4
The single unit implant in
the socket. Minor
alteration of abutment
done with rotatory
instrument for proper
inclination

6
7
8
9
10
5
case1
Amalgam carrier was used
to collect and inject the
bone repair material in
the residual space
Fig 5 & 6

6
7
8
9
10
5
case1
The raised gingiva is
sutured back to appose
the abutment and also
cover the bone repair
granules
Fig 7
… Primary closure

6
7
8
9
10
5
case1
The radiograph shows the
apex of the implant
firmly anchored in bone
apical to the socket
Fig 8

6
7
8
9
10
5
case1
The immediate temporary
crown, with occlusal
relief to prevent loading,
and the porcelain crown
placed after 3 months are
depicted. Both the crowns
were cemented directly
to the abutment
Fig 9 & 10
An acrylic tooth of
suitable size and
shade was used to
fabricate the temp.
crown

21
3
4
5
case2
Fig 1 & 2
Root stump 25 was
extracted after
exposing and
visualising the
bone… to prevent
fracture of the
socket wall
Osteotomy was
done to a depth
of 9mm, ie 2mm
apical to the
socket. Diameter
of the final drill
was 3.75mm

21
3
4
5
case2
Fig 3
The implant came
with a mount and
was inserted
manually holding
the mount. It was
then tightened to
its final position
with a wrench.
The final
position of the
implant is at
the crest of
the alveolar
bone

21
3
4
5
case2
Fig 4 & 5
The abutment was
attached to the
implant fixture by
screw

6
7
8 9
10
11
case2
Fig 6
Bone repair
granules was
inserted at the
implant-bone
interface

6
7
8 9
10
11
case2
Fig 7
The soft tissue was
sutured back to hold
the graft and closely
appose the abutment

6
7
8 9
10
11
case2
Fig 8
The radiograph
shows the
implant firmly
anchored in
bone
Fig 9
A temporary
crown was
fabricated for
immediate
esthetics; 2mm
occlusal relief to
prevent loading

6
7
8
9
10
11
case2
Fig 10
An aperture on the
occlusal aspect of the
permanent crown
during fabrication
After the abutment is
screw-tightened to the
implant fixture, the
crown was luted to the
abutment with composite
material - crown and
abutment becomes a
single unit
The aperture on the
crown provides a
pathway to the
abutment screw while
removing or tightening
the abutment-crown as
a single unit

Avoid IIP if…
Local infection including periodontitis
Fracture of socket wall or fenestration(>5mm)
Thin tissue biotype – chance of resorption of facial
bony wall and gingival recession
Type 2 or 3 procedure
Good time for grafting
procedures
Soft tissue
becomes thick

Atraumatic extraction to preserve the
alveolar bone..
for a clinically firm implant fixture
… Raise flap to expose, visualize and carefully
preserve socket bone (avoid flap if
damage to the wall can be avoided)
… Insert a threaded post into the
root stump and pull
… Make a window at the apical bone and push
the root tip occlusally away from the apex of
the socket
… Bur
… Periotome, luxators
Methods

Socket to guide but not determine the
drill direction
Drill to extend 2-4 mm beyond
the apex of socket
Drill to slide 2mm to the palatal aspect to avoid
contact with thin labial bone..1 mm space to be
maintained between implant and labial bone
Drill not to contact the
labial bone
Anchorage to be
obtained from the
bone apical to the
socket

Prefer a tapered implant
- prevent cutting
of excessive bone and fenestration or dehiescence
of bone; stronger structural support
- more easily allow
placement of the implant in original tooth
position
Since tapered implant is not much
displaced from the natural tooth
position… natural emergence profile
of prosthesis
Cylindrical implant may need palatal
displacement to prevent dehiescence
on facial wall

Debridement of periodontal ligament
… to remove soft tissue barrier and permit
osseointegration

Graft the residual space
…implant dimension incompatible with socket
…graft when more than 2mm gap at the implant-bone
interface on the facial wall of the socket
Grafting for repairing of socket
wall or dehiescence requires firm
soft tissue cover ..type 2 or 3
procedure

Prophylactive antibiotics and aseptic
technique critical
Grafting materials prone to
infection
Some infection usually
associated with the
extracted tooth

Single stage-surgery
in both the cases
Extraction, implant placement,
grafting, abutment attachment
and temporary crown on the same
day

A single-unit implant in 1st case
..space around the implant neck creating a
pocket inspite of graft placement
Should have put a membrane
over the graft for GBR

A 2-unit implant (meant for 2 stage surgery)
in the 2nd case ..excellent adaptation to
bone at the neck of the implant
… no residual space visible

The implants are clinically firm after
insertion in both cases

Excellent esthetics, immediately and
later, in both the cases
Both the patients extremely happy
(inspite of pain for 5 days in the 2nd patient)
Pain in the 2nd patient
could be attributed to
pressure of the implant
on the bone

Graft filling of the space after
implant insertion is tedious
Filling the socket first with
graft and inserting the implant
may be an option
Primary closure of the soft tissue to cover the graft was
achieved in both cases…no collagen membrane was used

Temporary crown is for esthetics…
loading after 3 months
A temporary crown durable in shade
and strength - acrylic denture teeth

based on the 2 cases, available case reports and the lack of
controlled studies …
1. Expect NO MORE than the immediate
restoration of esthetics as advantage over
conventional techniques
When esthetics is of no concern,
opt for the type4 procedure

Load bearing of the implant is initially dependent upon the
strength of the structural support and not on
osseointegration…Osseointegration does not increase
the strength of the support..
2. Immediate Loading to be done with
caution despite claims of success
…caution against micromovement
…Osseointegration prevents the formation of a
fibrous layer at the implant-bone interface and
maintain the bone-implant bond in the long
run

2. Immediate Loading to be done with
caution despite claims of success
…caution against micromovement
Rigid Splinting of an avulsed tooth is not unduly
prolonged to allow for some physiological movement
and prevent ankylosis…but the objective of implant
is osseointegration(ankylosis)… so caution against
micromovement !!!

3. Two unit implant with a separate
abutment is preferable despite the
problem of loosening
… Flexibility in choosing
abutment design
… Flexibility in changing to a
more aesthetic abutment as the
situation demands – Ceramic
abutment

4. Prefer a ceramic implant which
match the shade of the
patient’s dentition
If bone resorption and gingival
recession, the exposed
hardware will be relatively
more acceptable

5. A long term controlled study is
imperative to develop a
standard protocol for IIP

Immediate Dental Implant: an overview with two case reports

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Immediate Dental Implant: an overview with two case reports