immediate implant placement in aesthetic zone its protocols, indications are mentioned..

1. IMMEDIATE IMPLANT PLACEMENT
- DR. KAPIL ARORA

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

3. • 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

4. INTRODUCTION

5. • 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.

6. • 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.

7. 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

8. Hammerle 2004

9. 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

10. • To avoid time based descriptions, this
classification uses numeric descriptors
Type 1 is chosen- when an implant is placed
immediately following extraction
Type 2 is preferred- when advanced soft tissue
healing is desired
Type 4 – hard tissue healing is desired

11. SOFT TISSUE CHANGES AFTER
EXTRACTION

12. HARD TISSUE CHANGES AFTER
EXTRACTION

13. HEALING OF EXTRACTION SOCKET
OHTA 1993

14. AMLER 1969

15. LINDHE 2005

16. 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

17. CLINICAL SITUATION AT EXTRACTION
OF ANTERIOR TEETH IN MAXILLA

18. 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

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

20. 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

21. • 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.

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

23. 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

24. 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

25. CONTRAINDICATIONS
Presence
of pus
Lack of
bone
beyond
the apex
Close
proximity
to
anatomical
vital
structures
Clinical
conditions
preventing
primary
closure

26. 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

27. TREATMENT SEQUENCE AND
PLANNING PROTOCOL
Clinical examination
Radiographic examination
Fabrication of surgical guide
Surgical and prosthetic phase
Maintenance

28. 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.

29. • 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

30. • 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.

31. • 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

32. RADIOGRAPHIC EXAMINATION
The radiographic examination indispensable for determining the volume &
density of the bone
BONE VOLUME
Available Necessary
Useful
Surgical evaluation Prosthetic evaluation
Surgical + prosthetic
evaluation
CT
Scanora

33. • 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

34. 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

35. SURGICAL GUIDE

37. SURGICAL PROCEDURE
• Atraumatic extraction using mini surgical blade or a periotome
• Maintain most of the alveolar housing of the tooth to be
extracted.

38. careful inspection of the extraction socket
walls are thoroughly curetted to remove all
remnants of the periodontal ligament
Irrigated with normal saline

39. 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

41. • 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.

42. • 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

43. 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.

44. • 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.

47. temporary prosthesis,
removable or fixed,

48. 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.

49. 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)

50. STANDARD PROTOCOL (OPTION 1)
Implant
insertion
• Stage 1
surgery
Healing
phase
• 3-6
months
Stage 2
surgery
• Placement
of healing
abutment
Final
abutment
placement
Impression
for final
prosthesis

51. 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

52. OPTION 3
Implant insertion +
impression
•Stage 1 surgery
Healing phase +
provisionalization
•3-6 months
Stage 2 surgery +
final abutment
placement +
provisional acrylic
resin prosthesis
Impression for final
prosthesis

53. OPTION 4
Implant insertion +
impression
Placement of
healing abutment
•Stage 1 surgery
Healing phase +
provisionalization
•3-6 months
Final abutment
placement +
provisional acrylic
resin prosthesis
Impression for
final prosthesis

54. IMMEDIATE LOADING (OPTION 5)
Stage 1 surgery
+ placement of
final abutments
Gingival healing
Impression for
final prosthesis

55. 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.

56. POST-OP MANAGEMENT
• Antibiotics and analgesics
• Oral hygiene and Chlorhexidene mouth wash
recommended

57. • 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.

58. • 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.

59. • 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.

60. 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

61. 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.

62. • 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

63. • 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

64. • 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.

65. 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

66. CONCLUSION…..

67. 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

68. • 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.

69. • 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