Immediate and Early Placement of Dental Implants Healing ... course presentations...Immediate...

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Immediate and Early Placement of Dental Implants

Healing with Immediate Implants

David Wilson, DDS

Wednesday, September 24, 14

Protocols for Implant Placement

Type I: Implant placement immediately following tooth extraction and as part of the same surgical procedure

Type 2: Complete soft tissue coverage (typically 4-8wks)

Type 3: Substantial clinical and/or radiographic bone fill of the socket (typically 12-16 weeks)

Type 4: Healed site (typically more than 16 weeks)

Consensus Statements and Recommended Clinical Procedures Regarding the Placement of Implants in Extraction Sockets. Hammerle C, Chen S, Wilson T. Quintessence vol 19, supplement 2004

Evaluation for Implant Timing

Overall patient treatmentEsthetic expectations of the patientSoft tissue quality, quantity, and morphologyBone quality, quantity, and morphologyPresence of pathologyCondition of adjacent teeth and supporting structures

Consensus Statements and Recommended Clinical Procedures Regarding the Placement of Implants in Extraction Sockets. Hammerle C, Chen S, Wilson T. Quintessence vol 19, supplement 2004

Immediate Implant Loading: within 1week of placement

Early Implant Loading: 1 week - 2 months

Conventional Loading: > 2 months

The Effectiveness of Immediate, Early, and Conventional Loading of Dental Implants: A Cochrane Systematic Review of Randomized Controlled Clinical Trials. Esposito M, Gabriella M, Willings M, Coulthard P, Worthington H. Ing J Oral Maxillofac

Implants 2007;22:893-904

Reduced treatment time

Reduced number of surgeries

Psychological

Advantages of Immediate Implants

Cannot assure patient that implant will be placed that day

Potentially higher failure rates

Potential Lack of KT

Disadvantages of Immediate Implants

Insertion torque < 30 N/cmPoor bone qualityOcclusion (ej deep overbite)Active infectionLack of KTParafunctional habits< 10mm bone height < 3-4mm apical bone for immediate implants

Implants 2007;22:893-904

Immediate Loading: Contraindications

Extraction socket repair 1. Hemorrhage!

2.Clot formation!

3. Inflammatory reaction-> recruitment of cells!

4. 48-72 hrs granulation tissue starts to replace clot!

5. 4 days- epithelium proliferates, immature CT!

6. 7 days- granulation tissue completely replaces clot, osteoid evident at the base of socket!

7. 2-3 weeks (3 to 4 wks after ext)- CT replaces granulation tissue, osteoid mineralizes coronally !

8. 6 weeks- epithelialization complete, bone fills more than 2/3 of socket!

Boyne 1966, Amler 1969, Darby 2009!

pearldentalclinic.co.uk!

Courtesy of Dr. Prokopets

Immediate Implants: Prevent Bone Resorption?

004)18 pts with a total of 21 teeth scheduled for extraction

All received immediate implants with flap elevation

Gap not filled / no membranes placed

4 months re-entry, gap measuredHard-tissue alterations following immediate implant placement in extraction sites. Botticelli D, Berglundh T, Lindhe J. J Clin

Periodontol 2004;31:820-828

Horizontal bone resorption about 56%

70% of total horizontal bone resorption was attributed to buccal bone

Vertical resorption:buccal: 0.3lingual: 0.6mesial: 0.2distal: 0.5

Hard-tissue alterations following immediate implant placement in extraction sites. Botticelli D, Berglundh T, Lindhe J. J Clin Periodontol 2004;31:820-828

Gaps filled with bone from inside of the defects, but substantial ridge resorption noted

5 Beagles

Sectioned teeth and removed one root on each side

Control: socket left to heal

Test: SLA implant placed

Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. Araujo M, Sukekava F, Wennstrom J, Lindhe J. J Clin Periodontol 2005;32:645-652

Bony resorption was the same with or without immediate implant placement

Multi-center study (4 centers)

Very strict inclusion criteria (ideal cases for Type I placement)

Conical or Straight implants placed (randomized)

Measurements taken at placement and re-entry (16wks)

A prospective, randomized-controlled clinical trial to evaluate bone preservation using implants with different geometry placed into extraction sockets in the maxilla. Sanz M, Cecchinato D, Ferrus J, Pjetursson E, Lang N, Lindhe J. Clin Oral Impl

Res 2010;21:13-21

Submerged healing protocol

Measurements taken to nearest half millimeter with a caliper by calibrated examiner (not the surgeon)

No difference in bony resorption (36% buccal /14% palatal)

Type I placement does not prevent bone resorption

Res 2010;21:13-21

Although B-L width changed, M-D dimensions did not (adjacent teeth were kept)

Res 2010;21:13-21

Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after a healing period of 6 months: report of 24 consecutive cases. Grunder U. Int J Periodontics Restorative Dent

2011;31:9-17

Immediate Implants: CTG at time of placement

2011;31:9-17

24 pts treated consecutively with immediate implants in anterior maxilla

12 without CT graft / 12 with CT graft

Healing abutment placed at time of Sx and removable prosthesis delivered

2011;31:9-17

Bucco-lingual volume measured before tx and 6months after Sx

No CT graft group: avg loss 1.1mm (range 0.23-2.0mm)

CT graft group: avg gain 0.34mm (range 0.0-1.5mm)

2011;31:9-17

No bone defect around tooth to be extracted

Soft tissue level that would still be in harmony with the gingival level of the adjacent teeth AFTER some shrinkage in the apical direction

Thick Biotype

2011;31:9-17

Recommendations for case selection in esthetically demanding patients

Araujo 2005

Immediate Implants: Graft Gap?

Covani 2004

Gaps < 2mm fill spontaneously

Paolantonio 2001

Human Histologic Verification of Osseointegration of an Immediate Implant Placed into a Fresh Extraction Socket With Excessive Gap Distance Without Primary Flap Closure, Graft, or Membrane: A Case Report. Tarnow D, Chu S. Int J

Periodontics Restorative Dent 2011;31:515-521

Tarnow 2011

No primary flap closure

No bone grafting

No membrane

Straight healing abutment placed

4.2mm buccal gap

Allowed 5 months healing time

Biopsied 10 months after placement

3.2mm wide buccal plate

Immediate Implants: Fill Gap?

Tarnow 2014

Flapless postextraction socket implant placement in the estheetic zone: Part 1. The effect of bone grafting and/or provisional restoration on facial-palatal ridge dimensional change-a retrospective cohort study. Tarnow D, Chu S, Salama M, Stappert C,

Salama H, Garber D, Sarnachiaro G, Sarnachiaro E, Luis S, Saito H. Int I Periodontics Restorative Dent 2014;34:323-331

Immediate Implants: Graft Gap?

Aim: evaluate horizontal changes of ridge after flapless extraction and immediate implant placement with and without grafting, with and without a provisional

49pts, 70% Central Incisors

Facial-palatal changes evaluated form FMB and apical to labial bone crest

Teeth without endo lesions, dehiscences, recession, PD...

Minimum torque 35 N/cm

Maryland

Casts were measured 6 months to 4 yrs after final delivery

Average 0.5mm less thickness at all points compared to contralateral natural teeth

Immediate Provisionalization does not prevent resorption

Immediate Placement and Provisionalization of Maxillary Anterior Single Implants: 1-Year Prospective Study. Kan J, Rungcharassaeng K, Lozada J. Int J Oral Maxillofac Implants 2003;18:31-39

Immediate Provisionalization

35 pts / 35 implants

100% survival at 1-yr

Mesial and Distal papilla -0.55mm and -0.53 respectively after 1-yr

Mesial and Distal bone change -0.26 and -0.22 respectively at 1-yr

Midfacial change in position of gingiva -0.53

No pt noticed change at the gingival margin

All pts satisfied with the esthetic outcome

Comparison of Radiographic and Clinical Outcomes Following Immediate Provisionalization of single-tooth dental implats palced in healed alveolar ridges and extraction sockets. Cooper L, Raes F, Reside G, Soliva J, Giner L, Wiltfang J, Kern M, De

Bruyn H. Int J Oral Maxillofac Implants 2010;25:1222-1232

Prospective multi-center study, 1-yr follow-up

Measured Rx bone levels, soft tissue levels

139 pts / 157 implants in maxilla

58 implants healed ridges / 55 immediate / 23 needed bone grafting prior to DI placement / 11 DI lack primary stability

Healed Ridge vs Immediate Implant

3 immediate implants failed (5.2%)

1 failed in healed ridge (1.5%)

Zenith stable or moved incisally after definitive placement in 84% of immediate implants and in 87% of implants in healed ridges after 1 year

All implants immediately provisionalized

Responses of local bone and soft tissues at immediately loaded implants in extraction sockets or healed ridges were similar

1-year results suggest that clinical management of esthetically critical soft tissue may be predictably achieved in both indications

Esthetic outcomes of immediate implant placements. Evans, C, Chen S. Clin Oral Implants Res 2008;19:73-80

42 implants immediately placed, mean follow-up 19mo

Retrospective study

Not immediately provisionalized (delayed provisionalization)

Maxilla and mandible

100% survival rate

Esthetic outcomes of immediate implant placements. Evans, C, Chen S. Clin Oral Implants Res 2008;19:73-80

Highly SS change in crown height due to rec of 0.9mm for all sites, with no difference between implant systems

Thin biotype (probe seen through gingiva) more recession than thick (0.9 vs 0.7), NSSD

Implants with buccal shoulder position 3x more recession than lingual position (1.8 vs 0.6mm)

Finite Element Anaylsis

Increased length and diameter of implant decreased stress and strain on alveolar crest

Stress and strain increased on horizontal loading vs vertical loading

Diameter had a more significant effect than length to relieve crestal stress and strain concentration

Effect of Diameter and Length on Stress Distribution of the Alveolar Crest around Immediate Loading Implants. Ding X, Liao S, Zhu X, Zhang X, Zhang L, Clin Implant Dent Relat Res vol 11, num 4, 2009

Immediate Loading: Increased BIC

4 patients with 1 extra implant placed

Group A: immediate loading (non-functional)Group B: implants submerged

4 weeks: 1 of each group trephined out8 weeks: the other implants removed

Bone formation around immediately loaded and submerged dental implants with a modified sandblasted and acid-etched surface after 4 and 8 weeks: a human histologic and morphometric analysis. Degidi M,

Piatelli A, Shibil J, Perrotti V, Iezzi G. Int J Oral Maxillofac Implants 2009;24:896-901Wednesday, September 24, 14

Immediate Loading: Increased BIC

Immediate Loading group: 4wks BIC 65.6%; 8wks 76.2%

Submerged group: 4wks 54.7%; 8wks 62.3%

Bone formation around immediately loaded and submerged dental implants with a modified sandblasted and acid-etched surface after 4 and 8 weeks: a human histologic and morphometric analysis. Degidi M,

Piatelli A, Shibil J, Perrotti V, Iezzi G. Int J Oral Maxillofac Implants 2009;24:896-901Wednesday, September 24, 14

Outcome based on prosthesis failures, implant failures, and marginal bone levels measured on intraoral xrays

11 trials including 300pts:6 immediate vs conventional3 early vs conventional2 immediate vs early

NSSD between different loading protocols

Implants 2007;22:893-904

Correlation between placement torque and survival of single-tooth implants. Ottoni J, Fagundes Z, Mansini R, Melo A. Int J Oral Maxillofac Implants 2005;20:769-776

When Immediate Loading Fails...

10/23 immediately loaded implants failed

Single implants in anterior sites

9/10 failed implants had < 20 N/cm torque

No diet specifications given to paitents

Correlation between placement torque and survival of single-tooth implants. Ottoni J, Fagundes Z, Mansini R, Melo A. Int J Oral Maxillofac Implants 2005;20:769-776

47 consecutive cases treated (10 I, 5 C, 30 PM)

Single implants placed after flapless extractions

Gap grafted with porcine bone and collagen membrane

Clinical exams and standard PAs taken at baseline, 1, 3, and 5 years

Smokers >10cigs/day and all diabetics excluded from study

Tissue Stability of Implants Placed in Fresh Extraction Sockets: A 5-Year Prospective Single-Cohort Study. Covani U, Canullo L, Toti P, Alfonsi F, Barone A. J Periodontol 2014;85:e323-e332

Facial wall present after extraction

Implants submerged (no healing abutment/immediate load)

All implants restored 4-5 months later

Pre-med with atb and continued 4 days after sx

Survival rate at 5 years: 95.7% (1 removed at 7 and other 16mo)

Marginal Bone loss: SS1yr: -0.7

3yrs: -0.955yrs: -1.1

NSSD in width of KT (-0.2mm over 5yrs)

Facial Soft Tissue Level: 1yr: +0.71 5yr: +0.56 (decreased)

Patient satisfaction: 74% satisfied regarding overall implant tx73% satisfied regarding peri-implant soft tissue81% judged positively the finished crown appearanceNSSD at any point in time

Systematic Review 1991-2010

46 prospective studies, mean follow-up 2 years

Factors analyzed: reason for extraction, antibiotic use, position of implant (ant vs post, max vs man), type of loading

Only SS dif was for antibiotc use (POT atb lowered failures)

2-year survival rate 98.4%A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least

1 year. Lang N, Pun L, Yee K, Yan K, Wong M. Clin Oral Impl Res 23/Suppl 5, 2012, 39-66

Most soft tissue changes occurred in first 3 months, and stabilized towards end of first year

Marginal bone loss mostly took place within first year of implant placement, usually being less than 1mm

A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Lang N, Pun L, Yee K, Yan K, Wong M. Clin Oral Impl Res 23/Suppl 5, 2012, 39-66

275 implants immediately loaded in extraction sockets, 197 in periodontally infected sites (I, C, PM)

Marginal bone levels measured at baseline, 12, 24 and 48 months (digital PAs)

Immediate Loading of Dental Implats Placed in Periodontally Infected and Non-Infected Sites: A 4-Year Follow-Up Clinical Study. Crespi R, Cappare P, Gherlone E. J Periodontol 2010;81:1140-1146

Immediate Loading in Periodontally Infected Sites

At 4 yrs: infected group 98.9% survival (2 implants lost within 1st month), non-infected group 100% survival

NSSD between MBL at 4yrs (both lost 0.79mm)

Immediate Loading of Dental Implats Placed in Periodontally Infected and Non-Infected Sites: A 4-Year Follow-Up Clinical Study. Crespi R, Cappare P, Gherlone E. J Periodontol 2010;81:1140-1146

Summary

Type 1, 2, 3, and 4 DI placement have equal survival rates

More literature necessary for Type 2

SEVERAL CONTRAINDICATIONS FOR TYPE I PLACEMENT

More long-term studies needed for success of Type I Placement

References

1. Consensus Statements and Recommended Clinical Procedures Regarding the Placement of Implants in Extraction Sockets. Hammerle C, Chen S, Wilson T. Quintessence vol 19, supplement 20042. The Effectiveness of Immediate, Early, and Conventional Loading of Dental Implants: A Cochrane Systematic Review of Randomized Controlled Clinical Trials. Esposito M, Gabriella M, Willings M, Coulthard P, Worthington H. Ing J Oral Maxillofac Implants 2007;22:893-9043. Hard-tissue alterations following immediate implant placement in extraction sites. Botticelli D, Berglundh T, Lindhe J. J Clin Periodontol 2004;31:820-8284. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. Araujo M, Sukekava F, Wennstrom J, Lindhe J. J Clin Periodontol 2005;32:645-6525. A prospective, randomized-controlled clinical trial to evaluate bone preservation using implants with different geometry placed into extraction sockets in the maxilla. Sanz M, Cecchinato D, Ferrus J, Pjetursson E, Lang N, Lindhe J. Clin Oral Impl Res 2010;21:13-216. Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after a healing period of 6 months: report of 24 consecutive cases. Grunder U. Int J Periodontics Restorative Dent 2011;31:9-177. Human Histologic Verification of Osseointegration of an Immediate Implant Placed into a Fresh Extraction Socket With Excessive Gap Distance Without Primary Flap Closure, Graft, or Membrane: A Case Report. Tarnow D, Chu S. Int J Periodontics Restorative Dent 2011;31:515-521

References

8. Flapless postextraction socket implant placement in the estheetic zone: Part 1. The effect of bone grafting and/or provisional restoration on facial-palatal ridge dimensional change-a retrospective cohort study. Tarnow D, Chu S, Salama M, Stappert C, Salama H, Garber D, Sarnachiaro G, Sarnachiaro E, Luis S, Saito H. Int I Periodontics Restorative Dent 2014;34:323-3319. Immediate Placement and Provisionalization of Maxillary Anterior Single Implants: 1-Year Prospective Study. Kan J, Rungcharassaeng K, Lozada J. Int J Oral Maxillofac Implants 2003;18:31-3910. Comparison of Radiographic and Clinical Outcomes Following Immediate Provisionalization of single-tooth dental implats palced in healed alveolar ridges and extraction sockets. Cooper L, Raes F, Reside G, Soliva J, Giner L, Wiltfang J, Kern M, De Bruyn H. Int J Oral Maxillofac Implants 2010;25:1222-123211. Esthetic outcomes of immediate implant placements. Evans, C, Chen S. Clin Oral Implants Res 2008;19:73-8012. Effect of Diameter and Length on Stress Distribution of the Alveolar Crest around Immediate Loading Implants. Ding X, Liao S, Zhu X, Zhang X, Zhang L, Clin Implant Dent Relat Res vol 11, num 4, 200913. Correlation between placement torque and survival of single-tooth implants. Ottoni J, Fagundes Z, Mansini R, Melo A. Int J Oral Maxillofac Implants 2005;20:769-77614. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Lang N, Pun L, Yee K, Yan K, Wong M. Clin Oral Impl Res 23/Suppl 5, 2012, 39-6615. Immediate Loading of Dental Implats Placed in Periodontally Infected and Non-Infected Sites: A 4-Year Follow-Up Clinical Study. Crespi R, Cappare P, Gherlone E. J Periodontol 2010;81:1140-1146

References

16. Bone formation around immediately loaded and submerged dental implants with a modified sandblasted and acid-etched surface after 4 and 8 weeks: a human histologic and morphometric analysis. Degidi M, Piatelli A, Shibil J, Perrotti V, Iezzi G. Int J Oral Maxillofac Implants 2009;24:896-901

Immediate and Early Placement of Dental Implants Healing ... course presentations...Immediate...

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