Immediate Dental Implant: an overview with two case reports

transcript

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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llllllllllllllllllllllllllllllllllllllllllllllllllcase1 case2

MATERIALS

Indident Implant System; Defense Research Development Organization(DRDO),

Ministry of Defense; 2-unit, cylindrical and threaded : Case2

Diameter 4.2mm; length 9mm

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

910

5

case1

Amalgam carrier was used

to collect and inject the

bone repair material in

the residual space

Fig 5 & 6

6

7

8

910

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

910

5

case1

The radiograph shows the

apex of the implant

firmly anchored in bone

apical to the socket

Fig 8

6

7

8

910

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

89

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

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Atraumatic extraction to preserve thealveolar 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 allowplacement 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-boneinterface 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

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Immediate Dental Implant: an overview with two case reports

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