Dr.Sheeba glory2nd yr pg

IMMEDIATE IMPLANT

Contents:• Introduction• Terminology• What is immediate implant placement.• Advantages• Indications• Contraindications• Guideslines for extraction for immediate implant

placement• Atraumatic extraction• Osteotomy preparation• Implant selection- design,depth diameter• GAP- bone grafting

• Disadvantages• Case reports• Review of literature• Summary • conclusion

INTRODUCTION

shortened or immediate loading subsequent to implant placement;

alteration of the surface of the implant fixture to promote faster

healing; and o immediate placement of the implant

after extraction of the natural tooth.

TERMINOLOGY

• Immediate implant placement occurs at the time of extraction• Delayed implant placement is performed

approximately 2 months post-extraction to allow soft tissue healing• Staged implant placement allows for substantial

bone healing within the extraction site that typically requires 4-6 months or longer

Immediate placement of implant at the time of extraction

Following tooth extraction ,a variable amount of ridge collapse .Takes place because of bone

resorption .This bone loss can occur in either buccal –lingual /

Apicocoronal dimensions / both.As much as 3 to 4 mm of bucco lingual & apico

coronal Bone resorption during 6 months following

extraction

To avoid these problems a Technique has been introduced

involving Simultaneous tooth extraction & Immediate implant placement

This technique allows bone & Soft tissue Preservation

implants in extraction sites can be placed in the same positionAs the extracted teeth

Facilitates final restoration & minimizes need for severely angledAbutments /fabrication of telescopic copings

Surgeon can position the implant more favorably than the original position

socket as a Guide for determination of parallelism & alignment to the opposing & adjacent teeth

Reduces the treatment time & interval during the transitional period

Patients acceptability

ADVANTAGES REGARDING IMMEDIATE IMPLANTS

Main advantage of immediate implant placement

Timing of implant placement following tooth removal may be important to take advantage of soft tissue healing

But without risk of losing bone volume through resorption .The data to support enhanced soft tissue esthetic outcomes

with delayed implant placement are lacking

INDICATIONSCrown fracture Endodontic

failurecrown root ratio

Severe decay

CONTRAINDICATIONS

• Infected site (presence of purulent exudate)

• Insufficient depth for primary stability of the fixture

• Width of the extraction socket is less than 4-5 mm

Guidelines for extraction When planning for immediate implant placement

Pre operative evaluation

Antibiotic therapy initiation

Preservation of the bony Receptor sites

Procedural delays Interoperate decision

Avoidance of excessive pressure

Osteotomy preparation

Improvements for primary stability

Bone grafts 1973 , BOYNE (GUIDE LINES FOR BONE GRAFT)

Rapidosteogenesis Not elicit an

immunologic Responses

Osteoinductive provide for Osteo conduction

Soft tissue closure

Successful osseointegration Implant loading

• Preoperative evaluation• Antibiotic therapy• No purulent exudate at

extraction.• Warned of possible staged, or

delayed preocdure.

A TRAUMATIC EXTRACTION

After clinical / radiographic evaluation--- hopeless tooth extracted

Whenever possible, surgeon should avoid to reflect a flap

to preserve the integrity of vascular supply & periosteum covering the bone Will minimize the bone

resorption

PERIOTOME SECTIONING

Absence of acute non contained

infection

Immediate Implant placement

Determined by 3 factors

Achievement of initial stability of

the implant

Sufficient quantity & quality of

Bone

Ideal extracted sites are:• 4 wall socket• 3 wall dehiscence type defect (5 mm or less) in apico-

coronal direction• The osseous crest lies in the coronal 1/3 of the root to

be extracted• Sufficient bone (4-6mm) beyond the apex for primary

stability of the implant

Osteotomy preparation

• Lingual / palatal line of preparation and insertion of implant 2.0mm longer than the root.

• 2/3rd implant contacting bony receptor site.

• Implant must be immobilized at final placement

IMPLANT PLACEMENT AT TIME OF MAXILLARY MOLAR EXTRACTION

• The interradicular bone morphology and the need or

lack of need for additional bone height be assessed: 1) If No Additional Alveolar Bone Height Is Required:

Wide interradicular septum is present- 2.2-mm guide drill initial osteotomy to its final depth-

Tapered osteotomes sequential diameters

2) Narrow interradicular bony septum :• Piezo surgery is used to notch the most

crestal aspect of the interradicular bone(set point)

• a tapered osteotome the final depth of the planned osteotomy.

If Additional Bone Height Is RequiredIn The Interradicular Area:

• When inadequate alveolar bone height is present crestal to the fioor of the sinus for placement of an implant of the desired dimensions, therapy proceeds in one of the following two manners, depending on the morphology of the interradicular bone.• If a wide interradicular septum is present• If a narrow interradicular septum is present

Implant Placement At Time Of Maxillary Premolar Extraction

• 1. Implant placement in the area of the buccal root socket in the instance of a two-rooted bicuspid, or the buccal third of the extraction socket in instances where a one-rooted bicuspid is being replaced

• 2. Implant placement in the area of the palatal root socket in the instance of a two-rooted bicuspid, or the palatal third of the extraction socket in instances of a one-rooted bicuspid

• 3. Implant placement in the interradicular bone or central third of the extraction socket, depending upon whether a two- or one-rooted tooth had been removed

TAPERED IMPLANTS• Better buccal support and helps preserve the

root prominence (aesthetic zone)• Improves the implant to bone interface –

enhances stability and creates a more acceptable emergence profile.• May obviate the use of membrane.• Incidence of fenestration & dehiscence Is

greatly reduced.• In cases with adjacent convergent roots.

IMPLANT DIAMETER AND DEPTH• Maxillary first bicuspid -- -use of a narrower

diameter implant (3.3 to 3.8mm) • Maxillary first bicuspid bear load during function-

implant and abutment strength over time.• The use of a titanium-zirconium alloy implant,

which is considerably stronger than a corresponding titanium implant, helps ameliorate the concem regarding implant strength.• Implant depth-narrower implant will have to be

placed more deeply than its wider counterpart in a given situation

• Premolar region of either arch --esthetic concerns--bone-level implants. • Implants placed at the bone level permit

the restorative dentist to develop an esthetic emergence profile by transiting from the bone through the soft tissues into the restorative space. • The tissues surrounding the implant-

supported restoration can be manipulated to provide the appearance of a natural tooth framed by the gingival tissues. • Bone-level implants are technically more

difficult to restore than tissue-level implants.

• A tissue-level implant design is preferable when replacing a missing molar, as greater stability is provided for the restoration.• the widest implant neck diameter that is

feasible is preferred• utilization of either implant design with the

appropriate concomitant regenerative therapy will result in bone of adequate thickness bucally and lingually to withstand functional forces over time

THE GAP• Close adaptation of the implant to the socket wall promotes greater osseointegration.

Horizontal defect dimension (HDD)/jumping distance

In the intact socket , a critical component of the peri implant defect is the size of the horizontal defect (HD ) .

Implants With a HD of 2mm / less spontaneous healing &

osseo integration takes

place , if the

implant has rough surface

HD in excess of 2 mm to achieve bone healing bone fill like by using collagen barrier

membrane & implants with a sand blasted

&acid etched surface

WHEN TO CONSIDER GRAFTING PROCEDURES

• If any osseous defect exists circumferentially.• If there is translucence of bur or implant on labial

/buccal bone.• If there is residual exposure of implant body.• If dehiscence or fenestration exists.• If there is primary closure of soft tissue flaps.• If vertical relaxing incision is necessary.• If there is scoring of periosteum• If a water tight closure is no longer necessary.

Risk factors for immediate implant placement • Poor bone quality/volume

• Presence of infection

• Presence of high masticatory / para functional habits

DISADVANTAGES

• (i) lack of control of the final implant position• (ii) difficulty obtaining primary stability • (iii) inadequate soft tissue coverage• (iv) inability to inspect all aspects of the

extraction site for defects or infection• (v) difficulty in preparing the osteotomy

due to bur movement (chatter) on the walls of the extraction site; and • (vi) the added cost of bone grafting.

CONVENTIONAL LOADING The prostheses is attached in a second Procedure after a healing period of 3 to 6 months EARLY LOADING

A restoration in contact with the oppossing Dentition & placed atleast 48hrs after implant Placement but not later than 3 months afterwards

DELAYED LOADING The prostheses is attached in a second procedure that takes place some time later Than the conventional healing period of 3 to 6 months

Immediate functional loading Immediate non functional loading

Of implants involved patients receiving prostheses with occlusal function on the day of implant placement

Provision of prostheses 1 to 2mm Short of the occlusal contact

CASE REPORT

2 YR FOLLOW UP

CASE REPORT

Journal of Prosthodontics 17 (2008) 576–581

Journal of implant and advacned clinical dentistry Aug 2009

Immediate Non-occlusal Loading Of Immediate Post-extractive Versus Delayed Placement Of Single Implants In Preserved Sockets Of The Anterior Maxilla: 4-month Post-

loading Results From A Pragmatic Multicentre Randomised Controlled Trial-

Eur J Oral Implantol 2011;4(4):329–344

• Total 106 pts : 54 pts – immediate group & 52 pts –delayed group.

• Maxilla premolar- premolar.• Delayed group 4 months after socket preservation

implants placed.• Implants > 35Ncm Insertion torque – immediately

loaded with non occluding provisionals.

• Results: 19 (35%) implants were not immediately loaded in the immediate group vs 39 (75%) implants in delayed group .• 2 implants failed in the immediate group (4%)

vs none in the delayed group. • More minor complications occurred in the

immediate group (8) than delayed group (1) statistically significant (P = 0.032). • Conclusions: There were more complications at immediate post-extractive implants when compared to delayed implants. The aesthetic outcome appears to be similar for both groups and it seems more difficult to obtain a high insertion torque in sockets preserved with anorganic bovine bone.

Flapless Single-tooth Immediate Implant Placement

Int J Oral Maxillofac Implants 2013;28:783–789

• 430 immediate implants during a 15-year period (December 1994 to December 2009).

• 275 implants -immediate provisional crown & 155 -healing abutment.

• The implant survival rate was 93.03% .• survival rate mmediately restored without provisional (96.78%)

that were immediately restored with a provisional (90.9%).• Conclusions: study showed a favorable implant success rate

related to the flapless immediate implant placement protocol with healing abutment placement or an immediate provisional crown to replace a single missing tooth.

.

The Influence of Insertion Torque on the Survival of

Immediately Placed and Restored Single-Tooth Implants

Int J Oral Maxillofac Implants 2011;26:1333–1343

• To evaluate the medium- to long-term clinical outcome of single-tooth implants placed into fresh extraction sockets using a low-insertion-torque protocol and immediately restored with acrylic resin provisional crowns.• 68 implants placed into immediate

extraction sockets • Insertion torque 25ncm

• Results: overall survival rate 95.5%• The mean marginal bone loss :• 54 implants (24 months) 0.23 ± 0.60 mm

mesially & 0.20 ± 0.72 mm distally.• Overall, 78% of implants showed no

marginal bone loss, • 9% experienced 0.1 to 0.5 mm of bone

loss, and • 13% demonstrated > 0.5 mm of bone loss

Conclusion:• A torque of only 25 Ncm would seem more than

sufficient to yield a favorable clinical outcome. • Immediate provisionalization of single-tooth implants placed with a relatively low insertion torque can yield favorable survival rates and optimal maintenance of marginal bone levels compared to the generally accepted norm

A Retrospective Analysis of Immediately Placed Implants in 418 Sites Exhibiting Periapical

Pathology: Results and Clinical ConsiderationsInt J Oral Maxillofac Implants 2012;27:194–202• 418 implants -immediate implant placement -

1994-2008. • They were followed for a mean of 67.3 months. • 5 implants were either lost or demonstrated

progressive bone loss beyond acceptable levels,• Cumulative survival rate of 97.8%. • Conclusions: Implant placement at the time

of extraction of teeth demonstrating periapical pathology will result in implant survival rates comparable to those of implants placed immediately into sites without periapical pathology.

IMMEDIATE IMPLANT PLACEMENT

SUMMARY

ONE STAGE IMPLANT PLACEMENT

SURGICAL CONSIDERATIONS FOR EXTRACTION IMMEDIATE

IMPLANTATION.• Preoperative evaluation-Antibiotic therapy• No purulent exudate at extraction.• Warned of possible staged, or delayed preocdure.• Atraumatic surgical removal• Section with high speed bur.• Periotome removal• X-Trac system.

• Lingual / palatal line of preparation and insertion of implant 2.0mm longer than the root.

• 2/3rd implant contacting bony receptor site.• Implant must be immobilized at final placement.• Adequate soft tissue closure.

CONCLUSION

REFERENCES.

• Dental implants: the art and science- Charles A. Babush,Jack A. Han,Jack T. Krauser, Joel L. Rosenlicht.-Extraction and immediate implant reconstruction: single tooth to full mouth. 313-339.

• Immediate implant placement: treatment planning and surgical steps for successful outcomes -British Dental Journal Volume 201 No. 4 Aug 26 2006; 199- 205.

• Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages-Journal of Prosthodontics 17 (2008) 576–581

• Immediate Implant Placement in Posterior Areas, Part 2: The Maxillary Arch-Compendium July/August 2013 Volume 34, Number 7 ;518-527.

• Immediate Implant Placement In Posterior Areas: The Mandibular Arch – Compendium July/August 2012 Volume 33, Number 7 494-304

• Immediate non-occlusal loading of immediate post-extractive versus delayed placement of single implants in preserved sockets of the anterior maxilla: 4-month post-loading results from a pragmatic multicentre randomised controlled trial- Eur J Oral Implantol 2011;4(4):329–344

• The Influence of Insertion Torque on the Survival of Immediately Placed and Restored Single-Tooth Implants -Int J Oral Maxillofac Implants 2011;26:1333–1343

• Implant Placement In Extraction Sockets: A Short Review Of The Literature And Presentation Of A Series Of Threecases – Journal Of Oral Implantology 2008;34 (2) 97-108.

• A Retrospective Analysis of Immediately Placed Implants in 418 Sites Exhibiting Periapical Pathology: Results and Clinical Considerations -Int J Oral Maxillofac Implants 2012;27:194–202

• Flapless Single-tooth Immediate Implant Placement--Int J Oral Maxillofac Implants 2013;28:783–789