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Immediate Implant Placement

Dr. Mohammed AlshehriBDS, AEGD, SSC-Resto, SF-DI


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Introduction

The formation as well as the preservation of the alveolar

process is dependant on the continued presence of teeth.

Patient with long and narrow teeth have more delicate

alveolar process and, in particular, a thin, sometimes

fenestrated buccal bone plate.


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Its well documented that following multiple teeth

extraction and the subsequent restoration with removable

dentures, the size of the alveolar ridge will become

markedly reduced, not only in horizontal but also in

vertical dimension and the arch will be shortened.

Resorption more pronounced at the

buccal than the lingual/palatal aspects of

the ridge.


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Following an extraction, there is a 25% decrease in the

width of the alveolar bone during the first year, and an

average 4 mm decrease in height during the first year

following multiple extractions. (Carlson 1967, Misch 2000; Misch 2000)

Tatum and Mischhave observed a 40%-60% decrease in

alveolar bone width after the first 2 to 3 years post

extraction.


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Christensen reports an annual resorption rate of at least

0.5% to 1% during the remainder for the rest of a patients

life.

In the publication by Schropp et al. (2003) most of the

bone gain in the socket occurred in the first 3 months.


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The formation as well as the preservation of the alveolar

process is dependant on the continued presence of teeth.

Patient with long and narrow teeth have more delicate

alveolar process and, in particular, a thin, sometimes

fenestrated buccal bone plate.


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Healing of Extraction Socket

Amler (1969)


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Amler (1969)


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Ohta (1993)


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Ohta (1993)


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Araujo MG, Lindhe J (2005)

1 week 2 weeks


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Araujo MG, Lindhe J (2005)

4 weeks 8 weeks


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Soft Tissue Changes after Extraction

Immediately following tooth extraction there is a lack ofmucosa and the socket entrance is open

During the 1st weeks after extraction, cell proliferationwithen the mucosa will results in an increase in its C.Tvolume

The soft tissue wound will become epithelialized and

keratinized ,the mucosa will cover the extraction site

The contour of the mucosa will adapt to follow the changesthat occur externally in the hard tissue of the alveolar

process.


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Hard Tissue Changes after Extraction

The Theory of Bundle Bone

The Bundle Bone delineates the alveolar socket

Thickness approximately 0.8 mm

It's a tooth related bone structure

Blood supply through blood vessels of the PDL


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Hard Tissue Changes after Extraction

following extraction, since bone structure resorbesirrespective of therapy

This is critical on the facial aspect, since 2-3 mm of themost coronal bone wall is mainly made of bundle bone

(Schropp et al. 2003, Botticelli et al. 2004, Araujo & Lindhe 2005, Araujo et al. 2005, Araujo et al. 2006, Fickl et al. 2008)


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Changes in the soft and hard tissues

following tooth extraction


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Clinical situations at extraction of anterior

teeth in the maxilla


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Immediate Implant

Definition: Implant placed as part of the same surgicalprocedures and immediately following tooth extraction

Type I (Hammerle Classification)


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Rationale

Easier definition of the implant position

Reduced number of visits in the dental office

Reduced overall treatment time and costs

Preservation of bone at the site of implantation

Optimal soft tissue esthetics Enhanced patient acceptance

(Werbitt & Goldberg 1992; Barzilay 1993; Schwartz-Arad & Chaushu 1997a; Mayfi eld 1999; Hammerle et al. 2004)


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Immediate Implant & GBR


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Disadvantages

Site morphology may complicate optimal Placement and

anchorage.

Adjunctive surgical procedures may be required.

Technique sensitive procedures.

Thin tissue biotype may compromise optimal outcome.

Potential lack of keratinized mucosa for flap adaptation.


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Esthetic Complications with Immediate

Implants Observed complications with immediate implants in early

2000.

Increased risk for facial bone resorption and consequentsoft tissue recession.


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Mucosal Recession with Immediate Implants

Clinical studies reporting mucosal recessions

Lindeboom, Tjiook, Kroon: Immediate placement of implants in periapicalinfected sites: a prospective randomized study in 50 patients. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod 101:705, 2006.

Chen, Darby, Reynolds: A prospective clinical study of nonsubmergedimmediate implants: clinical outcomes and esthetic results. Clin Oral ImplantsRes 18: 552, 2007.

Kan, Rungcharassaeng, Sclar, Lozada: Effects of the facial osseous defectmorphology on gingival dynamics after immediate tooth replacement andguided bone regeneration: 1-year results. J Oral Maxillofac Surg 65: 13, 2007.


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Clinical studies reporting mucosal recessions

Evans, Chen: Esthetic outcomes of immediate implant placements. Clin OralImplants Res 19: 73, 2008.

Chen, Darby, Reynolds, Clement: Immediate implant placement post-extraction without flap elevation: A case series. J Periodontol 80: 163-172,2009.


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Keys of success in Esthetic Zone

Preservation of adequate amount of facial bone.

Surgical procedures which encourage healing capable ofmaintaining at least 2 mm of facial bone dimention.

Appropriate bone dimention (horizontal bulk in addition tovertical height) helps to maintain bone and soft tissue over

the longer term.


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Conclusion

The alveolar process following tooth extraction will adaptby atrophy and an immediate implant in this respectcannot prevent this problems ,and unable to substitute forthe tooth.

The problem with type 1 placement is that the bone losswill frequently cause the buccal portion of the implant to

gradually lose its hard tissue coverage, and that the metalsurface may become visible through a thin peri-implantmucosa and cause esthetic concerns.


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Conclusion

To overcome this problem

Placing the implant deeper into the fresh socket and inthe lingual palatal portion of the socket to overcome

buccal bone resorption

bone regeneration (augmentation) procedures may berequired to improve or retain bone volume and the

buccal contour at a fresh extraction site.


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Summary

There is no doubt today that this approach is associated with anincreased risk for esthetic complications Mucosal recession on the facial aspect

There are significant risk factors for such Complications :

Gingival biotype (thin, highly scalloped)

Oro-facial malposition of the implant

Shape of facial bone defect (V-shape vs. U-shape)

This treatment concept is of complex level

Clinician must be very experienced

Careful case selection is crucial Esthetic risk assessment

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