Are you providing the very best treatment for your patients in the shortest possible time? With the advances in implant technology and the diagnostic aides available, there are no excuses when treating a patient with an emergent condition.
The immediate placement of implants with immediate temporization has recently seen gains in popularity among clinicians. Barone et al1 demonstrated the validity of this clinical protocol, and Degidi et al2 presented a large number of immediately provisionalized implants with a 5-year success rate of 97.2%. The challenge is to improve upon protocols that permit more time-efficient, less traumatic, and highly predictable treatment outcomes in the aesthetic zone.3-5
With proper case selection, and with almost every implant on the market, a well-trained clinician can accomplish treatment such as this. The number of companies that claim to have something special or different when it comes to stability could fill volumes. The true differences relate to how predictable the treatment will be. This predictability comes from having an implant that attains outstanding primary stability, allows crestal bone preservation by platform switching, has a conical connection, and has restorative options that will result in outstanding aesthetics.
CASE REPORT
Diagnosis and Treatment Planning
A 27-year-old female patient presented, complaining that she had a loose tooth. The clinical evaluation revealed that tooth No. 10 had a large endodontic post with an oblique fracture (Figure 1). It was determined that the tooth was not restorable and required an extraction (Figure 2). After discussing all the treatment options with the patient, it was agreed that extraction of the tooth with immediate implant placement was the best long-term treatment. We also discussed the placement of an immediate temporary restoration, if possible. This would be done to maintain aesthetics in the short term and to help facilitate long-term aesthetic success.
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| Figure 1. Preoperative radiograph. | Figure 2. Crown removed from tooth. |
Clinical Protocol
The maxillary left lateral was atraumatically extracted using a spade proximator (yellow proximator [Karl Schumacher]) and a pair of narrow-beaked forceps (#4976P, [Dental USA]) (Figure 3). Atraumatic tooth removal without flap elevation is the most critical surgical strategy for immediate implant placement with immediate provisionalization, especially in the aesthetic zone.6 The socket was then completely debrided with a curette, and profuse bleeding was established (Figure 4). This step is extremely important to initiate regional acceleratory phenomenon (RAP). In simple terms, RAP is a tissue reaction to a noxious stimulus that increases the healing capacities of the affected tissues; this is typical not only of hard tissues, such as bone and cartilage, but also of soft tissues.7
A key aspect in the success of immediate implant placement is initial primary stability.8 This initial stability must be high enough to withstand and prevent micro motion to below 150 µm.9 In addition, there must be an even higher stability to allow the immediate placement of an immediate temporary crown restoration. In order to provide this stability, the implant is placed at least 3.0 mm into bone beyond the existing socket to engage solid bone. As commonly occurs in maxillary anterior implants, primary stability was attained by redirecting the osteotomy through the palatal aspect of the remaining socket. The osteotomy was prepared following the protocol as outlined by the implant manufacturer (Figures 5 and 6).
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| Figure 3. The extracted tooth, with an oblique fracture. | Figure 4. Preservation of the hard and soft tissues following atraumatic extraction. |
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| Figure 5. The redirected pilot drill. | Figure 6. Completion of the osteotomy with the final. |
Prior to placing the implant, blood from the socket was utilized to rehydrate a cortical/cancellous allograft (Newport Biologics) (Figure 7), which was then placed in the socket to graft the ensuing facial gap between the implant and the facial aspect of the socket. Grafting will ensure that there will be no collapsing of the facial plate and provide a foundation for support of the soft tissue. When measures are not taken to counteract physiologic bone remodeling after extraction, more than 50% of the buccal bone dimensions are lost in the first 4 months after immediate implantation.10
A 3.0- × 13-mm Hahn Tapered Implant (Glidewell Laboratories) (Figure 8) was placed by hand, with the platform placed approximately 1.5 mm below the facial crest of bone (Figure 9). The implant attained a seating torque value of 60 N/cm and an initial ISQ value of 67 using an Osstell IDx (Osstell). Both the seating torque and ISQ values were well within the safety zone necessary for immediate loading.11,12 A final seating radiograph was taken to evaluate the position of the implant (Figure 10).
A titanium abutment was then inserted into the implant (Figure 11), and the abutment screw was tightened by hand. No membrane was required since the occlusal flair of the abutment would seal the site (Figure 12). A pre-extraction impression was then filled with a provisional material (Visalys [Kettenbach LP]), and a full-contour temporary was created. After adjusting and polishing, the provisional restoration was temporarily cemented (Temp-Bond [Kerr Dental]). The excess cement was removed, and the occlusion was checked and adjusted as needed. Finally, the patient was given antibiotic (Amox 500 mg tid for 10 days) and analgesic (Toradol 10 mg prn q 4 to 6 hrs) prescriptions and postoperative instructions, and then she was dismissed.
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| Figure 7. Allograft regenerative material. | Figure 8. A 3.0- × 13-mm Hahn Tapered Implant (Glidewell Laboratories). |
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| Figure 9. The completely seated implant. | Figure 10. A radiograph showing platform position. |
Post-op evaluation appointments were then carried out at one week, one month (Figure 13), and 2.5 months. At the 2.5-month followup, the provisional restoration was removed, and an ISQ measurement of 81 was noted. Since the ISQ indicated that the implant was osseointegrated, the restorative phase was started with the restorative dentist. Because of the site being “trained” from the start with a full-contour temporary, the restorative phase could proceed without any delay.
It should be noted in the 2.5-month radiograph (Figure 14) that the internal conical connection and platform switching had contributed to the preservation of bone at the crest. Studies have shown high crestal bone stability around conical tapered platform switched implants.13 Platform switching has been shown to have a significant effect in the preservation of marginal bone levels compared to platform-matching restorations.14
A closed-tray impression coping was placed, and full seating was verified using a radiograph (Figure 15). The final impression was taken with a full-arch tray and a vinyl polysiloxane (VPS) impression material (Capture Impression Material [Glidewell Laboratories]). An opposing impression (Alginate) was taken along with a bite registration (Blu-Bite [Henry Schein]), and all were sent to the dental laboratory team for crown fabrication. It should be noted that, at the time the impressions were taken, it was observed that the distal papilla was a bit blunted. Rather than spend more time developing the soft tissue using the temporary restoration, the decision was made to move forward with the final restoration. In order to facilitate a rebound of the tissue and fill in the embrasure, the distal contact of the final restoration was placed approximately 4.0 to 4.5 mm above the bony crest. The papilla will predictably fill the papillary space between an implant and a natural tooth if the restorative contact is 4.5 mm or less.15
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| Figure 11. A titanium abutment was used for the provisional restoration. | Figure 12. Containment of the graft material. |
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| Figure 13. The provisional (temporary) restoration. | Figure 14. A 2.5-month postoperative radiograph. |
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| Figure 15. A radiograph, taken to verify proper seating of the impression coping. |
The case was returned to the office with a modified stock aesthetic abutment (Hahn Implants) and a full coverage, all-ceramic crown (Obsidian [Glidewell Laboratories]) (Figure 16). At the delivery appointment, the temporary was removed (Figure 17), and the site was irrigated using a 0.12% chlorhexidine gluconate oral rinse (Henry Schein) prior to the placement of the definitive abutment. The abutment was placed, and the abutment screw was torqued to 20 N/cm, per manufacturer directions. After 10 minutes, the screw was re-torqued to negate any changes in tightness due to metal pre-stretching of the threads. The crown was tried in for fit, and integrity of the margins was verified with a radiograph. Occlusal adjustments were done on the restoration after an evaluation of function in the full envelope of motion. Once the aesthetics were approved by the patient, the restoration was cemented using RelyX Unicem (3M) (Figure 18). After removing all excess cement, the occlusion was checked again, and the patient was dismissed.
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| Figure 16. The working model. | Figure 17. Soft-tissue contours at the time of the final impression. |
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| Figure 18. The completed lithium silicate restoration (Obsidian [Glidewell Laboratories]). |
CLOSING COMMENTS
When a patient presents with a clinical situation similar to this case, the clinician must ensure that the system and protocols used will result in a predictable and successful treatment outcome. Success comes from following sound implant principles, not only on the surgical end of the spectrum, but also on the restorative side. To achieve predictable aesthetic success with the immediate placement of implants into fresh anterior extraction sockets, the critical clinical keys that must be respected are: (1) atraumatic tooth removal without flap elevation, (2) the placement of a bone graft into the bone and tissue zones in the residual gap around an immediate fresh-socket implant,16 and (3) a full-contour provisional restoration.
Push yourself to achieve predictable success, and be certain to arm yourself with the tools that can make it happen!
References
- Barone A, Rispoli L, Vozza I, et al. Immediate restoration of single implants placed immediately after tooth extraction. J Periodontol. 2006;77:1914-1920.
- Degidi M, Piattelli A, Gehrke P, et al. Five-year outcome of 111 immediate nonfunctional single restorations. J Oral Implantol. 2006;32:277-285.
- Tarnow DP, Chu SJ. 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. Int J Periodontics Restorative Dent. 2011;31:515-521.
- Chen ST, Darby IB, Reynolds EC. A prospective clinical study of non-submerged immediate implants: clinical outcomes and esthetic results. Clin Oral Implants Res. 2007;18:552-562.
- Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in post-extraction sites. Int J Oral Maxillofac Implants. 2009;24(suppl):186-217.
- Sanz M, Cecchinato D, Ferrus J, et al. A prospective, randomized-controlled clinical trial to evaluate bone preservation using implants with different geometry placed into extraction sockets in the maxilla. Clin Oral Implants Res. 2010;21:13-21.
- Verna C. Regional acceleratory phenomenon. In: Kantarci A, Will L, Yen S, eds. Tooth Movement: Frontiers of Oral Biology, Volume 18. Basel, Switzerland: Karger; 2016:28-35.
- Gapski R, Wang HL, Mascarenhas P, et al. Critical review of immediate loading. Clin Oral Implants Res. 2003;14:515-527.
- Schlesinger C. Immediate placement of dental implants: A safe, predictable treatment option. Journal of Dental Science. 2016;4:146-152.
- Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol. 2004;31:820-828.
- Schlesinger C. Torque vs RFA in implant placement: a case study. Implant Practice US. 2016;9:14-20.
- Schlesinger CD. Immediately loading dental implants. Doing it right for long-term success. Dent Today. 2016;35:84-89.
- Ekstein J, Tandelich M, Nart J, et al. Marginal bone level around conical connection tapered implants with platform switching: A multicenter retrospective study at 14 months follow-up. Journal of Osseointegration. 2016;8:3-7.
- Rocha S, Wagner W, Wiltfang J, et al. Effect of platform switching on crestal bone levels around implants in the posterior mandible: 3 years results from a multicentre randomized clinical trial. J Clin Periodontol. 2016;43:374-382.
- Salama H, Salama MA, Garber D, et al. The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodontics Aesthet Dent. 1998;10:1131-1141.
- Chu SJ, Salama MA, Salama H, et al. The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent. 2012;33:524-534.
Dr. Schlesinger graduated from The Ohio State University College of Dentistry in 1996. After completing a General Practice Residency at the Veterans Administration Medical Center (VAMC) in San Diego, he went on to become the chief resident of the GPR Program at the VAMC West in Los Angeles. During his time at VAMC West, he received extensive training in oral surgery, implantology, and complex restorative dentistry. Dr. Schlesinger maintained a private practice in San Diego for 14 years before relocating to Albuquerque, where he served as the chief operating officer of an implant company. In 2016, he went back into private practice, providing comprehensive implant treatment through multiple offices in New Mexico. In addition to his clinical work, Dr. Schlesinger is an internationally renowned implant educator. He can be reached via email at cdschlesinger@gmail.com.
Disclosure: Dr. Schlesinger is a key opinion leader for Glidewell Laboratories. He receives a discounted fee from Glidewell Laboratories for products used and referred to in his clinical articles.
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