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Implants into fresh extraction site: A literature review, case immediate placement report


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Implants into fresh extraction site: A literature review, case immediate placement report

  1. 1. [Downloaded free from http://www.jdionline.org on Monday, December 09, 2013, IP:]  ||  Click here to download free Android application for this journa REVIEW ARTICLE Implants into fresh extraction site: A literature review, case immediate placement report Abu-Hussein Muhamad1,2, Abdulghani Azzaldeen3, Sarafi Anou Aspasia4, Kontoes Nikos5 ABSTRACT Immediate implants are positioned in the course of surgical extraction of the tooth to be replaced. The percentage success of such procedures varies among authors from 92.7-98.0%. The main indication of immediate implantation is the replacement of teeth with pathologies not amenable to treatment. Its advantages with respect to delayed implantation include reduced postextraction alveolar bone resorption, a shortening of rehabilitation treatment time, and avoidance of a second surgical intervention. The inconveniences in turn comprise a general requirement for membrane‑guided bone regeneration techniques, with the associated risk of exposure and infection, and the need for mucogingival grafts to seal the socket space and/or cover the membranes. The surgical requirements for immediate implantation include extraction with the least trauma possible, preservation of the extraction socket walls and thorough alveolar curettage to eliminate all pathological material. Primary stability is an essential requirement, and is achieved with an implant exceeding the alveolar apex by 3-5 mm, or by placing an implant of greater diameter than the remnant alveolus. Esthetic emergence in the anterior zone is achieved by 1-3 mm subcrest implantation. Regarding guided regeneration of alveolar bone, the literature lacks consensus on the use of membranes and type of filler material required. While primary wound closure is desirable, some authors do not consider it to be of great relevance. KEY WORDS: Dental implants, immediate implants, fresh extraction INTRODUCTION Immediate implants are defined as the placement of implants in course of surgical extraction of the teeth to be replaced. The insertion of implants immediately after extraction is not new, and in the 1980s, the University of Tübingen advocated the procedure as the technique of choice for Tübingen and München ceramic implants.[1,2] As a result of the success of the protocol designed by Brånemark and his team for their dental implant system, University of Napoli, Italy, 2University of Athens, Greece, Al-Quds University, Jeruslem, Israel, 4University of Athens, 5 Private Practice, Athens, Greece 1 3 Address for correspondence: Dr. Abu‑Hussein Muhamad, 123 Argus street, 10441, Athens‑Greece. E-mail: abuhusseinmuhamad@gmail.com Access this article online Quick Response Code: Website: www.jdionline.org DOI: 10.4103/0974-6781.118858 160 other procedures were largely relegated for many years. Initially, a healing period of 9-12 months was advised between tooth extraction and implant placement. Nevertheless, as a result of continued research, a number of the concepts contained in the Brånemark protocol and previously regarded as axiomatic; such as the submerged technique concept, delayed loading, machined titanium surface, etc.; have since been revised and improved upon even by actual creators of the procedure.[2‑4] Based on the time elapsed between extraction and implantation, the following classification has been established relating the receptor zone to the required therapeutic approach: a. Immediate implantation, when the remnant bone suffices to ensure primary stability of the implant, which is inserted in the course of surgical extraction of the tooth to be replaced  (primary immediate implants) b. Recent implantation, when approximately 6-8 weeks have elapsed from extraction to implantation, a time during which the soft tissues heal, allowing adequate mucogingival covering of the alveolus  (secondary immediate implants) Journal of Dental Implants | Jul - Dec 2013 | Vol 3 | Issue 2
  2. 2. [Downloaded free from http://www.jdionline.org on Monday, December 09, 2013, IP:]  ||  Click here to download free Android application for this journa Muhamad, et al.: Implants into fresh extraction site c. Delayed implantation, when the receptor zone is not optimum for either immediate or recent implantation. Bone promotion is first carried out with bone grafts and/or barrier membranes, followed approximately 6 months later by implant positioning (delayed implants) d. Mature implantation, when over  9  months have elapsed from extraction to implantation. Mature bone is found in such situations.[1,3‑7] INDICATIONS OF IMMEDIATE IMPLANTATION Primary implantation is fundamentally indicated for replacing teeth with pathologies not amenable to treatment, such as caries or fractures. Immediate implants are also indicated simultaneous to the removal of impacted canines and temporal teeth.[1,4,7] Immediate implantation can be carried out on extracting teeth with chronic apical lesions which are not likely to improve with endodontic treatment and apical surgery. et al., in a study in dogs, inserted immediate implants in locations with Novae’s chronic periapical infection. These authors reported good results and pointed out that despite evident signs of periapical disease, implant placement is not contraindicated if pre‑ and postoperative antibiotic coverage is provided and adequate cleaning of the alveolar bed is ensured prior to implantation.[3,4,8] While immediate implantation can be indicated in parallel to the extraction of teeth with serious periodontal problems, Ibbott et al., reported a case involving an acute periodontal abscess associated with immediate implant placement, in a patient in the maintenance phase.[1,4,6‑8] CONTRAINDICATIONS The existence of an acute periapical inflammatory process constitutes an absolute contraindication to immediate implantation.[4,8,9] In the case of socket implant diameter, discrepancies in excess of 5 mm, which would leave most of the implant without bone contact, prior bone regeneration and delayed implantation may be considered.[4,8,9] ADVANTAGES One of the advantages of immediate implantation is that post extraction alveolar process resorption is reduced, thus affording improved functional and esthetic results. Another advantage is represented by a shortening in treatment time, since with immediate placement it is not necessary to wait 6-9 months for healing and bone Journal of Dental Implants | Jul - Dec 2013 | Vol 3 | Issue 2 neoformation of the socket bed to take place.[4,9,10] Patient acceptance of this advantage is good, and psychological stress is avoided by suppressing the need for repeat surgery for implantation.[4,7,8] Preservation of the vestibular cortical component allows precise implant placement, improves the prosthetic emergence profile, and moreover preserves the morphology of the peri‑implant soft tissues; thereby affording improved esthetic‑prosthetic performance.[8‑10] SURGICAL CONSIDERATIONS The surgical criteria which apply to immediate implantation include the following: Ensure that extraction is as least traumatic as possible, to maximize bone integrity. In teeth with multiple roots, dental sectioning is indicated, with individualized extraction of the roots. The socket walls are to be preserved during extraction, particularly the vestibular wall, the level of which should be harmonized with that of neighboring teeth, to ensure esthetic emergence of prosthetic post.[1,3,4,7] Before positioning the immediate implant, careful curettage and alveolar cleaning is required to remove any trace of infected or inflamed tissue, together with remains of the periodontal ligament.[2,7‑9] The implant must possess sufficient primary stability. This is generally ensured by exceeding the apex by 3-5 mm, or by using an implant of greater diameter than the socket.[1,5] Implant placement In anterior teeth, the ideal orientation of implant axis does not usually correspond to that of the socket. Implant placement in the direction of root would oblige vestibular emergence of retention screw or use of prosthetic additaments for the change in angle. The implant bed is to be prepared palatal, and osteodilators can be used to this effect. In the molar region of the upper jaw, it is preferable to establish fixation in the palatal root, since the buccal counterparts are covered by a fine bone layer. In the posterior mandibular region, the inferior alveolar neurovascular bundle often lies very close to the apexes of premolars and molars, and roots of the latter tend to be large; thereby precluding adequate primary fixation of the implant. A common situation is implant placement in the inter‑root septum, which causes the bone bed surrounding the implant to condition very precarious initial stability. This problem can be solved by using an implant of larger diameter, waiting for the alveolar space to fill with bone, and then performing delayed placement or positioning two implants to reconstruct a lower molar.[3,7,9,11,12] 161
  3. 3. [Downloaded free from http://www.jdionline.org on Monday, December 09, 2013, IP:]  ||  Click here to download free Android application for this journa Muhamad, et al.: Implants into fresh extraction site Case clinic Topics History Root resorption of two front teeth after orthodontics therapy, extraction of front teeth, immediate placement of implants at time of extraction, and immediate load of implants with temporary crowns [Figures 1 and 2]. AN is an attractive 27‑year‑old that has been struggling with the thought of losing her two front teeth. It is not known why, but the roots of her two central have resorbed. This has made the two front teeth very loose for the past several years. AN has been concerned that Figure 2: Implants in place with stock abutments Figure 1: Retracted view pre op. Figure 4: Miner Oss to fill in the facial Figure 3: Abutments removed, Implants with flared healing collars Figure 5: Angled abutments placed 3 months post surgery 162 Figure 6: Implant placement, graft and membrane. Flared healing collars Journal of Dental Implants | Jul - Dec 2013 | Vol 3 | Issue 2
  4. 4. [Downloaded free from http://www.jdionline.org on Monday, December 09, 2013, IP:]  ||  Click here to download free Android application for this journa Muhamad, et al.: Implants into fresh extraction site Figure 8: Post op smile Figure 7: Final Zirconia coping crowns these teeth will come out if she bites into something hard or sticky. The teeth are not painful, but there is grave concern about these teeth falling out; and once they come out, how to replace them and make them look beautiful. AN has high esthetic demands and is very concerned that the replacement be immediate after the extractions and be as good or improve her smile. AN has a high smile line. Her upper teeth and gingiva are not covered by her upper lip. Her teeth are in full view when she smiles. Treatment plan A plan was developed with the patients prosthodontist, to include extraction of the two upper central incisors, # 8 and 9  [Figures  3‑5], immediate placement of two implants into those extraction sites and immediate temporary teeth on the implants to be fabricated by the patients prosthodontist  [Figure  6]. Once these implants are osteointegrated, porcelain crowns will be fabricated. Immediate ext/implantation with RePlant 5.0 × 13, Atlantis abutments, and EMAX A2 crowns [Figures 7 and 8]. CONCLUSIONS The present results indicate that immediate loading of immediately placed dental implants replacing single‑rooted teeth is a predictable treatment that depends mainly on; good patient/case selection, achieving good primary stability and maintaining primary stability. Hence, from the present study we conclude that the success of this technique depends on: • Good patient and case selection • Presence of sufficient healthy bone beyond the periapical lesion • Surgical technique used; atraumatic extraction, good curettage of the extraction socket, and drilling at least 3-4 mm beyond the root apex to gain maximum Journal of Dental Implants | Jul - Dec 2013 | Vol 3 | Issue 2 degree of primary stability • Implant selection; the implant has to be in length and diameter greater than that of the extraction socket, implants with a flared neck are better to be placed into fresh extraction sockets to increase bone implant contact at the coronal part of implant and implants with rough surface are recommended to be used for immediate loading • Patients’ motivation and cooperation to follow instructions and the follow‑up program. Finally, it is important to note that the data of the present study do not imply that delayed or delayed‑immediate implant placement or submerged approaches are no longer indicated. Additional research can be performed to investigate the possibility of immediate implant placement and provisionalization in the anterior mandible and in patients who are smokers, in old age, diabetics, osteoporotics, or bruxers. REFERENCES 1. Ozdemir E, Lin WS, Erkut S. Management of interproximal soft tissue with a resin‑bonded prosthesis after immediate implant placement: A clinical report. J Prosthet Dent 2012;107:7‑10. 2. Viskić J, Milardović S, Katanec  D, Vojvodić D, Mehulić K. Immediate implantation in infected tooth sockets. Coll Antropol 2011;35:217‑21. 3. Di Felice R, D’Amario M, De Dominicis A, Garocchio S, D’Arcangelo C, Giannoni M. Immediate placement of bone level Sraumann implants: A case series. Int J Periodontics Restorative Dent 2011;31:57‑65. 4. Alves  CC, Neves  M. Tapered implants: From indications to advantages. Int J Periodontics Restorative Dent 2009;29:161‑7. 5. Barone A, Rispoli L, Vozza I, Quaranta A, Covani U. Immediate restoration of single implants placed immediately after tooth extraction. J Periodontol 2006;77:1914‑20. 6. Hoffmann O, Beaumont C, Zafiropoulos GG. Immediate implant placement: A case series. J Oral Implantol 2006;32:182‑9. 7. Balshi  TJ, Wolfinger  GJ. Teeth in a day for the maxilla and 163
  5. 5. [Downloaded free from http://www.jdionline.org on Monday, December 09, 2013, IP:]  ||  Click here to download free Android application for this journa Muhamad, et al.: Implants into fresh extraction site mandible: Case report. Clin Implant Dent Relat Res 2003;5:11‑6. Romanos GE. Treatment of advanced periodontal destruction with immediately loaded implants and simultaneous bone augmentation: A case report. J Periodontol 2003;74:255‑61. 9. Liechtung M. A new approach to implant provisionalization. Dent Today 2012;31:70,72,74, Hains FO. Immediate implant placement in posterior areas: The mandibular arch. Compend Contin Educ Dent 2012;33:494‑6,498,500. 10. Meltzer AM. Immediate implant placement and restoration in 8. infected sites. Int J Periodontics Restorative Dent 2012;32:e169‑73. 11. Anitua  E, Orive  G. A  new approach for atraumatic implant explantation and immediate implant installation. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:e19‑25. How to cite this article: Muhamad A, Azzaldeen A, Aspasia SA, Nikos K. Implants into fresh extraction site: A literature review, case immediate placement report. J Dent Implant 2013;3:160-4. Source of Support: Nil, Conflict of Interest: None. Announcement “QUICK RESPONSE CODE” LINK FOR FULL TEXT ARTICLES The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free applications. 164 Journal of Dental Implants | Jul - Dec 2013 | Vol 3 | Issue 2