Immediate implant lecture

Immediate Implant Placement Dr. Mohammed Alshehri BDS, AEGD, SSC-Resto, SF-DI

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.

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.

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.

Christensen reports an annual resorption rate of at least 0.5% to 1% during the remainder for the rest of a patient’s life.
In the publication by Schropp et al. (2003) most of the bone gain in the socket occurred in the first 3 months.

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.

Healing of Extraction Socket
Amler (1969)

Amler (1969)

Ohta (1993)

Arau´jo MG, Lindhe J (2005)
1 week 2 weeks

Arau´jo MG, Lindhe J (2005)
4 weeks 8 weeks

Soft Tissue Changes after Extraction
Immediately following tooth extraction there is a lack of mucosa and the socket entrance is open
During the 1st weeks after extraction, cell proliferation withen the mucosa will results in an increase in its C.T volume
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 changes that occur externally in the hard tissue of the alveolar process.

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

Hard Tissue Changes after Extraction
following extraction, since bone structure resorbes irrespective of therapy
This is critical on the facial aspect, since 2-3 mm of the most 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)

Changes in the soft and hard tissues following tooth extraction

Clinical situations at extraction of anterior teeth in the maxilla

Immediate Implant
Definition: Implant placed as part of the same surgical procedures and immediately following tooth extraction
Type I (Hammerle Classification)

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)

Immediate Implant & GBR

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.

Esthetic Complications with Immediate Implants
Observed complications with immediate implants in early 2000.
Increased risk for facial bone resorption and consequent soft tissue recession.

Mucosal Recession with Immediate Implants
Clinical studies reporting mucosal recessions
Lindeboom, Tjiook, Kroon: Immediate placement of implants in periapical infected 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 nonsubmerged immediate implants: clinical outcomes and esthetic results. Clin Oral Implants Res 18: 552, 2007.
Kan, Rungcharassaeng, Sclar, Lozada: Effects of the facial osseous defect morphology on gingival dynamics after immediate tooth replacement and guided bone regeneration: 1-year results. J Oral Maxillofac Surg 65: 13, 2007.

Clinical studies reporting mucosal recessions
Evans, Chen: Esthetic outcomes of immediate implant placements. Clin Oral Implants 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.

Keys of success in Esthetic Zone
Preservation of adequate amount of facial bone.
Surgical procedures which encourage healing capable of maintaining at least 2 mm of facial bone dimention.
Appropriate bone dimention (horizontal bulk in addition to vertical height) helps to maintain bone and soft tissue over the longer term.

Conclusion
The alveolar process following tooth extraction will adapt by atrophy and an immediate implant in this respect cannot prevent this problems ,and unable to substitute for the tooth.
The problem with type 1 placement is that the bone loss will frequently cause the buccal portion of the implant to gradually lose its hard tissue coverage, and that the metal surface may become visible through a thin peri-implant mucosa and cause esthetic concerns.

Conclusion
To overcome this problem
Placing the implant deeper into the fresh socket and in the lingual palatal portion of the socket to overcome buccal bone resorption
bone regeneration (augmentation) procedures may be required to improve or retain bone volume and the buccal contour at a fresh extraction site.

Summary
• There is no doubt today that this approach is associated with an increased 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

Immediate implant lecture

by Mohammed Alshehri on May 18, 2011

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