2001 immediate implant


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2001 immediate implant

  1. 1. Various studies of implant 指導老師 吳逸民醫師 2001/2/4 perio-prostho seminars
  2. 2. Topic <ul><li>Immediate implant vs delayed immediate implant ( 王英斌 ) </li></ul><ul><li>Wide-diameter implant vs standard-diameter implant ( 蘇娟儀 ) </li></ul><ul><li>Single-stage vs Two-stage ( 黃文慧 ) </li></ul><ul><li>Immediate loading vs progressive loading ( 林偉祺 ) </li></ul>
  3. 3. <ul><li>Br änemark group – traditional protocol recommends a 12-month healing period between tooth extraction and placement of implants. (Adell R et al 1981 Int J Oral Surg) </li></ul><ul><li>Preserve alveolar bone concept  </li></ul><ul><li>immediate implant concept </li></ul>
  4. 4. <ul><li>Schulte(1984) </li></ul><ul><li>Tuebinger implant </li></ul><ul><li>Frialit-2 implant </li></ul><ul><li>Stepped-tapered root analog </li></ul>
  5. 5. Immediate implant <ul><li>Advantage </li></ul><ul><li>Preservation of the alveolar bone </li></ul><ul><li>Esthetic (extracted tooth has a desirable alignment) </li></ul><ul><li>ideal implant position </li></ul><ul><li>natural scalloping and distinct papillae are easier </li></ul><ul><li>to achieve </li></ul><ul><li>maximal soft tissue support </li></ul><ul><li>Fewer surgical interventions </li></ul><ul><li>Reduction in treatment time & cost </li></ul>
  6. 6. Immediate implant <ul><li>Disadvantages </li></ul><ul><li>Misalignment of the extracted tooth may lead to </li></ul><ul><li>unfavorable angulation of the fixture </li></ul><ul><li>Stabilization may require more bone than is available beyond the apex </li></ul><ul><li>Localized peri-implant bone defect </li></ul><ul><li>Primary soft tissue closure </li></ul><ul><li>( submerged vs transmucosal implant) </li></ul>
  7. 7. Indication for Immediate implant <ul><li>Root fracture </li></ul><ul><li>Trauma not affecting the alveolar he alveolar bone </li></ul><ul><li>Decay without purulence </li></ul><ul><li>Endodontic failure </li></ul><ul><li>Severe periodontal bone loss </li></ul><ul><li>Residual root </li></ul>
  8. 8. Contraindication for Immediate implant <ul><li>Presence of pus </li></ul><ul><li>Lack of bone beyond the apex or close relationship to the anatomical vital structures </li></ul>
  9. 9. Extraction site defects <ul><li>Residual defect morphology and the regenerative potential at the extraction sites </li></ul><ul><li>Salama H & Salama M </li></ul><ul><li>1993 IJPRD </li></ul>
  10. 10. Extraction site defects <ul><li>Type I –ideal site for immediate implant </li></ul><ul><li>4-/3-wall socket with minimal bone resorption (<5mm apico-coronal defect) </li></ul><ul><li>Sufficient bone available beyond the apex </li></ul><ul><li>Acceptable discrepancy between the fixture head & neck of the adjacent teeth </li></ul><ul><li>Manageable gingival recession or esthetics is not essential. </li></ul>
  11. 11. Extraction site defects <ul><li>Type II – need orthodontic extrusion </li></ul><ul><li>Dehiscence > 5mm </li></ul><ul><li>Substantial discrepancy between the fixture head & neck of the adjacent teeth </li></ul><ul><li>Significant gingival recession or esthetics . </li></ul>
  12. 12. Extraction site defects <ul><li>Type III –not suitable for immediate implant </li></ul><ul><li>inadequate vertical &B-L bone dimension </li></ul><ul><li>Recession and severe loss of labial bone </li></ul><ul><li>Severe circumferential and angular defect </li></ul>
  13. 13. <ul><li>The decision to submerge should base on the following factors </li></ul><ul><li>Plaque control </li></ul><ul><li>Smoking </li></ul><ul><li>Periodontal conditions </li></ul><ul><li>The degree of stability </li></ul><ul><li>The presence of provisional removable denture </li></ul>
  14. 14. Submerged implant <ul><li>Primary closure </li></ul><ul><li>Bowers & Donahue(1988) </li></ul><ul><li>Edel (1995) ,Chen & Dahlin(1996) </li></ul><ul><li>Rosenquist(1997) </li></ul>
  15. 15. Rotated palatal flap for immediate implant <ul><li>Nemcovsky CE </li></ul><ul><li>2000 COIR </li></ul>
  16. 16. Transmucosal immediate implant <ul><li>Cochran & Douglas(1993);Br ägger et al (1993) </li></ul><ul><li>Schultz(1993) ;Lang(1994) </li></ul><ul><li>Br ägger et al (1996);Hämmerle et al (1998) </li></ul><ul><li>Evidences emphasize the importance of infection control for a successful tx. of outcome following immediate implant of transmucosal implants </li></ul>
  17. 17. Transmucosal immediate implant <ul><li>Original peri-implant defect was the most critical factor relating to the final amount of bone-to-implant contact </li></ul><ul><li>Horizontal defect dimensions of >4mm resulted in a lower bone-to –implant contact than dimension of 1.5mm or less </li></ul><ul><li>Wilson et al 1998 JOMI </li></ul>
  18. 18. Conclusion about immediate implants <ul><li>High survival rate : 93.9%-100% </li></ul><ul><li>Implants must placed 3-5mm beyond the apex in order to gain a maximal degree of stability </li></ul><ul><li>Implant should be as close as possible to the alveolar crest(0-3mm) </li></ul><ul><li>Schwartz-Arad D et al 1997 </li></ul>
  19. 19. Conclusion about immediate implants <ul><li>There is no consensus regarding about the need for gap filling and the best graft materials </li></ul><ul><li>The use of membrane does not imply better results –on the contray ,membrane exposure may carry complications </li></ul><ul><li>The absolute need for primary closure </li></ul><ul><li>Schwartz-Arad D et al 1997 </li></ul>
  20. 20. <ul><li>Immediate vs non-immediate </li></ul><ul><li>implantation for full-arch fixed reconstruction following extraction of all residual teeth : A retrospective comparative </li></ul><ul><li>study </li></ul><ul><li>Schwartz-Arad D et al 2000 JP </li></ul>
  21. 21. Results <ul><li>5-year cumulative survival rate(CSR) </li></ul><ul><li>Immediate implant (96%) non-immediate(89.4%) </li></ul><ul><li>Mean potential contact area(PCSA) 230mm 2 </li></ul><ul><li>Significant differences in CSR in maxilla(96.6% vs 82.9%) </li></ul><ul><li>Posterior Max. </li></ul><ul><li>Immediate implant (100%) non-immediate(72%) </li></ul>
  22. 22. Conclusions <ul><li>Survival rates of implants placed to support full-arch ceramo-metal prosthesis can be ranked as follows : bone quality , immediate implant,PCSA </li></ul><ul><li>Immediate implantation exerts its effect through higher PCSA values by a compensatory effect for bone quality </li></ul><ul><li>Immediate implant does not carry additional morbidity </li></ul>
  23. 23. Delayed Immediate implant <ul><li>To allow primary soft tissue healing following tooth extraction for a period of 6-10 weeks ,prior to implant placement </li></ul><ul><li>Advantages </li></ul><ul><li>1) adequate soft tissue </li></ul><ul><li>2) minimized the effect of microorganism associated with the failed tooth or wound healing (Gher 1994) </li></ul><ul><li>3) highly osteogentic activity </li></ul>
  24. 24. Spontaneous in situ gingival augmentation <ul><li>Burton Langer </li></ul><ul><li>IJPRD 1994;14:525-535 </li></ul>
  25. 25. Delayed immediate implant <ul><li>Alveolar bone changes during the healing period </li></ul><ul><li>Strong tendency for the defects to fill-in in the horizontal plan and bone growth to occur in the vertical plane of the height of the cover screw . </li></ul><ul><li>Good short-term prognosis with bone regeneration occurring around the defect without the use of barrier membranes or bone substitutes </li></ul><ul><li>Nir-Hadar O et al (1998) </li></ul>
  26. 26. <ul><li>After an average follow-up of 12.4 months, peri-implant pocket depth, the gingival index, the hygienic index, and the degree of bone resorption were examined. A life-table approach (Kaplan-Meier) was applied for statistical analysis, and showed no difference between primary and secondary immediate implants . Also, none of the parameters examined demonstrated a statistically significant difference between the two groups. </li></ul><ul><li>Mensdorff-Pouilly et al 1994 JOMI </li></ul>
  27. 27. <ul><li>However, compared with the groups of secondary immediate implants, the group of primary immediate implants showed a tendency towards deeper pocket formation and an increased frequency of membrane dehiscences that may be due to the poorer quality of the soft tissue covering. </li></ul><ul><li>Mensdorff-Pouilly et al 1994 JOMI </li></ul>
  28. 28. 3-year Prospective Multicenter Follow-up <ul><li>No clinical difference with respect to socket depth or when comparing the different placement methods. </li></ul><ul><li>Higher failure rate was found for short implants in the posterior region of maxilla .(extracted for periodontitis) </li></ul><ul><li>Mean marginal bone resorption : (from loading to 1yr F/U) Max.(0.8mm),mand(0.5mm) </li></ul><ul><li>Implant survival : Max(92.4%);Mand(94.7%) </li></ul><ul><li>Grunder U et al 1999 JOMI </li></ul>
  29. 29. <ul><li>Generally, </li></ul><ul><li>primary immediate implant – </li></ul><ul><li>max. anterior </li></ul><ul><li>secondary immediate implant – </li></ul><ul><li>mandible,posterior maxilla </li></ul><ul><li>Mensdorff-Pouilly et al 1994 JOMI </li></ul>
  30. 30. Thanks for your attention!!
  31. 31. Evidence for osseointegration of immediate implant <ul><li>Experimental animal studies (Kohal et al 1997) </li></ul><ul><li>Controlled human studies(Palmer et al 1994) </li></ul>
  32. 32. Evidence for osseointegration of immediate implant <ul><li>Root-analogue titanium implants </li></ul><ul><li>Lundgren et al (1992) beagles dog study </li></ul><ul><li>Kohal et al(1997) monkeys </li></ul>
  33. 33. Evidence for osseointegration of immediate implant <ul><li>Conventional screw- or cylinder-type implant </li></ul><ul><li>Experimental animal studies </li></ul><ul><li>Parr et al (1993) dog study </li></ul><ul><li>Barzilay et al (1996) controlled monkey </li></ul><ul><li>Similar result for immediate and late implant ( Clinical,radiography,histology) </li></ul>
  34. 34. Evidence for osseointegration of immediate implant <ul><li>Clinical studies </li></ul><ul><li>Becker et al(1998) prospective clinical human trials of 47 immediate implants without bone augmentation </li></ul><ul><li>cumulative success rate of 93% followed between 4 to 5 years </li></ul>
  35. 35. Bone augmentation in combination with immediate implant <ul><li>GBR-barrier membranes </li></ul><ul><li>Experimental animal studies </li></ul><ul><li>Dahlin(1989)– rabbits </li></ul><ul><li>Becker et al (1991) – barriers enhance predictability of bone fill in immediate extraction sockets when compared with </li></ul><ul><li>a mucoperiosteal flap </li></ul>
  36. 36. Bone augmentation in combination with immediate implant <ul><li>GBR-barrier membranes </li></ul><ul><li>e-PTFE membrane </li></ul><ul><li>Lazarra(1989) </li></ul><ul><li>Becker &Becker(1990) </li></ul><ul><li>Nyman(1991) </li></ul><ul><li>Hammerle(1998) </li></ul>
  37. 37. Bone augmentation in combination with immediate implant <ul><li>GBR-barrier membranes </li></ul><ul><li>e-PTFE membrane </li></ul><ul><li>Becker (1994) 49 immediate implant with e-PTFE alone </li></ul><ul><li>--- 93.6% bone fill ,1-year functional loading success rate 93.9% </li></ul>
  38. 38. Bone augmentation in combination with immediate implant <ul><li>GBR-barrier membranes </li></ul><ul><li>e-PTFE membrane </li></ul><ul><li>Gher et al (1994 ) </li></ul><ul><li>influence of original defect morphology on bone fill with e-PTFE at immediate implant sites </li></ul><ul><li>Dahlin et al (1995) prospective multicenter study </li></ul><ul><li>2-year cumulative survival rate </li></ul><ul><li>Max.(84.7%) mand(95%) </li></ul>
  39. 39. Bone augmentation in combination with immediate implant <ul><li>GBR-barrier membranes </li></ul><ul><li>Collagen membrane( Cosci&Cosci 1997) </li></ul><ul><li>polyglactin (balshi 1991) </li></ul><ul><li>Polylactic acid (Lundgren 1994) </li></ul><ul><li>Fascia lata (Callen & Rohrer 1993) </li></ul><ul><li>Autogenous gingival grafts(Evian & Cutler 1994) </li></ul>
  40. 40. Bone augmentation in combination with immediate implant <ul><li>GBR-barrier membranes </li></ul><ul><li>Zitzmann et al (1997) </li></ul><ul><li>e-PTFE vs collagen ( deproteinized bovine bone ) </li></ul><ul><li>no significant difference in average percentage bone fill for collagen (92%) and e-PTFE(78%) But, 44% wound dehiscence and premature membrane removal in the e-PTFE group was reported. </li></ul>
  41. 41. Barrier membrane exposure <ul><li>Compromised results </li></ul><ul><li>Simion (1994) bone fill (97% vs 42%) </li></ul><ul><li>Augthun(1995) </li></ul><ul><li>Successful bone regeneration & complete bone filling ,but strict infection control is followed </li></ul><ul><li>Mellonig (1993) </li></ul><ul><li>Shanaman(1994) </li></ul><ul><li>Rominger & Triplett (1994) 96.8% </li></ul>
  42. 42. GBR and bone grafts <ul><li>DFDBA ( negative ) </li></ul><ul><li>animal study </li></ul><ul><li>Becker (1992) dogs study </li></ul><ul><li>Becker (1995) dogs study </li></ul><ul><li>Kohal(1998) dogs study </li></ul><ul><li>Clinical study </li></ul><ul><li>Gelb(1993) </li></ul>
  43. 43. GBR and bone grafts <ul><li>DFDBA ( positive ) </li></ul><ul><li>Callan (1990) </li></ul><ul><li>Mellonig (1993) </li></ul><ul><li>Landsberg (1994) combined with Tc </li></ul><ul><li>Gher (1994) </li></ul>
  44. 44. GBR and bone grafts <ul><li>Hydroxyapatite </li></ul><ul><li>Wachtel et al (1991) biopsies taken on </li></ul><ul><li>3M showed enhanced bone regeneration </li></ul><ul><li>than non-grafted sites. </li></ul><ul><li>Knox (1993) </li></ul><ul><li>Novaes & Novaes (1993) </li></ul>
  45. 45. GBR and bone grafts <ul><li>Simion(1994) </li></ul><ul><li>Cosci & Cosci(1997) </li></ul><ul><li>Fugazzotto (1997) </li></ul><ul><li>Schwartz-Arad & Chaushu(1997) </li></ul>
  46. 46. Compromised sites –infection <ul><li>Pecora(1996) </li></ul><ul><li>32 teeth due to root fx.,perforation,endo-perio complication ,F/u 16M </li></ul><ul><li>Rosenquist & Grenthe(1996) </li></ul><ul><li>periodontal disease (92%) </li></ul><ul><li>trauma,root fx.,endodontic failure (95%) </li></ul><ul><li>Novaes(1995,1998) </li></ul>
  47. 47. Compromised sites –infection <ul><li>“ Immediate implantation at chronically infected sites may be successful,the extent of the defect ,the implant primary stability,and esthetic consideration of future restoration must be considered.” </li></ul>
  48. 48. Biologically active bone-differentiating substances <ul><li>Cook (1995) recombinant human osteogenic protein-1(rhOP-1) </li></ul><ul><li>Cochran et al(1997) recombinant human bone morphogenetic protein-2(rhBMP-2) </li></ul><ul><li>Hedner & Linde(1995) membrane + BMP  compromised blood supply </li></ul>
  49. 49. Future about biologically active bone-differentiating substances <ul><li>Identification of the ideal carrier substrate </li></ul><ul><li>Dose application </li></ul><ul><li>The effect of combination </li></ul>
  50. 50. Late implants <ul><li>A period of >6 months for healing of the extraction site is recommendation prior to implant placement </li></ul>