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