There is no question that given the current state of the art in dentistry, that dental implants are pretty much the best way to replace teeth; they are stand alone tooth replacement systems that look and function just like natural teeth. They do not attach to adjacent teeth like a fixed bridge and don't have to be taken in and out like removable partial dentures. A dental implant is a tooth root replacement made of titanium, which has the unique property of being osteophilic (osteo-bone, philic-loving) and actually fuses to bone. A crown, the part of the tooth that you see in your mouth, is attached to the implant. And the great thing about implants is they are not susceptible to decay or periodontal (gum) disease in the same way that teeth are. Now here are a few important pointers, which hold for implants generally and are especially important in your case when replacing a front tooth for an imminent event . Dr Harshavardhan Patwal

1. IMMEDIATEIMMEDIATE
IMPLANTSIMPLANTS
Dr Harhavardhan Patwal

2. •Rationale
•Indications/Contraindications
•Scientific Overview
•Surgical Technique
•Issues
•Consensus Questions
IMMEDIATE IMPLANTS

3. 6-12 months healing is recommended following
tooth extractions prior to dental implant placement
Adell et al ,1981

5. Extraction of Teeth results in the loss of hard and soft tissues,
a reduction of arch circumference and deficient width and height
of the residual ridge

6. Extraction of Teeth results in the loss of hard and soft tissues,
a reduction of arch circumference and deficient width and height
of the residual ridge
Bone loss occurs both buccolingually and apicocoronally,
with the first six months carrying the highest rate of resorption
in either direction.
Atwood,1983

7. Advantages of Immediate Implant Placement
•Reduction of Treatment Time
•Minimization of Treatment Cost
•Enhancement of Patient PsychologicalOutlook
•Reduction of Surgical Procedure
•Preservation of Ridge Contour
•Enhanced Healing and Osteogenic potential
•Simplification of Prosthesis
•Optmization of aesthetic and functional results

8. • Traumatically Avulsed
•Residual Deciduous Teeth
•Horizontal/Vertical Fracture of Teeth
•Endo Failing
•Periodontally Compromised
•Non-Restorable Teeth
Indications

9. • Traumatically Avulsed
Indications

10. • Residual Deciduous Teeth
Indications

11. • Horizontal/Vertical Fracture of Teeth
Indications

12. • Endo Failing
Indications

13. • Periodontally Compromised
Indications

14. • Non-Restorable Teeth
Indications

15. • Inability to Develop Mechanical Stability
Width
Height
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications

16. • Inability to Develop Mechanical Stability
Contra-Indications

17. • Proximity to Adjacent teeth
Contra-Indications

18. • Placement outside alveolar envelope
Contra-Indications

19. • Presence of Infection
Contra-Indications

20. •Sulcular Incisions with Vertical release
•Atraumatic Extraction
Sectioning of Multi-root teeth
Periotome
•Thorough Degranulation
•Assessment of Socket Architecture
•Widening/Deepening of Osteotomy
•Placement of Implants
•Placement of Graft/Membrane
•Flap Closure
Surgical Technique

21. •Sulcular Incisions with Vertical Release
Surgical Technique

22. •Atraumatic Extraction
Surgical Technique

23. •Thorough Degranulation
•Assessment of Socket Architecture
Surgical Technique

24. •Widening/Deepening of Osteotomy
Surgical Technique

25. •Placement of Implants
Surgical Technique

26. •Placement of Graft/Membrane
Surgical Technique

27. •Placement of Graft/Membrane
Surgical Technique

28. •Flap Closure
Surgical Technique

29. (Salama and Salama 1993)

106. • Dahlin-JOMI,89
•Lazzara-IJPRD,89
•Becker-JP,90
•Nyman-JOMI,90
•Schwartz-JOP,97
•Gilb-JOMI,93
•Wilson-JOMI,98
•Paolantonio-JP,01
•Cornelini-JOMI,00
•Becker-Perio-2000

107. ISSUES
• Primary Stability
•Thin Buccal Plate
•Presence of Active
Infection
•Site- Posteriors?
Masticatory
Forces
Bone Density

108. 1) Jumping Gap- What is the Threshold Gap Distance
(HDD) b/n Implant & Bony Wall to warrant
use of Regenerative techniques?
2) Loading - When is it advisable to load an
Immediate Implant (In view of limited
Implant-Bony Contact).
(Immediate, Delayed Immediate, Conventional)
3) Primary Stability Quantification-
If Early Loading is an Acceptable Protocol,
what is the right measuring parameter
for Primary Stability.
Consensus Questions

109. Does the Gap Effects Osseointegration
Akimoto,Becker et al.
JOP,1990 * Experimental
* Canine Model
* 12 Weeks Study
* End Points- Clinical Bone Fill
Histomorphometry
*Control
*Coronal Gap of 0.5mm
*Coronal Gap of 0.975mm
*Coronal Gap of 1.35mm

110. Ctrl- 40
0.5- 25
.935- 12
1.35- 5
Apically No Difference Clinically/Histologically
Coronal 4 mm
No Statistical Difference
No Mobility Detected
“Gap Does Effect Osseointegration”
RESULTS
Clinical Bone Fill
Histomorphometrically(% BIC)

111. Bridging the GAP
Warrer,L, Got Fredien,K et al.
Clinical Oral Implant Research’91
•Experimental
•Canine Model
•Split Mouth
•12 Weeks
•Histological
Test Side Immediate Implant Covered
with Membrane
Control Side No Membrane was used

112. Control Soft tissue facing coronal Portion
of the Implant to varying degrees
Test Side Osseointegration was consistently
observed
“Use of Membrane helps in Increased BIC”
RESULTS

113. Critical Gap Distance
Wilson TG Jr,Buser,Cochran et al
JOMI’98
Conventional
II with HDD≤ 1.5mm
II with HDD≤ 4.0mm
BIC
72%
60%
17%
“HDD: 1.5-2mm is Critical for Osseointegration”
•Clinical
•6 Months
•Biopsy
Groups

114. Critical Maximum Gap Distance
Wilson TG Jr et al.
JP,2003:74(3);402-409
Covered with CT Membrane
%age Bone-Implant Contact similar in all 3 Groups
“HDD of 4 mm with membrane achieves Osseointegration”
•Clinical
•6 Months
•Biopsy
Conventional
II with HDD≤ 1.5-4 mm
II with HDD> 4.0mm
Groups

117. Placement of Immediate Implant in Infected Sites
Novaes & Novaes
IJOMI,1995
1st
Report
Chronic Peri-apical Infected
sites
Novaes et al ,
IJOMI,1998
Experimental,Canine,Histologic
al
BIC is Higher in Non-Infected
sites than in Infected sites
Grunder et al ,
IJOMI,1999,
14:210-216
Clinical, Prospective,3 year
Study
Increased Implant Failure,if the
tooth replaced was lost for
Periodontal Infection

118. Placement of Immediate Implant in Infected Sites
Nir-hader, Orly et al.
COIR,1998
Delayed Immediate Implant
better option in Infected sites
Ivorio,Giovanni,
Costigliola,G et al.
COIR,12(4),2001
Clinical,Prospective,n=130
N=36(Infected sites),
3-5 year survival rate
Overall Survival-97%
Failure- 6 Implants(PA PD’itis)
Survival rate-87%(In infected sites)

119. Immediate Loading of Immediate Implants
Ormiener et al COIR 2001,August
Multicenter, Clinical ,Prospective,Randomized, N=546
“Immediate Loading / Immediate Implants is a predictable procedure”
10 implants failed out of 546
Lorenzi,M et al,2002
Clinical, N=9 pat,Ant. Maxilla 50%-II,50%-Del.I
Periotest,Radiographs
Out of centric contact, Occlusal Splint-8 weeks
Success Rate- 96%

120. Factors for Early Loading of Immediate Implants
Kotsuyama,et al.Quintessence Dental Implantology,7(3)
357-367:2000
•Sufficient Primary Stability
•Soft Tissue Healing(2-3) weeks
•Healthy Bone Quality(Density) - 400-450 HU(Cochran)

121. •‘Drilling Feeling’
•Insertion Torque Mechanism
•Radiographic
•Transient Impact
•Periotest
•Resonance Frequency Analyzer
Primary Stability

122. •‘Drilling Feeling’ Trisi et al,COIR,1999
Good to distinguish between D-1 & D-4 Bone
But not between D-2 & D-3
•Insertion Torque Mechanism Friberg et al,COIR,1995
Limited only to Self-Tapping Implants,
A value of 45 Ncm has been advocated
•Radiographic
CT Scan, Simplant 400-450 Hensefield Units
Sundan et al., COIR,1995:6;220-226
Reproducibility Standardisation Radiation,Time needed
Cochran,1998

123. Periotest
Caulier et al IJOMI,1997:12;380-386
Periotest gives Mechanical Properties
Of Fibro-osseous Complex between Implant & Bone
Evans et al No Correlation between PTV & histologic BIC

124. Resonance Frequency Analyzer

125. Rassmussan,97,98,99
RFA Values, Histological Results & Removal Torque
Values show correlating results
Neil Meredith,AOO’01
Baseline-3 weeks ISQ Decreases
3 Weeks-10 Weeks ISQ increases
6 weeks-10 weeks No Statistical Difference
6 Weeks is Ideal Time to Load

126. Conclusions
•II have a high survival rate,between 93.9% to 100%
•Implants to be placed 3-5 mm beyond apex for
primary stability
•Implants to be placed close to alveolar crest
level (0-3mm)
•Consensus regarding HDD filling still not conclusive
•Membrane exposure is a question still unanswered
•Absolute need for primary closure is still a question ?

131. Surgical Technique
•Widening/Deepening of Osteotomy
•Placement of Implants
•Placement of Graft/Membrane
•Flap Closure

134. • Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications

137. • Traumatically Avulsed
•Residual Deciduous Teeth
•Horizontal/Vertical Fracture of Teeth
•Endo Failing
•Periodontally Compromised
•Non-restorable Dental Caries
Indications

138. • Traumatically Avulsed
•Residual Deciduous Teeth
•Horizontal/Vertical Fracture of Teeth
•Endo Failing
•Periodontally Compromised
•Non-restorable Dental Caries
Indications

140. • Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications

141. • Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications

142. • Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications