Immediate Implant Placement: Treatment Planning And .
PRACTICEIN BRIEF The most important step in treatment planning is determining the prognosis of theremaining dentition.There is some evidence that placement of foreign materials into extraction sockets willinterfere with normal bone formation.Immediate implant placement when indicated provides several advantages for bothpractitioner and patient.5Immediate implant placement: treatment planningand surgical steps for successful outcomesW. Becker1Diagnosis and treatment planning are key factors in achieving successful outcomes after placing and restoring implantsplaced immediately after tooth extraction. The efficacy of immediate implant placement has been established and shownto be predictable if reasonable guidelines are followed. Some or all of the following suggestions, depending on individualcircumstances, should be considered when evaluating a patient for dental implants: thorough medical and dental histories,clinical photographs, study casts, periapical and panogram radiographs as well as a linear tomography or computerisedtomography of the proposed implant sites. Reasons for tooth extraction include but are not limited to: insufficientcrown to root ratios, remaining root length, periodontal attachment levels, periodontal health of teeth adjacent to theproposed implant sites, unrestorable caries, root fractures with large endodontic posts, root resorption, teeth with deepfurcation invasions being considered as abutments for fixed partial dentures and questionable teeth in need of endodonticretreatment.IMPLANTS1. Rationale for dental implants2. Treatment planning of implants inposterior quadrants3. Treatment planning of implants inthe aesthetic zone4. Surgical guidelines for dentalimplant placement5. Immediate implant placement:treatment planning and surgicalsteps for successful outcomes6. Treatment planning of theedentulous maxilla7. Treatment planning of theedentulous mandible8. Impressions techniques forimplant dentistry9. Screw versus cemented implantsupported restorations10. Designing abutments forcement retained implant supportedrestorations11. Connecting implants to teeth12. Transitioning a patient fromteeth to implants13. The role of orthodontics inimplant dentistry14. Interdisciplinary approach toimplant dentistry15. Factors that affect individualtooth prognosis and choices incontemporary treatment planning16. Maintenance and failuresINTRODUCTIONTeeth requiring root amputations, hemisectionsor advanced periodontal procedures may havea questionable prognosis and patients shouldbe given the implant option before these procedures are implemented. Similarly, non vitalteeth, fractured at the gingival margin withroots shorter than 13 mm, should be consideredfor the implant option. This review will describethe steps for immediate implant placement at thetime of extraction as well as the ‘gap’ and socketpreservation. We will also discuss the conceptof minimally invasive surgery when applied toimplants placed at the time of extraction.Placement of endosseous implants has madeit possible to restore patients who are fully orpartially edentulous.1-3 Original protocolsrequired placement of implants into healededentulous ridges. Lizzara placed implants atthe time of extraction.4 These implants were1Clinical Professor of Periodontics at the University of SouthernCalifornia School of Dentistry, Los Angeles, California / AffiliateProfessor of Periodontics at the University of Washington,Seattle, WA, 801 N. Wilmot, B2, Tucson, Arizona 85711, USACorrespondence to: Dr W. BeckerEmail: branebill@comcast.netPortions of this paper were published in the California DentalJournal (2005; 33(4)). Permission has been granted by CDA touse this article and photos. The article was not reproduced in itsentirety.Refereed Paper British Dental Journal 2006; 201: 139-152DOI: 10.1038/sj.bdj.4813820BRITISH DENTAL JOURNAL VOLUME 201 NO. 4 AUG 26 20065pimplants.indd 1augmented with barrier membranes to preserveridge width and height and to decrease totaltreatment time. Becker et al. reported a 93.3%implant survival rate for implants placed at thetime of extraction and augmented with barriermembranes after one and five years after loading.5,6 Over the past 16 years numerous studieshave confirmed the predictability of placingimplants at the time of extraction.7-10 Smallosseous defects are frequently found adjacent toimplants placed at the time of extraction. Thesedefects can be implanted with small autogenousgrafts taken from edentulous ridges or othersites.11,12 A prospective clinical trial placedimplants immediately after tooth extraction.11Defects were grafted with small autologous bonechips harvested from adjacent edentulous ridges.One year after implant loading the survival rateswere 93.3% with clinically insignificant crestalbone loss. Others have used various materialsand methods including demineralised freezedried bone and barrier membranes to augmentedentulous ridges and small defects adjacent todental implants.13-23 The stability of the implantcan be verified using resonance frequency analysis.24-29 This method requires placement of anelectronic transducer onto the implant head orprosthetic abutment with a retaining screw, andpassing a low voltage current through the transducer. The current is not detected by the patient.Resistance to vibration of the transducer to thesurrounding bone is registered in a special small119/7/06 12:24:18
PRACTICEcomputer. The original research measurementswere made in Hertz. Hertz measurements havebeen calibrated for each transducer and areconverted to Implant Stability Quotient unitsby the computer. Measurements are recorded asISQ values.A recent study evaluated stability of implantsplaced at the time of extraction with resonancefrequency analysis.30 Stability measurementswere taken at the time of implant placementand after healing. The average interval betweenimplant insertion and abutment connection was5.6 months. Two implants were lost betweenimplant insertion and one year. At two to threeyears the cumulative survival is 97.2%. Resonance frequency measurements at implantplacement showed a mean primary stability of62.0 9.8 ISQ and a mean secondary stabilityafter one year of 64.0 9.8 ISQ for all implants.The increase was not statistically significant.The primary stability in the maxilla was significantly lower than in the mandible, while nodifference was seen for secondary stability. Initial average stability measurements were high.Measurements taken after healing were not significantly higher than those recorded initially.Studies indicate that implants with an RFAgreater than 50 are stable. Sites which receiveimplants at the time of extraction or within ashort time after extraction demonstrate slightdecreases in crestal bone width.30,31It is the purpose of this paper to review theconcept of immediate implant placement and toexpand the indications, limitations, anatomic,prosthetic and aesthetic requirements for placement of implants at the time of extraction. Theconcept of ‘socket preservation’ for sites thatmight receive dental implants as well as guided implant placement will be discussed. Wewill also introduce the idea of minimally invasive surgery and guided implant placement forimplants placed at the time of extraction.Diagnosis and treatment planningDiagnosis and treatment planning are key factors in achieving successful outcomes afterplacing and restoring implants placed immediately after tooth extraction. Following some orall of the following suggestions, depending onindividual circumstances, should be consideredwhen evaluating a patient for dental implants:thorough medical and dental histories, clinicalphotographs, study casts, periapical and panogram radiographs as well as a linear tomography or computerised tomography of the proposed implant sites.The most important step in treatment planning is determining the prognosis for the dentition, and in particular prognosis for the toothin question. Reasons for tooth extraction mayinclude but are not limited to, insufficientcrown to root ratios, remaining root length,periodontal attachment levels, status of furcations, periodontal health of teeth adjacent tothe proposed implant site, unrestorable caries, root fractures with large endodontic posts,25pimplants.indd 2root resorption and questionable teeth in needof endodontic retreatment.32 Teeth requiringroot amputations, hemisections or advancedperiodontal procedures may have a questionable prognosis and patients should be givenreasonable options before these procedures areimplemented. Similarly, the option for implantplacement for non vital teeth, fractured at thegingival margin with roots shorter than 13mm should be considered as the treatment ofchoice.33 If treated using traditional methods,these teeth will require crown lengthening procedures, endodontic treatment, and posts andcrowns. Removal of three or more millimetres of periodontal attachment during crownlengthening results in root length with less thanoptimal attachment. These factors are criticalwhen teeth are being considered for abutmentsfor fixed partial dentures. The risk to cost benefit ratio must also be considered.In the aesthetic zone bone morphology, scallop of the periodontium, level of crestal andinterproximal bone, smile line, morphology ofthe gingival tissues must be considered beforeinitiating treatment.34-37 Proposed interimplantdistance as well as existing contact relationships and interproximal bone must be analysedprior to implant placement.38-40 Patients with athin or moderately thin periodontium will havesoft tissue recession at the implanted sites. Inthese situations it is advisable to use orthodontic forced eruption procedures prior to toothremoval and implantation. This allows bone andsoft tissues to move coronally, thereby assuring adequate mucosal tissue adjacent to theimplant. Where there is a soft tissue deficiency subepithelial connective tissue grafting canfurther augment tissue height and thickness,thereby enhancing the aesthetic results.41,42This procedure compensates for the slight softtissue recession which usually occurs after toothextraction.Radiographic evaluation should consideravailability of native bone, bone shape, quality,quantity, bone width and height. A minimum of4-5 mm of bone width at the crest and 10 mm orgreater from the alveolar crest to a safe distanceabove the mandibular canal is recommended.43Sufficient distance must be available coronal tothe maxillary sinus and floor of nose. For a satisfactory aesthetic result in the aesthetic zone,the interproximal bone height should be 5 mmor less when measured from the contact pointof the adjacent tooth. As the distance from thecontact point to the interproximal bone increases, the likelihood of retention of the interproximal papillae post implant placement diminishes.Patients must be made aware of potential aesthetic short-comings if implants are placed injeopardised aesthetic zone sites.Once the decision has been confirmed thatthe patient is a candidate for immediate implantplacement, a surgical guide should be used toassure proper implant placement. A provisionalappliance with an ovate pontic should be available for insertion after implant placement.44-50BRITISH DENTAL JOURNAL VOLUME 201 NO. 4 AUG 26 200619/7/06 12:24:19
PRACTICETooth extraction and implant placementprocedureThe patient is anaesthetised and various flapprocedures can be used to gain access for toothextraction.51 Figures 1 to 11 represent theauthors’ routine surgical sequence for placement of a single tooth in the aesthetic zone afterimmediate implant placement using a minimally invasive method. Infection was presentas evidenced by the purulent exudate exuding from the palatal aspects. Many clinicianspostpone treatment of sites exhibiting infection. Villa recently reported on a case series ofpatients where implants were installed immediately after extraction.52 The extracted teethexhibited signs of periodontal or endodonticinfections. At two years the cumulative survivalrate was 100%. The results of this study indicatethat once the infected teeth were removed andimplants placed, there are no adverse results forthe implanted sites. Teeth to be removed andimplants placed immediately after extractioncan be accessed using either an open, flappedapproach or with a minimally invasive technique. With experience the surgeon can displacethe marginal tissues buccal/lingually to gainaccess to the surgical site (Fig. 5). A Molt C2(Hufriedy, Chicago) curette can be used to luxatethe root mesial-distally. Care must be exercisednot to luxate buccal-lingually. Excessive forcein this direction can damage the buccal plate.After tooth removal, a curette is used to explorethe location of the buccal plate and confirm thatit is intact. The surgical guide is placed over thesurgical site and a sharp Precison Drill (NobelBiocard, Precision Drill, Yorba Linda, California) is used to penetrate the palatal wall of theextraction socket (Fig. 7).11 This drill guides thedrills used to create the osteotomy. In the maxillary anterior region it is important to avoidplacing the implant directly into the extractionsocket. Placement of the implant in this positionwill invariably cause the implant to perforatethe buccal plate and jeopardise implant survival. The axis of the implant must be even withthe incisal edges of the adjacent teeth or slightlypalatal to this landmark. A direction indicatorshould be used to verify the correct angulationand trajectory of the proposed implant (Fig.8). Standard drilling procedures are performedaccording to the manufacturers’ instructions. Inthe aesthetic zone, the implant head should be aminimum of 3 mm apical to an imaginary lineconnecting the cemento-enamel junctions ofthe adjacent teeth and apical to the interproximal and crestal bone.53 A healing abutment orcover screw is placed in the implant. The healingabutment should be even with or slightly apicalto the adjacent marginal tissues. Interproximalpapillae adjacent to the implant can be adaptedwith interrupted sutures under minimal tension.The provisional is then inserted, and evaluated,making certain the pontic is clear of the healingabutment. The provisional restoration shouldhave an ovate pontic to support the adjacenttissues and help preserve soft tissue anatomyBRITISH DENTAL JOURNAL VOLUME 201 NO. 4 AUG 26 20065pimplants.indd 3Fig. 1 The maxillary left lateralincisor has a blunted short root witha severe palatal infection related to anon-vital toothFig. 2 Left maxillary lateral incisor(arrow) has a blunted apex, possiblecoronal fracture and a drainingabscessFig. 3 Supparation expressed frompalatal aspect of maxillary leftlateral incisorFig. 4 Extensive palatal granulationtissueFig. 5 Tooth has been extracted.Arrow points to socketFig. 6 Osteotomy has been preparedin palatal asect of extraction socket319/7/06 12:24:19
PRACTICEFig. 7 Guide pin within palatalaspect of surgical guideFig. 8 Implant has been insertedinto osteotomy and a 4 mm healingabutment has been placed ontothe implant. Arrow points to gapbetween mucosal tissue and healingabutmentFig. 9 Bovine bone has been layeredinto gap between mucosal tissue andabutment (arrow)Fig. 12 Two year follow up x-ray. Note stabileinterproximal boneFig. 10 Tissues sutured with noattempt to advance flap over bovinebone particlesFig. 11 Two year follow-upphotograph. Note how intedentalpapillae fill entire embrasurespaces. There is slight soft tissueinflammation between lateral andcanineadjacent to the implant. The patient is instructed in proper after surgery care and sutures areremoved in seven to 10 days. Restoration of theimplant can take place once osseointegrationhas been confirmed (maxillary anterior regionfour to six months). In the event that an immediately placed implant would encroach uponthe maxillary sinus, it might be prudent to delayimplant placement, augment the sinus, allow forbone healing and than place the implant.45pimplants.indd 4The gapOn occasion the marginal tissues do not adaptto the healing abutment. In experimental studies, if the gap is too wide, connective tissueforms between the coronal implant aspect andsurrounding bone.54,55 A series of animal andhuman studies has demonstrated that smallgaps between implants and bone will fill withbone with or without grafting materials or barriers.56-61 Botticelli et al. created 1.0-2.5 mmwide circumferential defects in dogs. At a fewsites, the labial bone adjacent to the socket wasreduced. Over a four month healing period thecircumferential defects healed with bone. Siteswhere the labial bone was reduced, properbone healing occurred at the mesial, distal andlingual defect aspects, but reduced bone volume occurred on the labial surface. The sameauthors repeated the study. Special implantswere inserted into the defects, leaving a 1.0-2.5mm gap between the implants and surroundingbone. Bovine bone alone or with a resorbablebarrier was used to augment some sites, whileothers were left to spontaneously heal. It wasdemonstrated that at four months, all defectsfilled with newly formed bone and the biomaterial placed in the marginal defect in conjunctionwith implant installation became incorporatedin newly formed bone tissue. A high degree ofcontact was established between the bovinebone particles and the newly formed bone. Inthe model used, bovine bone did not enhancethe process of bone formation and defect closure. Recently a prospective trial was reportedusing various augmentation techniques atimmediate implant sites.62 The efficacy of combinations of membranes and autogenous bonegrafts at immediate implants were compared.BRITISH DENTAL JOURNAL VOLUME 201 NO. 4 AUG 26 200619/7/06 12:24:29
PRACTICESixty-two consecutively treated patients eachreceived an immediate implant for a singletooth replacement at a maxillary anterior orpremolar site. Dimensions of the peri-implantdefect at the implant collar were measured asfollows: vertical defect height horizontal defectdepth and horizontal defect width. Each implantrandomly received one of five augmentationtreatments and was submerged with connectivetissue grafts: Group 1 expanded polytetrafluoroethylene membrane only, Group 2 resorbablepolylactide/polyglycolide copolymer membraneonly, Group 3 resorbable membrane and autogenous bone graft; Group 4 autogenous bone graftonly, and Group 5 no membrane and no bonegraft control. At re-entry, all groups showedsignificant reduction in VDH, HDD and HDW.Comparisons between groups showed no significant differences for VDH (mean 75.4%) andHDD (mean 77%) reduction. Significant differences were observed between groups for HDWreduction (range, 34.1-67.3%), with membranetreated Groups 1, 2 and 3 showing the greatestreduction. In the presence of dehiscence defectsof the labial plate, HDW reduction of 66.6% wasachieved with membrane use compared with37.7% without membranes. Over 50% morelabial plate resorption occurred in the presenceof a dehiscence defect irrespective of the augmentation treatment used. The results indicatethat VDH and HDD reduction at defects adjacentto immediate implants may be achieved withoutthe use of membranes and/or bone grafts.In practice, when the gap is present no effortis made to surgically advance the flap (Fig. 8).A small amount of allograft or alloplast is layered between the margin and implant abutment(Fig. 9). This material is left exposed. Within afew weeks some of the material will be exfoliated and gingival mucosa will migrate over theexposed materials and healing is uneventful.Bovine bone has been used to augmentsmall gaps adjacent to immediately placedimplants.63,64 Results from these studies demonstrate that the bovine bone does not affect thesurvival of implants. It is important to recognisethat placement of bovine bone, allografts orother substances with or without barrier membranes may support or improve soft tissue contours; however, these materials cannot be reliedupon to enhance
1. Rationale for dental implants 2. Treatment planning of implants in posterior quadrants 3. Treatment planning of implants in the aesthetic zone 4. Surgical guidelines for dental implant placement 5. Immediate implant placement: treatment planning and surgical steps for successful ou
which implant placement should be conducted (Cranin 1999; Singh, Cranin 2010). Consisting of guiding cylinders and a contact surface (e.g., fitting the patient's bone or teeth), the surgical template directs the implant drilling system and provides accurate placement of the implant(s) according to the surgical treatment plan. While the
9. Straumann PURE Ceramic Implant Monotype 35. 9.1 Design 37. 10. Surgical procedure for Straumann PURE Ceramic Implant Monotype 38. 10.1 Preoperative planning 38 10.2 Basic implant bed preparation 42 10.3 Fine implant bed preparation 45 10.4 Implant insertion 46. 11. Prosthetic procedure for Straumann PURE Ceramic Implant Monotype 49
Table of Contents Sequence strong List /strong . Unit 0 1 Introduction 2 How to take the placement tests 3 Placement Test I 4 Placement Test II 5 Placement Test III 6 Placement Test IV 7 Placement Test V 8 Placement Test VI 9 Placement Test VII 10 Placement Test VIII 11 Placement Test IX 12 Placement Test X
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Force Factors Related to Patient Conditions11. Implant Site Bone Density: A Key Determinant for Treatment Planning12. Key Implant Positions and Number for Fixed Implant Prosthesis: A Biomechanical Rationale13. Dental Implant Body Size: A Biomechanical and Esthetic Rationale14. Available Bone and Dental Implant Treatment Plans15.
Table of Contents Sequence strong List /strong . 50-090816 Unit 0 1 Introduction 2 How to take the placement tests 3 Placement Test I 4 Placement Test II 5 Placement Test III 6 Placement Test IV 7 Placement Test V 8 Placement Test VI 9 Placement Test VII 10 Placement Test VIII 11 Placement Test IX
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