Surgical Considerations in Placement of Immediate
Dental Implants- A Case Report
Vrushali Abhyankar1*, Zacharia Kashlan2, Cimara Ferreira3, Paul Luepke4
1Assistant Professor, Periodontology,Diplomate, American Academy of Periodontology,UTHSC, College of
Dentistry,Union Avenue Memphis
2Perio Atlanta- Private Practice,4200 Northside Pkwy NE,Atlanta, GA
3Associate Professor, Periodontology,Diplomate, American Academy of Periodontology,UTHSC, College of Dentistry,Union Avenue, Memphis
4Paul Luepke, Interim Associate Dean of Clinical Affairs and Chair, PeriodontologyUTHSC, College of Dentistry,875, Union Avenue, Memphis
2Perio Atlanta- Private Practice,4200 Northside Pkwy NE,Atlanta, GA
3Associate Professor, Periodontology,Diplomate, American Academy of Periodontology,UTHSC, College of Dentistry,Union Avenue, Memphis
4Paul Luepke, Interim Associate Dean of Clinical Affairs and Chair, PeriodontologyUTHSC, College of Dentistry,875, Union Avenue, Memphis
*Corresponding author: Vrushali Abhyankar, Assistant Professor, Periodontology, Diplomate, American Academy of Periodontology, UTHSC, College of
Dentistry, Union Avenue Memphis, E-mail:
@
Received: March 14, 2022; Accepted: April 08, 2022; Published: April 13, 2022
Citation: Vrushali Abhyankar, Zacharia Kashlan, Cimara Ferreira, Paul Luepke (2022) Surgical Considerations in Placement of
Immediate Dental Implants- A Case Report. J Dent Oral Disord Ther 10(1): 1- 5 DOI: 10.15226/jdodt.2022.001133
Abstract Top
Immediate implant placement can be challenging in the surgical and prosthetic fields. However, immediate implant placement is sometimes the
first treatment option of tooth loss in the esthetic zone. Proper treatment planning is imperative to obtain a successful esthetic and functional result
of the final prosthesis. The present case report shows a step-by-step technique for dental implant placement in the anterior maxilla, detailing the
importance of an atraumatic surgical technique to preserve the hard and soft tissues at the extraction site and to better position the implant. This
article also shows patient and site considerations that are necessary for the application of this technique in the clinic.
Keywords: Immediate Implant Placement; Extraction; Socket; Ridge Preservation
Keywords: Immediate Implant Placement; Extraction; Socket; Ridge Preservation
IntroductionTop
Dental implant therapy is the most conservative treatment
option for the lost dentition [1]. Despite the high success rate of
this treatment modality, long-term follow-up studies have shown
unesthetic results and the need for additional surgical procedures
[2], resulting in implant removal and/or additional procedures to
recover hard and soft tissue losses [3]. Clinical demand focused
on reduction of dental implant therapy time has lead research
studies in the field of immediate implant placement 4]. To achieve
this goal, studies have focused on immediate implant placement
[5], immediate loading [6], and improving implant surface
technology [7].
The aim of this case report is to give a step-by-step guide for surgically placing a dental implant immediately after tooth extraction.
Surgical Protocol Considerations
The original implant protocols consisted of implant placement in healed extraction sockets with various healing times ranging from a few months to a year. However, the need to shorten the overall treatment time and number of surgical interventions gave rise to the treatment of placing dental implants at the time of tooth extraction and in the same socket. In 1989, Lazzara placed implants in extraction sockets, thus giving way to a new treatment modality, the reliability and predictability of which, was later confirmed with numerous studies. Apart from reducing the overall treatment duration and the number of surgical procedures it also offered other advantages like preservation of bone crest, interdental papilla, reduced need for complex bone grafting procedures, increase patient acceptance and better aesthetic outcomes by maintaining the gingival architecture of the failing tooth [5]. However, this treatment is amenable only in a select few cases as uncontrolled infection and lack of initial implant stability are its primary contraindications. Also, it is technique sensitive and requires a higher degree of surgical skill and planning. However, in correctly planned and executed cases the survival rate of immediate implants is 93.9-100% [8].
The residual socket morphology including the inclination of axial wall, the root curvature, the residual bone present on all four walls, the position of the apex, proximity to anatomical structures and absence of infection dictate the placement of implant in the extraction socket. If the residual space between implant and the socket wall is more than 1.5mm, bone graft is recommended between the implant and socket walls. For soft tissue management around the implant a temporary crown can be used as part of the restorative plan to shape and manage the cervial gingival tissues for improved esthetics. The surgical requirements for immediate implant placement include atraumatic tooth extraction [9-11], ridge preservation [12], thorough alveolar curettage to eliminate possible pathologies [13]. Primary stability is an essential requirement, and is achieved with an implant exceeding the alveolar apex by 3–5 mm [14]. Esthetic emergence in the anterior zone is achieved by 1–3 mm sub-crest implantation [15].
The aim of this case report is to give a step-by-step guide for surgically placing a dental implant immediately after tooth extraction.
Surgical Protocol Considerations
The original implant protocols consisted of implant placement in healed extraction sockets with various healing times ranging from a few months to a year. However, the need to shorten the overall treatment time and number of surgical interventions gave rise to the treatment of placing dental implants at the time of tooth extraction and in the same socket. In 1989, Lazzara placed implants in extraction sockets, thus giving way to a new treatment modality, the reliability and predictability of which, was later confirmed with numerous studies. Apart from reducing the overall treatment duration and the number of surgical procedures it also offered other advantages like preservation of bone crest, interdental papilla, reduced need for complex bone grafting procedures, increase patient acceptance and better aesthetic outcomes by maintaining the gingival architecture of the failing tooth [5]. However, this treatment is amenable only in a select few cases as uncontrolled infection and lack of initial implant stability are its primary contraindications. Also, it is technique sensitive and requires a higher degree of surgical skill and planning. However, in correctly planned and executed cases the survival rate of immediate implants is 93.9-100% [8].
The residual socket morphology including the inclination of axial wall, the root curvature, the residual bone present on all four walls, the position of the apex, proximity to anatomical structures and absence of infection dictate the placement of implant in the extraction socket. If the residual space between implant and the socket wall is more than 1.5mm, bone graft is recommended between the implant and socket walls. For soft tissue management around the implant a temporary crown can be used as part of the restorative plan to shape and manage the cervial gingival tissues for improved esthetics. The surgical requirements for immediate implant placement include atraumatic tooth extraction [9-11], ridge preservation [12], thorough alveolar curettage to eliminate possible pathologies [13]. Primary stability is an essential requirement, and is achieved with an implant exceeding the alveolar apex by 3–5 mm [14]. Esthetic emergence in the anterior zone is achieved by 1–3 mm sub-crest implantation [15].
Case ReportTop
A twenty-three-year-old non-smoker male patient with non-contributory medical history reported to the department of Periodontics
with a chief complaint of pain in #9. The patient gave a history of trauma in the maxillary anterior region two years ago resulting from
a football game. Tooth #9, deemed non-vital and further treated with root-canal treatment, showed coronal discoloration as time
progressed (Figure 1).
The patient reported dull pain and discomfort in #9 for the previous 2-3 weeks, aggravated by contact and eating. Intraoral examination revealed discolored, slightly extruded #9 which responded positively for pain on percussion. The probing depths were 2-3mm overall except for disto-buccal #9, which was 7mm with bleeding on probing (Figure 2). The facial gingiva had thick phenotype with adequate keratinized tissue while palatal gingival tissues showed marginal erythema, edema, and bleeding on probing (Figure 3). Radiographic examination revealed endodontically treated #9 with horizontal fracture through the middle third and slight displacement of coronal half (Figure 4). Clinical and radiographic examination deemed #9 to have a hopeless prognosis and was treatment planned to be extracted. The patient was given multiple restorative options including no treatment, removable partial dentures, resin-bonded fixed partial dentures, conventional fixed partial dentures, and implant placement either at the time of extraction or delayed after ridge preservation procedure for #9.
The patient reported dull pain and discomfort in #9 for the previous 2-3 weeks, aggravated by contact and eating. Intraoral examination revealed discolored, slightly extruded #9 which responded positively for pain on percussion. The probing depths were 2-3mm overall except for disto-buccal #9, which was 7mm with bleeding on probing (Figure 2). The facial gingiva had thick phenotype with adequate keratinized tissue while palatal gingival tissues showed marginal erythema, edema, and bleeding on probing (Figure 3). Radiographic examination revealed endodontically treated #9 with horizontal fracture through the middle third and slight displacement of coronal half (Figure 4). Clinical and radiographic examination deemed #9 to have a hopeless prognosis and was treatment planned to be extracted. The patient was given multiple restorative options including no treatment, removable partial dentures, resin-bonded fixed partial dentures, conventional fixed partial dentures, and implant placement either at the time of extraction or delayed after ridge preservation procedure for #9.
Figure 1: Extra-oral view of the patient’s low smile line. Note presence
of a lip-line slanted in the left aspect of the lip. Note presence of darkened
crown for #9.
Figure 2: Intraoral pre-op view facial showing adequate keratinized tissue,
supraerrupted #9 and discolored crown
Figure 3: Intraoral pre-op view palatal showing presence of marginal
gingival erythema and edema for #9
Figure 4: Periapical radiograph showing fractured #9
Surgical phase: Proper diagnosis and meticulous treatment planning are the key requisites of any surgical procedure, and it is
important to pay close attention to all the surgical considerations discussed previously. Written and verbal consents were obtained
from the patient for extraction, ridge preservation, bone grafting and implant placement since it is always prudent to plan for
multiple treatment options when immediate placement of implants is considered. Local anesthesia was obtained with 2 carpules
of 4% septocaine, 1:100,000 epinephrine and 1 carpule of 0.5% Bupivacaine, 1:200,000 epinephrine with local infiltration. Using
a 15C scalpel blade intrasulcular incisions was made circumferentially around #9 to release periodontal fibers. #9 was extracted
traumatically using periotomes in the PDL of #9, with utmost attention to keeping the buccal plate and all 4 socket walls intact (Figures
5,6). The socket was debrided with curettes and copious saline irrigation.
Figure 5: Socket after extraction of #9
Figure 6: Extracted #9
The decision to place an implant the extracted socket
stemmed from the following considerations:
• non- smoker medically healthy patient
• absence of purulent discharge from the socket present
• thick phenotype with adequate keratinized tissue
• presence of intact socket walls after extraction including the buccal plate.
• adequate thickness of the buccal plate
• adequate bone apical (>5mm) to the socket to achieve primary stability
• linear anatomic configuration of the socket resulting from linear and non-dilacerated root
• absence of interference from anatomic structures like nasal cavity and incisive canal
• Sound adjacent teeth with adequate (>1.5mm) bone thickness between the roots and implant.
Dried Bone Allograft (FDBA), hydrated with saline was placed in the space between the implant and buccal wall (Figure 10). A prefabricated custom healing abutment was placed over the implant to achieve a favorable emergence profile (Figure 11,12). Amoxycillin antibiotic, Ibuprofen for pain and Chlorhexidine mouth rinse were prescribed post operatively. The patient was instructed to rinse twice daily for 2-weeks with 10 mL of 0.12% chlorhexidine Di gluconate. The patient was discharged in excellent condition with an Essex retainer and seen at 2 weeks for post-op appointment. The patient had no discomfort and tissues appeared healing adequately (Figure 13).
• non- smoker medically healthy patient
• absence of purulent discharge from the socket present
• thick phenotype with adequate keratinized tissue
• presence of intact socket walls after extraction including the buccal plate.
• adequate thickness of the buccal plate
• adequate bone apical (>5mm) to the socket to achieve primary stability
• linear anatomic configuration of the socket resulting from linear and non-dilacerated root
• absence of interference from anatomic structures like nasal cavity and incisive canal
• Sound adjacent teeth with adequate (>1.5mm) bone thickness between the roots and implant.
Dried Bone Allograft (FDBA), hydrated with saline was placed in the space between the implant and buccal wall (Figure 10). A prefabricated custom healing abutment was placed over the implant to achieve a favorable emergence profile (Figure 11,12). Amoxycillin antibiotic, Ibuprofen for pain and Chlorhexidine mouth rinse were prescribed post operatively. The patient was instructed to rinse twice daily for 2-weeks with 10 mL of 0.12% chlorhexidine Di gluconate. The patient was discharged in excellent condition with an Essex retainer and seen at 2 weeks for post-op appointment. The patient had no discomfort and tissues appeared healing adequately (Figure 13).
Figure 7: Implant #9 exiting palatally
Figure 8: Implant #9 exiting palatally
Figure 9: Implant placement radiographic view. Note equidistant positioning
and depth of the implant for an ideal fabrication of emergence
profile of the future crown.
Figure 10: Frontal view of the anterior maxilla after placement of
Freeze-Dried Bone Allograft (FDBA) between the implant and the buccal
wall of the alveolar ridge.
Figure 11: Prefabricated custom healing abutment used during the
healing phase for 4 months.
Figure 12: Prefabricated healing abutment placed over the implant
Figure 13: 2-week post-operative appointment
ConclusionTop
This case report gives a step-by-step guidance for the clinician
to obtain an appropriate esthetic and functional result for the
implant crown.
ReferencesTop
- Singh K, Gupta N, Unnikrishnan N, Kapoor V, Arora D, Khinnavar PK. A conservative treatment approach to replacing a missing anterior tooth. Case Rep Dent. 2014;2014:625784.
- Daftary F, Mahallati R, Bahat O, Sullivan RM. Lifelong craniofacial growth and the implications for osseointegrated implants. Int J Oral Maxillofac Implants. 2013;28(1):163-169.
- Matsumoto W, Morelli VG, de Almeida RP, Trivellato AE, Sverzut CE, Hotta TH. Removal of Implant and New Rehabilitation for Better Esthetics. Case Rep Dent. 2018:9379608.
- Ribeiro FS, Pontes AE, Marcantonio E, Piattelli A, Neto RJ, Marcantonio E. Success rate of immediate nonfunctional loaded single-tooth implants: immediate versus delayed implantation. Implant Dent. 2008;17(1):109-117.
- Lazzara RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. The International journal of periodontics & restorative dentistry. 1989;9(5):332-343
- Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013;2013(3):CD003878
- Degidi M, Piattelli A, Gehrke P, Carinci F. Clinical outcome of 802 immediately loaded 2-stage submerged implants with a new grit-blasted and acid-etched surface: 12-month follow-up. Int J Oral Maxillofac Implants. 2006;21(5):763-768.
- Schwartz D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. Journal of periodontology. 1997;68(10):915-923.
- Blus C, Szmukler S. Atraumatic tooth extraction and immediate implant placement with Piezosurgery: Evaluation of 40 sites after at least 1 year of loading. Int J Periodontics Restorative Dent. 2010;30(4):355-363
- Ren SX, Hu XL, Li JH, Jiang X, Lin Y.A minimally invasive extraction technique using Benex Extraction System in flapless immediate implant placement in anterior teeth. Shanghai Kou Qiang Yi Xue. 2016;25(3):334-339
- Gupta G, Gupta DK, Gupta N, Gupta P, Rana KS. Immediate Placement, Immediate Loading of Single Implant in Fresh Extraction Socket. Contemp Clin Dent. 2019;10(2):389-393.
- Atieh MA, Alsabeeha NH, Payne AG, Duncan W, Faggion CM, Esposito M. Interventions for replacing missing teeth: alveolar ridge preservation techniques for dental implant site development. Cochrane Database Syst Rev. 2015;(5):CD010176.
- Zhao L, Xu T, Hu W, Chung KH. Preservation and augmentation of molar extraction sites affected by severe bone defect due to advanced periodontitis: A prospective clinical trial. Clin Implant Dent Relat Res. 2018;20(3):333-344.
- De Rouck T, Collys K, Cosyn J. Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: A review. Int J Oral Maxillofac Implants. 2008;23(5):897-904
- Nevins/Melloning. Implant Therapy Chicago, Quintessence Publishing Co, Chicago, USA. 1998.
