|Year : 2018 | Volume
| Issue : 2 | Page : 70-74
Immediate placement of dental implants: An overview
Divya Sanjay Agarwal, Nihal Dattatray Devkar, Akshay Ramesh Vibhute, Praful Dhiraj Walke
Department of Periodontology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||1-Nov-2018|
Dr. Divya Sanjay Agarwal
Sinhgad Dental College and Hospital, 44/1, Vadgaon (BK), Off Sinhgad Road, Pune - 441 041, Maharashtra
Source of Support: None, Conflict of Interest: None
Extraction of a tooth means failure of a conservative approach which may give rise to the act of a reconstructive surgery i.e. immediate implant placement technique with the immediate loading. This therapeutic option of immediate loading compensates the negative psychological effect of extraction. There are two main advantages of immediate loading. The first is the biological effect which consists of the osseointegration of the implant despite the constraints experienced in the healing stage. The second is the imperative effect that is logical and consists of the subsequent production of the surgical and prosthetic stage in the shortest time.
Keywords: Immediate implant, immediate loading, osseointegration
|How to cite this article:|
Agarwal DS, Devkar ND, Vibhute AR, Walke PD. Immediate placement of dental implants: An overview. J Dent Allied Sci 2018;7:70-4
|How to cite this URL:|
Agarwal DS, Devkar ND, Vibhute AR, Walke PD. Immediate placement of dental implants: An overview. J Dent Allied Sci [serial online] 2018 [cited 2019 Dec 15];7:70-4. Available from: http://www.jdas.in/text.asp?2018/7/2/70/244764
| Introduction|| |
Tooth loss in the esthetic zone most often results in the loss of bone volume in the vertical and horizontal directions. To minimize this alveolar bone resorption and maintain the periodontal architecture, placement of implants immediately after tooth extraction has been advocated. In order to replace failing teeth, especially in the esthetic region, immediate implant placement and provisionalization are considered a viable treatment option when established clinical guidelines are followed. The long-term success and relative advantages of maxillary anterior single immediate implant placement and provisionalization in the esthetic zone have been well documented.
The merits of immediate implant placement and provisionalization in the anterior maxilla include reduced treatment time, immediate tooth replacement, and preservation of the existing osseous and gingival architecture.
In current years, facial/buccal bone dimensional changes in the alveolar process following tooth extraction and immediate implant placement have been under investigation in both humans and animals. In addition, studies have also demonstrated that the placement of graft materials into the implant-socket gap could minimize the resorptive process and/or promote better healing.
Early loading protocols have been designed, and a concept of immediate function has emerged which includes the achievement of an immediate esthetic result with or without immediate loading.
The timing of implant placement was classified as defined by Hämmerle et al.
- Type 1: Immediate implant placement in tooth extraction socket
- Type 2: Early implant placement with soft-tissue healing
- Type 3: Early implant placement with partial bone healing
- Type 4: Late implant placement.
Hence, in today's clinical practice, immediate implant placement after tooth extraction (i.e., the type 1 implant placement protocol) has become a common surgical protocol.
- Immediate/direct loading – The provisional/definitive prosthetic construction is attached to the implant within 24 h of the implant being placed
- Early loading/early functional loading – The provisional/definitive prosthetic construction is attached to the implant within days/weeks of the implant being placed
- Delayed/conventional loading – The provisional/definitive prosthetic construction is attached at a second procedure after a conventional healing period of 3–6 months
- Occlusal loading – The crown/bridge is in contact with the opposing dentition in centric occlusion
- Nonocclusal loading – The crown/bridge is not in contact in centric occlusion with the opposing dentition in the natural jaw position [Figure 1].
Immediate loading is often defined in terms of timing as at the same clinical visit as implant placement. With the single-implant scenario, this is often achievable and may be advantageous in supporting soft-tissue contour. When considering partial and complete edentulism, the logistics of providing a provisional restoration often dictate a delay from the time of implant placement. For this reason as opposed to any biological basis, “immediate” is most often defined as “within 48 h.” The term “immediate loading” is reserved for full occlusal loading in at least centric occlusion and “immediate restorations” or “nonocclusal loading” for restorations with no centric or eccentric contacts.
| Indications|| |
- Traumatically avulsed
- Residual deciduous teeth
- Horizontal/vertical fracture of teeth
- Failing endodontically treated teeth
- Nonrestorable teeth.
| Contraindications|| |
- Inability to establish mechanical stability (i.e., inadequate width and/or height of available bone)
- Proximity to adjacent teeth
- Placement of implant outside alveolar envelop
- Presence of infection.
| Advantages of Immediate Loading|| |
- Reliable method for developing soft-tissue site of single-tooth restoration
- Facilitates efficient fabrication of final restoration
- Reduces time duration until prosthesis
- More acceptable to patients (than the removable alternative)
- Immediate functional and esthetic (sculpting of soft tissues) rehabilitation of the patient
- Elimination of second-stage surgery
- Adjacent papillae are well preserved contributing to the final esthetic outcome
- Countersinking the implant below the crestal bone is eliminated reducing the early crestal bone loss.
| Discussion|| |
The original protocol of a dental implant placement requires a period of 6 months following extraction, to allow for healing of the extraction socket. Several studies have revealed that during this waiting period, there is a definitive postextraction resorption of bone, which will adversely affect the availability of bone for implant placement. To reduce this problem of bone loss, implants have been placed immediately into fresh extraction sockets. In 1989, Lazzara first reported immediate implant placement at an extraction socket. The success of dental implant treatment of partially and fully edentulous patients has been documented extensively. This healing pattern has been termed “Type 1” implant installation at a consensus conference.,
| Hard-Tissue Changes|| |
Various studies have evaluated the hard-tissue changes occurring in the bone around an immediately placed implant followed by immediate loading.
In general, most studies have reported very similar outcomes to the histological descriptions from experimental studies, i.e., significant horizontal and vertical bone dimensional changes occurring mainly in the buccal bone plate.
Aguirre-Zorzano et al. in a prospective clinical study evaluated immediate temporary restoration of single-tooth implants. They assessed the survival, marginal bone loss and complications around single-tooth implants with immediate provisionalization.
Seventy-eight implants were placed in 57 patients: 56 after extraction and 22 in healed sockets. Immediately after surgery, provisional crowns were delivered without contacts in both centric and excursive jaw movements. The marginal bone loss was measured using periapical radiograph at 1 and 6 months. The mean mesial bone loss was 0.2 ± 0.4 mm and the mean distal bone loss was 0.2 ± 0.4 mm observed at 6 months. There was no statistically significant difference found between immediate or delayed implants. Sixty-seven implants showed a bone loss <1 mm and 36 did not show any bone loss at all. The authors concluded that immediate restoration with single-tooth implants and provisional crowns may be considered as a predictable technique.
Roe et al. evaluated horizontal and vertical dimensional changes to the facial bone following maxillary anterior single-tooth immediate implant placement and provisionalization using cone-beam computed tomography (CBCT) study taken immediately after (T1) and 1 year after surgery (T2). Horizontal facial bone thickness (HFBT) was measured at 0, 1, 2, 4, 6, 9, and 12 mm apical to the implant platform. Vertical facial bone level (VFBL) was the perpendicular distance from the implant platform (0) to the most coronal point of the facial bone. At T2, the mean HFBT changes −1.23 to −0.08 mm at seven different levels were evaluated. The mean VFBT changes were at −0.82 mm. The HFBT changes at 0–9 mm levels was not significantly different from one another, but they were significantly smaller than the change at 0 mm level and significantly greater than change at 12 mm level. The study concluded that dimensional changes to the peri-implant facial bone following maxillary anterior single immediate implant placement and provisionalization should be expected.
Cristalli et al. (2015) assessed the vertical distance from the most coronal point of the alveolar crest to the most apical point of the bony defect, vertical distance from the implant shoulder to the most apical point of the bony defect, and the horizontal distance from the implant surface to the socket wall at the level of the alveolar crest (n = 24). Clinical parameters, marginal bone loss, as well as pink esthetic scores and white esthetic scores (PES and WES) were evaluated at 3, 6, and 12 months after implant placement. The mean marginal bone loss after 1-year follow-up was 0.383 (standard deviation [SD] ±0.749) at mesial site and 0.278 (SD ± 0.595) at distal site. The mean total PES/WES was 17.13 ± 1.91 (range: 13–20). The authors concluded that within the limitations of this study, when careful patient selection and strict clinical protocol are observed, the immediate placement and loading of a single Nobel Active™ implant in a fresh extraction socket may be considered a valuable and predictable option in terms of implant success as well as hard- and soft-tissue stability.
Kolerman et al. in a 1–4-year retrospective study assessed radiologic and biologic parameters of immediately restored implants combined with guided bone regeneration (GBR) and free connective tissue graft (n = 34). They measured the distance from the implant shoulder to the coronal bone-to-implant contact (DIB), i.e., the mesial and distal alveolar bone crest to implant shoulder distance. After 29 months, a mean mesial bone loss of 1.10 ± 0.39 mm (range: 0.5–2.4 mm) and mean distal bone loss of 1.19 ± 0.41 mm (range: 0.4–2.1 mm) with peri-implant probing depth of 3.49 mm (SD ± 61.06) and 2.35 (SD ± 60.52) for the contralateral tooth (highly significant P < 0.001) were observed. The authors concluded that the anterior maxillary single-tooth replacement, using GBR and connective tissue graft according to the concept of immediate implant placement and nonfunctional restoration, is an accepted treatment modality achieving favorable peri-implant soft-tissue condition. In spite of the bone deficiencies in the buccal walls of the sockets, this approach results in success rates similar to other methods of immediate loading or restoration, both clinically and radiographically.
For measuring horizontal bone resorptive changes, the most relevant factor was the thickness of the buccal bone wall, and for vertical bone resorptive changes, both the implant position and the thickness of the buccal bone wall significantly influenced the amount of vertical bone change. For the spontaneous filling of the gap between the implant surface and the inner bone plates, the most relevant factors are the implant (significantly better in cylindrical implants compared with the conical implants), the thickness of the buccal bone plate, and the patient (smokers performed significantly worse).
| Evaluation of Initial Stability and Crestal Bone Level in Immediate Implant and Immediate Loading|| |
Stability is the most important factor for the loading of an implant with prosthesis and for its success. In immediate implant cases, there is a customized socket wall for attaining good initial stability. To attain good initial stability/primary stability, implants 2 mm longer than the socket length are selected and excess preparation of 2 mm beyond the socket is performed, with initial drilling followed by sequential drilling. Therefore, the initial stability attained is primarily due to the contact of the implant–bone interface, only in the apical one-third. Selection of the implant body contour is very important to attain good initial stability. As the socket wall is tapered toward the apex, it is best to use cylindrical or straight screw implants. Drilling with drills that have exact angulation is also primarily important, as always, if the root is slightly curved, the drill goes toward the path of least resistance. Therefore, a firm grip is necessary to prepare a 2-mm implant site apically. Implants are placed into an extraction socket with the implant shoulder margin at least 2 mm below the crestal bone level.
The vertical resorption can be limited by placing the implant shoulder below the level of the crestal bone. Evaluation of the crestal bone level can be performed using standardized digital periapical radiographs with the long-cone paralleling technique.
In addition, it is critical to monitor the peri-implant bone changes after immediate implant placement, especially after prosthetic loading. This can be accomplished by a device that provides a three-dimensional view of the hard tissue. The recently developed CBCT scan meets these requirements, with the added benefit of decreased X-ray exposure as compared to conventional CT imaging.
The thickness of the buccal and lingual alveolar plates can be measured by the following technique [Figure 2].
|Figure 2: Horizontal facial bone thickness at levels 1, 2, and 3 was measured on the line extended from the corresponding horizontal implant lines to the outline of the facial bone. Vertical facial bone level was the perpendicular distance from the most coronal point of facial bone to the implant platform|
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- Postoperative measurements of the distance from the external surface of the buccal and palatal/lingual alveolar plates to the implant surfaces will be taken at coronal (L1), middle (L2), and apical (L3) levels of the implant at baseline (day of immediate nonfunctional loading) and 6 months after nonfunctional loading
- Postoperative measurements of the distance from external surface of the buccal alveolar plate to the external surface of the palatal/lingual alveolar plate (buccolingual width) will be taken at coronal (L1), middle (L2), and apical (L3) level of the implant at baseline (day of immediate nonfunctional loading) and 6 months.
- VFBL will be measured on facial surface of the implant as the perpendicular distance from the implant platform to the most coronal point of the facial bone.
Even though histometry serves as the gold standard to assess the crestal bone level accurately, a study by Hermann et al. comparing histometry and standardized periapical radiographs has shown that the precision of the radiographs is within 0.1 mm of the histometry in 73.4% and between 0.1 and 0.2 mm in 15.9% of the evaluations.
Östman et al. (2007) studied immediate-loaded implants in total edentulous maxillae. One hundred and twenty-six immediate-loaded implants were compared to 120 submerged implants with a healing period of 6 months. Resonance frequency analysis showed a tendency toward a more rapid increase in implant stability and less marginal bone resorption for the immediate-loaded implants compared with the submerged implants.
Fischer and Stenberg (2004) also found statistically less marginal bone resorption with immediate-loaded, sandblasted, large-grit, acid-etched implants (Straumann, Basel, Switzerland) than with a delayed loading group of implants.
| Criteria Associated with Success Using Immediate Provisionalization Include|| |
- Sufficient bone height, width, and density for stability of the implant at placement.
- Implant insertion torque: 20 N/cm
- Radiofrequency index: >60.
(Both these are deciding factors that indicate that implant stability is sufficient for provisionalization)
Sufficient mesiodistal, buccolingual, and interocclusal space for the placement of an anatomic restoration. If the opposing occlusion interferes with the provisional restoration, a two-stage technique is used rather than immediate provisional methodSufficient vertical dimension stability with occlusal stops to avoid occlusal loading of the provisional restorationWhole surface of implant to be covered with bone. Contraindicated in cases of peri-implant fenestration or dehiscenceCaution in bruxers and smokersUse of threaded implants results in high percentage of implant in contact with bone cortexUse of rough surfaced implants rather than smooth surfaced ones enhances osseointegrationUse of four implants with adequate length and diameter connected with a U-shaped bar for splinting –distribution of forces – reduces risk of macro- and micromovement and minimizes rotational movementsImplants should be at least 10 mm long. This number has been concluded empirically over numerous experiments as a minimum length of the implant required to impart adequate primary stability in the presence of other factorsMeticulous surgical protocol with minimal trauma (excessive trauma during surgery can damage bone and result in bone resorption in the initial postoperative period)Bicortical engagement to be achieved whenever possibleFavorable occlusal scheme (to minimize stresses on implants)The patient should agree to limit chewing to only the softest of foods, preferably liquids, for up to 8 weeks. In addition, patients with excessive parafunctional habits are not provisionally reconstructed.
| Disadvantages of Immediate Loading|| |
- Unpredictable nature of the results
- Micromotion of the implant that can cause resultant crestal bone loss or implant failure is greater than with two-stage approach
- Secondary infections in the grafted sites and recession in the thin tissue biotype areas.
| Conclusion|| |
There are an emerging need and demand for immediately loaded treatment solutions in the management of partial or total edentulism.
The results obtained according to those of the specialized literature reinforce the belief that the immediate implant loading is a good, reliable method that solves in very good conditions, both the functional and esthetic needs of an immediate postextractional implant.
Hence, immediate loading implant can be included in regular clinical practice if favorable soft- and hard-tissue components are available for achieving best esthetic outcome [Figure 3].
|Figure 3: (a and b) Submerged root piece of mandibular left central incisor (clinical and radiographic picture). (c) Extracted root piece of the mandibular left central incisor. (d and e) Immediate implant placement in fresh extraction socket. (f) Clinical picture after temporization within 72 h|
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]