RGUHS Nat. J. Pub. Heal. Sci Vol No: 16 Issue No: 4 pISSN:
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1Dr. Deepthi V, Department of Periodontics, Kannur Dental College, Anjarakkandy, Kannur, Kerala, India.
2Amar S Dental Clinic, Kannur, Kerala, India
3Department of Prosthodontics, Kannur Dental College, Anjarakkandy, Kannur, Kerala, India
4Department of Prosthodontics, Kannur Dental College, Anjarakkandy, Kannur, Kerala, India
5Department of Prosthodontics, Kannur Dental College, Anjarakkandy, Kannur, Kerala, India
6Doctor s Dental Care, Changanassery, Kottayam, Kerala, India
*Corresponding Author:
Dr. Deepthi V, Department of Periodontics, Kannur Dental College, Anjarakkandy, Kannur, Kerala, India., Email: deepv32@gmail.com
Abstract
Implant-retained prostheses are increasingly in demand due to the rising elderly population and the associated increase in edentulousness. Dental implants offer a number of benefits over traditional tooth-borne fixed prostheses. However, patients may choose not to pursue implant-based treatment due to factors such as treatment duration, the requirement for additional surgical procedures, and the requirement for prolonged periods of temporization. In such cases, immediate implants have proven to be a predictable therapeutic option.
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Introduction
Physiological dimensional changes that occur in the alveolar ridge after tooth extraction can be seen mostly within the first three months of socket healing. These dimensional alterations in height (apicocoronal) and width (bucco-lingual) may thereby affect subsequent implant placement. There are several clinical and experimental studies which report that the replacement of a hopeless tooth by an implant installed in a fresh extraction socket (immediate implant) is a predictable procedure and can prevent or decrease dimensional reduction of the alveolar ridge.1
History and Background
In clinical practice, immediate implant placement after tooth extraction has become a common procedure. This idea was first presented by Schulte and Heimke in 1976 as a substitute protocol for Branemark's traditional delayed implant surgery strategy.2,3 Anneroth and associates published the first study using monkeys as the animal model. In 1989, Lazzara first reported immediate implant placement in an extraction socket in humans.4,5 Since then, this treatment approach has gained considerable attention in the literature.
Terminologies
Three fundamental implant placement methods were established at the Third International Team for Implantology (ITI) Consensus Conference, taking into account the interval between extraction and implant placement.
In Type-1 protocol (Immediate implant placement), implants are placed in fresh extraction sockets, aiming to engage the remaining walls of socket.
In Type-2 protocol (Early implant placement), implant placement is undertaken approximately 4-8 weeks following tooth extraction. This protocol ensures absence of pathology while placing the implant, and also optimizes the availability of soft tissues for primary healing and probable lateral bone augmentation. It also helps to improve the availability of crestal bone for implant placement, because within this short interval from tooth extraction, part of the socket bone walls can still be preserved.
In Type-3 protocol (Early-delayed implant placement), implant placement is undertaken after majority of dimensional changes in the alveolar ridge have occurred (12-16 weeks).
Hammerle and colleagues published a consensus report in 2004 which contained a new classification system based on the timing of implant placement.6 The structural changes that occur after extraction served as the basis for this classification (Table 1).
Advantages
1. Decrease in the number of surgeries and appointments
2. Decrease in the overall treatment time
3. Ideal implant orientation
4. Bone preservation in extracted site
5. Optimum soft tissue esthetics
Disadvantages
1. Adverse esthetic outcomes
2. Difficulty in achieving primary stability
3. Intra operative complications like fracture of the buccal cortical plate, socket expansion during extraction, etc
4. Difficult closure of the flap due to lack of keratinized mucosa
Factors Affecting Clinical Outcome of Immediate Implants
Changes in the alveolar socket
Dimensional changes do occur in the alveolar bone after tooth extraction in which the resorption of buccal plate of bone was found to be more significant than the lingual/palatal bone plate.7 The two important factors affecting the remodeling process after implant placement are the thickness of the buccal bone as well as the dimension of the horizontal gap i.e., the space between the inner part of the alveolar wall and the implant surface.8-10
Hence a minimum thickness of 2 mm of buccal plate is recommended to avoid ridge collapse after tooth extraction. Various regeneration techniques alone or in combination with soft‐tissue grafts can be done to achieve adequate bony contours around the implants.8,11,12
Gingival biotype
One of the most unpleasant esthetic outcome that occurs with immediate implants is mid facial recession.13 It has been noticed that a thin biotype is three times more prone to midfacial recession following placement of immediate implants. Other risk indicators associated with recession of facial mucosal margin are, position of the implant too facially and thin or damaged facial bony walls.
Periapical or periodontal pathology
Immediate implants were initially contraindicated in cases with periapical or periodontal pathologies. Later studies by Siegenthaler et al. and Jung et al. proved that immediate implants can be placed with predictable success rates in sites with periapical pathology.14,15 A systematic review on immediate implants placed in infected sites revealed that successful osseointegration is possible at such sites, provided that thorough cleaning, socket curettage/ debridement and chlorhe-xidine irrigation are performed.16
Implant diameter and position
Vertical bone loss occurring after immediate implant placement was found to be doubled on using wider implants.11 Bone loss on the lingual/palatal aspect was minimal and hence implant should be placed towards lingual/palatal bone wall and 1 mm below the coronal margin of the buccal bone crest. In a study by Evans et al.,17 the mean midbuccal recession was 0.6 mm for immediate implants placed in a palatal position in contrast to 1.8 mm in sites where implants were placed towards the buccal crest. Therefore, it can be concluded that the implant body should avoid contact with the buccal bone which can be achieved using smaller diameter implants at a more palatal / lingual position.
Surgical protocol
Raising a surgical flap and thus exposing the underlying bone can cause vascular damage and an acute inflammatory response triggering the resorption of the exposed bone surfaces. In an animal study, the amount of buccal bone loss at three months was 1.3 mm in the flap group and 0.82 mm in the flapless group.18 A human study by Raes et al. demonstrated a significant decrease in recession when implants were placed with a flapless approach.19 Though these studies provide evidence for the superiority of flapless technique, there is no clear evidence that raising a flap for implant placement has a significant effect on increase in buccal bone resorption.
Bone grafts
Various grafting materials can be used to fill the buccal void after immediate implant placement. Experimental studies in this regard are limited and have found no additional benefit in clinical outcomes when graft materials were used in cases with thick gingival biotype. But in cases with a thin gingival biotype and narrow buccal bone crest, use of grafts may be recommended.
Connective tissue grafts
Use of connective tissue grafts has been recommended to prevent gingival recession seen with labial implant positioning and cases with thin gingival biotype. A minimum width of 2 mm keratinized mucosa should be present for long term maintenance of periimplant soft tissue health.20-23 So connective grafts can be used to provide good periimplant soft tissue health and optimum esthetics.
Immediate Loading
Immediate loading is defined as a provisional prosthesis connected to the implant during the first week of healing; early loading 1‐8 weeks of healing and conventional loading after two months.24 Artzi et al.25 found enhanced bone resorption in cases of immediate implantation associated with immediate loading when compared to delayed implantation in a healed site with immediate loading. Other authors have concluded that the immediate implant placement and provisionalization without functional loading could be a better therapeutic option in cases of anterior single tooth replacement.26,27
Immediate Implants and Survival Rates
Survival can be defined as implants remaining in situ at the follow up examinations irrespective of the conditions of the surrounding tissues. Lang et al.1 evaluated five factors for their impact on the survival rate of immediate implant: use of antibiotics, reasons for extractions, locations of implants (anterior vs. posterior, maxillary vs. mandibular), and timing of restorations. He found lower failure rates when teeth were extracted for non-periodontal reasons, when implants were placed in the anterior area and when implants were loaded with a delayed protocol. A systematic review on survival and success rates of Type 1, 2, and 3 implant placement protocols revealed similar survival rates for Type 1 and 2 placement.13
Conclusion
Immediate implants and their immediate restoration, whether provisional or final can be highly advantageous, provided that proper case selection and appropriate surgical and prosthetic considerations are addressed. If the ideal conditions for immediate implant placement are not encountered, it is better to consider alternative implant placement protocols.
Conflicts of Interest
Nil
Supporting File
References
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