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Proven concept with predictable outcomes

by: Drs. Paul Weigl and Pablo Hess

Nobel Biocare proudly provides reliable solutions for immediate placement plus Immediate Function.

Immediate implant placement in extraction sites is a well-proven concept with predictable outcomes for implants manufactured with a TiUnite surface.

As with any other demanding protocol, when you are planning for immediate placement and Immediate Function, careful patient selection is a crucial consideration. Selecting wisely limits the potential risk of implant failure.

After all, factors such as the type of extraction site, the presence of occlusal forces, the patient’s oral status, and his or her overall health can all affect the treatment outcome.

Accelerated healing with immediate implant placement

After tooth extraction, healing of the alveolus is characterized by connective tissue replacing granulation tissue in the first two weeks. Early osteoid appears at the periphery already after one week.

After six weeks, bone trabeculae fill the socket more or less completely; and after four months, bone fill is complete.

This healing sequence can be sped up by the installation of an implant, since the volume of the defect is substantially reduced and tissue ongrowth occurs directly on the implant surface.

Proven earlier with Brånemark System machined surface implants

Early results with machined surface Brånemark System implants showed that replacing teeth immediately with an implant is a valid treatment concept.

Tolman and Keller (1991), for example, reported up to six years of follow-up on 61 patients. They extracted 241 mandibular and 25 maxillary teeth, performed limited alveoloplasty and placed implants immediately in the extraction sites. At six years of follow-up, only two of 301 implants had been lost, both in the maxilla of a single patient due to post-operative infection.

Two years later, Gelb (1993) reported on 50 machined Brånemark System implants placed in 35 consecutive patients, starting in 1989. At follow-up in 1993, 49 implants (98%) were “osseointegrated and functional, supporting the predictability of immediate implant placement.”

After the year 2000, experience and the available data have quickly evolved—largely due to the introduction of the TiUnite implant surface, but also due to further refinement of immediate placement and Immediate Function protocols.

 

The editors ask ...

Why did you choose immediate implant placement with Immediate Function in the extraction site?

The authors: One of the great challenges in implant dentistry is to achieve a predictable, long-lasting, esthetic result. Successful treatment plans are based on minimal trauma and the effective shaping of the peri-implant soft tissue, especially anatomical shaping during early healing.

Normally, the transformation of an extraction socket to a healed site will end up with a complete loss of the 3D-topography of the gingival architecture, and consequently, in a loss of information about the natural emergence profile.

Additionally, a loss of vertical and horizontal bone volume will occur due to the bone-remodeling process that takes place during the healing of the socket. Therefore, delayed implant placement — or immediate implant placement combined with delayed restoration — require augmentation procedures, most typically of the buccal side, and especially when and if one is working with implants that have an inferior thread design.

With the NobelActive implant, on the other hand, the progressive thread design provides fully sufficient primary stability in cases such as the one we are presenting here—despite the fact that it involves a single tooth restoration.

I remember when Nobel Biocare launched the NobelActive implant design: I realized immediately, that for me, this was going to be the one and only implant for immediate placement.

Its aggressive thread alone leads to sufficient primarily stability, but additionally, the NobelActive feature that allows one to change the angle of the axis during insertion makes it possible to gain even more primary stability in a fresh extraction socket (although not in a healed site).

In our experience, the thread works like a spiral conveyor in mining — excavating additional bone and bringing it to the buccal-apical aspect of the site — as one changes the direction of the implant axis from a 45° angle (straight into the palatine bone) to an inclination approximating the original angle of the tooth root.

Do you view this strategy as a better alternative to delayed placement?

The authors: Of course we do! As we follow these procedures, our immediately placed, immediately functioning restoration simulates a “reimplanted tooth” and therefore triggers the healing mode of the extraction site as if a reimplanted tooth were present. This kind of socket-healing preserves the gingiva; and the complete original 3D-topography and structure of the pink tissue can thus be preserved from the start.

Sealing the fresh extraction socket with the patient’s own tooth—as we did here—or with a temporary crown serves to maintain the shape of the soft tissue envelope in a predictable way.

By the way, the initial healing of the socket with a perfect seal results in much less pain than in a conventional extraction site without a perfect seal. Patients are surprised and pleased in cases like these about the absence of major discomfort.

Why was using the existing tooth as a temporary crown the best option?

The authors: The existing tooth guarantees a perfect — and therefore predictable — seal of the extraction socket. Additionally, it saves expense and the time it would take to produce a temporary crown extraorally. Last but not least, reinserting the existing tooth generally produces an esthetically brilliant, natural-looking result.

The results are usually so good, in fact, that patients sometimes need to be convinced to invest in a final all-ceramic crown at the end of the healing period.

References

Tolman DE, Keller EE. Endosseous implant placement immediately following dental extraction and alveoloplasty: preliminary report with 6-year follow-up. Int J Oral Maxillofac Implants 1991;6:24-28

Gelb DA. Immediate implant surgery: three-year retrospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants. 1993;8:388-399

Quirynen M, Van Assche N, Botticelli D, Berglundh T. How does the timing of implant placement to extraction affect outcome? Int J Oral Maxillofac Implants 2007;22 Suppl:203-223

Atieh MA, Payne AG, Duncan WJ, Cullinan MP. Immediate restoration/loading of immediately placed single implants: is it an effective bimodal approach? Clin Oral Implants Res 2009;20:645-659

Esposito MA, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol. 2010;3:189-205

Mura P. Immediate Loading of Tapered Implants Placed in Postextraction Sockets: Retrospective Analysis of the 5-Year Clinical Outcome. Clin Implant Dent Relat Res 2012;14:565-574

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