bone ! implant · dental implants in the aesthetic zone navigating unvharted waters ..! ideal...

Dental Implants in the Aesthetic ZoneNavigating Unvharted Waters ..!

Ideal Aesthetic Function

Soft Tissues

!

Implant !Phil

osophy !

Bone !

ideal

prosthetic

positionNikos Mattheos, DDS, MASc, PhD Clinical Associate Professor in Implant Dentistry

Jakarta, October 2019

2 yrs part time MSc in Implant Dentistry3 yrs full time MDS in Implant Dentistrypatient care, research.

⾺毅剛

Immediate Implants ?

Ridge Preservation ?

Early + Simultaneous Augmentation ?

2 stage augmentation?

Block Graft ? Non- Resorbable membrane

Surgical Protocols - bone

Reduced diametre implants ? 2.9 mm? Tapered self-cutting implants ? BLX Implant?

Free gingival graft ?

Connective tissue graft ?

Repositioned flaps ?

Pedicle grafts?

Xenograft / Allograft?

Surgical Protocols - soft tissue

Timing?

Before, during , after implant ?

Immediate provisional/ loading

Removable denture

Transmucosal healing

Submerged healing - second stage

Early loading (<2 months)

Conventional Loading (2-4 months)

Delayed Loading ( <4 months)

Temporary and Restorative protocols

Surgical and Restorative protocols

Immediate Implants ?

Ridge Preservation ?

Simultaneous Augmentation ?

2 stage augmentation?

Block Graft ? Non- Resorbable membrane

Reduced diametre implants ? 2.9 mm?

Tapered self-cutting implants ?

BLX implant ?

Free gingival graft ?

Connective tissue graft ?

Repositioned flaps ?

Pedicle grafts?

Xenograft / Allograft?

Immediate provisional/ loading

Removable denture

Transmucosal healing

Submerged healing - second stage

Early loading (<2 months)

Conventional Loading (2-4 months)

Delayed Loading ( <4 months)

ideal implant position

Soft Tissues!

Bone !

Assess local Anatomy

Prosthesis !Implant !

Optimal clinical outcomeProtocol !

1

23

What happens after the extraction a tooth ? Assess local

Anatomy

1

Cardaropoli et al. J Clin Periodontol 2003 Araujo & Lindhe. J Clin Periodontol 2005

• Maximum loss of tissue contour occurs within the first 3 months Johnson 1969 et al

• A width reduction of approximately 50% over 12 months. 2/3rds of this occurs within the first 3 months Schropp et al 2003

• Mean horizontal: 3.8mm Mean vertical: 1.24mm 6 months post extraction Hammerle 2012

Average Hong Kong Patient Your Patient

Chappuis et al. Ridge alterations post-extraction in the esthetic zone: a 3D analysis with CBCT. J Dent Res 2013: 92: 195S–201S.

Extraction 8 weeks

Bone: width: - 62%

Buccal wall

< 1mm

> 1mm

Soft tissuethickness: x 7

Bone: width: - 9%

Soft tissuethickness: 0 Anatomy : buccal wall thickness

Neighbouring teeth Angle of the ridge Soft tissue biotype, thickness, height Apical bone volume

Implant Placement in the Aesthetic Zone

Checkpoint !Don’t generalise…Individualise

Patient

Systemic

Oral

Local site

to establish and satisfy the patient‘s needs for esthetics and function ...

... under healthy and sustainable conditions

Principle Driven Implant Dentistry: Our mission statement:

h

wImplant shoulder

2;!How much height?3;!How much width ? (thickness)4;!How much keratinised mucosa?5: How to design the prosthesis?

Soft tissue outcomes:

Necessary ?

Desired ?

Irrelevant ?

Clin Oral Implan.ts Res. 1991 Apr-Jun;2(2):81-90. The soft tissue barrier at implants and teeth. Berglundh T1, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P

3.8

Biologic width is not related to the soft tissue height !

ConnectiveTissue

JunctionalEpithelium

Sulcus

Biofilm

Prosthesis

Bone

Implant

Internal Connection

Supracrestal Complex

Screw

Abutment

Connective Tissue

Epithelium

Peripendicula Collagen Fibres

Bone

Sharpey’s fibres

Junctional EpitheliumJunctional Epithelium

Tooth Implant

Cementum

Periodontal ligament

⎬⎭ ⎫

Attachment Adhesion

Attachment Adhesion

Sulcus Sulcus Sulcus

Genetics

Anatomy

Critical zone

Critical zone

Sulcus

Sulcus

Attachment

Attachment

w

h3 mm Implant shoulder

Papilla

Mid buccal

p2-4 mm

height? 3mm / 2-4 mm

width ? 2mm

keratinised? 2mm

Optimal clinical outcome

2

2 mm

Soft tissues:

Checkpoint !

Bone: 1-1.5 mm

Prosthetic Manipulation?

Immediate implant?

Ridge Preservation?

How can we overcome the compromised Bone ? Loading Protocol

Surgical Protocol

Immediate Type A

Early Type B(<2 m)

Conventional Type C(>2 m)

Immediate Type 1 1A 1B 1C

Early Type 2(4-12 w)

2A 2B 2C

Conventional Type 3(>6 m)

3A 3B 3C

Clinically Documented

Clinically Insufficient Documentation

Scientific and Clinically Validated

Gallucci et al 2018 COIR

Immediate implant with Immediate Provisional 1A

Immediate implant with early / conventional loading 1B/C

Protocols 1A - 1B - 1C

Immediate Flapless:

ImmediateCrown

Customised Healing abutment

Immediate with Flap:

Immediate Implant?

2

31

Flapless - atraumatic (?)

Palatal placement

Augmentation

Immediate temporary

Permanent restoration

Immediate Implant? With Immediate Temporary Crown: 1 Success factors:

High Survival

Lower success

Higher complexity

Higher risk

Immediate Implants Protocols 1A - 1B - 1C

Success factors:

High Survival

Lower success

Higher complexity

Higher risk

Digital Workflow?

Immediate Implants Protocols 1A - 1B - 1C

Checkpoint 3 !

Free-hand SurgeryGuided Surgery

Computer-aided

Predetermined placement posistion

pre-Identified placement posistion

Comparison of the accuracy of of single tooth implant placed using static, dynamic and free-hand Computer Assisted Implant Surgery.

P. Smitkarn, , K. Subhalenka, N. Mattheos, A. Pimkhaokam

Immediate Implant?

With Custom healing abutment: 2

Not adequate primary stability

Unfavorable occlusion?

Maintain soft tissue architecture

Scientific evidence

soft tissues changes. In case of parametric data, a pairedt-test was used, whereas in nonparametric data aWilcoxon signed-rank test was used. A frequencyanalysis was used to describe the distribution of hardand soft tissue changes among the patients. Allcalculations were performed with the SPSS statisticalsoftware program (version 16.0, SPSS, Inc., Chicago, IL,USA).

RESULTS

The reasons for tooth loss of the 15 implants (13incisors, 1 canine, and 1 premolar) included in thisstudy are outlined in Table 1. The patient

demographics, implant characteristics and follow-upintervals are shown in Table 2. No implant loss orimplant associated pathology was observed atthe final follow-up visit. Representativeoutcomes of the treatment are illustrated inFigures 4 to 6.

Hard Tissue Measurements

Radiographic evaluation revealed a mean mesial bonegain of 1.20 ± 1.01 mm (p < 0.0001), which reachedstatistical significance. The mean distal bone gain was0.80 ± 1.14 mm (p = 0.01), which also reached statisticalsignificance. Table 3 shows that there was a significantchange in both the mesial and distal bone level betweenthe time of implant placement and the follow-upassessment. Table 4 shows the distribution of bone gainand loss in millimeters for individual patients. Themajority of the readings demonstrated bone gain!0.5 mm (13/15 cases).

Soft Tissue Measurements

The mean mid-buccal gingiva recession was 0.20 ± 0.78mm (p = 0.44). The mesial papillary height loss was0.50 ± 1.12 mm (p = 0.24), whereas the distal papillaryheight loss was 0.30 ± 0.82 mm (p = 0.27) Table 5. The

A B

FIGURE 2. Illustration of hard tissue measurements onperiapical X-ray. Cl = coronal line; Dbc = distal bone contact;Mbc = mesial bone contact.A set of paired radiographs usedfor measurements. A = baseline radiograph; B = follow-upradiograph.

FIGURE 3. Illustration of the measurements of soft tissue onphotographs. Bm = distance to middle of buccal gingival margin;Dp = distance to distal papilla; Mp = distance to mesial papilla;Ocl = occlusal line.

IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12083 Journal of Esthetic and Restorative Dentistry Vol •• • No •• • ••–•• • 2013 5

soft tissues changes. In case of parametric data, a pairedt-test was used, whereas in nonparametric data aWilcoxon signed-rank test was used. A frequencyanalysis was used to describe the distribution of hardand soft tissue changes among the patients. Allcalculations were performed with the SPSS statisticalsoftware program (version 16.0, SPSS, Inc., Chicago, IL,USA).

RESULTS

The reasons for tooth loss of the 15 implants (13incisors, 1 canine, and 1 premolar) included in thisstudy are outlined in Table 1. The patient

demographics, implant characteristics and follow-upintervals are shown in Table 2. No implant loss orimplant associated pathology was observed atthe final follow-up visit. Representativeoutcomes of the treatment are illustrated inFigures 4 to 6.

Hard Tissue Measurements

Radiographic evaluation revealed a mean mesial bonegain of 1.20 ± 1.01 mm (p < 0.0001), which reachedstatistical significance. The mean distal bone gain was0.80 ± 1.14 mm (p = 0.01), which also reached statisticalsignificance. Table 3 shows that there was a significantchange in both the mesial and distal bone level betweenthe time of implant placement and the follow-upassessment. Table 4 shows the distribution of bone gainand loss in millimeters for individual patients. Themajority of the readings demonstrated bone gain!0.5 mm (13/15 cases).

Soft Tissue Measurements

The mean mid-buccal gingiva recession was 0.20 ± 0.78mm (p = 0.44). The mesial papillary height loss was0.50 ± 1.12 mm (p = 0.24), whereas the distal papillaryheight loss was 0.30 ± 0.82 mm (p = 0.27) Table 5. The

A B

FIGURE 2. Illustration of hard tissue measurements onperiapical X-ray. Cl = coronal line; Dbc = distal bone contact;Mbc = mesial bone contact.A set of paired radiographs usedfor measurements. A = baseline radiograph; B = follow-upradiograph.

FIGURE 3. Illustration of the measurements of soft tissue onphotographs. Bm = distance to middle of buccal gingival margin;Dp = distance to distal papilla; Mp = distance to mesial papilla;Ocl = occlusal line.



Bone Soft tissue measurements2013Immediate placement and restoration of dental implants

In the aesthetic region: Clinical Case Series

Immediate Placement and Restoration of Dental Implantsin the Esthetic Region: Clinical Case SeriesNABIL KHZAM, BDS, MPhil, DClinDent*, NIKOS MATTHEOS, DDS, MASc, PhD†, DAVID ROBERTS, BDSc, MDSc‡,

WILLIAM L BRUCE, BDSc, MDSc§, SASO IVANOVSKI, BDSc, BDentSt, MDSc, PhD¶

ABSTRACT

Aim: The objective of this study was to assess the hard and soft tissue changes following immediate placement andprovisional restoration of single-tooth implants in the aesthetic zone.Methods: Thirteen patients with immediately placed and restored implants were included in this study. All participatingpatients underwent the same treatment strategy that involved removal of the failed tooth, flapless surgery, immediateimplant placement, and connection of a screw-retained provisional restoration.Three months following implantplacement, the temporary crowns were replaced by the definitive restorations. Implant survival rates, and hard and softtissue changes were measured using periapical X-rays and photographs.The range of the observation period wasbetween 12 and 37 months with a mean period of 23.2 ± 7.6 months.Results: At the time of follow-up, all implants were present with no complications. Radiographic evaluation revealed amean mesial bone gain of 1.20 ± 1.01 mm and a mean distal bone gain of 0.80 ± 1.14 mm, which reached statisticalsignificance.The mean mid-buccal recession was 0.20 ± 0.78 mm, whereas the mesial and distal papillae height loss was0.50 ± 1.26 mm and 0.30 ± 0.82 mm, respectively.The changes in the soft tissues did not reach statistical significance.Conclusion: Notwithstanding the limitation of a small sample size, this study shows that immediate implant placementand provisional restoration in the maxillary aesthetic zone can result in favorable treatment outcomes with regards tosoft and hard tissues changes over a follow-up period of 23.2 ± 7.6 months.

CLINICAL SIGNIFICANCE

Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zonehave focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissueschanges. However, this study assesses the soft tissue changes associated with this procedure, which is an importantarea of study given the esthetic demands of implant therapy in the maxillary anterior region.(J Esthet Restor Dent ••:••–••, 2013)

INTRODUCTION

Single tooth replacement with an implant supportedcrown is often the treatment of choice for missing teethin the anterior maxilla. The original implant treatmentprotocol described by Branemark involved 3 months of

healing following extraction of a failed tooth, and anadditional 3 to 6 months of a load-free period followingimplant placement.1,2 In the last 20 years, implantdentistry has evolved dramatically, with the originaltwo-stage protocol modified to include one-stagesurgery,3 immediate implant placement into a fresh

*Specialist Periodontist, Private Practice, University of Tripoli, Libya†Associate Professor, The University of Hong Kong, Hong Kong‡Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia§Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia¶Professor of Periodontology, School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia

RESEARCH ARTICLE


has some limitations, namely that the restorativecontact point is not going to be constant as theprovisional crowns will undergo replacement withpermanent restorations, whereas the radiographiclocation of the apical/coronal shoulder is easily a!ectedby image distortion.24

The results of the present study, which showed arelatively high amount of bone gain, compares favorablywith other studies involving implant therapy in the

maxillary anterior zone.18,19,22,25–28 Using the immediateplacement and restoration protocol, Kan and colleaguesshowed a mean marginal bone loss ranging from 0.26 to0.40 mm on the mesial and 0.22 to 0.28 mm on thedistal aspect of the implant at 1-year follow-up.23

Several other investigators have shown even greateramounts of bone loss. The study by De Rouck andcolleagues revealed a mean bone loss of 0.98 mm on themesial aspect of the implant and 0.78 mm distally at1-year follow-up.6 Other studies using the immediateimplant placement and immediate restoration approachhave shown similar outcomes.23,24,29–31 On the otherhand, Kan and colleagues reported that “scalloped”shaped implants placed into extraction sites showed amean bone gain of 1.0 mm after 1 year of follow-up.7The amount of bone gain in this study was attributed tothe placement of a bone graft into the gap between theimplant and walls of the extraction socket thatsubsequently resulted in radiographically assessed bonefill. Our study used a “platform switching” implant

FIGURE 6. Illustration of soft tissue on photographs,(21)-baseline and follow-up.

TABLE 3. Bone level changes (presented as millimeterschange)

Parameters Change in mm p-value

Mesial bone level 1.20 ± 1.01 0.001*

Distal bone level 0.80 ± 1.14 0.01*

Mean ± standard deviation.*Significant.

TABLE 4. Frequency analysis of hard tissue changes inmillimeters

Bone changes inmm/patients

2.5 and 2 mm 2.23 2.19 2.18

2 and 1.5 mm 1.79 1.75 1.58

1.5 and 1 mm 1.29 1.04 –

1 and 0.5 mm 0.82 0.71 –

0.5 and 0 mm 0.22 0.2 0.01

0 and !0.5 mm 0.09 – –

!0.5 and !1 mm 0.63 – –

TABLE 5. Soft tissue level changes (presented as millimeterschange)

Parameters Change in mm p-value

Mesial papilla level !0.50 ± 1.12 0.24

Distal papilla level !0.30 ± 0.82 0.27

Mid-buccal ginigval level !0.20 ± 0.78 0.44

Mean ± standard deviation.


DOI 10.1111/jerd.12083 © 2013 Wiley Periodicals, Inc.Vol •• • No •• • ••–•• • 2013 Journal of Esthetic and Restorative Dentistry8

13 patients 2 years

Immediate Implant?

OR I G I N A L A R T I C L E

Immediate implant placement and restoration in the anteriormaxilla: Tissue dimensional changes after 2-5 year follow up

Himanshu Arora, MDS1 | Nabil Khzam, DClinDent2 | David Roberts, MDSc3 |

William L Bruce, MDSc3 | Saso Ivanovski, MDSc, PhD1

1School of Dentistry and Oral Health,

Griffith University, Gold Coast, Queensland,

Australia2Private practice, Perth, Western Australia,

Australia3Private practice, Brisbane, Queensland,

Australia

CorrespondenceSaso Ivanovski, School of Dentistry and

Oral Health, Griffith Health Centre, Griffith

University - Gold Coast Campus, Parklands

Drive, Queensland 4222, Australia.

Email: [email protected]

Abstract

Background: Immediate implant placement followed by an immediate restoration has proven to

be a viable technique in the anterior maxillary region.

Purpose: This prospective study evaluated the mid-long term (2-5 years) tissue changes around

immediately placed and restored implants in the anterior maxilla using flapless surgery and simulta-

neous hard tissue augmentation.

Materials and methods: Thirty AstraTech implants were immediately placed in 30 patients, fol-

lowed by the delivery of an immediate provisional restoration on the same day. All participating

30 patients underwent the same treatment strategy that involved flapless removal of a failing max-

illary anterior tooth, immediate implant placement, simultaneous augmentation with a

deproteinized particulate xenograft, followed by the connection of a screw-retained provisional

restoration. Radiographs and photographs were used to measure hard and soft tissue changes.

Aesthetic evaluation was performed using the Pink Esthetic Score (PES).

Results: All implants remained osseointegrated during the follow up period of 2-5 years (mean

47615 months). Twelve of the thirty patients completed the 5 year follow up. Radiographic eval-

uation revealed average gains in bone levels of 0.18 and 0.34 mm mesially and distally,

respectively. Soft tissue evaluation showed a mean tissue loss of 0.0560.64 mm and 0.166

0.63 mm at the mesial and distal papillae, respectively, while mid-facial mucosal recession was

0.2960.74 mm. A significant improvement in the Pink Esthetic Scores was seen at the final

follow-up (mean PES 11.50), as compared to the baseline (mean PES 10.27) (P5 .001).

Conclusions: In addition to a favorable implant success rate and peri-implant bony response, the

soft tissue levels and overall aesthetics around single immediately placed and restored implants

can also be maintained in the mid-long term.

K E YWORD S

aesthetics, dental implants, immediate placement and restoration, osseointegration, soft tissue

1 | INTRODUCTION

Implant dentistry has progressed considerably since its introduction,

with modifications and enhancements being made to the surgical tech-

niques, restorative protocols, and the implants themselves. The initial

delayed loading and placement protocols1,2 have been modified to

expedite the treatment process. These modified protocols (immediate

placement and immediate loading) have been successfully applied in

both fully and partially edentulous patients.3,4 Additionally, immediate

implant placement has been combined with immediate restoration to

eliminate the load free healing period. Since first reported,5 the imme-

diate placement and restoration (IPR) technique has been recognized

as a viable treatment modality for partially edentulous situations.6

The nature of IPR treatment makes it particularly suited to implant

treatment in the anterior maxilla. Therefore, the focus has now shifted

from hard tissue and osseointegration outcomes to the aesthetic and

694 | VC 2017Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/cid Clin Implant Dent Relat Res. 2017;19:694–702.

Received: 29 December 2016 | Revised: 19 March 2017 | Accepted: 3 April 2017

DOI: 10.1111/cid.12487OR I G I N A L A R T I C L E








Australia






Abstract























K E YWORD S


1 | INTRODUCTION

















DOI: 10.1111/cid.12487

2017

30 patients 4 years (2-5)

1year 5 years

Distal - 0.1 (0.4) - 0.06 (0.6)

Mid Facial - 0.2 (0.4) - 0.2 (0.4)

Mesial - 0.3 (0.5) - 0.06 (0.6) OR I G I N A L A R T I C L E








Australia






Abstract























K E YWORD S


1 | INTRODUCTION

























Australia






Abstract























K E YWORD S


1 | INTRODUCTION

















DOI: 10.1111/cid.12487

2017

protocol in 30 patients (9 males and 21 females) with an age range of

20-78 years. Sixteen implants replaced central incisors, 12 replaced lat-

eral incisors, and 2 implants were placed in the canine region. The rea-

sons for tooth failure were recorded as fracture (21 cases), endodontic

failure (7 cases), and root resorption (2 cases). Implants placed had

diameters ranging from 3.5 to 5.0 mm and length ranging from 11 to

15 mm. After a mean postoperative period of 48 months (range: 2-5

years), all implants were stable with no loss of osseointegration result-

ing in a cumulative implant survival rate of 100%.

3.1 | Hard tissue measurements

Bone levels around the implants showed an overall gain in bone height

at the final follow up when compared to baseline. Mesial bone levels

showed a mean gain of 0.1861.38 mm (P5 .85), while distal bone lev-

els showed a mean gain of 0.3461.40 mm (P5 .22). Figure 2 shows

the frequency analysis of bone level changes mesially and distally.

Bone changes ranged from >2 mm mean loss (3%) to mean gains of

>2 mm (10%) with most of the values lying (30%) between 0.5 mm

loss to 0.5 mm gain (Figure 2).

3.2 | Soft tissue measurements

After a follow-up period of 2-5 years, the mesial and distal papillae

showed a mean recession of 0.0560.64 mm and 0.1660.63 mm,

respectively, while mid-facial mucosal margin showed a mean recession

of 0.2960.74 mm, with no value reaching statistical significance. A

frequency analysis of the soft tissue dimensional changes from baseline

to the final follow-up is shown in Figure 3. Most of the changes were

between 0.5 mm of tissue loss to 0.5 mm tissue gain (Figure 1).

Advanced soft tissue recession (defined as >1 mm by)22 was identified

in the mid-facial mucosa of four patients (13%). Further evaluation

revealed that two of these four patients had no soft tissue level dis-

crepancy when compared to the contralateral natural teeth (Figure 4).

To evaluate the effect of the IPR protocol on the soft tissue

changes in the long-term, a comparison between the 1- and 5-year

FIGURE 3 Frequency analysis of soft tissue changes frombaseline to final follow-up

FIGURE 4 Case with “advanced” mid-facial recession (>1 mm). (A) Pre-extraction view of maxillary right lateral incisor, (B) advanced mid-facial recession evident after definitive restoration, (C) comparison with the contralateral natural tooth reveals no discrepancy between thesoft tissue levels after 1 year, (D) soft tissue levels maintained after 5 years

FIGURE 2 Bone level changes from baseline to final follow-up

ARORA ET AL. | 697


OR I G I N A L A R T I C L E








Australia






Abstract























K E YWORD S


1 | INTRODUCTION

























Australia






Abstract























K E YWORD S


1 | INTRODUCTION

















DOI: 10.1111/cid.12487

2017

reported the incidence of advanced mid-facial recession in 8% of

cases (2/25 patients).22 Another study by the same group evaluating

the effect of the IPR technique found early aesthetic complications

(advanced mid-facial recession) in 5/22 cases after 3 months, which

were treated with a connective tissue graft.37 After a follow-up of 5

years, the cases treated with the soft tissue graft maintained

acceptable soft tissue levels, but the authors observed a late

advanced recession in three other cases leading to a high aesthetic

complication rate.9 In our study, advanced recession was seen in

13% of cases (four patients), which is in accordance with the results

from previous studies.12 No soft tissue grafting was performed in

any of the patients included in the current study. It is noteworthy

that out of these four cases with advanced recession, two had no

discrepancy when compared to the contralateral tooth at the final

follow-up and were given a score of 2 for the respective PES param-

eter (Figure 3). This is an interesting finding as sometimes gingival

recession can be deliberately induced by the prosthodontist to cre-

ate harmony with the soft tissue level on the contralateral tooth,

TABLE 2 PES change from baseline to final follow-up

Parameter Score Preoperative Final follow-up P value

Mesial papilla 0 0 0 .10

1 8 62 22 24

Distal papilla 0 1 1 .25

1 4 12 25 28

Midfacial level 0 3 2 .03

1 12 112 15 17

Midfacial contour 0 3 0 .01

1 16 132 11 17

Alveolar processde!ciency

0 0 1 .09

1 9 92 21 20

Soft tissue color 0 8 1 .007

1 9 132 13 16

Soft tissue texture 0 5 0 .001

1 14 102 11 20

Overall PES Mean (SD) {Median (IQR)} [Range] 10.27 (2.13) 11.50 (1.36) .001

{11.0 (9.0-12.0)} {12.0 (11.0-12.25)}[5-13] [8-13]

FIGURE 5 Pink esthetic score results over the time course of the study. (A) Cumulative percent scores for baseline and final follow-up, (B)average scores for individual variables

ARORA ET AL. | 699

11.5 Post treatment

10.2 pre treatment


Immediate Implant?

With Flap:3

Compromise soft tissue architecture

Socket and buccal augmentation (?)

Immediate Implant?

With Flap:

Immediate versus delayedimplant placement after anteriorsingle tooth extraction: the timingrandomized controlled clinical trialTonetti MS, Cortellini P, Graziani F, Cairo F, Lang NP, Abundo R, Conforti GP,Marquardt S, Rasperini G, Silvestri M, Wallkamm B, Wetzel A. Immediate versusdelayed implant placement after anterior single tooth extraction: the timingrandomised controlled clinical trial. J Clin Periodontol 2017; 44: 215–224. doi: 10.1111/jcpe.12666.

AbstractAim: To compare need for bone augmentation, surgical complications, periodontal,radiographic, aesthetic and patient reported outcomes in subjects receiving implantplacement at the time of extraction (Immediate Implant) or 12 weeks thereafter.Methods: Subjects requiring single tooth extraction in the anterior and premolarareas were recruited in seven private practices. Implant position and choice ofplatform were restoratively driven. Measurements were performed by calibratedand masked examiners.Results: IMI was unfeasible in 7.5% of cases. One hundred and 24 subjects wererandomized. One implant was lost in the IMI group. IMI required bone augmen-tation in 72% of cases compared with 43.9% for delayed (p = 0.01), while woundfailure occurred in 26.1% and 5.3% of cases, respectively (p = 0.02). At 1 year,IMI had deeper probing depths (4.1 ! 1.2 mm versus 3.3 ! 1.1 mm, p < 0.01). Atrend for greater radiographic bone loss was observed at IMI over the initial 3-year period (p-trend < 0.01). Inadequate pink aesthetic scores were obtained in19% of delayed and in 42% of IMI implant cases (p = 0.03). No differences inpatient reported outcomes were observed.Conclusions: Immediate implant placement should not be recommended whenaesthetics are important, IMI should be limited to selected cases. Longer follow-up is needed to assess differences in complication rates.

Maurizio S. Tonetti1,2,Pierpaolo Cortellini1,Filippo Graziani1, Francesco Cairo1,Niklaus P. Lang1, Roberto Abundo1,Gian Paolo Conforti1,Siegfried Marquardt1,Giulio Rasperini1,Maurizio Silvestri1, Beat Wallkamm1

and Anton Wetzel1

1European Research Group onPeriodontology, Genova, Italy; 2Departmentof Periodontology, Hong Kong University,Hong Kong SAR, China

Key words: bone augmentation; dentalimplants; human; randomized controlledclinical trial; tooth extraction

Accepted for publication 1 December 2016

Tooth extractions requiring pros-thetic replacement represent a majorindication for dental implant

placement. Immediate installation atthe time of extraction offers poten-tial advantages for both practitioners

and patients. It allows a decrease intreatment time and may result in anincrease in patient satisfaction. Some

Conflict of interest and source of funding statementThe authors have stated explicitly that there are no conflicts of interest in connection with this article.This study was sponsored by the European Research Group on Periodontology (ERGOPerio). The study was financially sup-ported in part by an unrestricted grant from Thommen Medical AG, Switzerland. The employed regenerative materials wereprovided at no cost by Geistlich AG, Switzerland. This research was initiated by the investigators who independently per-formed all phases of the study including protocol development, experimental procedures, data analysis and reporting. Anearly report of this trial received the 2010 clinical research award of the European Association of Osseointegration.

© 2016 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd. 215This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License,which permits use, distribution and reproduction in any medium, provided the original work is properly cited andis not used for commercial purposes.

J Clin Periodontol 2017; 44: 215–224 doi: 10.1111/jcpe.12666

2017

the majority of cases had WESscores greater than the arbitrarily setclinical acceptability level in an aes-thetic site. PES scores differed com-paring immediate and delayedimplants: arbitrarily set inadequatePES was obtained in 19% of delayedimplant cases and in 42% of imme-diate implant cases. The differencewas statistically significant (Chi-squared test, p = 0.03).

Discussion

This study shows the possibility tocomplete an ethically challengingtrial on a controversial topic inimplant dentistry with an appropri-ate control of potential sources ofbias. These results contribute to clar-ification of the relative merits ofimmediate and delayed implantplacement after single tooth extrac-tion in the anterior portion of thedentition.

The results challenge a series ofwidely held paradigms. Undisturbedhealing of extraction sockets withoutthe application of any ridge preser-vation/augmentation approachallowed restoratively guided implantpositioning in the control group. Insome cases a total buccal bone thick-ness >1.5 mm was obtained with theaddition of bone augmentation

materials at the time of implantplacement, in others without it. Aninteresting result was that, compar-ing immediate implant placement atthe time of extraction with delayedimplant placement, bone augmenta-tion was more frequently needed atimmediate implant placement. Thisresult may be partly due to the deci-sion to choose the implant diameterbased upon the cervical dimension ofthe tooth that needed to be replacedrather than selection based upon thesize of the alveolus. The lower fre-quency of bone augmentation in thedelayed implant seems to provide animportant argument for selection ofthis approach as bone augmentationincreases both the cost and the com-plexity of the procedure. Anotherimportant element related to theconditions of the alveoli after extrac-tion. In this trial significant loss ofboth the buccal and palatal wall waspresent and this increased the needfor bone augmentation at immediateimplant sites. The observation thatbone augmentation was less fre-quently needed in delayed placementchallenges the current paradigms ofthe significance of spontaneous alve-olar bone resorption during extrac-tion socket healing (Van der Weijdenet al. 2009). Recent research synthe-sis on interventions to preserve

extraction alveoli recognizes both theeffectiveness of the preservation/re-construction procedures (Avila-Ortizet al. 2014) and questions their clini-cal relevance (Atieh et al. 2015).More high quality research is neededto convincingly answer these ques-tions.

The issues related to timing ofimplant placement are complicatedby the lack of consensus on effectiveand established procedures and bythe wide array of confounders thathave played a role in previous trials.In this study we decided to use a flapat the time of extraction and implantplacement to be able to standardizesurgery in the two groups. Raising aflap will undoubtedly affect the heal-ing of the site. This has been shownin both preclinical (Blanco et al.2008) and clinical studies (Cosynet al. 2016, Stoupel et al. 2016). Thechoice not to immediately place atemporary reconstruction may havefurther influenced the results (Slagteret al. 2015, Stoupel et al. 2016).

Wound failure was observed at26% of immediate implant place-ment sites and almost five timesmore frequently than in the delayedgroup. It mostly related to relativelyminor complications that can beattributed to the challenge of achiev-ing primary wound closure. This has

Fig. 5. Twelve-month post-crown insertion comparison of pink and white aesthetic scores at immediate and delayed implants.Twelve month soft tissue (pink) aesthetic score (PES, blue box plot) and crown (white) aesthetic score (WES, red box plot) wereevaluated by two independent and calibrated examiners using photographs and study models as indicated by Belser et al. (2009).The red vertical dashed line highlights the level of clinical acceptability arbitrarily defined according to Belser et al. (2009). Out-comes above 6 have been considered clinically acceptable by a professional assessment.

© 2016 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd.

222 Tonetti et al.

(p < 0.01). Over the following36 months, immediate implantsshowed a statistically significanttrend for more RBL loss comparedto delayed implants (p fortrend = 0.03). No significant changesin RBL were observed comparingcrown insertion with 12, 24 and36 months in the delayed implantgroup.

Aesthetic outcomes

Figure S3 reports the dimensions ofthe keratinized tissue before theextraction, at the time of prostheticreconstruction and 12 months laterat the implant site (panel a) and atthe neighbouring teeth (panel b).The band of keratinized tissue

Table 1. Study population

Immediate Delayed Significance

Age (years) 50 ! 14 55 ! 13 p = 0.076Females 63% 73% p = 0.376Smokers 15% 15% p = 0.983FMPS 20 ! 16 17 ! 14 p = 0.333FMBS 11 ! 11 12 ! 16 p = 0.875

FMBS, full mouth bleeding score; FMPS, full mouth plaque score.Means ! SD.

Table 2. Comparison of surgical outcomes in the test and control groups

Immediate (%) Delayed (%) Significance

Need for bone augmentation 72 43.9 p = 0.01Primary wound closure 61.7 82.1 p = 0.05Wound failure 26.1 5.3 p = 0.02Patient post-op complaints 18.9 4.9 p = 0.06

Fig. 2. Bone measurements after implant placement. All measurements were taken using the implant shoulder as the reference pointto the nearest mm using a UNC-15 periodontal probe. Implant shoulder to bottom of the defect = depth of bone defect; Implantshoulder to bone crest – 1.5 mm = vertical implant position; implant shoulder to bone crest in a horizontal direction = width ofbone gap. (Panel a) Measurement scheme. (Panel b) Vertical implant position with reference to the mesio-distal bone level of thetwo adjacent teeth. (Panel c) Horizontal width of the implant to alveolar bone crest defect. At immediate implants, this alsoincludes the horizontal gap between the implant surface and the alveolar crest. At delayed implants it includes the buccal or lingualdefect with respect to the ideal bone contour. (Panel d) Depth of the vertical component of the defect around the restorativelyplaced implant. In all panels the measurements are taken at four points around the implant: mesial, distal, mid-buccal and mid-lin-gual. All data displayed are box-plots. p-values are reported for test versus control treatments and t-test after Bonferroni correctionfor multiple testing.

© 2016 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd.

220 Tonetti et al.

Immediate Implant?

With Flap:

Extraction

Yes No

Anterior Maxilla: The art and the Science Nikos Mattheos. 2019

Buser et al 2017

Immediate Implant

Indications for Flapless Immediate Implant ?

?

Prosthetic Manipulation?

Immediate implant?

Ridge Preservation?

How can we overcome the compromised Bone ?

Tissue Left CenterRigh

tMea

Bone 34 34 40 36Fibrous 30 22 18 23.33

Materials 36 44 42 40.67Total 100 100 100 100

Alveolar ridge preservation with guided bone regeneration and a synthetic bone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial Mardas et al 2010 Clin Oral Implants Res. 2010: 21:688-98.

26 patients » 13 SBC » 13 BioOss

Alveolar ridge preservation with guided bone regeneration and a synthetic bone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial Mardas et al 2010 Clin Oral Implants Res. 2010: 21:688-98.

New bone apically and middle part of socket but centrally and coronally graft particles surrounded by dense connective tissue

Both biomaterials partially preserved the width and the interproximal bone height of alveolar ridge

9/13 in SBC group and 8/12 in DBBM group required additional simultaneous augmentatio

Will reduce horizontal and vertical bone resorbtion

Clinical image is not always corresponding to bone profile

delays healing

delays implant placement

compromises bone quality

might not eliminate need for second augmentation

cost


Checkpoint !Ridge Augmentation

Extraction

Yes No

Immediate Implant

Indications for Flapless Immediate

Implant ?

Place the implant ASAP?

Ridge Preservationa) young ageb) postponed implant treatment

No Yes

?

Anterior Maxilla: The art and the Science Nikos Mattheos, Hong Kong, 2018

Cone Beam CT

Use radio-opaque crown in a splint !

Use lip / cheek retractors !

Step 2: Diagnose !

Check the Height

Check the Width

Check the bone quality (?) and neighbouring anatomy

Step 3: Plan !

height

ideal Block GraftGBR

ideal

Width

favorable unfavorable

Width

unfavorable

Width

unfavorable

ideal

favorable

Width If A or B or C is (1 out of 3):

then GBR

If A , B and C is :

then GBR

If A , B and C is : then Block Graft

A

B

C

BLX

C

B

A


then GBR

If A , B and C is :

then GBR


A

B

C

BLX

Cone Beam CT

Use radio-opaque crown in a splint !


Step 2: Diagnose !

Cone Beam CT

Januario et al 2008 Use radio-opaque crown in a splint !


Check the Height

Check the Width

Check the bone quality (?) and neighbouring anatomy

Step 3: Plan !

height

ideal Block GraftGBR

ideal

Width

favorable

unfavorable

Width

unfavorable

Width

unfavorable

ideal favorable


then GBR

If A , B and C is :

then GBR


A

B

C

BLX

C

B

A


then GBR

If A , B and C is :

then GBR


A

B

C

BLX

Immediate implants

GBR or CT

No GBR

A randomized controlled study comparing guided bone regeneration with connective tissue graft to re-establish convexity at the buccal aspect of single implants: a one-year CBCT analysis

Thomas De Bruyckere et al, J Clin Perio 2018

RCT21 patients1 year

GBR and CTG were equally effective

in re-establishing the convexity

Xenograft Ridge augmentation by applying bioresorbable membranes and deproteinized bovine bone mineral: a report of twelve consecutive cases. Clin Oral Implants Res 2008;19(January (1)):19–25.Hämmerle CH, Jung RE, Yaman D, Lang NP.

Bone width increased from 3.2 to 6.9 mm

10 months

Guided Bone Regeneration

Increase in clinical ridge width

Long term stability of ridge

High Survival

technique sensitive


Checkpoint ! Primary Stability?

2 stage augmentation

GBRa) sufficient height (palatal wall)b) primary b) ⅓ length fully in bone ORc) full length: bone contact > implant O!

Local Anatomy:

GBRBlock Graft

a) deficient height/widthb) gap <2-3 teeth

a) deficient widthb) self contained defect

a) deficient height/widthb) gap > 2-3 teeth

Non Resorbable

?

NoYes


Extraction

Yes

Early Placement

No

2 stage augmentation

Immediate Implant

Yes

a) fully intact buccal bone b) thick wall (>1mm) c) thick gingival biotyped) no inflammatione) sufficient bone for primary stability (35Ncm)

Yes

GBR

a) sufficient height (palatal wall)b) primary b) ⅓ length fully in bone ORc) full length: bone contact > implant O!

Reduced diametre implants (2.9 - 3.3)

Ridge Preservation

No

a) young ageb) postponed implant treatment

Technology

Self-cutting / tapered implants

Increased Osseoconductivity surfaces

piezoelectric surgery

resorbable barrier membrane

xenograft / allograft

5-10 %

5%

60-70 %

10 - 15 % Block Graft

Local Anatomy:

GBR

a) deficient height/widthb) gap <2-3 teeth

a) deficient height/widthb) gap > 2-3 teeth

a) deficient widthb) self contained defect

Non Resorbable

Place the implant ASAP?

No

Primary Stability?

Indications for Immediate Flapless Implant ?


bone ! implant · dental implants in the aesthetic zone navigating unvharted waters ..! ideal...

Documents