immediate implant placement and provisionalization after ... · immediate implant placement and...

T I TA N E S p e c i a l i s s u e | 2 0 0 9 | 4 9

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ntIMMEDIATE IMPLANT PLACEMENT AND PROVISIONALIZATION AFTER TOOTH EXTRACTION RATIONALE

Complete restoration of dentogingival harmonyis the primary objective of any restorativetreatment, particularly when the dental root is tobe extracted and replaced by an implant.The predictability and reliability of estheticoutcomes remains a challenge because ofpronounced changes in the hard and soft tissuesfollowing a simple extraction (Atwood,1963;Carlsson et al, 1966).

Alveolar ResorptionThe phenomenon of resorption occurs with regard toheight and to thickness, and also affects the soft tis-sues. Schropp et al (2003) studied the consequencesof the extraction of a single tooth (premolar or molar)without prosthetic treatment in humans.They observeda 50% change in the width of the bony ridge, two thirdsof which occured in the 3 months following extrac-tion. Resorption in the vertical direction is less pro-nounced, from 0.8 to 4.5 mm according to variousauthors (Camargo et al, 2000; Iasella et al, 2003;Schropp et al, 2003). It is more pronounced in casesof multiple extractions than in cases of simple extrac-tion. Cardaropoli et al (2005) and Araujo et al (2005)showed that, in dogs, the healing process led to moremarked resorption of the buccal wall than of the lin-gual or palatal walls at 8 weeks following extraction.The degree of bone resorption was proportional to thewidth of the bone wall.The thinner it was, the moreit resorbed.This is often the case with the anterior buc-cal wall (Bragger et al, 1988). Can this resorption beprevented by immediate implant placement?

Immediate extraction implantation and esthetic evaluationImmediate implant placement in a newly empty alve-olus and provisionalization with a crown is an alter-native to conventional treatment proposed to improveesthetic results and the comfort of the patient andto reduce treatment times. Since Schulte et al (1978),many authors have listed the advantages of immedi-ate extraction implantation (IEI) (Wagenberg andFroum, 2006), then immediate temporization(Ganales and Wismeijer, 2004). IEI must also beable to preserve gingival and bone architecture foran immediate and optimal esthetic outcome(Mayfield, 1999; Chen et al, 2004), particularly whenit is carried out flapless. A provisional crown helpsto guide the soft tissues during healing, resulting infavorable gingival architecture. Jemt (1999) shows thatthe use of a provisional crown allows for faster restora-tion of the peri-implant soft tissues than healingabutments, although the volume of papillae is iden-tical after 2 years.

Various studies of the healing sequences of the alve-olus show that while bone resorption is not pre-vented by immediate placement of an implant, thisdoes not compromise osseointegration and allows foran esthetic and stable result in certain conditions.Success rates for these treatments can be equivalentto those for conventional techniques. However, favor-able situations should be assessed according to pre-cise criteria, and require a procedure that will be pre-sented here in detail through a clinical case report.

Immediate implant placement and provisionalization after tooth extraction:

Rationale

BY Hadi Antoun and Pierre Cherfane

5 0 | T I TA N E S p e c i a l i s s u e | 2 0 0 9

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nt IMMEDIATE IMPLANT PLACEMENT AND PROVISIONALIZATION AFTER TOOTH EXTRACTION RATIONALE

that the loading of implants hada positive effect on bone matu-ration.Most authors conclude that thereis an equivalent success rate ver-sus conventional treatments(Ericsson et al, 2000; Testori etal, 2003). However, other stud-ies have shown a higher failurerate with single teeth thatincreases in posterior areas (DelFabro et al, 2002).Biomechanical factors linked totemporization methods are oftenheld responsible.It would therefore be justifiedwith regard to edentulism in theesthetic area, where conditionsare favorable, to adopt immedi-

ate flapless extraction implantation and to place pro-visional restorations immediately if primary stabil-ity is sufficient.

Clinical case and procedure1. Case presentation

Mrs S.L. wished to replace some lost teeth in the pos-terior maxillary area .Two implants placed oneach side enabled immediate esthetic restorationswith provisional crowns; 6 months later the provisionalcrowns were replaced with porcelain-fused-to-metalrestorations fastened to screwretained abutments

.In the light of her positive experience during this firstphase of treatment, the patient wanted to improve theesthetic appearance of her central incisors .Thereplacement of the old crowns on 11 and 21 as wellas a crown lengthening to position the margins moreapically seemed unavoidable.The age of the restora-tions, the presence of periodontal lesions, the teethmobility (grade 2), the unfavorable crown-to-rootratio, and the post lengths guided the indication forteeth extractions and implant restorations.The clinical examination showed that the buccal tablewas intact at the related teeth, confirming the treat-ment option.The preimplantation radiographic studyconfirmed sufficient bone volume, indicating the fea-sibility of IEI .Fig. 7

Fig. 6

Fig. 2 - 5

Fig. 1

In addition, the creation of a flap causes trauma tothe bony surface by separating it from its perios-teum, which results in bone remodeling at theexposed areas. A study by Blanco (2008) comparedextraction sites with immediate narrow-diameterimplants (3.3 mm) placement, with flap or flaplessprocedures, in dogs. The histometric results weresignificant: less bone resorption of the buccal walloccurred when flapless surgery was performed(0.8 mm compared to 1.4 mm with a flap). A morerecent study confirmed that resorption may bereduced by avoiding the flap elevation during IEI(Fickl et al, 2008).

It is recommended for these immediate surgical andrestorative procedures that the occlusal scheme avoidany contact during closing and above all during lat-eral excursive movements (Testori et al, 2003).Excessive micromovements – greater than 100 micronsfor implants with rough surfaces and 30 microns forimplants with a smooth surface – that occur duringbone healing in the bone/implant contact area canlead to fibrous healing and failure (Szmukler-Moncleret al, 2000). If primary stability is insufficient, boneremodeling is carried out in a progressive manner instages of osteoblastic or osteoclastic activity in equi-librium, which results in the implant remaining sta-ble during the entire osseointegration period(Schnitman et al, 1997). Schenk (1994) also showed

Initial panoramic radiograph showing posterior maxillary partial edentulism. Thepatient also presented chronic periodontitis, which was treated with root debridement andsurfacing.

Fig. 1


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Porcelain-fused-to-metal prosthesis bonded onto a Procera zirconia abutment on 13 and a titanium abutment on 14. The seating of 4-mm-diameter NobelSpeedy implants (NobelBiocare) on 13 and 14 was carried out in line with the available bone volume; 15 is a cantilever unit.

Fig. 2 and 3

Coronal cross-sections of a CT scan show bone volume thatwould allow implants to be placed on the day of extraction.

Fig. 7

Two twin porcelain-fused-to-metal crowns were bonded onto individualized titanium abutments.Note the stability of the marginal bone level after 2 years.

Fig. 4 and 5

View of the anterior maxillary area showing its unsightlyappearance, and in particular the restorations on 11 and 21. Notealso the uneven levels of the necks.

Fig. 6


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3. Drilling procedureDrilling of the implant site was done through thepalatal wall. The guide drill engaged the palatal wallof the alveolus at the level of its apical third, giving ita buccal inclination so as not to slip and avoiding thealveolar long axis . The drilling axis was grad-ually straightened up until an ideal direction vis-à-visthe future prosthetic emergence was obtained .The recommended orientation stays between the incisaledge and the cingulum of this tooth. Enlargement ofthe site was carried out using drills of increasing diam-eter, in accordance with the bone density.

Fig. 13b

Fig. 13a

2.Atraumatic extraction and socket preparation

After piezoelectric inserts were used to dissectthe alveolodental ligament, one of the roots was pre-sectioned using a fissure carbide bur mounted on ahandpiece .The extractions could thus be car-ried out atraumatically . A Lucas curetteenabled the removal of all soft tissue remnants on thesocket walls; this was followed by abundant irriga-tion using a povidone-iodine solution (Betadine®

green) .Fig. 11, 12

Fig. 10

Fig. 9

Fig. 8

The fragments of roots and the crowns were extractedwithout damaging the bone walls, in particular the buccal wall,which was often very thin.

Fig. 10

Piezoelectric inserts (Mectron) were used to dissect theperiodontal ligament fibers and to assist in tooth luxation foran atraumatic extraction.

Fig. 8

The alveoli were irrigated with povidone-iodine(Betadine 10%, Meda Pharma SAS) to decontaminate the sites,which might have retained some bacterial load, increasing the potential for reinfection.

Fig. 11 and 12

A fissure bur (Komet) mounted on a handpiece allowed theroots to be cut longitudinally in the buccolingual direction andextracted without exerting pressure on the buccal wall.

Fig. 9


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nt4. Placement of NobelActive™ implantsOnce the drilling diameter was achieved, the firstNobelActive™ implant was attached to the specificimplant driver that fitted into the internal hexagon

. Its placement was begun with an initial buccalangulation and engaging it in the osteotomy hole

; the action was completed by seeking out theideal axis and seating.The self-cutting properties of theapical part allow maintenance of the ideal predeterminedprosthetic axis that could be slightly modified. If place-ment of the implant had been carried out against the

Fig. 15

Fig. 14

palatal wall in an underdimensioned drill hole, a clas-sical selftapping implant would have a tendency to slipbuccally, despite an ideal drilling axis, compromisingthe final esthetic outcome.In addition, the possibility of seating this type of implantusing a manual handle enabled the implant axisto be directed more easily and palatal pressure to beexerted, ensuring self-tapping through the palatal walland thus ensuring ideal placement of the implant.Thisprocedure was repeated in the same way for the adja-cent implant.

Fig. 16

Guide drill engaging the palatalwall along a buccal axis, thus avoiding itslipping.

Fig. 13a

Placement of the implant in aninitially buccal direction, then the axis wasstraightened until the final position wasobtained.

Fig. 15

Gradual straightening of the drilluntil the ideal axis for the futurerestoration was achieved.

Fig. 13b

A manual handle allowsaccurate adjustment of the finalimplant position and direction.

Fig. 16

A NobelActive implant 4.3 mm indiameter and 13 mm in length (NobelBiocare) was placed on a punch-handle tobe inserted directly into the internalconnection of the implant.

Fig. 14


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5. Bone filling and connective tissue enhancement

The diameter of the implant is often smaller than thediameter of the alveolus, creating a crater around theimplant, predominantly in the buccal situation. Thiscrater is not incompatible with osseointegration, mostprobably when this distance is not greater than 1.5 mm.However, regardless of the size of this crater, we rec-ommend filling it with a bovine-derived hydroxyapatitebone substitute (Bio-Oss, Geistlich), a very slow-resorb-ing material, to maintain the best esthetic buccal con-tour and to partly compensate for the resorption of thebuccal bone wall . In addition, we routinelyemploy a buccal subepithelial connective tissue graft

in a mucous membrane envelope of split thick-ness to enhance the resistance of the cervical region topossible recession.This is an adequate approach whenfacing a thin periodontal biotype.The tuberosity is pref-ered as the donor site, when possible; alternatively, thepalate also constitutes an appropriate and frequently rec-ommended donor site .Fig. 20

Fig. 19

Fig. 17, 18

The connective graft taken from the palate enabled the softtissues to be thickened buccally, to compensate for an eventualbone resorption and to minimize the risk of recession.

Fig. 19The palate

was the donor site forthe connective tissuegraft.

Fig. 20

The alveolus is filledwith a low-resorptionhydroxyapatite ofbovine origin (Bio-Oss,Geistlich), to maintainthe best estheticcontour.

Fig. 17 and 18

6. Placement of provisional abutments andprovisional crowns placement

The provisional Quick Temp titanium abutments(Nobel Biocare) were torque-tightened to theimplants at 35 Ncm .A previously preparedprovisional acrylic denture is relined on the specificabutment caps . Note the practical tip for opti-mal seating of the provisional restoration on theabutments by means of acrylic wings as well as thesubcontour, designed to favor peri-implant tissuethickening and reduce the risk of recession .

7. Healing and evaluation of the soft tissueenvironment

A minimum of 3 to 4 months was required beforemoving on to the final phase. This time was neces-sary to achieve soft/hard tissue healing and stabilization

. Note the preservation of the bone levelbetween the implants and the adjacent teeth at thedental side, and in particular the preservation of theinterimplant bone peak, which is more difficult to

Fig. 27, 28

Fig. 25, 26

Fig. 24

Fig. 21 - 23


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Two provisional tapered abutments (Quick Temp formultiunit provisional cemented solutions) were tightened to theimplants on 11 and 21 respectively, at 35 Ncm torque. The cap actedas support for relining the provisional crowns.

Fig. 21 Postoperative view of the implant sites with connectedprovisional tapered abutments and connective tissue grafts withinthe inner buccal aspect of a split-thickness flap.

Fig. 22

Postoperativeretroalveolar radiographshowing the two implantsin place together with thetapered abutments. Notethe platform switchingbetween the abutmentsand the implant collars, aswell as the concavity ofthese abutments, thusensuring a thicker mucousmembrane crimp sealaround the implant collars.

Fig. 23

The two provisional crowns after trimming and polishing.Fig. 25 Clinical situation on the day the implants were placed. Thepatient has thus been able to benefit from immediate provisionalcrowns without having to use a removable prosthesis and wait forhealing to have a fixed restoration.

Fig. 26

Two provisional crowns were prepared beforehand; twoadditional wings attached to these shells enabled them to beoptimally positioned during relining.

Fig. 24


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Healing after 6 months and maturation of the soft tissues.Note the stability of the marginal gingival level compared to theinitial stage 6 months previously.

Fig. 27

Retroalveolar radiographafter 6 months showing thestability of the marginal bonelevel around the implant collarsand in particular between theimplants. The bone peak is well-maintained; it is the onlyguarantee of maintaining orrestoring the papilla between 11 and 21.

Fig. 28

The impressioncopings in place and the controlradiograph showing their fullinsertion. Their form respects thebone morphology that has beenguided by the provisionalabutments.

Fig. 29 and 30

Two Procera® Zirconia (Nobel Biocare) substructures were created and tried in. Note their similar form and thetexture of the peri-implant mucosa.Fig. 31 and 32


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maintain following extraction of two adjacent teeth.Osseointegration of the implant is clinically con-firmed before moving on to the usual restorativephase, which could be performed earlier to improvesoft tissue adhesion.The use of a titanium or zirco-nia scalloped abutment considerably improves theissue health instead of acrylic resin.The advent of theTiUnite surface is also an asset in favor of acceler-ated bone healing and improved toleration of micro-movements following immediate esthetic procedures.

8. Final restorationsAn implant-level impression was made toproduce the master model, from which two individ-ualized Procera® (Nobel Biocare) zirconia substruc-tures were fabricated . Composite restora-tions on the adjacent teeth were done to adjust arelatively small mesiodistal space. Direct porcelainveneering on the zirconia Procera substructures pro-vides one-piece screw-retained all-ceramic crowns,eliminating multiple assemblies and cementations

. In addition to the risk of cement encapsula-tion in the implant sulcus, the retrievability of therestorations represents a very positive advantage ofthis approach. After biscuit try-in and final glazing

, the crowns were directly tightened to theimplants at 35 Ncm torque .Fig. 37 - 41

Fig. 36

Fig. 35

Fig. 31 - 34

Fig. 29, 30

9. Follow-up and maintenanceAn occlusal adjustment was carried out just after thecrown placement on the implants; group anteriorguidance was sought, then checked after 2 weeks.Thepatient was then followed up at 3 months and at 1-year intervals thereafter.

Discussion and rationaleThe choice of this implant design for this clinical sit-uation was particularly appropriate for several reasons:

■ The self-cutting properties of the apical threadsenabled maintenance of the preestablished idealprosthetic axis.

■ The condensing properties obtained through thedecreasing depth of the threads between the apical andcervical parts of the implant gave it the possibility ofprimary stability with a low bone height, which is oftenthe case with immediate extraction implantations.

■ The diameter of the implant neck being smaller thanthe body allowed the bone thickness on the periph-ery to be managed better, in particular buccally,which favors maintenance of the esthetic outcomein the long term.

■ The connection of the implant abutments was setback in relation to the exterior collar of the implant

Occlusal view of try-in.The emergence of the implantstogether with their axis enabled two screw-retained crowns to becreated directly on the implants. The buccal curve has been wellmaintained despite the postextraction bone and soft tissueremodeling process.

Fig. 33 The provisional crowns allowed the emergence profilearound the implants to be worked on and prepared right from thefirst day.

Fig. 34


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Fitting of the biscuit and occlusal view showing soft tissuestability in the horizontal direction.Fig. 36The porcelain was veneered directly to the zirconia

substructures (Ceralor Laboratory, Mr Jean-Marc Étienne).Fig. 35

Finishing of the crowns in the laboratory. Note their texture and the zirconia tapered and hexagonal connection (Ceralor Laboratory, Mr Jean-Marc Étienne).Fig. 37 and 38

and therefore moved toward the center of theimplant. The microgap and associated inflamma-tory infiltrate were also displaced away from thebone, significantly reducing bone resorption(Cappiello et al, 2008). In addition, according toBerglundh and Lindhe (1996), a narrower abutmentwould enable more biological space to be gener-ated, and would thus limit the bone resorptionnecessary for the creation of a stable epithelial con-nective tissue attachment.

■ The tapered internal connection enabled the gapat the level of the joint to be reduced, as well as thebacterial colonization associated with it. Germsinducing an immune reaction that is the origin ofthe chronic inflammatory infiltrate observed inconnection with microgap may trigger the activa-

tion of osteoclasts (Cochran et al, 2009).This phe-nomenon is more significant because interventionsin esthetic areas encourage submergence of theimplant (Buser and Von Arx, 2000). In addition,the combination of an internal cone with an inter-nal hexagon allows for even better stabilization ofthis joint and facilitation of the abutment seating.

■ The stability of this connection seems to guaran-tee peripheral tissue preservation.Thus the rigid-ity of this connection should result in an improvedresponse by the tissues. It is therefore essentialfrom a practical point of view, and more particu-larly in the presence of a thin biotype, to tightenthe healing abutments or prosthetic abutmentscorrectly at the implant placement stage. Thisinvolves systematic tightening with a torque wrench.


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It is also important to inform the patient that in thecase of unscrewing he/she should point this out asquickly as possible, and to remedy this problem assoon as possible to limit the bone loss that couldresult from this.

■ The type of abutments that present concavity at thecervical level seems to favor the creation of a thickerepithelial connective tissue cuff, which is clearly ableto provide the necessary connective tissue.

The various factors mentioned here lead to the con-clusion that the crestal bone is deemed to be betterpreserved with this type of implant and associatedabutments than with collar forms and more traditionalimplant abutments. The achievement of stability ofesthetic results seems to be better guaranteed in the

case of two adjacent implants.This situation is oftenthe most difficult to manage in esthetic areas becausethe reproduction of the papillae between the implantsis very uncertain.

ConclusionImmediate extraction implantation and immediateesthetic provisionalization with regard to the centralincisors enabled us to manage the temporization phasein a neat manner for our patient.We avoided the dis-comfort of a provisional removable prosthesis for her,as well as the social inconvenience that this couldhave caused her. This approach allows several treat-ment phases, which would have meant more chair timeand a longer overall treatment time, to be reduced toa single stage. This was an advantage for both thepatient and the clinician.The immediate esthetic pro-visionalization also provides appropriate managementof the emergence profiles for a faster soft tissue con-touring. In short, the use of NobelActive™ implantsin this type of situation seems particularly well indi-cated with possible ideal seating and overall form, aswell as a connection favoring improved bone and softtissue healing at the cervical level, compared to moreclassical implant designs. Controlled studies withgreater scope should confirm these results.

Thanks to Dr Dora Dely Daly for her help in preparing this work.

The ceramic screw-retained crowns are in place directly onthe implants; note the soft tissue contour as well as the integration of therestorations.

Fig. 39 and 40

Radiographic checkshowing the stability of thebone level, notably withrespect to the adjacentteeth and in particularbetween the implants,where the bone peak isclearly maintained.

Fig. 41


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REFERENCES

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Hadi Antoun - Pierre Cherfane

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