immediate placement

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  • 1. Level II: Advanced Implant Placement and Restoration Course Dr. David Dalise Dr. Gary McCabe Ross

2. Immediate Implant Placement Following an Extraction 3. Immediate Placement

  • Rationale
    • Improves patient acceptance
    • Potentially best esthetic result
      • Prevents loss of ideal gingival contour
      • Minimizes post extraction bone loss
    • Gives perception of immediate function
      • Immediate load is really a misnomer in most of these situations.Correct nomenclature may be immediate temporization with delayed loading.
    • Shortest time from edentulous to functioning implant based prosthetic.
    • Potentially most profitable
      • Patient may be willing to pay higher fee for immediate gratification.
      • Doctor must be willing to assume additional risk which justifies an additional fee.

4. Immediate Placement

  • Advantages
    • Patient
      • Perception of immediate realization of goals to have teeth.
      • Reduction of time involved for procedure.
      • Potentially lower cost when considering time invested vs. loss of income from multiple visits to dental office.
      • Emotional component may be significant and immeasurable with regard to perceived value by patient.
    • Doctor/Restorative
      • Most likely to engender patient loyalty and future referrals.
      • Best means of establishing doctor as local authority for implants
      • Profitability may be the highest
      • Shortest time from implant placement to placement of final prosthetics.
      • Potentially lowest cost in time, labor, and materials.
      • Often best esthetic outcome.
    • Financial
      • Potentially lowest cost in time, labor, and materials.
      • Higher fee should translate into higher profitability
      • Procedure should generate higher rate of patient referrals.
      • Solidification of community image as local implant authority should result in ability for doctor to increase size of practice and get flexibility in pricing structure, resulting in more competitive position within the implant community.

5. Immediate Placement

  • Considerations/Complications
    • Tooth locations
      • Generally limited to single rooted teeth
      • Molars generally contraindicated; however, must be determined case by case.
    • Functional demands
      • Implant must be protected from all excessive occlusal forces, especially lateral stresses.
      • Should not be placed into immediate load unless splinted
        • Implant to implant splinting
        • Implant to natural tooth/teeth splinting

6. Considerations/Complications Continued

    • Hard and soft tissue evaluation
      • Buccal plate
        • Must establish if buccal plate is still in tact following extraction.
        • Determine extent of defect if buccal plate is compromised.
          • Evaluate for immediate grafting possibilities if willing to continue with immediate placement of implant.
      • Interproximal bone
        • Practitioner must evaluate mesial and distal proximal bone height relative to ideal implant placement.
        • Minimum of 1mm proximal bone and ideally 1 to 2mm of bone thickness between implant/implant interface or implant natural tooth interface.
      • Interdental Papillae
        • Do not disrupt papillary attachment of existing papillae if possible
          • Papillae sparing incision
          • Maximum 5mm from boney crest to height of interdental papillae for predictable maintenance of papillary height.
          • Note: Interdental boney contour will likely dissipate to highest point of implant osseous integration.
        • Abutment implant interface/microgap becomes critical issue in esthetic zone.Biotype must be considered.

7. Immediate Placement

  • Extraction Technique
    • Management of soft tissue
      • Sharp dissection of circumferential fibers
      • Maintentance of existing soft tissue architecture
        • Avoid compression/maceration of tissue with elevators
    • Elevation Techniques
      • Periotomes/microtomes
      • Forceps as an elevator
        • Rotational expansive force
        • Vertical expansive force
    • Surgical Sectioning
      • The objective is to minimize fracture of buccal and interadicular bone.
      • Minimizes need for excessive lateral forces to remove roots.
      • Allows for multi rooted teeth to be extracted like single rooted teeth.
      • Internal sectioning of single rooted teeth allows for medial displacement of lateral wall of root and removal without compromise of surrounding bone.

8. 9. 10. Immediate Placement

  • Preparation of the post extraction osteotomy
    • Anatomical considerations
      • Evaluate post extraction residual bone on all aspects
    • Where to start and how
      • Buccal plate evaluation may be primary consideration
      • Evaluate apical aspect of extraction socket to determine entry point for apical extension of osteotomy if any as planned.
      • Evaluate proximal bone
      • Decortication of lateral wall of extraction socket
        • Rotary
        • Hand instrumentation with curette
        • Must initiate bone bleeding to assure osseointegration
        • Must remove all residual soft tissue from walls of extraction site
          • I.E. Periodontal ligament, granulomatous tissue, or epithelial attachment

11. Immediate Placement

  • Finishing techniques
    • Rotary
      • Generally initial pilot osteotomy will generally be on lingual wall of extraction socket, not at apex.
      • Use either high speed or straight slow speed surgical hand piece at high RPM to initiate osteotomy.
      • Must avoid tendency for displacement of osteotomy angulation toward buccal
    • Osteotomes
      • Used to expand residual bone and condense bone surrounding osteotomy