Level II: Advanced Implant Placement and Restoration

Course

Dr. David DaliseDr. Gary McCabe Ross

Immediate Implant Placement

Following an Extraction

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.

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.

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

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 ½ 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.

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.

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

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• Allows for greater initial stability of implant in “soft” bone (D2, D3, and D4)• Gradual boney expansion is very important to minimize chance of fracture of

surrounding bone

• Implant Selection– How to pick a size– One piece or two-piece

Immediate Placement

• Implant Selection– How to pick a size

• Measure extraction site/osteotomy, both coronal and apical dimension

• Select an implant of proper length and diameter– Implant diameter must be ≤ 1mm of contact with wall of

osteotomy/extraction site» Intimate contact is ideal but not mandatory along entire

implant osseous interface.

• Blood clot surrounding implant must be present and originating in an origin of blood must be from surrounding bone to assure success.

• Immediate grafting of bone around implant may or may not improve or impede successful integration

• Proximation of implant to surrounding bone and initial stability are most important prognosticators of success

Immediate Placement

• One Piece or Two Piece

– Primary consideration is loading forces on the implant following placement and subsequent temporization

• Micromovement of implant will cause failure of implant to integrate.

– One piece is ideal if implant can be protected from occlusal/perifunctional forces.• Bruxism• Tongue thrust • Protrusive or lateral excursive forces

– Two piece allows implant to be placed without regard to external occlusal or lateral stresses.

• Maybe most conservative approach• Mandates placement of abutment in future, thus issue of abutment implant

interface/microgap must be considered.• Think about platform shifting

Immediate Placement

• Evaluation of prognosis for success– Initial stability

• Implant must be non mobile– Initial torque

• 40 to 45 N/Cm if immediate load is contemplated• 20 N/Cm for maxilla• > 20 N/Cm ideal for mandible

– Implant/Osseous proximation• Ideal is ≤ 1mm at coronal 1/3rd of implant

– Blood supply/Clot formation• Clot must be generated bone origin and stable after implant placement.

– Soft tissue adaptation• Tissue should adapt snuggly to abutment of choice

– Objective is to maintain original tissue contours prior to extraction– I.E. temporary abutment, healing abutment, or cover screw

– Post placement stress factors• Occlusal loading • Tongue thrust• Perifunctional habits• Dietary

Pre extraction

Scaling Prior to Extraction

Post Scaling View

Initial Sharp DisectionRemoval of Circumferential Fibers

Atraumatic Extraction

Post Extraction Osteotomy Sites

Full Thickness Flap

Osseous Defect

Alveolar Ostectomy

Decortication

Osteotomy

Implant Insertion

Post Insertion Alignment Verification

Initial Torque Stability

DMFDB Allograft

Graft Placement

Pre Closure

Initial Suture Placement

Final Closure

Post Placement

Post Placement

Placement of Barrier for Impression

Putty Impression with Barrier

Post Impression

Post Impression without Barrier

Final Impression with Analogs

THANK YOU

Questions?