the management of immediate implant placement to ... international dentistry –african edition vol....

48 INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL. 4, NO. 4

The management of immediate implant placementto optimize aesthetic outcome in the anterior maxilla

Howard Gluckman1 and Jonathan Du Toit2

IntroductionFollowing tooth extraction the implant surgeon may select between various implantplacement timing and loading protocols.1 Ideally these are to be determined prior toextraction, be it immediate (type 1), early (type 2, 3), or late placement (type 4).2

Immediate implant placement even in the aesthetic zone is a literature supportedtreatment modality with success comparable to alternative placement protocols.3, 4

Immediate placement reduces the number of surgical interventions, shortens time to finalrestoration, may offer a fixed provisional restoration alternative to a removable interimprosthesis, and may partially support the peri-implant tissues prior to collapse from theextraction socket remodelling.5-8 Certain clinical criteria however need to be met inorder to achieve a successful treatment outcome, namely: intact extraction socket walls,facial bone residual at ≥ 1 mm, thick gingival biotype, absence of acute infection, andsufficient residual bone at the palatal and apical tooth socket.9 Compromising on thesecriteria may lead to aesthetic complications in the long term, even if functional survivalis maintained.10 Midfacial soft tissue recession is a common complication with anaverage of 1 mm loss to be expected in most immediate implant cases.9 Ridge collapsein a buccopalatal dimension following loss of the buccal plate may lead to a concavity,creating a shadow with perceivably poor aesthetics.11 This concavity is attributed toloss of the bundle bone and is more pronounced in thin gingival biotype patients, thinbuccofacial plates, dehiscences following extraction, or incorrect buccofacial placementof the dental implant.9 The net result may be an unacceptable aesthetic outcome thatis difficult or impossible to repair.12 Nonetheless, knowing, understanding, andmanaging these risks may improve the predictability of successful immediate implantplacement in the aesthetic zone. Whilst augmentation may correct a midfacial recessionand/or a buccopalatal collapse, soft tissue augmentation of the facial tissues at implantplacement may provide tissue bulk regardless of the biotype, and prevent thiscomplication.13 Immediate placement positioning within a fresh extraction socket mustbe modified as opposed to early or delayed protocols to better manage the foreseenchanges in tissues that follows healing.9, 14 Additionally, the provisionalization andearly loading of implants in the aesthetic zone is recommended.12 Such a provisionalrestoration should be anatomically correct with a desirable emergence profile with

C L I N I C A L

1 Howard Gluckman, BDS, MChD (OMP) Specialist in Periodontics andOral medicine. Director of The Implant and AestheticAcademy Cape Town, South Africa. Email:[email protected]:www.implantacademy.co.za

2 Jonathan Du Toit, BChD, Dip Oral SurgPostgraduate student, University of the WitwatersrandJohannesburg, South Africa.

Figures: 1, 2, 3: The preoperative presentation.

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VOL. 4, NO. 4 INTERNATIONAL DENTISTRY – AFRICAN EDITION 49

a Class III mobility and soft tissue inflammation (Figs. 1, 2,3). A preoperative cone beam computed tomography(CBCT) scan demonstrated significant external resorption oftooth 22 with surrounding bone loss (Fig. 4). Clinicalexamination and photographs identified a high lip-line witha high aesthetic value (Fig. 5). The tooth was indicated forextraction and the patient’s primary desire was to have theedentulous space rehabilitated with a fixed prosthesis. TheITI SAC Assessment Tool classified the case as complex, withtreatment planned for immediate implant placement followingextraction of tooth 22, a connective tissue graft of the facialaspect by tunnel technique, and immediate provisionalizationwith the patient's own tooth. The aim was to provide a nearidentical and immediate tooth replacement, as well as to

respect to the peri-implant soft tissue and supporting alveolarbone, and this may be done with the patient’s own tooth formore natural aesthetics.15 Correct implant selection, correctplacement positioning, grafting techniques, and immediateprovisionalization may better ensure a desirable outcome toimmediate implant placement. Hereafter is a casepresentation of these techniques by Covani, Grunder, Azzi,and Steigman in an attempt to realize these aesthetic aims.13-16

Case HistoryA 35 year old healthy male patient presented with a maincomplaint of a mobile tooth. A history of trauma was unclear.Clinical examination noted an asymptomatic tooth 22 with

C L I N I C A L

Figure 4: Preoperative CBCT scan. Figure 5: A high lip-line that requires implicit soft tissue management.

Figures 6a, 6b: Prosthetic planning is transferred to the surgical guide.

6a 6b

maximally support the peri-implant tissues. These would beassessed by radiographic and photographic documentationof the treatment.

Methods and MaterialsPreoperative treatment planning demonstrated the restorativeoutcome via study casts with an anatomical wax-up. Thisideal prosthetic representation was translated to the surgicalguide (Figs. 6a, 6b). Planning from the CBCT scans mappedthe anterior maxillary ridge architecture with its bone volumedimensions. From this information a screw retained prosthesiswas planned, and a 4 mm x 11.5 mm tapered andthreaded implant was selected (AnyRidge, MegaGen). Atday of treatment, tooth 22 was extracted with an as

G L U C K M A N | D U T O I T


Figure 7: Grafting the buccal gap. A cover screw seals implantentrance.

Figure 8: CT graft secured in place on the facial aspect withinthe tunnel flap preparation.

Figure 9: The extracted tooth crown – sectioned, etched. Figure 10: Dentinal bonding agent applied.

Figure 11: The sectioned tooth crown repositioned within theputty guide.



each side of the extraction site.16 The CT graft thatcorresponded to the recipient site was harvested from theipsilateral palate, drawn into to the tunnel preparation bysutures at its medial and distal portions, secured into place,and bulked the soft tissue facial of the implant site (Fig. 8).With the grafting steps completed, the implant wasimmediately provisionalized with the patient's own toothaccording to Steigman.15 A template was taken of themaxillary teeth using a polyvinylsiloxane putty prior toextraction. Once the tooth was removed, its root wassectioned off with a hydrated dental bur, the root and pulpaltissues removed, and the remaining crown sectioned leavingthe tooth’s facial and palatal aspects only. The cut toothcrown surfaces and dentine were then etched for 30 secondswith a 37% phosphoric acid etchant (Scotchbond, 3M), thenrinsed and dried (Fig. 9). A layer of dentinal bonding agent

minimally traumatic technique as possible. The tooth socketretained all its walls intact, verified by probing of the alveolarcrests. The implant was then immediately placed into thefresh extraction socket. Covani recommends immediateplacement toward the palatal/lingual aspect of the socketand in a deeper position.14 The implant’s ISQ was thenmeasured and recorded (M-80, B-76). A cover screw wassecured in place and the buccal gap filled apico-coronallywith a xenograft material (OsteoBiol, Tecnoss). Placing acover screw before this step prevents foreign material lodgingin the implant’s entry point (Fig. 7). Following Grunder'srecommendations, a connective tissue (CT) graft was usedto augment the facial soft tissue simultaneous to implantplacement.13 The attached gingiva was lifted as a splitthickness tunnel preparation according to Azzi’s technique,with release incisions made in the sulcular areas one tooth

Figures 12a, 12b: Flowable composite is applied into the guide, bonding the patient’s crown to the provisional abutment.

12a 12b

Figures 13a, 13b: Provisional abutment is fixed to a laboratory abutment for handling outside the mouth. Composite is added tocreate the desired morphology and emergence profile.

13a 13b


covered with a layer of composite. Occlusion was checkedand adjusted to ensure no contact with the opposingdentition in either occlusion, excursive or protrusivemovements. Postoperative photographs documented theimmediate post-treatment presentation (Figs. 15a, 15b).Postoperative instructions stipulated the patient avoid the useof and directly chewing with the provisional crown for 6weeks minimum and no direct brushing in the area for atleast 10 days. The patient was recalled for follow up at 1week, and at 1, 3, and 6 months (Figs. 16a, 16b).Integration was evaluated at 3 months and ISQ was againmeasured (M-81, B-78) (Fig. 17). Clinical photographsdocumented the soft tissue profile at the implant site (Figs.18a, 18b). The implant was restored thereafter with a finalscrew-retained zirconium crown (Figs. 19a, 19b).Radiographs at the 6 month follow-up visit demonstratedexcellent bone growth. The radiographs showed to whatextent bone had grown toward the implant, and even ontoand over the neck of the implant, illustrating how the morsetaper connection maintains the bone and encourages itsgrowth (Figs. 20a, 20b, 20c). Viz the peri-implant and facialtissues were positively supported (Figs. 21a, 21b, 21c).With the before and after incisal views digitallysuperimposed, the near identical facial tissue profile can benoted – central incisor and canine coinciding in thesuperimposed images with the implant restoration positionedslightly palatal (Fig. 22).

DiscussionMeticulous planning is paramount in implant dentistry.17

Preemptively positioning the proposed implant is aprerequisite to avoiding incorrect angulation, injury and

was generously applied to the etched surfaces, dried, andlight cured (Fig. 10). The prepared tooth crown wasrepositioned within the putty guide and returned to the mouth(Fig. 11). Flowable composite restorative material wasapplied into the guide filling the palatal aspect of theprovisional and bonding the tooth to the abutment (Figs.12a, 12b). The material was then light cured, the abutmentloosened, and both guide and provisional restorationremoved from the mouth. With the provisional abutment fixedto a laboratory abutment for easier handling outside themouth, the restoration was inspected for voids and additionalflowable composite applied where needed (Figs. 13a,13b). The material was then trimmed, polished and finishedto create a desirable emergence profile. A final layer ofdental adhesive was applied to the trimmed surfaces andlight cured (Fig. 14). The provisional was returned to themouth, fixed in place, and a digital peri-apical radiographtaken to confirm abutment to implant fit. The access hole was sealed with a teflon tape barrier and

Figure 14: The completed provisional restoration. Figure 15a, 15b: Immediate postoperative presentation.

15a

15b




the tooth in-situ.11 Removal of the tooth without interventionresults in greater tissue collapse, resorption, remodeling, anda possible tissue deficit.19 In delayed implant placementtiming, soft tissue augmentation or guided bone regenerationmay be required to correct this.9 Alternatively, immediateimplant placement into a fresh extraction socket in theaesthetic zone coupled with grafting of the facial tissues withimmediate provisionalization may reduce and prevent thistissue loss.4 Immediate placement must ensure the implanttable is distanced ≥ 2 mm from the socket’s facial perimeter.9

Placement should be deeper within the socket, andorientated more lingual/palatal so as to ensure a ‘safetyzone’ of bone healing with resorption whilst ensuringcoverage of the implant.14 Grafting of the buccal gap bettercounteracts this resorption from the facial.14, 4 Implantselection is key. As demonstrated in this case, an internalconnection morse taper implant with a built-in platform switchis superior in that it reduces the amount of abutment

complication at sites with anatomical limitations. Thebuccofacial plate thicknesses at maxillary anterior teeth areapproximately 0.97 ± 0.18 mm (central incisors), 0.78 ±0.21 mm (lateral incisors), and 0.95 ± 0.35 mm (canines)respectively.18 This micro-tissue is supported and vitalized by

Figure 16a: 1 week follow up.

16a

Figure 17: ISQ evaluation at 3 months.

Figure 16b: 1 Month follow up.

16b

Figures 18a, 18b: Soft tissue presentation at 3 months ofprovisionalization with the patient’s own tooth.

18a

18b



contamination by repeated material additions andadjustments and insertions of the provisional. When usingthe patient's own tooth crown and positioning it via a puttyguide, a provisional as true to life as possible can beprovided to the patient immediately at day of toothextraction. By carrying out a tunnel technique with aconnective tissue graft, the facial tissues can further bereinforced to maintain ideal aesthetics.13, 16 The tunneltechnique is a split thickness approach obviating thestripping of periosteum, ensuring vital vascularization to theunderlying bone, further preventing unnecessaryresorption.24 The connective tissue benefits from being anautograft and bulks the facial soft tissue. While the buccalgap has been proposed by some authors as able to healadequately by blood-fill alone, an osteogenic and resilientgraft material for filling the buccal space may besuperior.25 An immediately placed provisional restorationwith a desirable emergence profile circumferentially

inflammatory cell infiltrate exposure to the crestal bone.20 AMorse taper connection also provides the best abutmentstability and the lowest von Mises stress concentration in theabutment screw.21 Not only is resorption of the crestalbone minimized, it can grow toward and onto the implant,as seen with this case. This critically contributes to the softtissue stability, support of interdental papillae, and apositive aesthetic outcome of the rehabilitation over thelong-term.22 Tarnow states that for a 98% papilla fill thedistance from contact point to alveolar crest must be ≤ 5mm.23 This case could possibly have ensured better papillafill were the mesial contact of the provisional sculptedfurther apical with a direct restorative material. Whilst theimplant can be provisionalized with a prefabricatedpontic, or chairside entirely out of direct restorativematerials, this case demonstrates the use of the patient'sown tooth to create a 'walk out as you walk in' provisionalrestoration.15 This saves time and reduces site

Figure 20: (a) Radiograph at day of implant placement; (b) At 4 months follow up with finalrestoration, (c) At 6 months follow up. Note chronologically the development of the bone,to eventually grow over the implant table.

20a 20b 20c

Figures 19a, 19b: Final implant crown at day of delivery. Soft tissue symmetry between both lateral incisors is maintained.

19a 19b



and techniques may preserve and ensure natural aesthetics.Utilizing the patient’s own tooth crown can betterprovisionalize the implant with a ‘walk out as you walk in’result.

DeclarationNo conflicts of interest are declared

supports coronal tissues and prevents their collapse.26

Ensuring pontic to tooth contact at the appropriate heightswill further ensure papillae preservation.23

ConclusionMeticulous restorative treatment planning of a tooth destinedfor extraction is essential. Selecting the appropriate implant

Figures 21a, 21b, 21c: Positive support of the peri-implant tissues.

21a

21c

21b

Figure 22: Before and after incisal views of the facial contours digitally overlaid.

augmentation after a healing period of 6 months: report of 24consecutive cases. Int J Periodontics Restorative Dent.2011;31(1):9-17.14. Covani U., Cornelini R., Calvo J.L., Tonelli P., Barone A.

Bone remodeling around implants placed in fresh extractionsockets. Int J Periodontics Restorative Dent. 2010;30(6):601-7.15. Steigmann M., Cooke J., Wang H.L. Use of the natural

tooth for soft tissue development: a case series. Int J PeriodonticsRestorative Dent. 2007;27(6):603-8. 16. Azzi R., Etienne D., Carranza F.. Surgical reconstruction

of the interdental papilla. Int J Periodontics Restorative Dent.1998;18(5):466-73.17. Du Toit J., Gluckman H., Gamil R., Renton T. Implant

Injury Case Series and Review of the Literature Part 1: Inferioralveolar nerve injury. J Oral Implantol. 2014 Jun 19. [Epubahead of print].18. Han J.Y., Jung G.U. Labial and lingual/palatal bone

thickness of maxillary and mandibular anteriors in humancadavers in Koreans. J Periodontal Implant Sci. Apr 2011;41(2): 60–6619. Araujo M.G., Sukekava F., Wennstrom J.L., Lindhe J.

Ridge alterations following implant placement in fresh extractionsockets: an experimental study in the dog. J Clin Periodontol2005; 32: 645–652.20. Lazzara R.J., Porter S.S. Platform switching: a new

concept in implant dentistry for controlling postrestorative crestalbone levels. Int J Periodontics Restorative Dent. 2006;26(1):9-1721. Pessoa R.S., Muraru L., Júnior E.M., Vaz L.G., Sloten J.V.,

Duyck J., Jaecques S.V. Influence of implant connection type onthe biomechanical environment of immediately placed implants- CT-based nonlinear, three-dimensional finite element analysis.Clin Implant Dent Relat Res. 2010;12(3):2322. De Angelis N., Nevins M.L., Camelo M.C., Ono Y.,

Campailla M., Benedicenti S. Platform switching versusconventional technique: a randomized controlled clinical trial.Int J Periodontics Restorative Dent. 2014;34 Suppl:s75-9. 23. Tarnow D.P., Magner A.W., Fletcher P.The effect of the

distance from the contact point to the crest of bone on thepresence or absence of the interproximal dental papilla. JPeriodontol 63:99524. Blanes R.J., Allen E.P. The bilateral pedicle flap-tunnel

technique: a new approach to cover connective tissue grafts.Int J Periodontics Restorative Dent. 1999;19(5):471-9.25. Greenstein G., Cavallaro J. Managing the buccal gap

and plate of bone: immediate dental implant placement. DentToday. 2013;32(3):70, 72-7.26. Son M.H., Jang H.S. Gingival recontouring by

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