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Stuart J. Froum, DDS • Sang-Choon Cho, DDS" • Helena Francisco, CDS' • Young-Sang Park, DMD: Nicolas Elian, DDS" • Dennis P. Tarnow, DDS"
Endoszsaous dental implants haw traditionally been placed using a two-stage surgical procedure with a 6- to 12-month healing period following tooth extraction. In order to decrease healing time, protocols were introduced that included immediate implant placement and provisionalization following tooth extraction. Although survival rates for ihk technique are high, postoperative gingival shrinkage and bone resorption in the aesthetic zone are potential limitations. The two case reports described herein present a surgical technique for the preservation of anterior aesthetics that combines minimally invasive extraction, immediate implant placement, provisionalization, and the use of implants with a laser micro-grooved coronal design.
Learning Objectives:
This article describes the use of on immediate implant placement and provisionalization technique. Upon completing this exercise, the reader should:
- Be awore of the clinical implications associated with on immediate implant
placement and provistonalizafion technique.
- Recognize the role of implant design on overall aesthetic and func
tional success.
Key Words: immediate implant placement, provisionalization, minimally invasive
'Clinical Professor, Department of Periodontology and Implant Dentistry, New York University
College of Dentistry, New York, NY; private practice, New York, NY. tAssislanl Clinical Professor, Department of Periodontology and Implant Dentistry, New York
University College of Dentistry, New York, NY. ^Resident, Department of Periodontology and implant Dentistry, New York University College
of Dentistry, New York, NY. SFormer Resident, Department of Periodontology ond Implant Dentistry, New York University
College of Dentistry, New York. NY. IIAssiitant Professor and Director, Department of Periodontology and Implant Dentistry, New
York University College of Dentistry, New York, NY.
"Professor and Chair, Deportment of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, NY, private practice, New York, NY.
Dr. Stuart 1. Froum, 17 West 54lh Street, Suite 1C/D, New York, NY 10019
Tel: (2121 536-4209 • E-mail: dr.froum@veriion.net
Dental implanls have been successfully used during the last 30 years to restore partially and fully edentulous patients.1!Prior lo implant placemen!, the traditional pro tocol recommended a six to 1 2-month heating period for the alveolar bone following tooth extraction. In addition, a load-free healing period of three to six months was generally recommended lor osseoinlegration lo occur.
In an attempt to decrease ihis nine- lo I 8-month healing time, protocols weie developed lhat suggested the viability of implonl plocemenl immediately following tooth extraction. In this regard, there has been an increasing interesi In implant insertion into a fresh extraction socket, because ihis procedure has been shown lo be a predictable treolment modality.58 The advantages of Immediate versus delayed implanl placemenl include a reduclion in treatment time, fewer surgical interventions,""' and a decrease in surgical Irauma lo ihe tissues at ihe Impant site.
Unpredictable gingival recession and creslal bone resorpllon ore two disadvantages associated with immediate implant placement in the aesthetic zone. Continued bone and soft lissue loss may also cause the exposure of the implanl surface, resulting in a compromised aesthetic outcome following implant placement.
Immediate provisionalization of denial implanls enables ihe patienl to avoid ihe psychological and physical discomfort of wearing a removable inlerim proslhe-sis.1'Critical faclors for success of immediate restorations include; 1) initial implant stability: 2| eliminolion of macro-movement of the implant during initial healing; and 3) complete removal of excess luling agents following provisional cementation.11"™ With respect to soft lissue con-lours, the fixed provisional restoralion facilitates conlouring ihe gingival tissue from the narrow cylindrical implant to ihe gingival form of o tooth as the implant emerges from the sulcus. Thus, several authors hove slated hat it is easier to achieve optimal sulcular form with a fixed provisional prior to definitive restoration.
The following case presentations demonstrate an immediate implant and provisional protocol that follows the biological paramaters for three-dimensional implant placement, along with grafting of the gap between the buccal plate and the implant. In both cases, implants with a laser microgrooved gingival collar of 8 um and 12 um were used. These groove patterns have previously been shown in animal studies to selectively attach to soft and hard tissue, respectively. The technique and implant design will be discussed relative to implant success.
A 35-year-old non-smoking female patient in general good health and with no contraindications to treatment presented with a questionable maxillary right central incisor 10 years following traumatic injury. The discolored tooth exhibited external root resorption. Class II mobility, and was extruded. CLinical evaluation revealed a buccal fistula and exudate present at the apex of the tooth, and (he ioolh was diagnosed as hopeless (Figure 2). Treatment options were reviewed, and informed consent was obtained. Based on the patient's desire to reduce treatment time, it was decided to perform immediate implanl placement with immediate provisionalizalion following toolh extraction.
A preliminary impression was mode and diagnostic caste were fabricated wilh type IV dental stone (Die-keen, Heroeus Kulzer. Armonk, NY], A resin denture loath with appropriate shape ond shade was selected prior to tooth extraction, A removable partial denture was prepared in Ihe event thai the initial stability of the Implonl was insul-ficient to support a fixed provisional tooth (Figure 31)
Following administration of local anesthesia (ie, lidocaine wilh epinephrine 1:100,000, Henry Schein Inc. Melville, NY|, alraurnatic toolh extraction was accomplished without flap reflection to preserve the Inlerproximal papillae and the remaining buccal and lingual plates of bone (Figure 4). Following socke! debridemenl, on implant (ei, 3.4 mm x 13 mm; Laser-Lak, BioHorjzons, Birmingham, AL] wos placed according to the manufacturers protocol and with reference to three-dimensional positioning. The implani showed adequate initial stability when placed with o lorque driver ai 35 Nan. It had a laser micro-grooved coilar, which was positioned with the 8-/jm grooves in soft tissue and ihe 12-pm grooves in bone. The implani wos placed 2 rnm mesiodistally from the adjacent teeth, lingual to the buccal plote of the bone, toward the cingulum and with Hie implant abulmenl connection 3 mm apical to the anticipated gingival mat-gin." The latter was determined with a surgical template that denoted the apical extent of the anticipated buccal margin of the restoration. In this position, the implant had a distance of 3 mm between the implani and the buccal plate [Figure 5|. A mineralized cancellous bane allografl (ie, Puros 0.25 g to 1 g, Zimmer Dental, Carlsbad, CA) was placed between the buccal plote of bone and the implant in order to fill the space and maintain the soft tissue contour. No attempt was made to advance the buccal fbp to cover the graft material
Immediate Provisionalizalion and Postoperative Care A plastic cylinder was selected and prepared In order to receive the provisional restoraiion (Figure 6). The selected crown form (Bioform IPN, Dentsply Trubyte, York, PA) was relined intraorally with self-curing acrylic to ensure accurate fit and was cemented with tempo-rary cement (Temp Bond, Kerr Corporation, Orange, CA|. Centric and excursive contacts were eliminated and the palienl was advised to avoid biting or chew ing on the provisional crown The patient was also instructed to rinse twice daily with 0.12% chlorhexl-dine and to avoid brushing the surgical area. The palient selected, Ridge augmentation in the edentulous lateral incisor orec was also performed,
A preliminary impression was made, diagnostic casts were prepared, and a provisional restoration was fabricated for immediate provtsionalization o+f implants #8(111 #9(21 ], and a cantiievered ponlic on tooth #7.
Local anesthesia lie, lidocaine wilh epinephrine 1:100,000, Henry Schein Inc. Melville, NY) was administered anc alraumalic extraction of the central incisor teeth was accomplished without flap reflection fo preserve the interproximal papillae and ihe remaining bucco! and llrr gual plates of bone [Figure 14]. Following socke debridement, two implants |3.4 mm and I 3 mm) with laser micro-grooved collars (ie, Laser-lok, BioHorizons, Birmingham, AL) were placed at sites #8 and #9. Nc attempt woe made for primary closure of the flap to cove ihe graft. All implants were guided by the surgical tern plate into an ideal prosthetic position, and primary sta bility was achieved. The implants were placed 2 mrr from the odjacenl teelh, 3 mm between implants, one with the implant platform 2 mm to 3 mm apical to ihe anticipated gingival margin. The implants were alsc placed so that they emerged toward the cingulum of the anticipated restorations, leaving a distance of 3 mm re 4 mm between the implont and the buccal plate of bone. This space was filled wilh the mineralized concellou; bone allograft |MCBA] (Figure 15). During the surgica procedure, guided bone regeneration utilizing a graf of MCBA covered with an absorbable collagen merrr brane (ie, Bio<5ide, Geiistlich Biomoterials, Inc, Wolhusen, Switzerland] was performed b augment the edentulous #7 area adjacent to the #8 implant (Figure 16],
Immediate Provisionalizotion and Postoperative Care The laboratory-fabricated provisional restorations were relined chairside wilh self-curing acrylic to ensure accurate fit and (he three-unit splint was cemented wilh temporary cement (ie, Temp Bond, Kerr Corporation, Orange, CA). Centric and excursive contacts were removed, and ihe patient was advised to avoid biting or chewing on the crowns and to avoid brushing the surgical area.
The paiienl functioned wilh this provisional FPD in non-occlusion for six monlhs prior to delivery of the definitive Implant restoration (Figure 17).
Restorative Phase and FollowUp Evaluation Following six monlhs of heoling, the provisional FPD was removed ond the final ceramic abutment lorqued down wilh 35 Ncm. An abutment-level impression wos performed and, two weeks later, ihe final all-ceramic crowns were delivered. For ihe purpose of achieving a natural aesthetic result, a cantilevered right lateral pontic was constructed instead of adding o Ihird implant. The final restoration was cemented with temporary cement |ie, Temp Bond, Kerr Corporalion, Orange, CA). The potienl was re-examined ai three, six, 1 2, 24 and 30 monlhs poskrementotion of the find prosthesis. During this period, the level of ihe inter-proximal bone and ihe buccal gingival level remoined stable [Figures 18 and 19.
Mid-Facial gingival recession is ihe most common complication of anterior single-tooth implanls. Small and Tatnow reported greater facial recession with wide-body implants,ld lt was speculated that this recession wos caused by pressure against the buccal plate, causing resorpiion and consequent gingival recession. In the case reports presented in this article, the mid-buccal tissue remained undisturbed because the implant was placed 3 mm lingual to the buccal plate, and o graft was positioned to maintain the soft tissue contour. Placement of an immediate implant following extraction may or may not decrease ihe horizontal resorption of this buccal plate of bone. Since the distance from the implant to the buccal plate of bone was greater lhan 2 mm in bolh coses presented, a decision was made to fill this void wilh MCBA. No controlled sludies exist lo determine whot, il any, material is necessary lo fill ihe space to achieve improved implanl survival." Hisiological evalu-alions in humans have, however, demonslraled lhal ihe horizontal component of the perio-implanl defect around implants placed immedialely following loolh extraction was "the most critical (actor relating lo the final amount of bone-to-implant contact.
Moreover, it has been demonslraled in animals lh< Tie Greater Ihe distance, Ihe more apical the o ma on
ihe bone-to-implant contact.3B Therefore, wish a di tance greater than 2 mm present in ihe twocases
reported, a graft material was indicated to support the
buccol sotl I issue complex ctunng healing lo a en e ^ lproved oesthelics In bolh cases reported, thi e a o o e ipt to cover the ojotl wilh a membrane b* e a id/or buccal flap. Bone auqmenlation techniaues fol lowing immediale implant placement may not be required, if Ihe dislance between implant and bor a is less lhan 2 mm, when implanls wilh a rough surface are used."
Very few studies have addressed the effect of using □ grafl or bone subslilute alone to (ill spaces greater than 2 mm without use of a barrier membrane. Various materials used to fill this gap have been described in reviews of the literature, bul Ihe aulhors concluded lhat (hey "could find no indication...as to the superiority of ony of ihese components or iheir necessity wilh respeci lo immediate implonlalion.
In ihis study, no attempt was made to advance ihe flap to cover the graft material. Advantages of this approach include the following: the microgingivcil needed and if it serves to keep the epithelium of the flop away from the wound, allowing more time for connective tissue and bone to repopulale the space.
In ihe first cose presentation, the interproximal papilla was not presenl one week posloperatively, but developed over a four-week period once the contact poinl was established. The papillae have remained intact 2.5 years posl surgery. Following tooth removal, there is usually a collapse of the interproximal papilla due to loss of supracrestal gingival libers. The popillo may be restored by restoration of the contact point of the impla.nl-crcw/n replacement, provided thai distance of ihe bone crest on the adjacent tooth to coniact point does noi exceed 5 mm."11 This response is, however, also affecled by the peri-implant biotype because there is a greater peri-implant mucosal dimension in the presence of thick perhmplanl biotypes compared to the thin biotype
Although ihe tooth in Case 1 hod □ thin scalloped biotype, proper implant placemenl and creation of a contact poinl within 5 mm ol the crestal bone resulted in papillae maintenance. The buccal soft tissue level hos been maintained even more coronal than on the loolh that was extracted. This buccal gingivol level was also more coronal on the implant than ihe marginol gin-Qival level on ihe natural left central incisor. Ihe gingival margin on ihe implant hos been stable for 2.5 years post crown placement. In Case 2, two adjacent implants were immediately placed and provisionalized. Because of ihe biological limilalions of the papilla height between two adjacent implants (average 3.4 mm), aesthetics were even more challenging.
In ihe cases presented, proper implant positioning was essential in achieving the desired aesthetic goals. In addition, the aim of ihe provisional restoration was to duplicate the nolural tooth contour ond mimic its conlraloteral natural tooth coronal to the free gingival margin. The shops ol the provisional restoration with a reduced emergence profile allowed the soft tissue restoration was placed into a correctly contoured gingival sulcus. The use of implants with a laser micro-grooved coronal design may have contribuled to the maintenance ol buccal soft lissue, providing attachment and prevenling epithelial cell downgrowth, which often occurs with machined collar implanls.1J Maintenance of this supra crestal soft tissue oflen depends on its ability to establish an attachment supercrestally to the implant surface.
These two cose reports describe a surgical technique that preserves anterior aesthetics by combining minimally invasive extraction, immediate three-dimensional implant placement, grafting o( the buccal space with MCBA without primary coverage, immediate non-occluding provisional izati on, and the use of implants with a loser micro-grooved coronal design.
In both cases presented, the grngival complex surrounding lh$ implants has remained stable with no recession 2.5 years following crown placement. Additional prospective clinical and histological studies are, however, required to determine if this protocol using implants with different coronal designs and surface morphologies with ond without grafting con rrcainlain the soft and hoftj tissue levels over time.
Acknowledgment
The authors declare no financial interest in any of the products cited herein.
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