Dr. Charles D. Schlesinger illustrates a case involving immediate implant placement
Immediate placement of dental implants has become a successful and dependable treatment modality in today’s modern implant practice. One of the biggest advantages is the drastic decrease in overall treatment time for the patient. In today’s world of instant gratification, an average decrease in treatment time from 7-8 months in traditional extract/graft/wait/place/wait protocol to a much more palatable 3-4 months is a true practice builder. Though immediate temporization or restoration is the ultimate goal in mind when extracting a tooth, many times this does not constitute a prudent treatment plan. Factors to consider include primary stability sufficient enough to load, prosthetic considerations, and the size of the resulting extraction socket.
The success rate of immediate implant placement approaches the success rates of delayed placement1; therefore, with the right technique and the correct implant, this should be done as routine rather than the occasional treatment option.
A 65-year-old female presented to the clinic with a non-restorable lower right first molar. The tooth had an existing large restoration with extensive re-decay (Figure 1). The patient was given the following treatment options:
- Extraction without bone grafting
- Extraction with bone grafting
- Extraction with immediate implant placement and bone grafting
The patient chose option No. 3, and since there were no medical issues to contend with and no evidence of infection, the decision was to commence with extraction along with immediate implant placement the day it was agreed upon.
Profound anesthesia was carried out with 4% Septocaine® (Septodont USA). Although an inferior alveolar nerve (IAN) block is not usually performed for implants placed in the mandibular arch, it was determined that the benefit of his type of technique outweighed the possibility of discomfort for the patient since concomitant extraction was being performed. Along with the IAN block, a long buccal block was utilized. This type of anesthesia should only be carried out if sufficient 2D and 3D radiographs are available.
Once the patient reported that she was numb and comfortable, tooth No. 30 was atraumatically extracted. After removal of the crown, the tooth was sectioned through the furcation with a high-speed handpiece (Kavo USA). A 301 elevator was used to split the roots further and was followed by the use of a 151 forcep. Each root was removed individually with particular attention to preserving the inter-septal bone. After removal of the tooth roots, the socket was debrided with a serrated curette and inspected for bony integrity (Figure 2).
A 557L surgical carbide created a purchase point on top of the interseptal bone. This allowed a 1.8 mm pilot drill to be used to create the initial trajectory between the mesial and distal root sockets
(Figures 3 and 4). Immediate placement, especially in molars, can be challenging with respect to creating an osteotomy while fighting the natural tendency for the bur to wander into the path of least resistance. In this case, that path would be either the mesial or distal sockets.
Once a path of insertion was established, the osteotomy was enlarged using a progression from a 3.7 mm osteotomy former (Figure 5) to the final osteotomy former for a 5.0 mm implant (4.7 mm) (Figure 6).
The usual two-step protocol was not followed in order to make sure that the maximum amount of bone was preserved for implant placement (Figure 7). A 5.0 x 12 OCO Biomedical TSI implant was chosen for this case (OCO Biomedical). This particular style of implant has an emergence from the 5.0 mm body to a 5.7 mm restorative platform (Figure 8). The divergent imbedded tapered platform has a 32xx machined surface rather than being polished; this allows the implant to be placed at the appropriate restorative level without regard to the “collar’s” position (Figure 9).
The imbedded tapered platform is at home in either bone or soft tissue. Another advantage of the divergent platform is that it will contribute, along with the bull nose auger tip, to the patented dual stabilization of the implant. Finally, the increase in platform size helps seal the top of the socket to contain the grafting material.
The final osteotomy will stabilize the implant by use of the remaining buccal and lingual chords of bone along with the auger tip condensing bone at the apex.
The implant was delivered by hand and then torqued into position. The final torque value was 30+ N/cm (Figure 10); enough for primary stability, but not sufficient enough for immediate loading. In order to immediate load this implant, it would require at least 45 N/cm and/or at least an ISQ value of 64 with an Osstell meter.2
After the implant was in position, SteriGraft™ DBM putty (OCO Biomedical) was placed in the remaining socket around the implant (Figure 11), since the buccal-implant gap exceeded 2 mm.3,4 In order to confine the graft material, an RCM6 (ACE Surgical) Type 1 collagen membrane was used to span the socket opening with at least 5 mm of membrane extending beyond the opening. A technique was utilized where the cover screw was placed through a hole made in the membrane (Figure 12). This hole allows the cover screw to stabilize the membrane without having to use tacks; a 3.0 silk suture (Ethicon) was used in an interrupted fashion to hold the soft tissue immobile during healing (Figures 13 and 14).
Since only the minimum primary stability was achieved, the implant was given 3 months for osseointegration to take place. During this time, the graft was replaced with host bone under normal healing conditions, and keratinized tissue advanced over the membrane by secondary healing (Figure 15). Once complete healing was verified by radiographs and the stability checked with an Osstell meter, the decision to commence the restorative phase was decided upon.
The cover screw was removed, and a 5.5 mm tall solid crown and bridge abutment was torqued to 30 N/cm and then re-torqued after a 5-minute interval elapsed. This re-torquing of the abutment will counter any pre-stretch of the metal caused by the first tightening.
A tissue retraction impression pickup (TRIP) coping was snapped into place. Light body VPS material was used to capture the detail of the soft tissue and adjacent teeth. Heavy body VPS in a stock triple-tray was used to complete the final impression (Figure 16). A bite registration was also taken at this appointment as a backup to verify the occlusion.
A metallic analog was placed (Figure 17) into the TRIP, and the impression was sent to the lab for fabrication of a PFG restoration. The cover screw was replaced and the patient dismissed until the delivery appointment.
At the final delivery appointment 2 weeks later, the final restoration was tried in, and the occlusion checked with articulating paper. After adjusting the restoration, the porcelain was re-polished, and the crown was cemented with RelyX™ (3M) cement (Figure 18). Excess cement was removed, and a final X-ray was taken (Figure 19).
Immediate implant placement is not only a viable treatment option, but one that most patients will choose if given the choice. It is important for the practitioner to make sure that sound implant protocols are followed with respect to medical history, current oral condition, and the prerequisites necessary for primary stability. The ability to cut down the overall rehabilitation time by potentially a factor of two not only produces a satisfied patient, but also is benefit for any dental practice trying to increase its practice performance and patient care.
- Lang NP, Pun L, Lau KY, Li KY, Wong MC. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res. 2012;Feb;23 Suppl 5:39-66.
- Schlesinger CD. Short Implants: a viable alternative to sinus augmentation. Dent Today. 2014;33(4):128,130,132-133.
- Rosenbach, D. GAP management around immediate implants: a review of the literature and its application in clinical practice. Dentaltown. September 2014:44-49.
- Chu SJ, Salama MA, Salama H, Garber DA, Saito H, Sarnachiaro GO, Tarnow DP. The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent. 2012;33(7):524-532, 534.