rgical Su andRestcrative ?

hases

lmplant Therapy-sequence of
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thoroughcurettage of the socketbe performed to removeany remnants of the cystic tissue. Socket preservation is recommended to aid in the stabilizationof the buccalplate. Implant placementshould be delayed until thc soft tissuehas healedfully and any evidenceof inl'ectionand inflarnmationhasdisappcared (Figure2). Systemic antibiotics administered during the first r.veek following extractionwill aid thc body in clearingbacteriaand inflamrnatorycells l'ronrthc site. Initial healing norrrally rvill occur rvithin a 4- kr 6-rvcek period follorving
Oss@us Gratt

extraction of the sourcc of the infection (ie, the failed tooth).The presence of keratinizcd tissuelvitlr closureof the extraction site indicatesthat the site is readyfor the next

F I ailurc ofthe natural dcntition due

to periodontal- or endoilontic-dated osseous infections may complicate (ie, staging) implant therapy. Sequencing of the surgical aspectsof the treatment is essential to achieaethe desireilrestoratizteobjectioes. Additionally, for indications in zohichthe adjacent nafiral teeth require cosmetic enhancementas part of the oaerall trcatment plan, proper sequencingzoill influence the definitioe results. The following article discusses the surgical and restoratiae phases of implant treatment utilizing a step-bystep approach. The success of implant placementin well docimmediate extraction sites hasbeen umented in the literature, and irnplanttreatment is steadilymoving towardimmediate placement at the time of extraction.r Yet, in of active infection, osseous healthepresence the newly placedimplant ing surrounding
may lcad to its Iailure to plopcrly integrate. Inflammation associatedr.vith chronic periodontal or endodontic infections or acute with visible cxudatecreatcsa local inf-ections environmentthat doesnot favor osseous healing and subsequcnt integrationol'the irnmediately placedimplaut.

phase of the surgical treatment-implant placement(Figule -3).At this juncture, the authorsrecommcndthat a radiographbe taken to ascertain r,vhetherbone had regenerated or il'a guided bone regeneration procedure is required. A crestalincision is made at the healed cxtracticln site and cxtendedas an intmsulcular incision mesiodistal to the site.The incision should be extendedrvide enough to allow visualization of the facial osseousplate afier implant placement. If verticalreleasing incisions are required lbr visualizaticln, they shor.rld be located a distanccfiom the site to preventoverlzrp over the implantor any graft placed. 'l'he previously labricated implant placement guide (ie, surgicaltemplate)is tried in. and stability is verified. A pilot drill is introducedinto the guide hole and insertedto the desireddepth. Angulationand positionare verified n,ith respectto the osseoustriangle that rvill house the implant. Modil'icatic;ns to the final position may be performed at this stage !vithout overpreparation of bone at the

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The presence of a fistula (eithermoderate or larger),periapical isolatedsol't radiolucency, tissuechanges crestally. obviouscxudatc,or lack of facial wall in the presence of moderate inflammation may lvarranl delaying implant placement follorving extraction (Figure l). Localized inflammatory changes associated rvith infection can trigger osteoclastic activity leading to bone resorption.When infection is visibly present at extraction, it is pnrdentthat

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osteotomy. Subsequently,larger oste<ltorny drills are usedrvith the surgicaltemplateuntil the final diameter and depth of the site are achieved(Figure4). 't'hesite should be exzrmined to detennineif there is any loss of facial plate or if a thin crestalmargin will necessitate gralting.'I'he implant js then introclucecl into the site to its proper depth and examined for any threadexposureon the facial plate. If a dehiscence or a thin crestalmargin .ispresent, osseous grafting rvill be requiredprior to site closure.

ffi*r*'lp$$*er$*n* mmp trflFsffi af mxtrm*tf *ru sltssw$'$#fl# $raep:$m*t* ffi r# $)$#$t$Tma$, mmk$ruffi trmatp'xtmrx$ stmg$n*g *tre m$$*r'eg$xtg. @
An appropriate osseous gralt nratcrialis packed on the facial to cover any exposetl threadand thicken the facial plate (Figure -5). Primary closr-rre o1 the site is critical to ensure stability of the cresralbonefollor.ving healing. Elevationof the palatalaspectof the flap will allow harvesting of connectivetissueto be relocatedover the crestalaspectof the site (Figure 6). If additionalconnecrrve tlssueis required,harvestable palatally,regenerative tissuematerial (AlloDerm, LifeCell Corpora_ tion, Branchburg, N.I) may be utiljzed. .I.he connectlve tissue is placed r-rnder the flap marglnsand tackedapically with a resorbable suture to stabilize the soft-tissuegral.t. Flap margins are overlayed in a tension_frce manner and the site closed lvith resorbable sutures.'l-he connective tissuegraft neednot be completely covered by the f'laps.A tissue adhesive(Periacryt,GluStitch,point Roberts, WA) is then applied over the site to cover the flaps and any exposedconnectivetissue, creating a water-tight barrier. This barrier will prevent bacteria or plaque penetration into the site through the soft tissue and improve healing.

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59rlng 2005

F'ollowing a healing period of 6 months (Figurc 7), the irnplant is exposedwith a crestal incision similar to the incision used to place the implant. An abutment labricated from an impression taken at the time of surgical placement is placed on the irnplant and torqued as recornmendedby the manufacturer. A prefabricatedtemporary crown is placed rvith temporarycement,and the restorationis removed from any occlusal contact. Temporization of adjacent teeth that rvill receive crolvns or veneersto the desired facial contours is perforrned.At this stage, soft tissue recontouring of the adjacent teeth rvould be accomplished.'l'he soft tissueis suturedin the desired position with a resorbablesuture mate(Figure8). The rial and the patientdismissed soft tissuesare allowed to heal and rnature for a 4-rveekperiod prior to the final impressions required for the fabrication of the definitive restoration(Figures9 and l0).

Atlantis Abutments Zimmer Dental, Carlsbad, CA produce p at ient - specif C l i n i cal l y based computer desi gn and i ntegrated machi ni ng ic profile. Atlantis Abutments with idealshape, contours, and emergence Exact duplicate a b u tm ents can be fabri cated, typi cal l y el i mi nati ng the needfor a fi nal im pr ession. C o mbi ne thi s w i th S martS teps techni ques and the number of pati ent visit sis signif ii t easy i mpl ants c a n tl yreduced, maki ng to choose overtradi ti onal crownand br idge. Atl a n ti s A butments for fr ict ion- f it areexcl usi vel avai y l abl from e Zi mmerD ental int er n a l h e xand S pl i nei nterfaces.* available in U.S. onlv. "Atlantisabutments Provide Abutments 3i, PalmBeach Gardens, FL With increasing demands for implanttherapy, Restorative offers the Provide System moreopti ons b o ths urgi cal andrestorati ve cl i ni ci ans andgreater fl exi bilit y. Fourcollar provi de In addi ti on, height opti ons unmatched surgi cal fl exi bi l i ty. si ncet he im plantis placedat boneleveland not transgingivally, the final crownmarginis not predeterm i n edat the ti me of surgery w i thoutthe needto prepare the i mpl antdue t o t issue protocol. recession and can be usedin a one-or two-stage surgical Healing Abutments Attleboro, MA Sterngold, R e g ul ar A butments i n tw o styl es, P l atform H eal i ng are avai l abl e S tandar d Pr of ile and N a tural P rofi l e. TheS tandard P rofi l e hasa cyl i ndri cal shape and i s 4.5 m m in diam ei s to i ncl ude te r a n d mostoftenusedw henthe fi nal restorati on oneo f t he st andar d a b u tments. TheN atural P rofi l e H eal i ng A butments areavai l abl ie n R eg ular Wide, , and Narrow Platform Platform and featurea taperedtissuecuff. The Regular abutments i n di ameters a re manufactured of 5 mm,6 mm, or 7 mm, eachw i t h f our m ar gin produci ng 12 shapes h e i g hts, that enabl eshapi ng of the ti ssuei nto a m or enat ur al profile. emergence System SolidAbutment Straumann USA, Waltham, MA fo r Regular W i th i ts rel i abl e Morsetaperconnecti on, the S ol i dA butment system Neck a n d W i de N eck i mpl ants ensures a secureand exceptl onal lstable y abut m ent - t ol ooseni ng. The i mpressi on i s then takenovert he i mp l a ntconnecti on and prevents i n s e r ted Theabutments ar eavailable in abutments usi nghi ghl ypreci se components. different heights, andthe abutments and corresponding transfer components arecolorcodedfor accurate and simpleprosthesis fabrication. Locator Abutments ZestAnchors, Escondido, CA Locator implant abutments shouldbe ordered measto the exactheightof the gingival u re ment. TheLocator Femal e A ttachment w i l l addan addi ti onal 1.5 mm t o t he height Female of the measured tissuecuff and allows the Locator to extend above the tissue The Locat orM ale b y 1 .5 mm and enabl es the LocatorMal e to seat compl etel y. provides Replacement Malecan Processing Package a choiceof retention; the Locator (20 degrees an implant with up to 10 degrees of divergence between be usedto restore t o r educe i m p l ants). The Locator LR (l i ghtretenti on) R epl acement Mal ei s designed or rootsand can of an overdenture supported by multipleimplants the overall retention gradual where loading alsobe usedin cases is preferred. Procera Abutments Linda, Nobel Biocare, Yorba CA and development, the Proceraline Supportedby more than 20 yearsof research i mpl antabutments. P rocera a but m ent pr s oi n c l u des and zi rconi a al umi na, ti tani um, for t he Br inem ar k In addi ti on to abutments v i d evi rtual l y unl i mi ted desi gn capabi l i tl es. Procera for otherimplant sysand Replace Select, abutments arealsoavailable System provi des bioS traumann. P rocera unparal l el ed strength, aest het ics, te m s i ncl udi ng fi t. c o m p ati bi l i ty, and preci se

CO N C L U $ I O N
Complicationsnray arise at extraction sites where irnplantsare planned,making treatmcrnt staging challenging. When combined rvith restorative treatnrent on the acljacent dentition, sequencingof the surgical phase of implant planning treatmentcan simplify multiaspect results. and provide predictable

ASKNOWLEOGEMENT
Prosthetic trcatment courtesv of Dr. Marc E. Mos kowitz, P rosthodon tist, Mu r iet ta, Georgia. The authors would like to thank Dr David Kurtzmanfor his contribution to the illustration demonstrating conilective tissueplucement. V

RETERE}ICE
and proyil. Petrungaro PS.lmmediateimplantplacement sionalization in edentulous,xtraction. and sinus gmfted sites. Compend Cont Educ Dent 20o3,24\21:95-113.

*Assistant Clinical Professor, Department of Restorative Dentistry, University of Maryland, Baltimore College o! Dental Surgery; pivate practice, Silver Spring, Maryland. tAssociate Clinical Professor of Periodontics, Medical College of Georgio, Augusta, Georgia; author of the textbook "Principles of Dental Suturing A Complete Guide to Suryical Closure;" private practice, Marietta, Georgia. iAssistant Clinical Professor of Peiodontics, Medical College of Georgia, Augusta, Georyia; private practice, Marietta, Georyia,