Immediate Implant Placement

Dr. Mohammed Alshehri BDS, AEGD, SSC-Resto, SF-DI

Introduction
The formation as well as the preservation of the alveolar
process is dependant on the continued presence of teeth.

Patient with long and narrow teeth have more delicate
alveolar process and, in particular, a thin, sometimes
fenestrated buccal bone plate.
Its well documented that following multiple teeth
extraction and the subsequent restoration with removable
dentures, the size of the alveolar ridge will become
markedly reduced, not only in horizontal but also in
vertical dimension and the arch will be shortened.

Resorption more pronounced at the
buccal than the lingual/palatal aspects of
the ridge.
Following an extraction, there is a 25% decrease in the
width of the alveolar bone during the first year, and an
average 4 mm decrease in height during the first year
following multiple extractions. (Carlson 1967, Misch 2000; Misch 2000)


Tatum and Mischhave observed a 40%-60% decrease in
alveolar bone width after the first 2 to 3 years post
extraction.


Christensen reports an annual resorption rate of at least
0.5% to 1% during the remainder for the rest of a patients
life.

In the publication by Schropp et al. (2003) most of the
bone gain in the socket occurred in the first 3 months.



The formation as well as the preservation of the alveolar
process is dependant on the continued presence of teeth.

Patient with long and narrow teeth have more delicate
alveolar process and, in particular, a thin, sometimes
fenestrated buccal bone plate.

Healing of Extraction Socket

Amler (1969)


Amler (1969)



Healing of Extraction Socket

Ohta (1993)


Ohta (1993)



Healing of Extraction Socket

Araujo MG, Lindhe J (2005)


1 week 2 weeks
Araujo MG, Lindhe J (2005)


4 weeks 8 weeks

Soft Tissue Changes after Extraction

Immediately following tooth extraction there is a lack of
mucosa and the socket entrance is open

During the 1st weeks after extraction, cell proliferation
withen the mucosa will results in an increase in its C.T
volume

The soft tissue wound will become epithelialized and
keratinized ,the mucosa will cover the extraction site

The contour of the mucosa will adapt to follow the changes
that occur externally in the hard tissue of the alveolar
process.



Hard Tissue Changes after Extraction

The Theory of Bundle Bone

The Bundle Bone delineates the alveolar socket

Thickness approximately 0.8 mm
It's a tooth related bone structure
Blood supply through blood vessels of the PDL



Hard Tissue Changes after Extraction

following extraction, since bone structure resorbes
irrespective of therapy

This is critical on the facial aspect, since 2-3 mm of the
most coronal bone wall is mainly made of bundle bone







(Schropp et al. 2003, Botticelli et al. 2004, Araujo & Lindhe 2005, Araujo et al. 2005, Araujo et al. 2006, Fickl et al. 2008)
Changes in the soft and hard tissues
following tooth extraction
Clinical situations at extraction of anterior
teeth in the maxilla
Immediate Implant
Definition: Implant placed as part of the same surgical
procedures and immediately following tooth extraction


Type I (Hammerle Classification)





Rationale
Easier definition of the implant position
Reduced number of visits in the dental office
Reduced overall treatment time and costs
Preservation of bone at the site of implantation
Optimal soft tissue esthetics
Enhanced patient acceptance


(Werbitt & Goldberg 1992; Barzilay 1993; Schwartz-Arad & Chaushu 1997a; Mayfi eld 1999; Hammerle et al. 2004)



Immediate Implant & GBR
Disadvantages
Site morphology may complicate optimal Placement and
anchorage.

Adjunctive surgical procedures may be required.

Technique sensitive procedures.

Thin tissue biotype may compromise optimal outcome.

Potential lack of keratinized mucosa for flap adaptation.

Esthetic Complications with Immediate
Implants
Observed complications with immediate implants in early
2000.

Increased risk for facial bone resorption and consequent
soft tissue recession.

Mucosal Recession with Immediate Implants
Clinical studies reporting mucosal recessions

Lindeboom, Tjiook, Kroon: Immediate placement of implants in periapical
infected sites: a prospective randomized study in 50 patients. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 101:705, 2006.


Chen, Darby, Reynolds: A prospective clinical study of nonsubmerged
immediate implants: clinical outcomes and esthetic results. Clin Oral Implants
Res 18: 552, 2007.


Kan, Rungcharassaeng, Sclar, Lozada: Effects of the facial osseous defect
morphology on gingival dynamics after immediate tooth replacement and
guided bone regeneration: 1-year results. J Oral Maxillofac Surg 65: 13, 2007.
Mucosal Recession with Immediate Implants
Clinical studies reporting mucosal recessions

Evans, Chen: Esthetic outcomes of immediate implant placements. Clin Oral
Implants Res 19: 73, 2008.


Chen, Darby, Reynolds, Clement: Immediate implant placement post-
extraction without flap elevation: A case series. J Periodontol 80: 163-172,
2009.
Mucosal Recession with Immediate Implants
Keys of success in Esthetic Zone
Preservation of adequate amount of facial bone.


Surgical procedures which encourage healing capable of
maintaining at least 2 mm of facial bone dimention.

Appropriate bone dimention (horizontal bulk in addition to
vertical height) helps to maintain bone and soft tissue over
the longer term.

Conclusion
The alveolar process following tooth extraction will adapt
by atrophy and an immediate implant in this respect
cannot prevent this problems ,and unable to substitute for
the tooth.


The problem with type 1 placement is that the bone loss
will frequently cause the buccal portion of the implant to
gradually lose its hard tissue coverage, and that the metal
surface may become visible through a thin peri-implant
mucosa and cause esthetic concerns.
Conclusion
To overcome this problem

Placing the implant deeper into the fresh socket and in
the lingual palatal portion of the socket to overcome
buccal bone resorption

bone regeneration (augmentation) procedures may be
required to improve or retain bone volume and the
buccal contour at a fresh extraction site.

Summary
There is no doubt today that this approach is associated with an
increased risk for esthetic complications
Mucosal recession on the facial aspect

There are significant risk factors for such Complications :
Gingival biotype (thin, highly scalloped)
Oro-facial malposition of the implant
Shape of facial bone defect (V-shape vs. U-shape)

This treatment concept is of complex level
Clinician must be very experienced

Careful case selection is crucial
Esthetic risk assessment