|Year : 2018 | Volume
| Issue : 2 | Page : 43-47
Immediate implant placement: A longitudinal study to assess soft and hard tissue
Mamatha Nanjappa Siddalingappa, Yogish Puttashamachari, Rithesh Kulal, Rohit Srikanthan, Mohammed Umer Sharieff
Department of Oral Implantology, Rajarajeswari Dental College and Hospital, Affiliated to Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||17-Dec-2018|
Dr. Mamatha Nanjappa Siddalingappa
Department of Oral Implantology, Rajarajeswari Dental College and Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: The aim of this prospective study was to evaluate clinically the success and esthetic result (soft-tissue and hard-tissue changes) of immediate implant placement after 1 year.
Materials and Methods: Eighteen patients with 23 titanium screw-shaped implants (13–16-mm length and 4.3–5-mm diameters) were placed in the extraction sockets. The jumping distance after implant placement was filled up with G bone synthetic hydroxyapatite granules and platelet-rich fibrin. It was again reevaluated at second-stage surgery. Clinical parameters of the peri-implant conditions were assessed after 1-year follow-up.
Statistical Analysis: Statistical Package for Social Sciences (SPSS) for Windows, Version 22.0. released 2013. Armonk, NY: IBM Corp, was used to perform statistical analyses.
Descriptive Statistics: It includes expression of the study variables with categorical data regarding number and percentage whereas in mean and standard deviation for continuous data.
Results: The cumulative implant survival and success rate were determined after 1-year observation period. The analysis of the esthetic result, papillary index, interdental bone, gingival biotype, modified plaque index, and modified bleeding index was analyzed.
Conclusion: This study determines us the success rate and esthetics of immediate implant placement after tooth extraction.
Keywords: Esthetic rehabilitation, immediate implants, jumping distance, pink esthetic score
|How to cite this article:|
Siddalingappa MN, Puttashamachari Y, Kulal R, Srikanthan R, Sharieff MU. Immediate implant placement: A longitudinal study to assess soft and hard tissue. J Dent Implant 2018;8:43-7
|How to cite this URL:|
Siddalingappa MN, Puttashamachari Y, Kulal R, Srikanthan R, Sharieff MU. Immediate implant placement: A longitudinal study to assess soft and hard tissue. J Dent Implant [serial online] 2018 [cited 2019 Oct 14];8:43-7. Available from: http://www.jdionline.org/text.asp?2018/8/2/43/247579
| Introduction|| |
Loss of alveolar bone may be attributed to a variety of factors, such as endodontic pathology, periodontitis, facial trauma, and aggressive maneuvers during extractions. Most extractions are done with no regard for maintaining the alveolar ridge. Extraction due to caries, trauma or advanced periodontal disease and subsequent healing of the socket commonly result in osseous deformities of the alveolar ridge, including reduced height and reduced width of the residual ridge. The progressive involution of the alveolar bone begins following tooth loss, and it is accompanied by a reduction in both the quality and quantity of hard and soft tissues. To estimate the appropriate time for implant insertion, it is essential to understand the healing events that occurred after tooth extraction. It was shown that after extraction of natural teeth, the greatest reduction of the alveolar bone occurs in the first 6 months to 2 years. An estimate of 25% decrease in faciopalatal width occurs within the 1st year. For this reason, within the last decades, the “gold standard” implant treatment protocol has been challenged by experiments, which aimed at shortening the treatment period and by reducing the number of surgical procedures. The literature has demonstrated that it is no longer needed to wait for complete healing of the extraction socket before implant placement. With this surgical approach, it allows a better final rehabilitation because it facilitates morphological ridge contour preservation as well as accurate prosthetic implant installation– maintaining the natural tooth angle. However, the study of Araújo et al. showed that the placement of an implant in the fresh extraction site obviously failed to prevent the re-modeling that occurred in the walls of the socket. It is suggested that the resorption of the socket walls that occurs following tooth removal must be considered in conjunction with implant placement in fresh extraction sockets.
Surgical procedure planning in the case of immediate implant placement must fulfil several preset clinical conditions. These include the following: implant primary stability, qualitative osseointegration, proper prosthetic location, and esthetic result. An absolute requirement is that 3–5 mm of implant must be inserted into the host bone to gain initial implant stability.
To ensure optimal esthetic implant rehabilitation, the following prerequisites are considered essential: Adequate bone volume (horizontal, vertical, and contour), optimal implant position (mesiodistal, apico-coronal, buccolingual, and angulation), stable and healthy peri-implant soft tissues, esthetic soft-tissues contours, and ideal emergence profile. The level of bone support and the soft-tissue dimensions around the implant-supported single tooth restoration are factors suggested to be important for the esthetic outcome of implant therapy.
The aim of this prospective study was to evaluate clinically the success and esthetic result (soft-tissue and hard-tissue changes) of immediate implant placement after 1 year.
| Materials and Methods|| |
The study was conducted on 18 patients who received 23 titanium screw-shaped implants in the Department of Implantology, Rajarajeswari Dental College and Hospital, Bangalore. Eighteen implants were placed in the maxilla and five in the mandible.
The inclusion criteria included systemically healthy patients and patients with both thick and thin gingival biotype. Patients who were heavy smokers and with acute periapical infection, periodontitis were excluded from the study. The height of the alveolar process and the available remaining bone for dental implant insertion above the extraction socket apex was estimated by the orthopantomogram and cone-beam computed tomography. After local anesthesia, teeth were atraumatically extracted to avoid fracture of the socket walls. The width of the extraction socket was measured with a standard periodontal probe intraorally in mesiodistal and labiopalatal directions at the socket margin. The mesiodistal dimension between adjacent teeth was measured in the mesiodistal direction between the most prominent points at the cemento-enamel junction level.
Osteotomy site preparation and implant placement were done. If the jumping distance was more than 2 mm, it was filled up with bone graft and platelet-rich fibrin. The prosthetic rehabilitation was done after 3–4 months. Implant esthetic result evaluation was performed after prosthetic rehabilitation and at 1-year follow-up [Figure 1].
|Figure 1: Immediate implantation done wrt 21. (a) Preoperative picture showing missing 22. (b) IOPR showing root stumps wrt 22. (c) Atraumatic extraction has been done. (d) Measurement of the extracted tooth. (e) Guiding pin placed after osteotomy. (f) Implant placement done. (g) IOPR showing placement of healing abutment. (h) Abutment is fixed. (i) IOPR showing abutment fixed onto implant. (j) Impression is taken. (k) Final prosthesis|
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The criteria of success set for this study were chosen according to Albrektsson et al. and included the following: absence of persistent subjective complains, such as (a) absence of pain and foreign-body sensation, (b) absence of peri-implant infection with suppuration, (c) absence of mobility, (d) absence of a continuous radiolucency around the implant, and (e) vertical bone loss <1.5 mm in the 1st year of function. The health and stability of soft tissues were assessed by modified plaque index (MPI) and modified bleeding index (MBI) as proposed by Mombelli et al. Esthetic and harmonious implant-supported restoration to the preexisting dentition was evaluated according to Fürhauser et al. The pink esthetic score (PES) is based on mesial papilla, distal papilla, soft-tissue level, soft-tissue contour, and texture. Each variable was assessed with a 2–1–0 score, with 2 being the best and 0 being the poorest score.
Dental papilla preservation was evaluated clinically using a papillary index described by Jemt The analysis of the gingival biotype was also done.
| Results|| |
The cumulative implant survival and success rate was determined after 1-year observation period. The analysis of the esthetic result, papillary index, interdental bone, gingival biotype, modified plaque index, and MBI was analyzed. All implants were stable and painless, and no discomfort was recorded. No sign of continuous radiolucency around the implants [Table 1].
|Table 1: Distribution of Post op complications & other characteristics among the among the study subjects|
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The cumulative implant survival and success rate was 96% after the 1-year observation period. Mean bone loss, (mesial-0.74 and distal-0.78) is in line with previously reported data (Albrektsson et al. 1986, Schropp et al. 2005) [Graph 1] and [Table 2]. MPI (0.94) and MBI (0.28) remained at low value [Graph 2]. Interdental papillae fills entire space in 15 cases (65.20%) [Graph 3] and [Table 3]. 18 cases (78.3%) presents with thick gingival biotype. The PES, describing mesial and distal papillae, soft tissue level, soft tissue contour after 1year post implant placement showed promising results [Table 4].
|Table 2: Descriptives of implant size characteristics, bone loss plaque and bleeding indices among the study subjects|
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|Table 3: Condition of interdental papilla post implant placement among study groups|
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|Table 4: Descriptives of pink aesthetic scores w.r.t the gingiva during post implant placement period in study subjects|
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Statistical Package for Social Sciences (SPSS) for Windows, Version 22.0. IBM Corp: Armonk, NY, USA was used to perform statistical analyses.
| Discussion|| |
Dental implant therapy is one of the pioneering treatment modality for replacement of missing teeth. Bone loss after tooth extraction remains an important issue in dentistry. Anatomically, bone resorption occurs both buccolingually and apicocoronally. Resorption of the buccal wall of the extraction socket may lead to significant disadvantages, especially in the anterior part of maxillae. A buccal concavity in the alveolar process or an implant that is placed more lingually than the adjacent teeth may result in poor esthetics. In addition with increasing resorption, the incisive canal is positioned relatively farther buccally, which forces the surgeon to place implants replacing the central incisors too close to laterals. Eventually, the alveolar process may become too narrow to allow implant placement. To reduce the problems resulting from this loss of bone, dental implants have been placed into fresh extraction sockets.
Frequently, when implants were placed into extraction socket, a partial incongruency between the outer surface of the implant and the bony walls of the socket is often seen. This space is known as jumping distance or critical space. Use of wide diameter implants helped in obliterating the jumping distance. Therefore, there is no need to place any bone grafts to compensate the jumping distance, also several studies have shown that bone augmentation techniques may not be required when the distance between the implant and the bony wall is <2 mm.
Implant survival and success rate were 96%. This is in agreement with previously published papers (Lazzara 1989; Becker and Becker 1994). Immediate implantation method reduces the time from tooth extraction to complete rehabilitation when compared with classical delayed and late implantation protocols. Resorption of the thin buccal wall and the alveolar crest after extraction may be reduced by a timely insertion of the implant.
Clinical parameters such as PES, MPI, and MBI remained unchanged (or low value), suggesting stable peri-implant tissue conditions. Furthermore, all sites presented stable crestal bone levels. The mean vertical bone loss for all implants after 1 year of function was mesial-0.74 and distal-0.78. This is in line with previously reported data (Albrektsson et al. 1986, Schropp et al. 2005). At 1-year follow-up, the photoelectron spectroscopy was analyzed. Features such as mesial and distal papillae had a good score in 70% of cases. Other features such as soft-tissue level and contour were good in 80% of cases. About 75% of cases presented with good soft-tissue texture. All these features indicate good esthetics.
This implantation method reduces the time from tooth extraction to complete rehabilitation when compared with classical delayed and late implantation protocols. Resorption of the thin buccal wall and the alveolar crest after extraction may be reduced by a timely insertion of the implant.
Jemt (1997) proposed an index to assess the size of the inter-proximal gingival papillae adjacent to single-implant restorations. Our data showed that 15 cases (65.2%) had papillae which filled entire space.
Another prerequisite to successful implant rehabilitation, both functionally and esthetically, is the proper location of the implant fixture and restoration in the edentulous space. Implants should be placed in the optimal position mesiodistally, apicocoronally, and buccopalatally. The mesiodistal dimension between adjacent teeth should be 6 and 9 mm to ensure minimal (1.5 mm) distance between implant fixture and adjacent teeth. Natural buccal and proximal restorative contours can be ensured by correctly orienting the implant in a bucco-palatal position. A minimum space of 2 mm should be maintained on the buccal side in front of the external implant collar surface.
| Conclusion|| |
Immediate implantation in the fresh extraction socket offers many advantages over placing in the healed bone. Careful evaluation of potential extraction sites before immediate implant placement promotes optimal implant esthetics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Marcus SE, Drury TF, Brown LJ, Zion GR. Tooth retention and tooth loss in the permanent dentition of adults: United States, 1988-1991. J Dent Res 1996;75:684-95.
Mecall RA, Rosenfeld AL. Influence of residual ridge resorption patterns on implant fixture placement and tooth position 1. Int J Periodontics Restorative Dent 1991;11:8-23.
Bianchi AE, Sanfilippo F. Single-tooth replacement by immediate implant and connective tissue graft: A 1-9-year clinical evaluation. Clin Oral Implants Res 2004;15:269-77.
Araújo MG, Sukekava F, Wennström JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: An experimental study in the dog. J Clin Periodontol 2005;32:645-52.
Carlsson GE, Persson G. Morphologic changes of the mandible after extraction and wearing of dentures. A longitudinal, clinical, and x-ray cephalometric study covering 5 years. Odontol Revy 1967;18:27-54.
Lazzara RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:332-43.
Werbitt MJ, Goldberg PV. The immediate implant: Bone preservation and bone regeneration. Int J Periodontics Restorative Dent 1992;12:206-17.
Nemcovsky CE, Artzi Z, Moses O, Gelernter I. Healing of marginal defects at implants placed in fresh extraction sockets or after 4-6 weeks of healing. A comparative study. Clin Oral Implants Res 2002;13:410-9.
Jovanovic SA. Bone rehabilitation to achieve optimal aesthetics. Pract Periodontics Aesthet Dent 1997;4:41-51.
Belser UC, Buser D, Hess D, Schmid B, Bernard JP, Lang NP. Aesthetic implant restorations in partially edentulous patients – A critical appraisal. Periodontol 2000 1998;17:132-50.
Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:11-25.
Mombelli A, van Oosten MA, Schurch E Jr., Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol 1987;2:145-51.
Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single-tooth implant crowns: The pink esthetic score. Clin Oral Implants Res 2005;16:639-44.
Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997;17:326-33.
Zarb GA, Schmitt A. The edentulous predicament. I: A prospective study of the effectiveness of implant-supported fixed prostheses. J Am Dent Assoc 1996;127:59-65.
Schropp L, Kostopoulos L, Wenzel A. Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: A prospective clinical study. Int J Oral Maxillofac Implants 2003;18:189-99.
Kazor CE, Al-Shammari K, Sarment DP, Misch CE, Wang HL. Implant plastic surgery: A review and rationale. J Oral Implantol 2004;30:240-54.
Ohrnell LO, Hirsch JM, Ericsson I, Brånemark PI. Single-tooth rehabilitation using osseointegration. A modified surgical and prosthodontic approach. Quintessence Int 1988;19:871-6.
[Table 1], [Table 2], [Table 3], [Table 4]