Year : 2016 | Volume
: 6 | Issue : 2 | Page : 49--50
Rapid implant solutions:Immediate protocols, is it always predictable?
Editor-in-Chief, ACE Dental Clinic and Implant Centre, Dr. L H Hiranandani Hospital, Mumbai, Maharashtra, India
Editor-in-Chief, ACE Dental Clinic and Implant Centre, Dr. L H Hiranandani Hospital, Mumbai, Maharashtra
|How to cite this article:|
Shetty S. Rapid implant solutions:Immediate protocols, is it always predictable?.J Dent Implant 2016;6:49-50
|How to cite this URL:|
Shetty S. Rapid implant solutions:Immediate protocols, is it always predictable?. J Dent Implant [serial online] 2016 [cited 2017 Dec 13 ];6:49-50
Available from: http://www.jdionline.org/text.asp?2016/6/2/49/202159
Tooth loss has always plagued mankind and implant prosthesis have been successfully used to restore such handicaps. The most reviewed and managed total and partial edentulous cases with Branemark's protocol of delayed placement has yielded success ranging from 94% to 99% under varied conditions.
The timing of implant placement can be probably differentiated as:
Immediate placement after extractionImmediate delayed placement from 48 hours to three weeks, when there is soft tissue coverage. This allows resolution of local infections and primary closure of flaps, post-implant placementDelayed placement from 12 to 16 weeks, when sockets are filled radiographicallyDelayed placement beyond 16 weeks, in completely healed sockets or grafted sites.
There has been an ever-increasing demand from the patients to curtail the time from extraction to placement. Also there have been significant morphological changes and physiological changes seen in the native bone and soft tissue during healing period. The estimated loss in the horizontal buccolingual width of bone is 3 to 7 mm and vertical occlusoapical height is 1.5 to 3 mm in six months. Some of the anticipated and possible advantages of immediate placement of implants include less surgical trauma and bone necrosis, so faster remodeling and osseointegration. It also reduces treatment time and preserves alveolar bone and current soft tissue esthetics.
Schulte and Heimke first described this procedure way back in 1976. Recent trends in clinical practice has seen a greater surge in immediate placement of implants after extraction of teeth, irrespective of the location and size of the sockets, the current bone status, infections in and around the sites of extraction. However, such generalized and blanket therapies in the garb of “same day implants and restorations” need to be carefully undertaken to avoid disruptions in the outcomes and patient's faith in implant treatment. There seems to be bias towards the protocol rather than risk-evaluation and placement. The only yardstick used is the high torque values but they also fail if it induces high osteoclastic activities as seen with type 1 bone. The question is whether there are more rational criteria to do immediate placement.
There is a strong need to create a checklist for immediate placement of implants. Some of the variables to be considered and re-evaluated to ensure a favorable outcome are:
Reasons for extraction: Traumatic, carious and intra-radicular endodontic failure causes have better prognosis with immediate placement than with extra-radicular infections and periodontal infections. Outcomes with implant placed immediately in infectious sites as reported in literature show lower and unpredictable success of less than 93%. So it is safer to place them in infection free sites after healing period of 2-3 weeks as failures have more catastrophic results of both hard and soft tissuesType of extraction: Traumatic extraction using varied sizes of luxators, pressure and drilling of bone leads to destruction of local architecture and cellular viability. Use of periotomes and peizosurgical techniques are least traumatic. Raising the flap would lead to compromised supply to the underlying bone and possible resorptionCondition of labial/buccal plate and possible distance from the implant surface: If here is dehiscence of 2-5 mm, immediate placement is acceptable as fill is expected. Defects greater than 5 mm will need augmentation and/or delayed placement. There needs to be at least 2 mm of space between the buccal plate and implant surface so that eventual healing leaves behind bone of at least 1 mm over the implant. Socket shield has also been effectively used to preserve the buccal bone but it is technique-sensitivePrimary stability: The implant should be engaged in native bone 3-5 mm apical to the extraction socket. A minimum length of 10 mm of implant is needed for immediate placement. A torque of 35 Ncm is desired for stability and success of immediate placement. Paraxial views help to determine the undercut areas beyond the root tips, dipped maxillary sinus and neurovascular bundles close to the socket tip ruling out immediate placement for want of primary stability3D placement of implants and its surface characters: The implant should be placed at least 1.5 mm away from adjacent tooth and 3 mm from adjacent implant. Cervically it should be 5 mm away from the contact area and 3 mm below the CEJ of tooth. Macroscopically implant should have bone compressive threads and grooves and microscopically surface treated for greater stabilityGaps between implant surface and existing bone and fills: Spaces greater than 2 mm should be preferably filled with autogenous bone harvested from local areas or mixed with other external substitutes and with a hermetic sealBiotype of the soft tissue: Thick and shallow gingivae have lesser degree of resorption. Effort should be made to improve the quality of gingival tissue at the time of surgery or second stage by appropriate soft tissue grafting techniquesPossible occlusal loading: Loads leading to micromotion greater than 50 microns can disrupt healing process and lead to failure. If provisionals are made to bioengineer the soft tissue or maintain the architecture, functional loading should be avoidedMedical conditions contraindicating placement: Uncontrolled systemic disorders and nicotine consumption are suspect for failure and hence should be controlled for predictable outcomes. Besides taking effective antibiotics a day prior to surgery, continued use after immediate implant placement is essential.
Occlusal overload has huge failures and frustrations in restorative practices. Teeth with their periodontal ligament adapt or respond with mobility and pain but are restored back to their physiologic health on removal of the occlusal insults. Implant prosthesis only fail or ail under such obnoxious overloads, as there are no protective mechanisms. Hence it is mandatory to avoid any overload, which means micromotion of less than 50 microns. Multiple splinted implants, which have been immediately placed and capable of withstanding excess micromotion, can be loaded minimally with softer food. Nonsplinted and mobility-prone immediately placed implants can be restored with no functional loading especially in the esthetic zone. It is prudent to load the posteriors after 3 months of implant healing.
Immediate implant placement and loading is a treatment strategy and an emotional one, but is multifactorial in nature and hence evaluation should be accurate, relevant and realistic to meet patient's specific needs and desires. There are alternate predictable options specially when there are questionable findings.
“Nature is trying very hard to make us succeed, but nature does not depend on us. We are not the only experiment.”
- Buckminster Fuller