Dr Azade CheraghzadeDept. of prosthodontics, Dental School, Shahid Beheshti University of Medical

Sciences

OUTCOMES OF IMPLANT PLACEMENT

IN POST-EXTRACTION SOCKETS

OUTLINE INTRODUCTION STATEMENT OF PROBLEM PREOPERATIVE EVALUATION INTRAOPERATIVE

EVALUATION POSTOPERATIVE

EVALUATION SUMMARY

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INTRODUCTION

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1. Wagenberg BD, Ginsburg TR. Immediate implant placement on removal of the natural tooth: retrospective analysis of 1,081 implants. Compendium of Continuing Educ Dent 2001;22:399-404.

2. Cooper LF, Rahman A, Moriarty J, et al. Immediate mandibular rehabilitation with endosseous implants: simultaneous extraction, implant placement, and loading. Int J Oral Maxillofac Implants 2002;17:517-25.

History

Schuelte (1976)

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51. Wagenberg BD, Ginsburg TR. Immediate implant placement on removal of the natural tooth: retrospective analysis of 1,081 implants. Compendium of Continuing Educ Dent 2001;22:399-404.

2. Avinash S. Bidra. Evidence-Based Prosthodontics ;Fundamental Considerations, Limitations, and Guidelines. Dental Clinics of North America 2014 ; Jan, 1-17.

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PATIENTS WANT TEETH

NOT IMPLANTS!!

Carefully evaluate patient’s status for

PREDICTABLE TREATMENT OUTCOMES

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PATIENT IDENTIFICATION November 2014

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THE 3D DIAGNOSIS MODEL

Clinical exam. Radiographic exam.

Risk prediction

3D

Diagnosis

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Ahmad I, Protocols for Predictable Esthetic Dental Restorations. 2nd Edition, 2006, Blackwell

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GENERAL RISK FACTORSMedical

Periodontal

Oral Hygiene/Compliance

Occlusion

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Buser D, Belser C, ITI Treatment Guide. 2008, Vol 1

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1. PRE-OP EVALUATION

Pre-Op Evaluation

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ESTHETIC RISK ASSESSMENT1) Patient’s expectations

2) Smoking

3) Lip height

4) Gingival biotype

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4) GINGIVAL BIOTYPE

Thick Vs. Thin

Thick Vs. Medium Vs. Thin

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Fu JH, Lee A, Influence of tissue biotype on implant esthetics. Int J Oral Maxillofac Imp 2011;26:499-508

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MEASUREMENT TECHNIQUES

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o Visual inspectiono Trans gingival

probingo Probe

transparencyo Ultrasonic deviceo CBCT imaging

Fu JH, Lee A, Influence of tissue biotype on implant esthetics. Int J Oral Maxillofac Imp 20011;26:499-508

ESTHETIC RISK ASSESSMENT1) Patient’s expectations

2) Smoking

3) Lip height

4) Gingival biotype

5) Infection at the

implant site

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5) INFECTION

1. Guidelines for Immediate Implant Placement in Periodontally Compromised Patients, 20132. Crespi R, Cappare P, Gherlone E. Fresh-Socket Implants in Periapical Infected Sites in Humans. J Periodontol ; 2010; 81(3): 378-383.

o Acute Vs. Chronic

o Long term tissue stability

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17ESTHETIC RISK ASSESSMENT

6) SHAPE of the missing and adjacent teeth

7) BONE LEVEL at adjacent teeth

8) RESTORATIVE STATUS of the adjacent

teeth

9) Characteristics of the edentulous space

10)Width of hard and soft tissue

11)Height of hard and soft tissue

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2. Intra-Op Evaluation November 2014

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2. INTRA-OP

EVALUATION

SITE ASSESSMENT (Where?)

TIMING OF IMPLANT

PLACEMENT (When?)

TECHNICAL CONSIDERATIONS

(How?)

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SITE ASSESSMENT

Bone quality and

quantity

Socket Classification

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LEKHOLM & ZARB CLASSIFICATION (1985)

Lekholm & Zarb Classification (1985) November 2014

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SITE ASSESSMENT

Bone quality and

quantity

Socket

Classification

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1) Closed - contained - Extraction socket

2) One Wall - Dehiscence, Fenestration

3) Multiple Wall Defects - Horizontal Defect

4) Vertical Defect

BONE DEFECTS

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EXTRACTION DEFECT SOUNDING,

CLASSIFICATION

Caplanis N, Lozarra JL, Kan JY. Extraction Defect: Assessment, Classification and Management. International Journal of Clinical Implant Dentistry, 2009;1(1):1-11

EDS, Classification

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EXTRACTION DEFECT — TYPE 1

Pristine, undamaged single-rooted socket

Thick biotype systemically healthy

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Caplanis N, Lozarra JL, Kan JY. Extraction Defect: Assessment, Classification and Management. International Journal of Clinical Implant Dentistry, 2009;1(1):1-11

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EXTRACTION DEFECT — TYPE 2Any socket with up to

mild crestal bone loss or interproximal tissue loss

of 2 mmthin or thick biotype buccal plate thickness

<1 mm, or any combination

systemically healthy 1 socket wall is

compromised

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Caplanis N, Lozarra JL, Kan JY. Extraction Defect: Assessment, Classification and Management. International Journal of Clinical Implant Dentistry, 2009;1(1):1-11

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EXTRACTION DEFECT — TYPE 3

Moderate compromise of the local tissues

Systemically healthy Vertical or transverse

hard- and/or soft tissue loss of 3 to 5 mm

1 or 2 compromised socket walls

Thick or thin biotype

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Caplanis N, Lozarra JL, Kan JY. Extraction Defect: Assessment, Classification and Management. International Journal of Clinical Implant Dentistry, 2009;1(1):1-11

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EXTRACTION DEFECT — TYPE 4

Severely compromised socket

Greater than 5 mm vertical or transverse loss of hard and/or soft tissue

2 or more reduced socket walls

Systemically healthyBiotype either thick or

thin

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Caplanis N, Lozarra JL, Kan JY. Extraction Defect: Assessment, Classification and Management. International Journal of Clinical Implant Dentistry, 2009;1(1):1-11

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POSTERIOR AREASComplications

Anatomic structures

Bone DensityAccessSoft tissue

Contraindications

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Guidelines for immediate implant placement in periodontally compromised patients; Dental Learning 2010; 4(6), 131-137

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SURGICAL CONSIDERATIONS

Flap design

Ideal implant position

Adjunctive surgeries

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Bhat V, Bangawala MR, Immediate implant placement without flap elevation - A Review. NUJHS; 2014;4(3): 131-137

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IDEAL IMPLANT POSITION

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Fradeani M, Esthetic rehabilitation in fixed

prosthodontics. 2011

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November 2014THE BONY GAP?!

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Regenerative outcomes (Effectiveness)

Prevent bone resorption?

Effect on facial plate?

Effect on Dehiscence?

Antibiotics?

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Chen, Buser. Clinical and esthetic outcomes of implant placement in post-extraction sockets, 2009

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Esthetic Outcomes

Soft tissue Alterations?

Risk indicators?

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Chen, Buser. Clinical and esthetic outcomes of implant placement in post-extraction sockets, 2009Chen, Buser. Esthetic outcomes of immediate implants in anterior maxilla, 2014

39 3. POST-OP EVALUATION

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3. POST-OP EVALUATION Loading

Protocols

Maintenance

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LOADING PROTOCOLS

Immediate Early Conventional

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Touati B, Guez G. Immediate Implantation with provisionalization: From literature to clinical implications; Pract Proced Aesthet Dent 2002; 14(9): 699-707

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Chen, Buser. Esthetic outcomes following immediate and early implant placementin anterior maxilla,Int J Oral Maxillofac Imp 2014

Immediate Loading

Prosthetic Requirements

Immediate Vs. Conventional Loading?

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SURVIVAL RATE? > 95%

1. Martínez JP , Pascual TP, Bueno SM, Immediate implants following tooth extraction: A systematic review. Med Oral Patol Oral Cir Bucal. 2012;17 (2): 251-61. Chen, Buser. Esthetic outcomes of immediate implants in anterior

maxilla, 2014

MAINTENANCE November 2014

Patient Satisfaction?

SUMMARY

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1. Prasad DK, Mehra D, Prasad DA, Recent advances, current concepts and future trends in oral implantology: Indian Journal of Oral Sciences, 2014; 5(2): 55-62

2. Misch CE, Dental implant prosthetics 2015

Advantages

Disadvantages

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462. Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages. Monish Bhola, Anthony L. Neely, Journal of Prosthodontics17(2010) 576–581 .

1. Immediate Implant Placement: Positive and Negatives. Richard U. Koh, Ivan Rudek, Hom-Lay Wang, IMPLANT DENTISTRY /VOLUME19, NUMBER2 2010 : 98-105

INDICATIONS ABSOLUTE CONTRAINDICATIO

NS

RELATIVE CONTRAINDIC

ATIONSSystematically

HealthyComplicated

systemic diseasesHeavy

smokersAdequate soft

tissueMaxillary sinus

involvementAdequate hard

tissueHistory of

bisphosphonatesIntact facial

plateHistory of

periodontal disease

Thick tissue biotype

Absence of intact labial plate

Presence of active infection

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Criteria for

Case Selection

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Esthetic Risk Factors

Low Medium High

Medical statusHealthy,Intact

Immune System

-

Compromised Immune System

Smoking Non-smoker

Light smoker(<10 cig/d)

Heavy smoker (>10 cig/d)

Esthetic expectations

Low Medium High

Lip line Low Medium High

Gingival biotypeLow-

scalloped, thick

Medium-scalloped,Medium-thick

High-scalloped,thin

Shape of tooth crowns

Rectangular

- Triangular

LOW MEDIUM HIGH Novem

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Infection at implant site None Chronic Acute

Adjacent teeth bone

level

≤5 mm to contact point

5.5-6.5 mm to contact point

≥7 mm to contact point

Adjacent teeth

restorative status

Virgin - Restored

Width of edentulous

span

1 tooth (≥7 mm)

1 tooth (≥5.5 mm)

1 tooth (<7 mm)

1 tooth (<5.5 mm)

2 teeth or more

Soft tissue anatomy

Intact soft tissue

- Soft-tissue

defectsBone

anatomy of alveolar crest

without bone deficiency

Horizontal bone

deficiency

Vertical bone

deficiency

MEDIUM HIGH

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FACTORS INFLUENCING DECISION-MAKING Scientific

documentationBenefit for the patient

Risk for complications

Difficulty of treatment

(SAC Classification) Cost-effectiveness

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CONCLUSION

Proper diagnosis and implant position despite

challenges Need for further evidence The key to implant success is primary

stability

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Thank you

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