Immediate Dental Implant Placement, Immediate Restorative Treatment and Immediate Loading: Treatment Options in Dental Practice?

MINIREVIEW 91

Norbert Enkling Immediate dental implant placement, immediate restorative treatment and immediate loading: treatment options in dental practice?

Background tion). The healing of the implant can implant survival rates of fixed im- Immediate treatment concepts in ensue non-submerged or submerged plant-supported restorations as a dental implantology are becoming under the mucosa. If a partially eden- function of the different, temporal increasingly popular because the re- tulous dentition is restored, the im- treatment concepts in partially eden- duction in treatment time is highly plant is fitted immediately with a tulous patients (Table 1). From the 9 appreciated by patients and uncom- provisional fixed restoration in the conceivable surgical-prosthetic treat- fortable provisional restorations can form of a provisional crown or ment options, the scientific data con- be avoided. Given the correct indi- bridge, without static and dynamic cerning 8 treatment concepts was cation, the prognoses of immediately occlusal contacts after its insertion. evaluated and published. Very good placed implants and their prosthetic Immediate loading involves the di- implant survival rates of 96–100 % restoration are comparable to con- rect insertion of a restoration that is were described. No publications ventional, delayed treatment con- in occlusion. In cases where the could be found regarding the option cepts. Thus, immediate treatment edentulous jaw is rehabilitated, im- of delayed-immediate implant place- concepts should be considered as mediate loading is thus achieved in ment and immediate restoration, and therapeutic options in routine dental principle. In prosthetic dentistry, a therefore, this treatment option is an practice. distinction is likewise made between outlier. On the other hand, the fol- early loading (after approximately lowing 4 options, which are sup- Introduction 6 weeks/or rather 1–6 weeks after im- ported by a large body of scientific A distinction is made between implant placement) and late loading data, are recommended as they show mediate, early and late treatment concepts, with the latter approach strong long-term clinical evidence: concepts in terms of both the surgical ensuing after osseointegration (start- • immediate implant placement and and prosthetic phases of implant ing after approximately 6–8 weeks) delayed loading (implant survival therapy. This results in 9 different [18, 19]. rate 96 %), possibilities relating to the temporal With regard to restorative treat- • delayed-immediate implant place- sequence of treatment. ment, fixed restorations and remov- ment and delayed loading (im- Implant therapy includes the fol- able prostheses can be planned using plant survival rate 96.3 %), lowing possibilities: immediate after different loading options. This em- • delayed implant placement and tooth extraction, delayed-immediate phasizes the need to specify which early loading (implant survival rate after the healing of the mucosal option is being referred to when dis- 98.3 %), wound (approximately 8–12 weeks cussing the topic of the temporal se- • delayed implant placement and after extraction) or late after bone quence in implant therapy. In a re- delayed loading (implant survival healing (from 6 months after extrac- cent review, Gallucci et al. compiled rata 97.7 %).

Translation from German: Cristian Miron Citation: Enkling N: Immediate dental implant placement, immediate restorative treatment and immediate loading: treatment options in dental practice? Dtsch Zahnärztl Z Int 2021; 3: 91–97 DOI.org/10.3238/dzz-int.2021.0011

Surgery/implant place- Restorative treatment, loading Scientific Implant survival rate ment after extraction after implant placement documentation

Immediate Immediate 98.4 % +

Immediate Early 98.2 % +

Immediate Late 96 % ++

Early Immediate n.a. o

Early Early 100 % o

Early Delayed 96.3 % ++

Delayed Immediate 97.9 % +

Delayed Early 98.3 % ++

Delayed Delayed 97.7 % ++

++: scientifically and clinically validated +: clinically documented o: insufficient clinical documentation

Table 1 Different time-based protocols for surgical implant insertion and prosthetic implant restoration (according to Gallucci et al. [22])

Immediate implant placement and is needed and the patient is in good extraction. Thus, a large change in immediate restoration (implant sur- general health, open healing may be the vestibular contour results when vival 98.4 %) as well as late implant preferable. thin alveolar walls are present placement and immediate restoration Based on past experience, conser- (< 1 mm). Considerable bone loss (implant survival 97.9 %) also show vative treatment concepts involving often requires vestibular augmen- very good values, but are less docu- late loading tend to be selected in tation, especially in esthetically rel- mented clinically in the long term cases of doubt [42]. Modern implant evant jaw areas, which in turn pro- [22]. designs and surfaces exhibit osseoin- longs the treatment time [3, 12, 23]. Brånemark‘s treatment concepts, tegration features which permit the Due to the resorption of the bundle which represent the beginning of application of faster restoration con- bone, on average, about 1 mm of modern dental implantology, involve cepts with predictable success. Cur- resorption occurs in the anterior delayed implant placement and im- rent data shows that immediate con- maxilla in immediate implant place- plant loading times [13]. This results cepts have equivalent implant sur- ment [12, 49]; therefore, immediate in treatment periods of one year and vival and success rates as conven- implant placement cannot com- more. In a recent review, it was stated tional protocols [2, 21, 34, 39]. that submerged implant healing is The extraction wound initially advantageous with regard to the im- closes with soft tissue after tooth plant survival rate. However, initially extraction, whereas bone healing submerged implants displayed more takes about 6 months. In this time, crestal bone loss after one year of the remodeling and resorption of the function, on average, than implants bone occurs, after which, the bone healing openly [48]. Open healing structure remains relatively constant. can also be used in conjunction with The maxilla shows higher bone re- a provisional restoration. This ap- sorption rates than the mandible pears to be advantageous given the [16]. In a review, Tan et al. showed appropriate indication because im- that within the first 4–12 months mediate loading tends to stabilize after extraction, circa 50 % of the the peri-implant bone, and approxi- width of the alveolar process and mately 0.1–0.2 mm less bone resorp- about 15 % of its height resorbed; a tion occurs than in late loading [19, vertical loss of 3.1–5.9 mm and a 43]. This suggests that, in case of horizontal loss of 1 mm took place doubt, submerged healing should be [46]. Based on the thickness of the performed. However, in cases where vestibular alveolar lamella, varying the bone condition is good, the im- degrees of bone atrophy can be ex- plant’s primary stability is sufficient, pected because the bundle bone Figure 1 Initial radiological situation: no bone or soft tissue augmentation close to the tooth resorbs after fractured tooth 12

pletely prevent bone remodeling [17]. Moreover, the careful selection of the diameter and position of the implant is important in immediate implant placement. The diameter of the implant must not be chosen to be too large, and particularly for maxillary implants, a more palatal position should be selected due to the centripetal resorption pattern of the maxilla. These measures help to reduce the risk of vestibular recession with areas of exposed implant surface [5, 24, 49]. Immediate implant placement Figure 2 Initial clinical situation: fractured tooth 12 and immediate restorative treatment of the partially edentulous dentition is anticipated to result in a vestibular mucosal recession of approximately beautiful results can be achieved in [30]. Lower primary stability values 0.5–0.9 mm on average, although early or late restorative treatment on have been described successfully for more than 1 mm of recession may implants. However, this procedure is splinted full-arch restorations as occur in 20 % of cases [9]. These soft rather labor-intensive, and thus, well [31, 50]. For immediate loading, tissue changes occur within the first time-consuming and financially de- ideally, a quadrangular, primary 3 months [28]. The following vari- manding for patients [20, 51]. splinting of the implants appears to ables have been identified as risk fac- Immediate implant placement for be beneficial for the survival prog- tors for increased mucosal recession single restorations is performed more nosis [41]. For instance, the second- [24]: smoking, absent or thin buccal frequently in the anterior region than ary splinting of immediately loaded alveolar walls (< 1 mm), thin gingival in the posterior region. This is re- interforaminal implants using 1 to biotypes, limited buccal keratinized flected by the number of existing 2 Dalla Bona-type ball attachments mucosa, facially-oriented implant scientific studies. Immediate implant averaged an implant survival rate of positions, and excessive implant di- placement in the posterior region is only 81.6 % after one year, although ameters [7, 26, 29, 37]. However, if likely to result in increased bone loss, the majority of the implant failures guided bone regeneration in the form although the presence of a buccal al- occurred within the first month after of filling the alveolar crevices with veolar lamella reduces the bone loss loading [27]. In contrast, when a bone substitute material [3, 6, 12, 32] [37, 40]. In immediate implant place- dolder bar was used for the primary and/or buccal soft tissue augmen- ment, the implant’s stability is splinting of 2 implants, a survival tation with free connective tissue is usually ensured by the residual bone rate of 98.8 % was seen after performed at the same time as im- apical to the alveolar socket. A height 1–3 years [45]. mediate implant placement, the es- of 3 mm should be available in this When planning the immediate thetic result can be influenced favor- case. Especially for implants that are loading of several implants, implant ably through the preservation of the intended to support single crowns, splinting should be performed in buccal contour [23]. sufficient primary stability seems to the healing phase. The “All-on-Four” Immediate implant placement in be relevant. With regard to implant concept of cross-arch splinting, for conjunction with direct, immediate geometry, tapered (conical) implants example, shows very good results restoration using bridges or single are superior to parallel-walled im- when 4–6 implants are splinted to- provisional crowns helps support the plants [4]. A favorable condition for gether in the edentulous jaw. Given circular soft tissues and preserve the immediate loading is usually con- that the “All-on-Four” method has existing optimal red-white esthetics. sidered to be an ISQ of 60 and an in- been well-documented in the litera- The peri-implant soft tissue is sup- sertion torque of 35 Ncm [42]. How- ture, it is has become an evidence- ported reliably in the papillae region ever, there is disagreement in the lit- based and real planning option that [5, 10] and the preservation of the erature as to whether primary stabil- can be discussed with patients [33, papillae facilitates the attainment of ity values of 35 Ncm or 25 Ncm 38, 44]. The “All-on-Four” method re- esthetically pleasing results. In de- should be used for immediate load- stores the edentulous jaw with fixed layed restorative therapy, the flat- ing. In a recent review, the implant restorations by using 4 implants tened proximal soft tissues must first survival rates did not differ between which are placed specifically into the be grown again and reconstructed torque values of 25 Ncm or 32 Ncm existing subnasal maxilla or interfo - into a pseudo papilla; via the step- [49]. In principle, higher torque raminal mandibular bone, preferably by-step reconstruction of, or pressure seems to lead to better implant sur- in the region of the second incisors on, the approximal emergence profile vival rates, notably, when 40 Ncm and second premolars. Bone augmen- using provisional crowns, very or 50 Ncm was defined as the limit tation over the inferior alveolar nerve

implants appear to osseointegrate in the form of either immediate or late under occlusal load with similar suc- implant placement, appear to be par- cess rates as in non-occlusion [11, 19, ticularly interesting. 49]. On the other hand, the splinting together of several implants appears Clinical Recommendations to be beneficial because single pro- In immediate implant place- visional restorations show poorer im- ment and immediate restora- plant survival rates compared to tive treatment, the implant is horseshoe-shaped full-arch restora- placed in the area of the fresh extrac- tions [41]. At present, non-occlusion tion socket during the same appoint- Figure 3 Prepared provisional restora- is recommended clinically for the im- ment as tooth extraction. Immediate tion (CAD/CAM) mediate restoration of single-tooth implant placement is not indicated implants [41]. in an alveolar socket that shows signs In a recent review, flap-less sur- of acute inflammation. On the other gery was shown to be riskier in terms hand, chronic apical periodontitis of implant survival compared to does not represent a contraindication open surgery (risk factor: 1.70-fold). for immediate implant placement. If immediate loading is also perform- The scientific literature largely de- ed, the risk increases to 2.24-fold [12, scribes similar implant survival rates 52]. The extent to which current digi- as in immediate implant placement tal techniques will optimize these re- in healthy alveolar sockets [8, 29, 37]. sults is currently the subject of clini- However, a recent review reports a cal studies; in a currently ongoing 3-fold increased risk in the rate of im- study by the Implantology and plant failure [14]. This suggests that Biomaterials Research Group at the thorough excochleation of granu- University of Bonn (DRKS No. lation or cystic tissue is necessary be- 00022273), very good intermediate fore implant placement. results have been documented for Clinical studies show very good flap-less, guided implantology in a results for immediate implant place- fully digital workflow with prepared ment with an implant survival and single-tooth provisionals (CAD-CAM success rate of 98.4 % after 2 years Figure 4 Post-operative X-ray: imme - technique), for both the indication (95%-CI: 97.3–99 %) and < 1 mm of diate implant placement in region 12 immediate implant placement and bone loss. An improvement of the (SICvantage tapered: 3,7 x 14,5 mm/ immediate loading as well as the in- survival rate could be achieved by ad- SIC invent AG, Basel, CH), Flap-less, dication late implant placement and ministering systemic antibiotic ther- Guided-Surgery. immediate loading (Fig. 1–6). apy post-operatively [28]. Immediate Immediate concepts show an opti- implant placement is possible for mized patient satisfaction and are pre- both fixed restorations and remov- ferred by patients; long treatment able prostheses. However, the posi- or in the region of the maxillary si- times represent a burden for patients tion of the implant does not usually nuses is avoided through the distal because the provisional phase is follow the exact course of the alveolar inclination of the dorsal implants, usually associated with shortcomings socket. Instead, attention is needed to and an adequate prosthetic support in terms of the masticatory function, ensure that the implant’s axis is in- polygon is thus established. Implants phonetics, and esthetics [1, 25]. This clined away from the alveolar socket’s that are placed obliquely do not helps to explain why clinical experi- original course, to be offset palatally show increased failure rates or in- mentation with shorter, immediate into the local bone and deepened creased bone resorption compared to treatment concepts began as early as into the basal bone; this approxi- vertically placed implants [15, 35]. the 1970s and why various protocols mates to 1 mm below the buccal The “All-on-Four” concept, devel- with shortened treatment times were bone level or 3 mm apical to the ce- oped as an immediate implant place- documented. The collected data points mentoenamel junction of the adja- ment protocol by Malo in the 1990s, to the fact that immediate treatment cent teeth [49]. For multi-rooted teeth, has the advantage that the phase of approaches have an evidence base and insertion into the interradicular bone passive edentulism can be avoided. can be successfully applied in clinical or positioning into the palatal al- The extent to which occlusal practice nowadays, given that the indi- veolar socket is also possible. When loading should be avoided for im- cation is carefully selected [13]. In the implant is positioned, caution to mediate restorations in partially summary, from the patient‘s view- achieve primary stability and to an- edentulous dentition and the pro- point, immediate implant placement ticipate subsequent alveolar healing visionals should initially be designed combined with immediate restorative should be exercised. Usually, this re- in non-occlusion has not been scien- treatment in the visible region and im- sults in a palatal offset and a subcres- tifically clarified so far; single-tooth mediate loading in the edentulous jaw, tal position of the implant‘s shoulder.

© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3) MINIREVIEW 95 (Tab. 1, Fig. 1–6: N. Enkling) Fig. 1–6: 1, (Tab. Figure 5 Clinical situation: 1 week after immediate restoration with a provisional resto- Figure 6 Close-up X-ray: 1 week after ration in non-occlusion. immediate restoration

The impending prosthetic restoration to current data, the restoration of the immediate implant placement, the should also be taken into account edentulous mandible using a dolder crestal alveolar portions must be re- when positioning the implant; if a bar on two standard implants is con- moved generously and the implant is screw-retained crown is planned in sidered a safe immediate loading con- placed primarily in the basal bone. the anterior region, a steep implant cept [36, 47]. When quadrangular The extent of bone remodeling that axis should be chosen so as to allow primary splinting is used for imme - occurs after implant placement is not screw access in the area of the palatal diate loading, as is the case in the comparable to immediate implant cingulum and prevent contact with “All-on-Four” concept, even implants placement in a preserved extraction the incisal edge. If, on the other with lower primary stability (around socket, but is considerably less. The hand, a steeply placed implant is to 20–30 Ncm) can be loaded imme - surgical vertical ridge reduction must be restored with a cemented crown, diately in the mandible and maxilla be taken into account beforehand, es- a palatally over-contoured crown with success [31, 50]. A combination pecially when the vertical bone avail- would be the result. An implant that of immediate implant placement and ability is evaluated in order to deter- is planned for cementation must immediate loading is possible. How- mine realistic implant lengths. This have an oblique insertion direction ever, from a prosthetic standpoint, it flattening of the alveolar bone and so that the abutment required for ce- must be noted that a pronounced the possible smooth, basal design of mentation can be integrated in the change in hard and soft tissue mor- the bridge pontics presents hygiene contour of the crown. Good surgical phology occurs as a result of alveolar advantages; the contact surface be- and prosthetic planning is therefore healing; this leads to a change/cavity tween the mucosa and the base of the essential [49]. Given sufficient pri- formation in the interface between restoration is reduced and it becomes mary stability, the prognosis of im- the mucosa and the prosthesis, thus easy to clean using hygiene tools. plant success for imme diate restora- requiring the adjustment of the pros- A risk factor for a subsequent in- tive treatment is comparable to the thesis at a later point [13]. Provision- crease in the incidence of peri-im- results of restorative treatment after al restorations are usually used for plant mucositis and peri-implantitis osseointegration has been completed double immediate treatment for this is the amount of keratinized mucosa [13]. The provisional restoration is reason. Exceptions to this are defini- at the implant [37]. Thus, the quality usually prepared and inserted during tive restorations with PMMA coating; of the soft tissue (keratinized gingiva implant surgery. The splinting to- PMMA can be used as part of a relin- and biotype) must be considered be- gether of adjacent implants is desir- ing procedure and the transition sub- fore making a decision [26, 29, 37], able during the provisional phase. sequently optimized. and this emphasizes the need for ap- Conversely, immediate load- In the “All-on-Four” concept, propriate patient selection; if the ing represents an implant-supported prosthetically, the red esthetics are ini tial esthetic and anatomical situ- prosthesis in the edentulous jaw made using pink gingival replace- ation is good, immediate concepts which is fixed, if possible, within the ment materials (PMMA or ceramic). should be applied to preserve good first day (up to the third day) after The transition zone between the pink esthetics. implant placement [13]. In this case, gingival replacement material and the occlusal loading is unavoidable. The natural mucosa must be located out- Conclusion restoration may be either provisional side of the esthetically relevant zone, The expected vestibular contour or definitive. Immediate loading is which is visible during laugh ter. changes of the alveolar process when possible for both fixed restorations Therefore, it is often necessary to level immediate concepts are used must be and removable prostheses. According the alveolar bone; this means that, in functionally and esthetically accept-

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