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Immediate Maxillary Molar Implant Placement with Simultaneous Crestal Approach Maxillary Sinus Bone Graft and Flapless Extraction Jone Kim, DDS, MS

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Immediate Maxillary Molar Implant Placement with Simultaneous Crestal Approach Maxillary Sinus Bone Graft and Flapless Extraction Jone Kim, DDS, MS Immediate Maxillary Molar Implant Placement with Simultaneous Crestal Approach Maxillary Sinus Bone Graft and Flapless Extraction Jone Kim, DDS, MS INTRODUCTION extraction, crestal sinus lift, immediate implant placement and ridge preservation P.I. Bränemark introduced the idea of can be combined into one surgical visit for osseointegration when he noticed the the reconstruction of posterior maxillary incorporation of titanium with bone molars with appropriate preoperative tissue.1 The concept of osseointegration evaluation and meticulous surgical revolutionized the replacement of missing technique. teeth with dental implants. Greater understanding in bone and soft tissue EXTRACTION physiology, accelerated by technological There is a theoretical advantage to flapless advances, has resulted in significant extractions in decreasing bone resorption. improvements in dental implant surgery; Canine studies comparing flapped versus enabling a reduction in the number of flapless extractions of second, third and surgeries with less invasive surgical fourth premolars without bone grafting or techniques, optimized esthetics, and implant placement demonstrate no decrease in the length of total treatment significant difference in horizontal and time from extraction to final restoration. vertical bone loss. 2-4, 5 However, canine Contemporary implant surgeons employ studies comparing flapped versus flapless less traumatic surgical techniques, place extraction of more anterior first and implants immediately, and combine second premolars demonstrates a multiple surgical techniques with fewer significant difference with less bone surgeries. resorption with the flapless technique. 6 A The posterior maxillary molar site is plausible explanation for this difference particularly challenging due to reduced between the two studies may be that the alveolar bone and the presence of the stripping of the periosteum in areas of maxillary sinus. A ridge preservation bone thinner buccal bone in the more anterior graft and/or a maxillary sinus bone graft is portion of the maxilla causes greater bone often required prior to implant placement, resorption. Studies have shown that thin complicating immediate implant buccal bone (< 1 mm) has more bone placement. Simultaneous flapless resorption compared to thicker bone (> 1 mm).7-12 In addition to alveolar bone RIDGE PRESERVATION BONE resorption, full thickness flap may lead to marginal recession at the adjacent teeth, GRAFT (RPBG) defective papillae and loss of keratinized After extraction, the surrounding alveolar mucosa.13 bone goes through stages of remodeling Flapless surgery makes it simpler to bone resulting in alveolar dimensional 16-18 17 graft the socket than flapped surgery. The changes. Cardaropoli et al. and 18 flapless extraction socket is basically an Araujo and Lindhe, demonstrate empty cavity where bone grafting particles horizontal and vertical bone resorption is can be placed with ease and with less from loss of bundle bone within two weeks mobility. In addition, since no incisions are after extraction. The crestal part of the made, a flapless extraction results in less buccal bone is solely made up of bundle surgical trauma, shorter surgical time, no bone, whereas lingual bone is comprised of need of suturing and decreased swelling lamellar and bundle bone. After extraction, and pain. Because of these advantages, since the crestal part of the buccal bone is the flapless extraction technique should be made primarily up of bundle bone, considered for all teeth that require an increased bone resorption is observed in 17-24 extraction, even if the extraction site is not buccal bone compared to lingual bone. for socket management or immediate Immediate bone grafting is performed implant placement. after the extraction to preserve the However, the most important aspect of the alveolar ridge, to minimize future bone extraction, in the author’s view, is not grafting, and increase the success of the whether the flap is made or not but rather implant surgery. There is horizontal bone minimizing removal of bone. Therefore, the reduction of 32% at three months, and 29- extraction technique should focus on 63% at six to 12 months after 18,19,25-30 preserving the alveolar bone, especially extraction. There is 11-22% the buccal and interradicular bone. Among vertical bone resorption observed at six the socket bony walls, buccal bone is the months post-extraction and increasing thinnest and will, therefore, resorb more vertical resorption with multiple 19,22,31,32 than other bony walls, and the extractions. Ridge preservation preservation of interradicular bone is bone grafting (RPBG) is a predictable critical for immediate molar implant surgical modality to preserve the alveolar placement after the extraction.7,9,14,15 If the bone after the extraction and allow for 19,33-37 flapless extraction is too difficult, it is wider and longer implant placement. better to make a minimal flap and remove In a recent randomized controlled clinical less bone than to do a flapless extraction trial, 48 implants were placed into either with more bone removal. If the flapless RPBG sites or spontaneously healed extraction can be achieved with no bone extraction sites four months after tooth removal, then this should give the best extraction. All implants survived at the one clinical outcome. year follow up, but during surgery, 14/24 (58%) spontaneously healed extraction sites required additional bone grafting, whereas only 1/24 (7%) needed additional one bone graft material being superior to bone grafting in RPBG sites.38 the others. 29,33,37,40-47 No matter which bone grafting material or surgical There is an inverse correlation, resulting in technique is utilized, the ultimate goal of thinner buccal bone showing a two-fold RPBG is to preserve the alveolar bone for increase in horizontal bone loss compared future implant placement reducing the to thicker buccal bone in spontaneous need for additional bone augmentation at healed sites. Whether there is thick or thin the time of implant placement. 6,48-50 buccal bone, without bone grafting there is an average of 4.04 mm horizontal IMMEDIATE IMPLANT reduction.39 There is no correlation between the thickness of the buccal bone PLACEMENT and alveolar bone loss in RPBG sites. In an In the beginning stages of implant surgery, RPBG site there is an average of 0.71 mm implants were primarily placed in a horizontal bone reduction. RPBG is able to delayed manner. Extraction sockets healed compensate for alveolar bone contraction for several months prior to implant for both thin and thick buccal bone plates. placement. Implants placed in a delayed Therefore, what is important is not the approach have a high success rate.51- thickness of the buccal plate, but rather 55 The first clinical study of immediate whether or not RPBG was performed after implant placement was published in the extraction. 1978.56 Surgical techniques have evolved RPBG ideally should be performed in a along with increased knowledge of bone flapless manner to prevent horizontal bone healing in the extraction site to improve loss and maintain keratinized gingiva. In a the immediate placement of dental 7,26,57- prospective randomized clinical trial that implants with predictable results 65 compared flapped and flapless RPBG, Short term survival rates and clinical horizontal bone loss was 3.5 + 0.9 mm outcomes are similar in both immediate 63 and 1.7 + 0.6 mm for the flapped and and delayed approaches. Advantages of flapless approach, respectively.13 In immediate implant placement include the addition, the flapless technique showed an reduction in the number of surgeries and increased width of keratinized gingiva treatment time, preservation of alveolar compared to pre-operative measurement, height and width, optimal gingival esthetic, whereas the flapped approach showed ideal implant placement and patient’s 47,59,66-72 decreased width. However, the flapped convenience. There is more group had a slightly less vertical buccal favorable bone healing and improvement bone reduction compared to flapless (-0.6 in soft tissue contour with immediate 26 + 0.7 vs. -1.1 + 0.9 mm), which was placement. statistically significant. One of the major concerns with immediate Even though autogenous bone is the gold implant placement is the presence of standard for bone grafting, many bone infection at the extraction 73 graft alternatives such as xenograft, site. Successful outcomes have been allograft, alloplast , and bone demonstrated with placement of implants morphogenetic protein have been used in placed into extraction sites with periapical 5,74-76 RPBG. Currently, there is no consensus on lesions. A retrospective study of 418 immediate implants placed into extraction stability of the implant can be attained. For sites with periapical lesions demonstrated immediate molar implant placement after a 97.8% survival rate with mean follow up extraction, besides vital structures such as of 67 months. 77 Immediate implant the maxillary sinus, adequate dimensions survival rates are similar for extraction of the alveolar bone, particularly of sites with or without perapical lesions. interradicular bone, are crucial for achieving primary stability of the There are several factors that are implant.15,86 Primary stability of the implant important to ridge alteration and survival is achieved by placing the implant in the after immediate implant placement: interradicular bone. Anatomical dimensions thickness of buccal wall, horizontal bone
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