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Quality Resource Guide Third Edition Quality Resource Guide Immediate Dental Implants Author Acknowledgements Educational Objectives GUY HUYNH-BA, DDS MS Following this unit of instruction, the learner should be able to: Adjunct Professor/Clinical 1. Describe the different timings of implant placement. Department of Periodontics UT Health San Antonio 2. Describe the outcomes of immediate implant placement. School of Dentistry San Antonio, Texas 3. Recognize the prevalence of mid facial mucosal recession around immediate implants. Dr. Huynh-Ba has no relevant relationships to disclose. 4. Identify the risks factor for mid-facial mucosal recession. 5. List clinical guidelines to decrease risk for mid-facial mucosal recession. The following commentary highlights fundamental and commonly accepted practices on the subject matter. The information is 6. Identify treatment alternative to immediate implant placement. intended as a general overview and is for educational purposes only. This information does not constitute legal advice, which can only be provided by an attorney. © 2021 MetLife Services and Solutions, LLC. All materials subject to this copyright may be photocopied for the noncommercial purpose of scientific or educational advancement. Originally published July 2014. Updated and revised December 2017 and May 2021. Expiration date: May 2024. The content of this Guide is subject to change as new scientific information becomes available. MetLife designates this activity for 1.0 continuing education credits for the review of this Quality Resource Guide and successful completion of the post test. Address comments or questions to: Cancellation/Refund Policy: MetLife is an ADA CERP Recognized Provider. [email protected] Any participant who is not 100% satisfied with this course Accepted Program Provider FAGD/MAGD Credit 05/01/21 - 06/30/25. can request a full refund by contacting us. ADA CERP is a service of the American Dental Association to assist dental MetLife Dental Continuing Education professionals in identifying quality providers of continuing dental education. 501 US Hwy 22, Area 3D-309B Concerns or complaints about a CE provider may be directed ADA CERP does not approve or endorse individual courses or instructors, Bridgewater, NJ 08807 to the provider or to ADA CERP at www.ada.org/goto/cerp. nor does it imply acceptance of credit hours by boards of dentistry. Navigating life together Quality Resource Guide l Immediate Dental Implants 3rd Edition 2 Timing of Implant Placement Outcomes Assessment of Figure 1 The use of dental implants to replace missing Type 1 Implant Placement teeth has been universally accepted based on The outcomes of immediate implant placement a large body of scientific evidence since the (Type 1) has been documented as a predictable, early 1970s. While the initial guidelines published safe and effective approach to replace extracted by Brånemark and coworkers (1977)1 required teeth, with survival rates greater than 95% implants to be placed in healed alveolar ridges, in longitudinal studies up to 10 years.3-12 In the improvement in implant surface technology comparative trials immediate implant placement and understanding of wound healing around (Type 1) and implant placement in healed ridges dental implant have allowed the development of (Type 4) yielded similar survival rates without any more time efficient treatment protocol. statistical significant difference.13-16 Clinical picture illustrating an esthetic failure following immediate implant From a surgical standpoint, the climax of these While these results are encouraging, the placement at site #10 developments is represented by immediate assessment outcome (survival rate) falls short implant placement, i.e. the implant is placed in the when trying to reflect patient satisfaction with a (Courtesy of Dr. Brian Mealey, DDS, MS) same procedure as the extraction. given procedure. Indeed, the patient may rely more on the subjective esthetic perception of between the positions of soft tissue margins Different classifications of timing of implant an implant supported restoration to evaluates around the implant supported restoration and placement have been described.2,3 The the outcomes, successful or not, of therapy. For its contralateral natural counterpart. In esthetic terminology used in the present article uses the example, the case depicted in Figure 1 illustrates sensitive areas, this loss of symmetry leads to definitions established by the International Team an implant that would be considered as a positive 27 3 unpleasant esthetic outcomes. for Implantology (ITI). This classification is based outcome if survival is the outcome measured. on the desired clinical outcome during the post However, to the patient eyes this situation is an Risk Indicators of Recessions extraction healing period quality of healing of the esthetic failure. Several putative risk factors have been associated extraction socket. In an effort to address this shortcoming many with the development of soft tissues recessions Type 1 studies have reported esthetic outcomes of dental around immediate implants including a non-intact Tooth extraction and implant placement take place implant therapy including the level of the mid- facial plate following extraction, a thin buccal during one single dental appointment facial mucosal margin. plate, a facial positioning of the implant and thin Type 2 periodontal phenotype. The paragraphs below Soft Tissue Management present some relevant literature for each of these The extraction site is left to heal for 4 to 8 weeks Many immediate dental implants are placed in risk factors and some suggested clinical strategies allowing soft tissue healing over the extraction site the anterior region so a patient may maintain the in order to control them. before implant placement appearance of an intact dentition. Several factors Type 3 must be carefully considered during planning and Loss of buccal plate integrity Prior to implant placement, the least traumatic Following tooth extraction the site has healed for therapy in an attempt to minimize tissue recession extraction (see QRG on Atraumatic tooth 12 weeks allowing for complete healing of the soft and maximize the esthetic outcome. tissue and partial bony healing of the extraction extraction) must be performed with the goal to Immediate Implants and socket. maintain the integrity of the socket bone walls. Recessions This is of paramount importance since it has Type 4 One of the major esthetic concerns following been shown that the presence of a dehiscence Represents the implant placement in healed sites, immediate implant placement is the recession defect of the buccal plate at the extraction led to similar to the Brånemark protocol. of the facial peri-implant mucosa. The incidence a significant amount of buccal plate resorption, of peri-implant mucosal recession (up to 1mm) Implants placed in a healed ridge (Type 4) probably which in turn can lead to recession.21,22, 28-30 reported ranges between 8 and 40%.4,10,17-26 represent the most conservative approach and is Therefore, in case the integrity of the socket bone widely propagated, especially in conjunction with Some of these studies reported up to 2mm of peri- walls was not maintained, it is recommended ridge preservation procedure (See QRG Alveolar implant mucosal recession following immediate to reconstruct the alveolar ridge and place the Ridge Preservation Following Tooth Extraction). implant placement, leading to discrepancies implant in a staged approach.31 www.metdental.com Quality Resource Guide l Immediate Dental Implants 3rd Edition 3 Thin buccal plate Periodontal phenotype However, complete recession coverage is yet to Pre-clinical and clinical studies have convincingly Traditionally, the gingival phenotype characterized be a predictable outcome and no specific treatment demonstrated that the pattern of alveolar ridge the quality of the soft tissue around teeth taking modality can be recommended based on the current resorption and remodeling following tooth extraction in account four parameters including the width of limited available scientific data.62,63 was influenced by the width of the buccal plate. Due keratinized tissue, the gingival thickness, the shape Taken together, it can be concluded that preventive to the thin nature of the buccal plate, especially in and size of the interdental papillae and the crown strategies should be implemented to avoid mucosal maxillary anterior sites,32-35 ridge resorption will width/height ratio. Usually a thin gingival phenotype recession as no scientifically sound established decrease the width of the alveolar ridge and a loss is associated with a limited amount of keratinized treatment protocol is available at present to treat of the vertical height of the buccal plate is expected tissue, a thin gingiva with long interdental papillae 36-42 these unfavorable outcomes. following tooth extraction. It is important to creating a marked gingival scalloped architecture mention that the sole placement of a dental implant and reduced crown width/height ratios, i.e. triangular Clinical Considerations in the extraction socket cannot prevent these shaped teeth. Conversely, a thick gingival phenotype a) Anatomy physiological changes from happening.15, 43-46 is associated with large zones of keratinized tissue, One of the requirements for successful immediate Moreover, emerging evidence seems to indicate a thick gingiva, short interdental papillae with a flat implants is the ability to achieve primary stability
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