Immediate implants - Dr Harshavardhan Patwal

IMMEDIATE IMMEDIATE IMPLANTS IMPLANTS

Dr Harhavardhan Patwal

•Rationale•Indications/Contraindications•Scientific Overview•Surgical Technique•Issues•Consensus Questions

IMMEDIATE IMPLANTS

6-12 months healing is recommended following tooth extractions prior to dental implant placement

Adell et al ,1981

Extraction of Teeth results in the loss of hard and soft tissues,a reduction of arch circumference and deficient width and heightof the residual ridge

Extraction of Teeth results in the loss of hard and soft tissues,a reduction of arch circumference and deficient width and heightof the residual ridge

Bone loss occurs both buccolingually and apicocoronally,with the first six months carrying the highest rate of resorptionin either direction.

Atwood,1983

Advantages of Immediate Implant Placement

•Reduction of Treatment Time•Minimization of Treatment Cost•Enhancement of Patient PsychologicalOutlook•Reduction of Surgical Procedure•Preservation of Ridge Contour•Enhanced Healing and Osteogenic potential•Simplification of Prosthesis•Optmization of aesthetic and functional results

• Traumatically Avulsed

•Residual Deciduous Teeth

•Horizontal/Vertical Fracture of Teeth

•Endo Failing

•Periodontally Compromised

•Non-Restorable Teeth

Indications

• Traumatically Avulsed

Indications

• Residual Deciduous Teeth

Indications

• Horizontal/Vertical Fracture of Teeth

Indications

• Endo Failing

Indications

• Periodontally Compromised

Indications

• Non-Restorable Teeth

Indications

• Inability to Develop Mechanical Stability

Width

Height

•Proximity to Adjacent teeth

•Placement outside alveolar envelop

•Presence of Infection

Contra-Indications

• Inability to Develop Mechanical Stability

Contra-Indications

• Proximity to Adjacent teeth

Contra-Indications

• Placement outside alveolar envelope

Contra-Indications

• Presence of Infection

Contra-Indications

•Sulcular Incisions with Vertical release•Atraumatic Extraction

Sectioning of Multi-root teethPeriotome

•Thorough Degranulation•Assessment of Socket Architecture•Widening/Deepening of Osteotomy•Placement of Implants•Placement of Graft/Membrane•Flap Closure

Surgical Technique

•Sulcular Incisions with Vertical Release

Surgical Technique

•Atraumatic Extraction

Surgical Technique

•Thorough Degranulation•Assessment of Socket Architecture

Surgical Technique

•Widening/Deepening of Osteotomy

Surgical Technique

•Placement of Implants

Surgical Technique

•Placement of Graft/Membrane

Surgical Technique

•Placement of Graft/Membrane

Surgical Technique

•Flap Closure

Surgical Technique

(Salama and Salama 1993)

• Dahlin-JOMI,89

•Lazzara-IJPRD,89

•Becker-JP,90

•Nyman-JOMI,90

•Schwartz-JOP,97

•Gilb-JOMI,93

•Wilson-JOMI,98

•Paolantonio-JP,01

•Cornelini-JOMI,00

•Becker-Perio-2000

ISSUES• Primary Stability•Thin Buccal Plate•Presence of Active Infection•Site- Posteriors?

Masticatory Forces

Bone DensityBone Volumes

1) Jumping Gap- What is the Threshold Gap Distance (HDD) b/n Implant & Bony Wall to warrant

use of Regenerative techniques?2) Loading - When is it advisable to load an

Immediate Implant (In view of limited Implant-Bony Contact).

(Immediate, Delayed Immediate, Conventional)3) Primary Stability Quantification-

If Early Loading is an Acceptable Protocol, what is the right measuring parameterfor Primary Stability.

Consensus Questions

Does the Gap Effects Osseointegration

Akimoto,Becker et al.JOP,1990 * Experimental

* Canine Model* 12 Weeks Study* End Points- Clinical Bone Fill

Histomorphometry*Control*Coronal Gap of 0.5mm*Coronal Gap of 0.975mm*Coronal Gap of 1.35mm

Ctrl- 400.5- 25.935- 121.35- 5

Apically No Difference Clinically/Histologically

Coronal 4 mmNo Statistical DifferenceNo Mobility Detected

“Gap Does Effect Osseointegration”

RESULTS

Clinical Bone Fill

Histomorphometrically(% BIC)

Bridging the GAPWarrer,L, Got Fredien,K et al. Clinical Oral Implant Research’91

•Experimental•Canine Model•Split Mouth•12 Weeks•Histological

Test Side Immediate Implant Covered with Membrane

Control Side No Membrane was used

Control Soft tissue facing coronal Portion of the Implant to varying degrees

Test Side Osseointegration was consistently observed

“Use of Membrane helps in Increased BIC”

RESULTS

Critical Gap Distance Wilson TG Jr,Buser,Cochran et al JOMI’98

Conventional II with HDD 1.5mm II with HDD 4.0mm

BIC72%60%17%

“HDD: 1.5-2mm is Critical for Osseointegration”

•Clinical•6 Months•Biopsy

Groups

Critical Maximum Gap Distance

Wilson TG Jr et al. JP,2003:74(3);402-409

Covered with CT Membrane

%age Bone-Implant Contact similar in all 3 Groups“HDD of 4 mm with membrane achieves Osseointegration”

•Clinical•6 Months•Biopsy

Conventional II with HDD 1.5-4 mm II with HDD> 4.0mm

Groups

Placement of Immediate Implant in Infected Sites

Novaes & NovaesIJOMI,1995

1st Report Chronic Peri-apical Infected sites

Novaes et al , IJOMI,1998

Experimental,Canine,HistologicalBIC is Higher in Non-Infected sites than in Infected sitesGrunder et al ,

IJOMI,1999,14:210-216

Clinical, Prospective,3 year StudyIncreased Implant Failure,if the tooth replaced was lost for Periodontal Infection

Placement of Immediate Implant in Infected Sites

Nir-hader, Orly et al.COIR,1998

Delayed Immediate Implant better option in Infected sites

Ivorio,Giovanni, Costigliola,G et al.COIR,12(4),2001

Clinical,Prospective,n=130N=36(Infected sites),3-5 year survival rateOverall Survival-97%Failure- 6 Implants(PA PD’itis)Survival rate-87%(In infected sites)

Immediate Loading of Immediate Implants

Ormiener et al COIR 2001,AugustMulticenter, Clinical ,Prospective,Randomized, N=546

“Immediate Loading / Immediate Implants is a predictable procedure”

10 implants failed out of 546

Lorenzi,M et al,2002Clinical, N=9 pat,Ant. Maxilla 50%-II,50%-Del.I

Periotest,RadiographsOut of centric contact, Occlusal Splint-8 weeksSuccess Rate- 96%

Factors for Early Loading of Immediate Implants

Kotsuyama,et al.Quintessence Dental Implantology,7(3)357-367:2000

•Sufficient Primary Stability

•Soft Tissue Healing(2-3) weeks

•Healthy Bone Quality(Density) - 400-450 HU(Cochran)

•‘Drilling Feeling’•Insertion Torque Mechanism•Radiographic•Transient Impact•Periotest•Resonance Frequency Analyzer

Primary Stability

•‘Drilling Feeling’ Trisi et al,COIR,1999

Good to distinguish between D-1 & D-4 BoneBut not between D-2 & D-3

•Insertion Torque Mechanism Friberg et al,COIR,1995Limited only to Self-Tapping Implants, A value of 45 Ncm has been advocated

•RadiographicCT Scan, Simplant 400-450 Hensefield Units

Sundan et al., COIR,1995:6;220-226

Reproducibility Standardisation Radiation,Time needed

Cochran,1998

Periotest

Caulier et al IJOMI,1997:12;380-386

Periotest gives Mechanical PropertiesOf Fibro-osseous Complex between Implant & Bone

Evans et al No Correlation between PTV & histologic BIC

Resonance Frequency Analyzer

Rassmussan,97,98,99

RFA Values, Histological Results & Removal TorqueValues show correlating results

Neil Meredith,AOO’01

Baseline-3 weeks ISQ Decreases3 Weeks-10 Weeks ISQ increases6 weeks-10 weeks No Statistical Difference

6 Weeks is Ideal Time to Load

Conclusions

•II have a high survival rate,between 93.9% to 100%•Implants to be placed 3-5 mm beyond apex for primary stability•Implants to be placed close to alveolar crest level (0-3mm)•Consensus regarding HDD filling still not conclusive•Membrane exposure is a question still unanswered•Absolute need for primary closure is still a question ?

Surgical Technique•Widening/Deepening of Osteotomy•Placement of Implants•Placement of Graft/Membrane•Flap Closure

• Inability to Develop Mechanical Stability

•Proximity to Adjacent teeth

•Placement outside alveolar envelop

•Presence of Infection

Contra-Indications

• Traumatically Avulsed

•Residual Deciduous Teeth

•Horizontal/Vertical Fracture of Teeth

•Endo Failing

•Periodontally Compromised

•Non-restorable Dental Caries

Indications

• Traumatically Avulsed

•Residual Deciduous Teeth

•Horizontal/Vertical Fracture of Teeth

•Endo Failing

•Periodontally Compromised

•Non-restorable Dental Caries

Indications

• Inability to Develop Mechanical Stability

•Proximity to Adjacent teeth

•Placement outside alveolar envelop

•Presence of Infection

Contra-Indications

• Inability to Develop Mechanical Stability

•Proximity to Adjacent teeth

•Placement outside alveolar envelop

•Presence of Infection

Contra-Indications

• Inability to Develop Mechanical Stability

•Proximity to Adjacent teeth

•Placement outside alveolar envelop

•Presence of Infection

Contra-Indications