The loss of a tooth in the anterior esthetic region due to periodontal disease, trauma, endodontic failure, or root resorption can be a traumatic experience for the patient to go through. Traditional implant therapy often required two to three months of alveolar ridge remodeling following tooth extraction and an additional six months of non-loaded healing for implant osseointegration to be successful. 1-3 Aesthetic single-tooth implant placement using a traditional two-stage surgery has been well documented in the literature. 4-6 Many complications can occur during the healing phase. Loss of papilla due to flap elevation, provisionalization with a removable appliance that is not stable can cause blunting of the papilla. Ridge resorption can also occur if an implant is not placed following extraction. Bone and gingival tissue loss following maxillary anterior tooth extraction and implant surgery may present additional esthetic challenges. 7 Clinical and histological studies have demonstrated that non-submerged implants osseointegrated as well as submerged implants and functioned comparably under load over extended periods. 8-11
Immediate implant placement using a single-stage surgical approach can reduce the duration of treatment, preserve papilla, and limit apical migration of the free gingival margin. Several studies have shown successful bone regeneration in extraction sites around immediately placed implants with clinical results similar to two stage procedures. 12-15
Extraction, implant placement and provisionalization combine surgical and restorative principles for tooth replacement. The advantage to this approach is patient comfort, increased esthetics, and better patient acceptance. When using a fixed provisional, the patient’s phonetics is much better than using a removable appliance. Immobile immediate provisionalization can enhance soft tissue management as well. 16-18
When using a flapless, one-stage approach, soft tissue healing and maturation can occur simultaneously with implant integration. In addition, implant placement into a fresh extraction site provides an adequate blood supply to the wound and allows sufficient bone maintenance since resorption and remodeling will not yet have occurred. Raising a surgical flap compromises the bone vascularization and may result in marginal bone loss19 and soft tissue recession with collapse of the interdental papillae, particularly in the presence of thin, scalloped gingiva. 20
As with traditional implant treatment, approximately 1mm of gingival recession may occur at the free gingival margin following placement of the definitive restoration. 21-22 This may be attributed to the biologic width formation following repeated removal and replacement of the implant components during impression making, try-in, and fitting of the restoration. 23-24
If a failing tooth has a FGM positioned more incisally compared to the adjacent tooth, that will allow the final FGM to be similar following apical migration of 1mm after implant placement. A hopeless tooth with the FGM positioned ideally or more apical would benefit from orthodontic extrusion before extraction. 25-26
The form of the periodontium plays an important part in the final esthetics of the implant restoration. 27 The three categories of gingival scallop are high, normal and flat. Based on a clinical survey of 100 patients, the average or normal gingival scallop is positioned 4 to 5mm more incisally than the FGM. 28 The high or long gingival scallop will have a much higher risk for gingival loss or flattened papilla following extraction versus the normal or flat scallop. The flat scallop has less volume of papilla in the interproximal area, therefore it is much more predictable and maintainable following extraction. One of the principal advantages of the immediate technique is the prevention of post extraction bone resorption. Bone loss may affect approximately 23% of the anterior alveolar crests during six month following extraction. 29
Infection affecting the tooth being extracted may be a contraindication to the immediate technique, as it is most often accompanied by apical or lateral bone loss that can impair primary stability. Primary stability following implant placement is important when provisionalizing immediately. Drilling 3-5mm beyond the apical limit can insure sufficient stability. 30 The success rates being achieved using this single stage approach, contradicts the basic tenets of the original Branemark technique, which was to allow the implants to be covered and protecting the implant against early loading. It appears that it is not early loading that creates the effect of fibrous encapsulation, but rather a certain degree of micro movements at the bone/implant interface31 resulting from inadequate primary stability. Various experimental studies incicate that the range of tolerance of these micro movements is approximately 50-150 microns for rough surfaces32-34 and about 100 microns for smooth machined surfaces.35 Thus, the implant surface is not an indifferent factor in the process of bone healing. Rough surfaces appear to tolerate greater micro movements and therefore could be placed under load at an earlier time.33
Research on the preservation of the tissue architecture, the reduction of surgical sequences, the augmentation of patient comfort during provisionalization, and greater aesthetic requirements37have led many practioners to consider immediate replacement of the missing or freshly extracted tooth.
Care must be taken when an immediate single-tooth implant restoration is planned in the anterior region. Successful esthetic results may ultimately be determined by the patient’s own presenting anatomy; rather then the clinician’s ability to manage state of the art procedures.38
CASE PRESENTATION
An 18-year-old female patient presented with root resorption of the maxillary right central incisor (Fig. 1). Available restorative options were presented to the patient, which included a removable partial denture, a fixed bridge, or an implant supported restoration. The adjacent teeth had not been previously restored, so the patient chose to have an implant-supported restoration to avoid preparation of the adjacent teeth. The patient also did not want to wear a removable appliance during the implant, healing phase.
There was no active infection present, or apical pathology seen radiographically. Periodontal evaluation revealed a thick normal scalloped periodontal bio type. Approximately 85% of the population present with thick, flat perio dontal forms, wheras the perio dontal architecture of the remaining population is thin and scalloped. 39 Although the amount of post-operative soft tissue modifications is generally minimal for patients with thick and flat gingiva, significant changes have been observed in those with thin and scalloped type. 40
The projected interproximal tissue height depends on the interproximal bone height of the adjacent teeth. Bone sounding of teeth adjacent to the failing tooth can ascertain predictable interproximal tissue height. A normal osseous crest was revealed following bone sounding. Gingival tissue approximately 3mm from the osseous crest facially and 5.0mm interproximally. The risks and benefits of treatment were presented to the patient, and an implant was selected for immediate placement and fixed provisionalization using the patient’s natural tooth on the abutment after it is sectioned, hollowed out and relined following extraction. Using the natural tooth as a provisional will allow tissue support and create an emergence profile similar to the pre-extraction condition. This will support the periimplant mucosa and maintain the papilla height, gingival outline and form throughout the osseointegration phase. Wohrle has described several reports with simultaneous provisionalization on an implant placed into an extraction socket.41
Maintenance of gingival tissues and papillae c
an be a demanding task when using a full periosteal flap reflection. Several reports have proposed implant placement without flap elevation to minimize bone loss.42-43
Although initial results appear promising, the lack of direct visibility in flapless surgery may present limitations that require careful evaluation of the osseous topography as well as meticulous surgical execution.44
Prior to the extraction of the tooth, stone models were made and a putty index was formed over the teeth. This would act as a guide to placing the tooth in the proper orientation following surgery.
Surgical Procedure
Local anesthetic was administered and periotomes were used to loosen the periodontal ligament. The tooth was extracted atraumatically, without flap reflection. A periodontal probe was used post-extraction to verify the integrity of the facial plate, and the socket was thoroughly debrided.
Primary stability was achieved by engaging the palatal wall and bone approximately 4mm beyond the apex to the extraction socket with a 13mm Straumann standard diameter 4.1mm implant with a 4.8mm collar. The top of the implant was placed approximately 3mm from the final proposed free gingival margin. Ideally the 1mm polished collar should be above the bone level. With the new Straumann bone level implant this will no longer be necessary. With a flapless surgical approach, this is sometimes difficult to visualize. The implant diameter was within the confines of the tooth socket, without engaging the coronal portion of the facial plate to prevent possible perforation. A minimal distance of approximately 1.5-2.0mm between the implant and adjacent teeth is recommended to minimize marginal bone loss due to encroachment.45 Although not necessary with a horizontal distance less than 2mm from the implant to the facial bone, synthetic bone was placed around the implant and a healing cap (Fig. 2) was lightly tightened. Immediate provisionalization was then begun.
A Straumann 5.0mm solid abutment was placed on the implant and hand tightened (Fig. 3). No preparation was necessary as this is a stock component and the occlusion did not interfere. At the time of this placement, the Straumann Meso temporary abutment was not available. The Meso temporary abutment would allow the margins to be placed more coronally and aid in cement clean up.
RESTORATIVE PROCEDURE
The coronal portion of the patients tooth was to be used as the provisional restoration. The extraction was necessary due to the resorption of the root (Fig. 4). The root of the tooth was sectioned horizontally with a diamond bur (Brasseler USA) approximately 3mm from the cementoenamel junction (Fig. 5). The tooth was then hollowed out, so that it would fit over the abutment (Fig. 6). Prior to relining the tooth, it was placed on the solid abutment to make sure it would fit and that there would be no occlusal contact on the final provisional (Fig. 7). After confirming an accurate fit, the tooth was etched for 30 seconds with Ultra Etch (Ultradent) (Fig. 8). This was rinsed and air-dried. A bonding agent D/E resin (Bisco Inc.) was applied and light cured for 20 seconds (Fig. 9). A bis-acryl material (Protemp 3, 3M corp) was injected into the tooth (Fig. 10) and was then placed intraorally onto the abutment and allowed to self-cure for two minutes. It is difficult to get an accurate margin when relining a provisional, (Fig. 11) so it is necessary to reline the margins out of the mouth with a flowable resin (Fig. 12).
It is very important when relining the restoration extra-orally that you use an analog that is exactly the same as intra orally. Do not use a laboratory implant abutment analog for this purpose. It is important to get an accurate fit of the restoration. The provisional was refined and contoured flat or slightly under-contoured (Fig. 13) on the facial as not to put too much pressure on the free gingival margin, which can cause apical migration of the tissue. This is done with finishing disks and polishing points to create a smooth surface. The interproximal tissue should be supported by the natural emergence profile of the tooth. It is impossible to create too much interproximal pressure, as it is the exact emergence profile that existed prior to the extraction. One of the possible complications from immediate placement and provisionalization, using a cement-retained restoration, is the possibility of leaving excess cement subgingivally. If the implant is placed too deep, and it is impossible to remove all the cement, it is bet ter to use a screw-retained provisional. A tech nique first described by Hig ginbottom, allows the majority of the provisional cement to be removed extraorally using the same analog as used for the fabrication of the temporary. Zone (Dux Dental) temporary cement is placed in the crown and then placed on the abutment extra-orally (Fig. 14).
The excess cement is then removed prior to placing the temporary intra-orally. This allows minimal clean up intra-orally and prevents possible gingival irritation. Do not be fooled into placing more cement into the restoration after cleaning. There is adequate cement to hold the restoration on. Place the restoration onto the abutment and allow the cement to fully set. Clean off any excess cement.
Figure 15 shows the restoration on the day of surgery. The tooth was taken out of occlusion and the patient was advised against using the surgical site and instructed not to have any contact on that tooth while eating. It is very important for the patient to understand the importance of their part in the success of the restoration. If the patient is not willing to accept some responsibility in the final success, then an immediate restoration may be a contraindication for treatment. Patients with deep bites, bruxers, or active infection present, are not good candidates for this type of treatment. The patient presented two weeks post surgery for a clinical evaluation. The area was healing without any complications (Fig. 16).
Following three months of healing, the patient returned for a final impression of the implant. A fixture level impression was made for a custom abutment. A synocta gold abutment (Straumann) was used as the final abutment. This is a UCLA type abutment, that is waxed, (Fig. 17) cast and then porcelain is added to it. This would allow the use of a Lava (3M) restoration for maximum esthetics. The custom abutment was placed and torqued to 35 newton centimeters (Fig. 18). The final Lava restoration was cemented with resin reinforced glass ionomer cement (Fuji Plus GC America). The final restoration is shown in Figure 19. The preoperative smile is shown in figure 20 and the postoperative smile is shown in Figure 21.
Conclusion
Immediate provisional restorations placed on immediate implants in extraction sockets enhance the preservation of the soft and hard tissue contour. Use of the natural tooth on the abutment will provide an emergence profile similar to the pre-existing condition. This is particularly advantageous for the thin periodontium, where there is greater chance for bone and tissue recession. It is important to evaluate the patient thoroughly before attempting this technically demanding procedure. The patients presenting anatomy can ultimately dictate the final esthetic outcome.
oh
Dr. Margeas maintains a full-time private practice focusing on comprehensive restorative and implant dentistry in Des Moines, IA. He is Board Certified by the American Board of Operative Dentistry and is an adjunct professor in the department of Operative Dentistry at the University of Iowa.
Oral Health welcomes this original article.
References
1. Andersson B, Odman P, Lindvall AM, Lithner B. Single-tooth restorations supported by Osseo integrated implants: Results and experiences from a prospective study after 2 to 3 years. Int J Oral Maxillofac Impl 1995;10(6):702-711.
2. Avivi Arber L, Zarb GA. Clinical effectiveness of implant-supported single-tooth replacem
ent: The Toronto study. Int J Oral Maxillofac Impl 1996;11(3):311-321
3. Branemark P-I. Osseointegration and its experimental background. J Prothet Dent 1983;50: 399-410
4. Becker W, Becker BE. Flap designs for minimization of recession adjacent to maxillary anterior implant sites: A clinical study. Int J Oral Maxillofac Impl 1996;11(1):46-54.
5. Israelson H, Plamons JM. Dental implants, regenerative techniques, and periodontal plastic surgery to restore maxillary anterior esthetics. Int J Oral Maxillofac Impl 1993;8(5):555-561.
6. Mathews DP. Soft tissue management around implants in the esthetic zone. Int J Periodont Rest Dent 2000;20(2):141-149.
7. Carlsson GE, Bergman B, Hedegard B. Changes in contour of the maxillary alveolar process under immediate dentures. A longitudinal clinical and x-ray cephalometic study covering 5 yrs. Acta Odontol Scand 1967;25(1):45-75.
8. Leimola-Virtanen R, Peltola J, Oksala E, et al. ITI titanium plasma-sprayed screw implants in the treatment of edentulous manibles: A follow-up study of 39 pts. Int J Oral Maxillofac Impl 1995;10(3): 373-378.
9. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8 yr life table analysis of a prospective multicenter study with 2359 implants. Clin Oral Impl Res 1997;8(3):161-172.
10. Vassos DM. Single-stage surgery for implant placement: A retrospective study. J Oral Implantol 1997;23(4):181-185.
11. BeckerW, Becker BE, Israelson H, et al. Onestep surgical placement of Branemark implants: A prospective multicenter clinical study. Int J Oral Maxillofac Impl 1997;12(4):454-462.
12. Grunder U, Polizzi G, Goene R, et al. A 3-yr prospective multicenter follow-up report on the immediate and delayed immediate placement of implants. Int J Oral Maxillofac Impl 1999;14(2):210-216.
13. Becker BE, Becker W, Ricci A, Geurs N. A prospective clinical trial of endosseous screw-shaped implants placed at the time of tooth extraction without augmentation. J Periodontol 1998;69(8):920-926.
14. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets: Implant survival. Int J Oral Maxillofac Impl 1996;11(2): 205-209.
15. Schwartz-Arad D, Grossman Y, Chaushu G, The clinical effectiveness of implants placed immediately into fresh extraction site of molar teeth. J Periodontol 2000;7(5):839-844.
16. Bain CA, Weisgold AS. Customized emergence profile in the implant crown-A new technique. Compend Contin Educ Dent 1997;18(1):41-45.
17. Chee WW, Donovan T. Use of provisional restorations to enhance soft-tissue contours for implant restorations. Compend Contin Educ Dent
1998;19(5):481-489. 18. Markus SJ. Interim esthetic restorations in conjunction with anterior implants J Prosthet Dent 1999;82(2):233-236.
19. Bragger U, Hafeli U, Huber B, et al. Evaluation of postsurgical crestal bone levels adjacent to non-submerged dental implants. Clin Oral Impl Res 1998;9(4):218-224.
20. Becker W, Becker BE, Israelson H, et al. Onestep surgical placement of Branemark implants: A prospective multicenter clinical study. Int J Oral Maxillopac Impl 1997;12(4):454-462.
21. Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-yr results. Int J Periodont Rest Dent 2000;20(1): 11-17.
22. Small PN, Tarnow DP Gingival recession around implants: A 1-yr longitudinal prospective study. Int J Oral Maxillofac Impl 2000;15(4):527-532.
23. Hermann JS, Buser D, Schenk RK, et al. Biologic width around titanium implants. A physiologically formed and stable dimension over time. Clin Oral Impl Res 2000;11(1):1-11.
24. Herman JS, Buser D, Shenk RK, et al. Biologic width around one and two-piece titanium implants. Clin Oral Impl Res 2001;12(6):559-571.
25. Salama H, Salama M, Garber D, et al. Developing optimal peri-implant papillae within the esthetic zone: guided soft tissue augmentation. J Esthet Dent 7(3):125-129, 1995.
26. Salama H, Salama M: The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent 13(4):312-333, 1993.
27. Kois J. Predictable Single Tooth Peri-implant Esthetics: five Diagnostic Keys. Compend Contin Educ Dent 2001;22(3):199-206.
28. Kois J. Altering gingival levels; the restorative connection part 1: biologic variables. J Esthet Dent 6:3-9, 1994.
29. Carlsson GE, Bergman B, Hedegard B. Changes in contour of the maxillary alveolar process under immediate dentures. A longitudinal clinical and x-ray cephalometric study covering 5 years. Acta Odontol Scan 1967;25(1):45-75.
30. Schwartz-Arad D, Chaushu G. Placement of implants into fresh extraction sites: 4 to 7 years retrospective evaluation of 95 immediate implants. J Periodontol 1997;68(11):1110-1116.
31. Szmukler-Moncler S, Piattelli A, Favero GA, Dubruille JH. Considerations preliminary to the application of early and immediate loading protocols in dental implantology. Clin Oral Impl Res 2000;11(1): 12-25.
32. Cameron CE, The cracked tooth syndrome: Additional findings. J Am Dent Assoc 1976;93(5): 971-975.
33. Saballe K. Hydroxyapatite ceramic coating for bone implant fixation. Mechanical and histological studies in dogs. Acta Orthop Scand Suppl 1993;255:1-58.
34. Vaillancourt H, Pilliar Rm, McCammond D. Finite element analysis of crestal bone loss around porous-coated dental implants. J Appl Biomater 1995;6(4):267-282.
35. Brunski JB. Biomechanical factors affecting the bone-dental implant surface. Clin Mater 1992;10(3): 153-201.
36. Taborelli M, Jobin M, Francois P, et al. Influence of surface treatments developed for oral implants on the physical and biological properties of titanium. Surface contamination. Clin Oral Impl Res 1997;8(3):208-216.
37. Touati B, Guez G, Saadoun A. Aesthetic soft tissue integration and optimized emergence profile: Provisionalization and customized impression coping. Pract Proced Aesth Dent 1999; 11(3):305-314.
38. Kois J. Predictable Single Tooth Peri-implant Esthetics: five Diagnostic Keys. Compend Contin Educ Dent 2001;22(3):199-206.
39. Olson M, Linghe J. Periodontal characteristics in individuals with varying form of the upper central incisors. J Clin Periodontol 1991;18(1): 78-82.
40. Salama H, Salama M: The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent 13(4):312-333, 1993.
41. Wohrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen consecutive case reports. Pract Periodont Aesthet Dent 1998;10(9): 1107-1114.
42. Wilderman MN. Exposure of bone in periodontal surgery. Dent Clin 1964;3:23-36.
43. Lansberg CJ, Bichacho N. Implant placement without flaps. A single-stage surgical protocol — part 1. Pract Periodontics Aesthet Dent 1998;10:1033-1039.
44. al Ansari BH, Morris RR. Placement of dental implants without flap surgery. A clinical report. Int J Oral Maxillofac Implants 1998;13:861-865.
45. Esposito M, Ekestubbe A, Grondahl K. Radiological evaluation of marginal bone loss at tooth surfaces facing single Branemark implants. Clin Oral Impl Res 1993;4(3):151-157.
———
When using a fixed provisional, the patient’s phonetics is much better than using a removable appliance
———
A hopeless tooth with the FGM positioned ideally or more apical would benefit from orthodontic extrusion before extraction
———
Care must be taken when an immediate single-tooth implant restoration is planned in the anterior region
———
Prior to the extraction of the tooth, stone models were made and a putty index was formed over the teeth
———
The interproximal tissue should be supported by the natural e
mergence profile of the tooth
———
If the patient is not willing to accept some responsibility in the final success, then an immediate restoration may be a contraindication for treatment
