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Implant in postextraction site

Implant placement in postextraction is a common situation in implant dentistry nowadays. For the clinician, the timing of when to place an implant is critical for the achievement of the proposed primary and secondary objectives of implant therapy. The clasification concerning the timing of postextraction implant was adopted for the third ITI Treatment Guide and for the proceedings of the recent ITI consensus conference that took place in Stuttgart, Germany, in August 2008. For both publication, the clasificaition was expanded with descriptive terms to allow he clinician an easier understanding of the various treatment options (Daniel Buser, 20 Years of Guided Bone Regeneration in Implant Dentistry, Quintessence Publishing, 2009, 7:153 - 154):

Each type has both advantages and disadvantages.

TYPE 1: IMMEDIATE IMPLANT PLACEMENT

Immediate implant placement after extracion reduces the overall treatment time and has a maximum amount of local bone volume available at the time of implant placement as well as gets the esthetic result in right indications. However, the main disadvantage of this type is immediate implant are associated with a significant risk for esthetic complications, in particular the development of mucosal recession on the facial aspect.


Implant gets the high esthetic result	mucosal recession on the facial aspect (20 year of guided bone regeneration Buser 2010)

The risk factors of mucosal recession on the facial aspect:

- Facial malpositioning of the implant is a common complication with immediate implants. At the time of implant insertion, the dense cortical bone of the palatal wall can often cause the implant to deflect toward the facial aspect.

- The patient has thin tissue biotype.

- The relative lack of soft tissue to achieve submerged or semisubmergedhealing.

- Another risk factor is a clinician with insufficient skills and clinical experience to perform such a delicate surgical procedure.

Though immediate implant placement reduces the overall treatment time, the idea clinical conditions are very importance for a successful esthetic outcome:

- A thick facial bone wall

- A thick gingival biotype

- Absence of acute infection in the extraction site

- A low lip line

- Condition include a healthy, non smoking patient

CLINICAL CASE:

Surgeon: Dr. Võ Văn Nhân

A 25 years old patient was in good general healthy condition. His incisor tooth had broken by an accident so he wanted to get implant treatment therapy. The patient had a low lip line and medium thick tissue biotype and the facial bone of the maxillary right central incisor socket was thick and undamaged. For these reasons, immediate implant placement after tooth extraction was recommended.


According to the x ray, the facial bone was undamaged	An incisor tooth had broken by an accident

The root was carefully extracted without elevation of a flap. The facial bone was checked to confirm that it was intact.


The root was carefully extracted without elevation of a flap	Immediate implant placement after extraction

Because of implant placement without elevation of a flap, we took an x ray to check positon of implant during implant procedure.


Take CT scan to check implant position	Take a panorex after implant procedure

After implant placement, a temporary crown which was made by our lab technician was filled in the gap. This crown, however, will be removed when the final crown is performed.


Temporary crown was filled in the gap	after implant placement

3 months later, the temporary crown was replaced by the final crown after we took an x ray to make sure that there was no gap between implant and crown. It is very important to prevent implant infection in long term.


The final crown on the implant	An x ray was taken to check the crown


Before treatment	After treatment

TYPE 2: EARLY IMPLANT PLACEMENT FOLLOWING SOFT TISSUE HEALING

The main advantages of early implant following soft tissue healing after 4 weeks - 8 weeks extraction:

- The increased amount of keratinized mucosa available in the implant site helps to closure the wound easier so the chronic and acute infection can be prevent.

- Another advantage of this approach is reducing mucosal recession on the facial aspect (Buser D 2008, 2009).

During this soft tissue healing period of 4 to wekks, a certain degree of ridge alteration takes place. However, this bone resorption is mainly limited to the bundle bone.

Early implant placement is the most commonly used approach today in postextraction sites. In particular, this approach iss widely favored in esthetic sites because it offers the most advantages and the fewest disadvantages.

CLINICAL CASE

Surgeon: Dr. Vo Van Nhan

A young female patient whose incisor tooth was damaged and soft tissue in lip and chin area was injured by accident so the root of the tooth had to remove. After having taken some x rays (panorex and CT cone beam) to check jaw bone condition, we decided to place implant in postextraction site 8 weeks later.


The healing wound after 8 weeks	soft tissue in upper lip and chin area

8 weeks later, implant placement was inserted in postextraction site without bone graft. Because of incisor tooth, the temporary crown was made by our technician to filled in the gap. This temporary crown, however, would be removed when the final crown was performed.


Implant was placed in postextraction site without bone graft	The healing cap was inserted after implant placement


The temporary crown was filled in the gap	after implant placement a few day

After 4 months, the soft tissue healed completely and implant was well integrated for the final crown on the implant. During 4 months of healing period, the soft tissue was also restored as natural tissue.


The soft tissue healed completely	the soft tissue's restored as natural tissue


Before	After

TYPE 3: EARLY IMPLANT PLACEMENT FOLLOWING PARTIAL BONE HEALING

Early implant placement following partial bone healing provides for a healing period 12 weeks to 16 weeks prior to implant placement to allow more bone healing in the future implant site. In addtion, such a standard implant placement without bone augmentation uasually allows short healing period of 6 weeks to 8 weeks and treatment expenses were reduced.

This approach is usually recommended in the esthetic area but if molar site show a crest width of more than 8mm, this approach will be applied. However, because of a crest width, the primary implant stability is the challenge for the clinician.

CLINICAL CASE

Surgeon: Dr. Vo Van Nhan

A 40 years old female, missing molar tooth because of infection. It was decided that an extended healing period of more than 3 months following extraction would achieve partial bone healing in the defect area. After extraction and infection had treated, implant placement was inserted in postextraction 16 weeks later.

The mandibular right molar shows a large bone lession

According to panorex, the mandibular right molar shows a large bone lession because of infection so we had to extract this tooth and remove infection first to prevent bone resorptiom in long term that is not facility for the restoration.

The soft tissue healing after extraction 4 months

After extraction 4 months, soft tissue and defect bone had partial healed. It was very important that the primary implant stability be increased. In this case, the bone had partial healed but a large bone defect was present so implant placement and substitute bone were performed simultaneously.


Following flap elevation, a large bone defect was present	Substitute bone and implant placement were performed at the same time

To stable substitute bone, the augmentation material was covered by a collagen membrane that would be resorption without another surgery to remove this membrane so the patient just experienced a surgery to place implant and flap elevation surgery to expose implant for the final restoration.


Using collagen membrane to stable grafting material	The surgery is completed with tension free premary wound closure

Following implant placement procedure, we took an x ray to check position of the implant to make sure everything was well performed.

The postsurgical radiograph showed the well-positioned implant

4 months later, the patient came back to our clinic for the final restoration. Before exposing the flap, we had taken an x ray to check subtitute bone development and implant integration. In this stage, we just needed to expose implant with 3 incisions so the patient didn't stand serious wound.


Implant was well integrated with jaw bone	To expose implant for the final restoration

In this case, a special technique was performed to restore natural soft tissue. It was called the soft tissue restoration technique. To get high esthetic result, this procedure had to performed by an expert.


The soft tissue restoration technique	The result of soft tissue restoration


Before treatment	After treatment

And finally, an x ray was taken after the final crown on the implant had been performed to make sure that there was no gap between crown and implant to prevent peri-implant. The treatment procedure was completed with the esthetic result and chewing function as expected.

The radiograph showed that there was no gap between crown and implant

TYPE 4: IMPLLANT PLACEMENT FOLLOWING COMPLETE BONE HEALING

Late implant placement is frequently used in adolescent patients who are too young for implant placement and when extraction of a tooth can not be delayed. It may also be used for patients who are not available or ready for implant therapy following extraction for personal reasons.

The major disadvantage of waiting 6 months or longer is the potential collapse of the facial ridge anatomy, leading to a reduce crest width of less than 6mm.A reduce crest width must be avoided whenever possible because it might require bone graft procedure. In addition, waiting too long make this approach doesn't attract the patient.

CLINICAL CASE

Surgeon: Dr Vo Van Nhan

A female patient had the partial removable denture for 5 years since her incisor tooth was lost by the accident. She felt unconfident when wearing the partial removable denture because it became looser and looser so she wanted to restore the missing tooth with implant therapy. According to the initial diagnostic, the soft tissue need to be restored with soft tissue restoration technique.


A 36 year old female has lost one central incisor in an accident	The occlusal view reveals the lack of adequate bone volume for traditional implant placement

To insert implant, first we took CT cone beam and panorex radiograph to evaluate jaw bone density and checked general healthy of the patient. The bone defect was augmented with local harvested autogenous bone and substitute bone. The augmentation was performed with implant placement simultaneously.


Following flap elevation, an implant was inserted. A large bone defect is present	The bone defect was augmented with local harvested autogenous bone and substitute bone

The augmentaton materials was covered by a collagen membrane. This membrane would be resorpt without another surgery to remove it. The surgery was completed with tensionfree primary wound closure to protect the applied biomaterials in the oral cavity.


The augmentaton materials was covered by a collagen membrane	The surgery was completed with tensionfree primary wound closure to protect the applied biomaterials in the oral cavity

During the period of wound healing, patient could use the old removable denture or a new one which was performed by lab technician.

After 3 months following implant placement procedure, the implant was exposed to prepare for the final restoration on the implant. The soft tissue restoration was performed at that time.


The implant was exposed to prepare for the final restoration on the implant	The soft tissue restoration technique

In this case, the patient also wanted to restore the next central incisor by all ceramic crown to get the best esthetic result because there is no the gum recedes in long term so it is the best choice for esthetis teeh area.


All ceramic frames	All ceramic crowns


Before treatment	After treatment

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