Immediate Implants

Immediate Implants are defined as Dental Implants that are placed at the time of an extraction into the extraction socket. The extraction socket is essentially utilized as the space for the implant fixture after some minor re-adaptation with a series of shaping drills. The biochemical rationale is to take temporal advantage of the "repair cell cascade" of events that take place after a tooth has been extracted. Other, more clinically oriented advantages include a decrease in treatment time for the patient and a means of immediately restoring the empty space with an implant supported temporary crown, if the initial stabilization of the implant fixture is adequate. In contrast to a temporary stay plate (a.k.a. flipper), the immediate temporization of a dental implant will yield better maintenance of the gum shape, especially the scalloping of the gums between the teeth, during the osseointegration phase.

Indications and Contraindications

The following parameters are necessary in order for a patient to be considered for this procedure:

The patient should be a non-smoker.
The patient needs to be compliant enough to avoid excessive forces on the temporized implant during the first 4 - 6 weeks (i.e. no chewing on the implant)
The doctor will need to check other parameters in order to establish candidacy.

If any of the above parameters are not met, an immediate implant with immediate temporization may be a strong contraindication.

A case study:

The featured patient below presented with moderate to severe symptoms of pain on one of his upper incisors. The history on this tooth included a sharp frontal impact several weeks prior. Although the soft tissues had healed well since then, the pain in that particular tooth never vanished. An x-ray revealed a very thin horizontal fracture line at the bottom area of the root. The tooth and fractured root tip were extracted in and a dental implant fixture was placed into the re-adapted extraction socket. A temporary abutment was prepared and shaped into its proper form and a temporary crown was made with a strong composite material. The temporary crown was then cemented onto the temporary abutment.

The patient was able to leave with a temporized tooth within the same appointment of the extraction. The entire procedure took about 2 hours and was performed with only minimal local anesthetic.

Final impressions were taken approximately 5 months after the initial placement of the implant fixture. The final restoration consisted of a custom-cast and milled gold abutment, and a cementable metal-ceramic crown.

The case study is illustrated in more detail below:

The pre-op photo shows a rather inconspicuous looking right lateral incisor. The above described symptoms and history, however hinted at a definite problem. An x-ray eventually confirmed a fracture at the bottom third of the root (not shown due to the low resolution of JPEG images).

This image shows the tooth and fractured tip after both have been retrieved.

The implant fixture is placed immediately after the extraction in the proper depth and angulation. The implant diameter and length is selected based on the initial socket measurements.

Once the implant fixture is in place and the initial stabilization is adequate, the immediate temporization process can begin. The proper temporary abutment is be pre-sectioned to the approximate length, as shown.

Once the cut abutment is connected to the implant, it is prepared to the proper shape and angulation. Resin is injected into the gingival socket space around the abutment, which will “preserve” the architecture of the socket space. Finally a temporary crown is cemented over the abutment.

Prior to final cementation, the abutment and temporary crown are removed and the margins are refined and a proper seal is assured.

At this point the assembly can be placed onto the implant and the temporary crown can be cemented with temporary cement. At this point the patient needs to be instructed to “avoid” the temporary as much as possible during the initial 4 to 6 weeks.

Five months later, the implant is ready for final impressions. The temporary assembly is removed and the final impression is taken. Notice the nice gum architecture of the former socket.

This image shows a top view of the well preserved gum architecture after approximately 5 months.

At the time of delivery, a custom gold abutment is torqued into position.

Finally, a metal ceramic crown is cemented over the custom abutment. Note how well the gum architecture was preserved around this tooth.

Discussion:

The case presented above represents only one way to treat a front tooth in need of an extraction. This case could have been alternatively treated with a bridge, or even with a dental implant, temporized with a temporary stayplate (flipper). We will not dwell on the advantages and disadvantages of bridges vs. implants, suffice to say that in this particular case the implant offers the better long-term success rates, as well as better long-term esthetics. With respect to the options of stayplate (flipper) vs. temporary implant crown, the latter option offers a much better chance of maintaining the gum architecture in its most natural state. A temporary stayplate (flipper) will eventually cause loss of gum tissue in-between the teeth, which will manifest itself as “black triangle syndrome” between teeth. An example of this can be seen between the upper central incisors.

In conclusion, the concept of immediately placed implants into a fresh extraction socket can be considered a viable and predictable treatment modality, yielding reliable clinical success rates and a shortened treatment time for the patient. Furthermore, the concept of immediate temporization of the implant has also been shown to be very predictable and successful. Immediate temporization, as outlined, will not only provide the patient with a bone-anchored temporary prosthesis, but will also improve esthetic outcome of the final crown.