Immediate Dental Implants for Esthetic and Premolar Sites E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
A detailed, state-of-the-art reference for immediate implantation techniques for non-molar teeth
Immediate Dental Implants for Esthetic and Premolar Sites presents a detailed and comprehensive discussion of all aspects of immediate dental implant treatments in anterior and premolar sites in both arches. The book offers complete information on managing these challenging cases, providing step-by-step procedures for recommended and often innovative techniques.
The authors summarize the latest advances in the field—including anatomically-guided immediate implantation, peri-implant gap management, dealing with compromised situations, soft tissue grafting preservation with customized transitional restorations, prosthetic procedures, early loading protocols, and innovative implant designs.
Readers will also find:
- A thorough introduction to screening, along with unique considerations for placing immediate dental implants at different sites
- Comprehensive explorations of the techniques and outcomes for each discussed site
- Hundreds of high-quality, full-color clinical and radiographic images demonstrating the techniques discussed within
- Complete case management, from case selection to long-term outcomes
Immediate Dental Implants for Esthetic and Premolar Sites is a critically important reference resource for clinicians offering implant treatments but will also benefit students, residents, and fellows with an interest in immediate dental implantation.
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Veröffentlichungsjahr: 2025
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
List of Contributors
Foreword
Preface
Acknowledgments
1 Introduction, History and General Principles
Background
The Timing of Implant Placement
Early Work with Immediate Implant Placement
Biological Benefits of “Immediacy”
Indications for Immediate Implant Placement in Anterior and Premolar Sites
Impact of Socket Configuration on Immediate Implant Placements
Accepted Ways of Minimizing Peri‐Implant Crestal Bone Loss with Immediate Implant Placements
Conclusions
References
2 Radiographic and Anatomic Considerations
Introduction
Imaging Techniques
Cone Beam Computed Tomography
Radiographic Evaluation for Immediate Implant Placement
General Osseous Considerations
Alveolar Bone Thickness
Variations in Trabecular Bone Density
Nasopalatine Canal and Foramen
Middle Superior Alveolar Canals
Nasal and Maxillary Sinus Floors
Mental Foramen
Anterior Loop of the Inferior Alveolar Nerve
Mandibular Incisive Canal
Lingual Foramina
Tooth‐Related Complications
Conclusions
References
3.1 Immediate Implant Placement in the Maxillary Esthetic Zone
Introduction
Preoperative Screening
Diagnosis and Planning Procedures
Surgical Procedures
Prosthetic Procedures
Follow‐up
Discussion
Conclusions
References
3.2 Immediate Maxillary Premolar Implant Placement
Introduction
Sagittal Root Position and Bone Angulation
Case Selection
Suggested Surgical Protocols
Implant Selection
Soft Tissue Modification
Discussion
References
3.3 Challenges in Placing Multiple Immediate Implants in Anterior Maxilla
Introduction
Case Selection
Conclusions
References
4 Immediate Implant Placement in Mandibular Anterior and Premolar Sites
Introduction
Sample Cases
Conclusions
References
5.1 Minimally Invasive Guided Bone Regeneration Techniques for Hard and Soft Tissue Augmentation with Simultaneous Immediate Implant Placement
Introduction
Tunneling
Conclusion
References
5.2 Immediate Implants Needing Traditional Guided Bone Regeneration
Introduction
Sample Cases
Discussion
References
5.3 Immediate Implant Placement in Compromised Maxillary Anterior and Bicuspid Sites
Introduction
Immediate Dentoalveolar Restoration Technique
Conclusions
References
5.4 Aesthetic Reconstruction of Severely Resorbed Alveolar Bone with Immediacy using Tenting Healing Abutments or Tooth Bone “Rings”
Introduction
Background
Discussion
Conclusion
References
6 Soft Tissue Grafting with Immediate Implant Placement
Introduction
Evolution of Soft Tissue Grafting during Immediate Implant Placement
Should Soft Tissue Grafting be Considered as the Standard of Care in Esthetic Immediate Implant Placement?
Surgical Techniques for Soft Tissue Grafting
Why Perform Soft Tissue Grafting and Immediate Implant Placement in the Same Surgery?
How Stable Are the Results of Soft Tissue Grafting?
Conclusion
References
7 Anatomically Guided Immediate Implant Placement in Maxillary Anterior and BicuspidSites
Introduction
The Concept of Anatomically Guided Implant Placement
Discussion and Conclusions
References
8 Guided Surgery for Placing Immediate Implants using Standard Osteotomy Preparation or Osseodensification
Introduction
Guide Production
Guided Implant Surgery
Immediate Implant Placement with Customized Provisional or Healing Abutment
Conclusions
References
9 Optimizing Immediate Loading with Immediate Implants
Introduction
Conclusions
References
10 Emergence Profile Following Immediate Implant Placement in the Esthetic Zone
Introduction
Implant Selection and its Relation to the Emergence Profile
Implant Placement in the Esthetic Zone
The Emergence Profile Contours
Timing of Implant Placement and its Relation to Emergence Profile
Prosthetic Modification of the Emergence Profile
Transfer of the Emergence Profile
Restorative Materials and their Relation to the Emergence Profile
Conclusions
References
11 Immediate Implant Placement in Infected Tooth Sockets
Introduction
Treatment Steps
Complications
Conclusions
References
12 Angled Implant Design (Dual Axis Implants) in Immediate Implant Placement in the Anterior Maxilla
Introduction
Anatomy of Teeth, Alveolar Bone, and Sagittal Root Position
Apical Socket Perforation Rate
Cement‐Retention Versus Screw‐Retention and the Issue of Buccally Inclined Implants
Angle‐Correcting Abutments and Angled Screw Channels
Subcrestal Angle Correction: Development of a Root Form Dual Axis Implant
Screw Loosening
Variable Platform Switching
Macro Hybrid Subcrestal Angle Correction Implant (Body Shift Concept)
Conclusions
References
13 Complications with Immediacy and their Management
Introduction
Potential Complications
Esthetic and Soft Tissue Complications
Post‐Treatment Infection
Conclusions
References
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Classification of radial root positions for maxillary incisors....
Table 1.2 Mean values of socket orifice dimensions by tooth type.
Chapter 2
Table 2.1 Mean values and standard deviations of alveolar vestibular bone t...
Table 2.2 Mean values and standard deviation of alveolar vestibular and pal...
Table 2.3 Studies reporting the prevalence and length of the anterior loop ...
Chapter 3_2
Table 3.2.1 Percentage of premolars that reached a buccal bone thickness of...
Table 3.2.2 Randomized controlled trials included in the meta‐analysis by S...
Chapter 4
Table 4.1 Mean values of socket orifice dimensions by tooth type in both ar...
Chapter 6
Table 6.1 Types of soft tissue defects might occur as a consequence of imme...
Chapter 11
Table 11.1 Infected socket multifactorial classification.
Table 11.2 Recommended dosage for prophylactic systemic antibiotic therapy ...
List of Illustrations
Chapter 1
Figure 1.1 (a) This patient presented with a hopeless maxillary right centra...
Figure 1.2 (a) This patient presented with a failed endodontic treatment wit...
Figure 1.3 (a) Two maxillary central incisors suffered endodontic complicati...
Figure 1.4 (a) A large (> 2 mm) buccal gap between implant and buccal bone w...
Figure 1.5 (a) This right central incisor would be a good candidate for imme...
Figure 1.6 A typical very thin buccal plate over a maxillary incisor.
Figure 1.7 A Magnetic Mallet with handpiece inserted.
Figure 1.8 A set of Magnetic Mallet extraction tips.
Figure 1.9 (a) This mandibular carious and fractured first bicuspid retained...
Figure 1.10 Radial root positions in sagittal cone beam computed tomography ...
Figure 1.11 Suggested osteotomy initiation points for maxillary anteriors [1...
Figure 1.12 (a) Three socket types based on the amount of buccal bone and de...
Figure 1.13 The subclassification of Elian's type II socket.
Chapter 2
Figure 2.1 Selected cone beam computed tomography renderings illustrating a ...
Figure 2.2 Selected cone beam computed tomography renderings illustrating an...
Figure 2.3 Selected cone beam computed tomography renderings illustrating a ...
Figure 2.4 Selected cuts from a cone beam computed tomograph illustrating a ...
Figure 2.5 Selected cone beam computed tomography renderings illustrating an...
Figure 2.6 Selected cone beam computed tomography renderings illustrating a ...
Figure 2.7 Selected cone beam computed tomography renderings illustrating bi...
Chapter 3_1
Figure 3.1.1 (a) Initial situation of failing right upper central incisor. (...
Figure 3.1.2 (a) Initial situation of failing left and right upper central i...
Figure 3.1.3 (a) Panoramic radiograph of the initial situation. (b) The clin...
Figure 3.1.4 (a) The patient's left maxillary first bicuspid had fractured a...
Chapter 3_2
Figure 3.2.1 On average, first maxillary premolars (a) exhibit thinner bucca...
Figure 3.2.2 (a–d) Cross‐sectional cone beam computed tomography views depic...
Figure 3.2.3 (a) A technically challenging case for immediate implant placem...
Figure 3.2.4 Jung et al. [19] proposed a classification with regards to the ...
Figure 3.2.5 (a) Radiographic assessment revealed an unfavorable root–sinus ...
Figure 3.2.6 (a) The first premolar presented with a buccal fistula as a res...
Figure 3.2.7 (a) A buccal view of the normal gingival profile of a hopeless ...
Figure 3.2.8 Virtual planning demonstrating suitable three‐dimensional impla...
Figure 3.2.9 (a) A maxillary first premolar with vertical root fracture was ...
Figure 3.2.10 (a) This maxillary first premolar had a hopeless restorative p...
Figure 3.2.11 (a) Cross‐sectional cone beam computed tomography (CBCT) view ...
Chapter 3_3
Figure 3.3.1 (a) This patient's two maxillary central incisors required repl...
Figure 3.3.2 Achieving parallelism in cases using multiple immediate implant...
Figure 3.3.3 An esthetic and maintenance nightmare was created by placing im...
Figure 3.3.4 (a) The maxillary anterior three‐unit bridge in this patient ha...
Figure 3.3.5 (a) This patient's maxilla was edentulous except for five, whic...
Figure 3.3.6 (a) An existing maxillary fixed prosthesis at time being suppor...
Figure 3.3.7 (a) This patient presented with a neglected mouth and required ...
Chapter 4
Figure 4.1 (a) An example of typically thin buccal walls at mandibular anter...
Figure 4.2 (a) This patient's four mandibular incisors were replaced by a fo...
Figure 4.3 (a) The preoperative cone beam computed tomographs for a patient ...
Figure 4.4 (a) After removing the two right mandibular incisors, a single im...
Figure 4.5 (a) Two implants and a fixed four‐unit prosthesis were planned fo...
Figure 4.6 (a) This patient required full mouth rehabilitation. (b) He had p...
Figure 4.7 (a) This individual presented with advanced damage to his six man...
Figure 4.8 (a) This patient presented with a non‐restorable second bicuspid ...
Chapter 5_1
Figure 5.1.1 (a) The left lateral incisor was deemed hopeless. (b) A cone be...
Figure 5.1.2 (a) The patient's left lateral incisor was removed because of c...
Figure 5.1.3 (a) Pretreatment cone beam computed tomography sagittal views r...
Figure 5.1.4 (a) The exploratory panoramic radiograph revealed signs of sign...
Figure 5.1.5 (a) Examination revealed an 8‐mm periodontal buccal pocket at t...
Figure 5.1.6 (a) The right central incisor was deemed hopeless. (b) A sagitt...
Chapter 5_2
Figure 5.2.1 (a) The maxillary left lateral incisor was deemed hopeless. (b)...
Figure 5.2.2 (a,b) The patient presented with two hopeless maxillary central...
Figure 5.2.3 (a) Cone beam computed tomograph of a hopeless maxillary left c...
Chapter 5_3
Figure 5.3.1 (a) The maxillary left canine condemned due to a root fracture....
Figure 5.3.2 (a) The maxillary left central incisor was condemned due to roo...
Figure 5.3.3 (a) The maxillary right lateral incisor needed replacement due ...
Figure 5.3.4 (a) A pretreatment panoramic radiograph showed advanced general...
Chapter 5_4
Figure 5.4.1 (a) SANTA‐1 has a 1 mm cuff height and is indicated for horizon...
Figure 5.4.2 (a) A SANTA‐2 was placed on the first molar implant for vertica...
Figure 5.4.3 (a) A Sohn Bone Builder (SBB) with a wide head. (b) A single SB...
Figure 5.4.4 (a) A rectangular Sohn Bone Builder (SBB) being used to regener...
Figure 5.4.5 (a) Intraoral and (b) radiographic images of the failed maxilla...
Figure 5.4.6 (a) An intraoral image documented gingival inflammation and ext...
Figure 5.4.7 (a) Severe bone loss was seen in the healed extraction sites. (...
Figure 5.4.8 (a) The two anterior implants were positioned 2 mm below the cr...
Figure 5.4.9 (a) Postoperative periapical radiographs showed bone grafting o...
Figure 5.4.10 (a) Periapical radiographs taken at 5 months confirmed substan...
Figure 5.4.11 (a) Considerable amounts of regenerated alveolar bone were obs...
Figure 5.4.12 Scanning electron microscope images of demineralized dentin. T...
Figure 5.4.13 Preparation of osteoinductive tooth–bone “ring” blocks.
Figure 5.4.14 A tooth–bone “ring” block (left) can be created from the upper...
Figure 5.4.15 (a) The patient's maxillary left canine was condemned. (b) A p...
Figure 5.4.16 (a) The clinical photograph on presentation. (b) The correspon...
Chapter 6
Figure 6.1 Soft tissue deficiency following immediate implant placement. Thi...
Figure 6.2 Scarf‐connective tissue graft (CTG). (a) Tooth #14 was diagnosed ...
Figure 6.3 Scarf‐connective tissue graft (CTG). Removing the epithelium of t...
Figure 6.4 The process of tunneling using specialized instruments. (a) Tunne...
Figure 6.5 Modified tunnel flap and connective tissue graft. (a) A 40‐year‐o...
Figure 6.6 Augmentation of keratinized mucosa (KM) in conjunction with immed...
Figure 6.7 Formation of bulge‐shaped mucosa following immediate implant plac...
Figure 6.8 Tunnel flap and connective tissue graft. Note the locations of th...
Figure 6.9 Coronally advanced flap and connective tissue graft (CTG). A 43‐y...
Figure 6.10 Vertical releasing incision. (a) Note the beveled angle of the b...
Figure 6.11 Soft tissue scar formation at the papilla following immediate im...
Figure 6.12 Two adjacent implants. (a) Teeth #11 and 21 were hopeless as a c...
Figure 6.13 Immediate implant placement (IIP) in an area between neighboring...
Figure 6.14 Immediate implant placement in conjunction with soft tissue graf...
Figure 6.15 Rotated pedicle palatal flap. (a) Tooth #25 was hopeless due to ...
Figure 6.16 Coronal positioning of the mucosal margin, mucosal thickening, a...
Figure 6.17 Different compositions of connective tissue grafts. (a) Subepith...
Figure 6.18 De‐epithelialization of the connective tissue graft.
Figure 6.19 Decompression technique. (a) A buccal fistula at tooth #25 indic...
Chapter 7
Figure 7.1 (a) A type I radial root position according to Gluckman et al. [1...
Figure 7.2 (a) A Gluckman type II radial root position (thick crestal bone)....
Figure 7.3 Type IIB root position with a very thin buccal plate where bur dr...
Figure 7.4 Assuming that the tooth's crown is intact or has been rebuilt wit...
Figure 7.5 (a) The patient asked to have his maxillary left lateral incisor ...
Figure 7.6 (a) Patient #2 presented with a maxillary left lateral incisor ha...
Figure 7.7 (a) The condemned maxillary left lateral incisor had been previou...
Figure 7.8 (a) The patient's maxillary left central incisor had a history of...
Figure 7.9 (a) The patient presented with his maxillary left lateral incisor...
Figure 7.10 Two flowcharts showing the treatment steps used in the original ...
Chapter 8
Figure 8.1 Digital workflow in guided implant surgery. Tx, treatment.
Figure 8.2 (a) The teeth and other anatomical structures such as bone need t...
Figure 8.3 (a) Radiographic and optical surface scan data must be perfectly ...
Figure 8.4 (a) The hopeless tooth is selected in a virtual tooth extraction ...
Figure 8.5 (a) The existing crown. (b) A digital wax‐up in the implant plann...
Figure 8.6 Ideal three‐dimensional implant positioning: The distance to adja...
Figure 8.7 (a) Define the insertion direction. (b) Select the guide supporti...
Figure 8.8 The Standard Tessellation Language file of the guide is prepared ...
Figure 8.9 (a) Interference of support structures with the sleeve tube or th...
Figure 8.10 (a) Examples of guided surgery systems using (a) drill‐handles, ...
Figure 8.11 (a) The implant position is exported as Standard Tessellation La...
Figure 8.12 Immediate implant and indirect prefabricated immediate temporary...
Figure 8.13 Guided osseodensification for an immediate implant. (a) The uppe...
Figure 8.14 Guided osseodensification with septum expansion for an immediate...
Chapter 9
Figure 9.1 (a) The mandibular teeth were extracted and site preparation perf...
Figure 9.2 Intraoral images of a post‐extraction immediate functionally load...
Figure 9.3 (a) A preoperative radiograph showing the hopeless maxillary left...
Figure 9.4 (a) The preoperative radiograph of a patient with two hopeless ma...
Figure 9.5 (a) A maxillary left first bicuspid required replacement. (b) Fla...
Figure 9.6 (a) This patient's maxillary left canine had failed adjacent to a...
Figure 9.7 (a) The maxillary left first bicuspid was deemed inappropriate fo...
Figure 9.8 Representative images of dynamic computer‐aided implant surgery (...
Figure 9.9 (a, b) The patient's maxillary left lateral incisor required remo...
Figure 9.10 A complex magnetic field device is provided for the patient to u...
Chapter 10
Figure 10.1 Apicocoronal position of the implant according to its type. (a) ...
Figure 10.2 (a) Intermediate abutment allowing the fabrication of restoratio...
Figure 10.3 (a) Three‐dimensional planning using cone beam computed tomograp...
Figure 10.4 Emergence profile contours: A, critical contour; B, subcritical ...
Figure 10.5 The critical contour was maintained in the final restoration rep...
Figure 10.6 (a) A central incisor needed removal due to root fracture. (b) M...
Figure 10.7 A palatal position of the implant associated with an adequate co...
Figure 10.8 (a) Initial situation showing soft tissue deficiency and absence...
Figure 10.9 (a) Customized transfer impression coping after copying the same...
Figure 10.10 Provisional restoration on the left side and replicated contour...
Figure 10.11 Zirconia restoration being installed, copying the emergence pro...
Chapter 11
Figure 11.1 (a) The patient presented with a history of trauma, which had re...
Figure 11.2 (a–c) Replacing an infected tooth with an immediate implant is n...
Figure 11.3 (a) This patient's left maxillary central incisor presented with...
Figure 11.4 (a) The left central incisor presented with periapical infection...
Figure 11.5 (a) Both central incisors were deemed hopeless due to severe int...
Figure 11.6 In cases of failed endodontic treatment, mechanical debridement ...
Figure 11.7 (a) Following immediate implant placement, a retrograde peri‐imp...
Figure 11.8 (a) Immediate implantation was used to replace the patient's lat...
Chapter 12
Figure 12.1 (a) Crown‐to‐root angle disparity measured to be 11.6 degrees in...
Figure 12.2 (a) Uniaxial implant aligned to a dual axis implant. (b) Apical ...
Figure 12.3 The subcrestal angle correction concept incorporates the angle c...
Figure 12.4 The angulated prosthetic platform or dual‐axis implant...
Figure 12.5 (a) A clinical view of the left central incisor, which will need...
Figure 12.6 (a) Clinical view of an existing implant which was incorrectly p...
Figure 12.7 (a,c) (upper row) The dual axis implant allows enhanced apical‐p...
Figure 12.8 The top row displays root form uniaxial implants with different ...
Figure 12.9 Schematic representation of a 12‐degree dual axis implant connec...
Figure 12.10 Dual axis implants resulted in abutment screws being loaded at ...
Figure 12.11 (a,b) The overall implant configuration is “inverted...
Figure 12.12 (a) The preoperative clinical view of the maxillary right centr...
Figure 12.13 (a) The left central incisor required extraction due to endodon...
Chapter 13
Figure 13.1 (a) This maxillary central incisor was deemed unrestorable and s...
Figure 13.2 (a, b) Initial implant insertion with a major buccal plate perfo...
Figure 13.3 Anatomical shapes in anterior mandible.
Figure 13.4 (a) During drilling at this mandibular first bicuspid site, a bu...
Figure 13.5 (a) To avoid buccal plate perforation during freehand placement ...
Figure 13.6 (a) In this case, an immediate implant placement was used to rep...
Figure 13.7 (a) The patient's maxillary right lateral and central along with...
Figure 13.8 (a) This patient's treatment involved placement of an immediate ...
Figure 13.9 Misplacement of implant in large deep marrow space.
Figure 13.10 (a) This patient was scheduled for immediate implant placement ...
Figure 13.11 (a) A hybrid prosthesis with pink porcelain to simulate inadequ...
Figure 13.12 In this illustration, the central incisor tooth is represented ...
Figure 13.13 (a): A clinical example of a case not favoring satisfactory int...
Figure 13.14 (a) Increased distance of contact point and alveolar bone of gr...
Figure 13.15 (a) These two implants were placed too close together while too...
Figure 13.16 (a) This preoperative panoramic radiograph suggested endodontic...
Figure 13.17 (a) This patient had received an immediate implant at her maxil...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
List of Contributors
Foreword
Preface
Acknowledgments
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Immediate Dental Implants for Esthetic and Premolar Sites
Edited by
Douglas Deporter, DDS, PhD
Professor in the Discipline of PeriodonticsFaculty of DentistryUniversity of TorontoCanada
Mohammad Ketabi, BDS, MDS
Professor in the Discipline of PeriodonticsFaculty of Dentistry at IAU (Isfahan Branch), IranandAdjunct ProfessorFaculty of Dentistry, University of Toronto, Ontario, Canada
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Hardback ISBN: 9781394187102
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List of Contributors
Reza Amid
ProfessorDepartment of Periodontics, School of DentistryShahid Beheshti University of Medical SciencesTehranIran
Domenico Baldi
Assistant ProfessorDepartment of Surgical Sciences and IntegratedDiagnosticsSchool of Medical and Pharmaceutical SciencesUniversity of GenoaItaly
Antonio Barone
Professor and DeanDepartment of SurgicalMedical and Molecular Pathology and Critical CareMedicine, University of PisaPisaItaly
Ehsan Birang
Dental Implant Research CenterSchool of DentistryIsfahan University of Medical SciencesIsfahanIran
Stephen Chu
Clinical professorDepartments of Periodontology, Implant Dentistry,and Prosthodontics, Restorative, and ImplantDentistry, College of DentistryNew York UniversityNew York, USAandPrivate practice, New York CityNew YorkUSA
Chiara Cinquini
Department of Surgical, Medical and MolecularPathology and Critical Care MedicineUniversity of PisaPisaItaly
Alessandro Cipollina
Independent ResearcherSciaccaAgrigentoItaly
Luca Comuzzi
Independent ResearcherSan VendemianoTrevisoItaly
José Carlos Martins da Rosa
Specialist in Periodontics and ProsthodonticsPrivate PracticeCaxias do Sul‐RsBrazil
Douglas Deporter
ProfessorDiscipline of Periodontology and Oral ReconstructionCenter, Faculty of Dentistry, University of TorontoTorontoCanada
Natalia Di Pietro
Department of Medical, Oral and BiotechnologicalSciencesCenter for Advanced Studies and Technology“G. D’Annunzio” University of Chieti‐PescaraChietiItaly
Vincent J. J. Donker
Department of Oral and Maxillofacial Surgery andDepartment of Restorative DentistryUniversity Medical CenterUniversity of GroningenGroningenNetherlands
Nasrin Esfahanizadeh
ProfessorDepartment of Periodontics, Faculty of DentistryTehran Medical Sciences, Islamic Azad UniversityTehranIran
Stuart Froum
Clinical Adjunct Professor and Director ofClinical ResearchAshman Department of Periodontology and ImplantDentistry, College of Dentistry, New York UniversityNew YorkUSA
Benedetta Grassi
Advanced Clinical Fellow in Implant DentistryAshman Department of Periodontology and ImplantDentistry, College of Dentistry, New York UniversityNew YorkUSA
Arndt Guentsch
Professor of Periodontics and ChairDepartment of Surgical and Diagnostic SciencesMarquette University School of DentistryMilwaukee, WIUSA
Dale Howes
Associate Professor of ProsthodonticsSchool of Dentistry, University of SydneyNew South WalesAustralia
Rossana Izzetti
Department of Surgical, Medical and MolecularPathology and Critical Care Medicine, University of PisaPisaItaly
Mahdi Kadkhodazadeh
Head of Research Institute for Dental SciencesShahid Beheshti University of Medical SciencesTehran, IranProfessorDepartment of Periodontics, School of DentistryShahid Beheshti University of Medical SciencesTehranIran
Mohammad Ketabi
ProfessorDepartment of Periodontology and Implant DentistryFaculty of Dentistry, Islamic Azad UniversityIsfahan Branch, IsfahanIranandAdjunct ProfessorFaculty of Dentistry, University of TorontoTorontoCanada
Mehrdad Lotfazar
PeriodontistPrivate Practice, ShirazIranandVISTA Institute for Therapeutic InnovationsWoodland Hills, CAUSA
Amirhossein Majidi
ProsthodontistPrivate PracticeTehranIran
Giulia Marchioli
Department of MedicalOral and Biotechnological SciencesCenter for Advanced Studies and Technology“G. D’Annunzio” University of Chieti PescaraChietiItaly
Richard Martin
Private PracticeLewisville, TexasUSA
Henny J. A. Meijer
Department of Oral and Maxillofacial Surgery andDepartment of Restorative DentistryUniversity Medical Center GroningenUniversity of GroningenGroningenNetherlands
Venessa Mendes
Associate Professor Teaching StreamDirector, Graduate Program in PeriodonticsFaculty of DentistryUniversity of TorontoToronto, Canada
Amir Moeintaghavi
ProfessorDepartment of Periodontics, Faculty of DentistryMashhad University of Medical SciencesMashhadIran
Anahita Moscowchi
Research Institute for Dental Sciences, Shahid BeheshtiUniversity of Medical SciencesTehranIran
Neda Moslemi
ProfessorDepartment of Periodontics, Tehran University ofMedical SciencesTehranIran
Quang Nguyen
Atlantic Regional Periodontist for Canadian militaryInstructor, Graduate Periodontology ProgramDalhousie UniversityHalifaxCanadaand
Private Practice, Halifax
Costa Nicolopoulos
Private PracticeDubaiUnited Arab Emirates
Patrícia Pauletto
School of DentistryUniversidad de las AmericasQuito, EcuadorandBrazilian Centre for Evidence‐Based ResearchDepartment of Dentistry, Federal University of Santa CatarinaFlorianópolisBrazil
Adriano Piattelli
ProfessorSchool of Dentistry, Saint Camillus InternationalUniversity of Health and Medical Sciences (Unicamillus)Rome, Italy
Lenin Proaño
School of Dentistry, Universidad EspirituSanto GuayaquilEcuadorandCenter for Education and Research on Dental Implants,Department of Dentistry, Federal University of SantaCatarinaFlorianópolisBrazil
Gerry M. Raghoebar
Department of Oral and Maxillofacial Surgery andDepartment of Restorative DentistryUniversity Medical Center GroningenUniversity of GroningenGroningenNetherlands
Dai Lao Rodriguez
FellowAdvanced Clinical Fellowship in Implant Dentistry,Ashman Department of Periodontology and ImplantDentistryCollege of Dentistry, New York UniversityNew YorkUSA
Tea Romasco
Department of Medical, Oral and BiotechnologicalSciencesCenter for Advanced Studies and Technology (CAST)“G. D’Annunzio” University of Chieti‐PescaraChietiItaly
Edwin Ruales‐Carrera
School of DentistryUniversidad de las AmericasQuitoEcuadorandCenter for Education and Research on Dental ImplantsDepartment of Dentistry, Federal University ofSanta CatarinaFlorianópolisBrazil
Chih Hao Shyu
Advanced Clinical Fellow in Implant DentistryAshman Department of Periodontology and ImplantDentistry, College of DentistryNew York UniversityNew YorkUSA
Dong Seok Sohn
ProfessorDepartment Oral and Maxillofacial SurgeryDaegu Catholic University Medical CenterRepublic of South Korea
Celine Soon
Periodontics registrarUniversity of Western AustraliaDental School, Division of Oral Restorative andRehabilitative Sciences, Department of GraduatePeriodonticsPerthWestern Australia
Mohammad Reza Talebi
ProfessorDepartment of PeriodonticsShahid Beheshti University of Medical SciencesTehranIranandPresident of Iranian Academy of Periodontology
Trevor Thang
Assistant ProfessorTeaching Stream, Faculty of DentistryUniversity of TorontoTorontoCanada
Mehdi Valizadeh
Clinical Associate ProfessorUniversity of Western AustraliaDental School, Division of Oral Restorative andRehabilitative Sciences, Department of GraduatePeriodonticsPerthWestern AustraliaandPrivate PracticeVision Periodontics Centre for Advanced Periodontics andImplant DentistryPerthWestern Australia
José Luis Viteri
School of DentistryInternational University of EcuadorQuitoEcuador
Petros Yuvanoglu
Clinical Associate ProfessorTufts University School of Dental MedicineBoston, MAUSA
Foreword
I have known Professor Douglas Deporter for many years as a teacher, mentor, and colleague. As the former Discipline Head and Graduate Director of Periodontology at University of Toronto, Faculty of Dentistry, I have witnessed Professor Deporter as a leader in the field of dental implant dentistry. I have witnessed how he challenged traditional implant concepts. He would introduce evidence‐based concepts many years before they were adopted in the mainstream scientific community. During the early 1980s, he was already conducting animal and clinical studies on short endosseous dental implants, where he challenged the traditional concepts of having long implants and the importance of having adequate crown : root ratio for implants. In today’s literature, there is now an acceptance of using short dental implants and Professor Deporter was at its forefront.
His innovations and creative thinking are reflected in his publications and his previous books, which include Minimally Invasive Dental Implant Treatment, Short and Ultra‐Short implants, and Immediate Molar Implants.
In this book, Current Approaches with Immediate Implants in Anterior and Bicuspid Sites, you will find a similar approach. The editors, Professor Douglas Deporter and Professor Mohammad Ketabi, have produced a book that challenges traditional implant concepts. These new concepts push the envelope but in a careful and evidence‐based approach to ensure long‐term success. Their book discusses various approaches for immediate implants in the anterior and bicuspid sites, various hard and soft tissue augmentation protocols at the time of implant placement, guided surgery, immediate loading of immediate implants, and complications associated with these immediacy approaches.
This book will intellectually challenge and enhance dental implant dentistry. I truly believe you will enjoy exploring and contemplating the new and advanced approaches discussed for immediate implants in the anterior and bicuspid sites.
Professor Jim Yuan Lai, DMD, MSc, EdD, FRCDC
Diplomate, American Board of Periodontology
Vice‐Dean, Education, Faculty of Dentistry
University of Toronto
Toronto, Canada
Preface
“To have the sense of creative activity is the great happiness and the great proof of being alive”
Matthew Arnold (1822–1888), England
One of us had the good fortune of visiting with the great innovator, Professor P‐I Branemark, in Goteborg, Sweden, in 1979, some years before he introduced the modern era of implant dentistry to North American academic oral surgeons and prosthodontists at the so‐called “Toronto Conference” held in 1982. At that time, Branemark’s original device was being manufactured by Nobel Pharma and their policy was to sell their products only to these two specialty groups. Periodontists and general practitioners were denied access. In retrospect, the initial exclusion of periodontists was strange, since periodontics had long been a surgical specialty and heavily involved in research. In any event, with time and the entry of other implant companies into the marketplace, periodontists, and indeed all dentists, were allowed to use implants in their practices. Periodontists, including both of us and our collaboration for over 15 years, subsequently became heavily involved in implantology research contributing much to the advancement of implant science, including more recently, the importance of peri‐implant soft tissues in implant survival and success. Eventually, using implants to replace missing and hopeless teeth became so widespread as to be seen as treatment of first choice in many situations. Not to say that this was or is always a wise decision!
It may have been inappropriate for licensing bodies to allow dental professionals without extensive formal education and hands‐on training to have the freedom to offer unrestricted dental implant therapy to their patients. The result has been a tsunami of peri‐implant diseases and failure. Above all, this was the reason that we chose to undertake this book project. Placing immediate dental implants is a complicated undertaking and not for the novice. It can be inviting to the uninitiated to use an immediate implant to replace a tooth in the esthetic zone, but without the proper knowledge and experience the clinician may inadvertently be condemning their patients to an unending series of complications which can seem earth‐shattering because of their esthetic and psychological impacts.
It is our hope that this book will help to minimize the risks and ensure the benefits of “immediacy” for both clinicians and patients. As we did for our previous book, Immediate Molar Implants, we have gathered an international group of recognized authorities who have helped to establish successful protocols for “immediacy” in the esthetic zone. We hope that our efforts will help clinicians already trained and experienced in routine delayed dental implant treatment to determine whether they are up to the challenge of offering immediate tooth replacement with dental implants to their patients.
Douglas Deporter and Mohammad Ketabi
Acknowledgments
Conceiving and undertaking this second book on “immediacy” was a natural progression after our earlier book devoted to immediate molar implants. Our attempt was to provide proven and published, research‐based information to ensure successful treatment outcomes using immediate implant placement and if appropriate with immediate, non‐occlusal loading. It has been a tremendous learning experience working with the gifted and enthusiastic international cast of contributors who readily offered to share their knowledge. Every one of them has made significant and often highly significant contributions to the field. None hesitated to share their work with us, and we are grateful and honored by their trust.
“Immediacy” in providing rehabilitations using dental implants is currently “all the rage,” to turn a well‐worn phrase. However, without in‐depth and constant learning of relevant basic biology and anatomy, well‐researched treatment protocols, surgical and prosthetic finesse, limitations and risks with “immediacy”, clinicians should not undertake such treatment. Failures can result in dire outcomes for patients that may be impossible to re‐treat and more than negate any initial advantages of the approach particularly in the esthetic zone. The purpose of this book then was to assist clinicians already well‐trained and experienced in traditional placement of dental implants to carefully expand their treatment options for highly selected patients. By no means was it intended to inform and encourage the novice dental implant provider to join the “rage”.
In addition to the contributions made by the generous and supportive group of authors, we are indebted to the many colleagues who shared individual cases with us. We also need to thank the big and welcoming team at Wiley Blackwell Inc. for making this project a reality. It is always a pleasure to work with them.
Douglas Deporter
Over the past two decades, the field of implant dentistry has seen remarkable changes and advancements. However, few innovations have been as intriguing and beneficial for both my patients and me as immediate implantation, especially in the esthetic zone. From the patient’s perspective, immediate implantation is particularly appealing because it requires the least amount of time and the fewest surgical interventions to achieve optimal results.
The latest systematic reviews on immediate implantation are encouraging, showing promising outcomes. Nevertheless, placing implants in the esthetic zone remains a challenging procedure that often requires a high level of expertise and experience, typically provided by surgeons who perform these cases regularly. This book aims to provide a comprehensive review of all aspects, techniques, and challenges associated with immediate implantation in both the upper and lower esthetic zones. It reflects years of collaboration with internationally respected experts in implantology, particularly in immediate implantation, and I am deeply grateful for their invaluable contributions.
I would like to extend my special thanks and appreciation to Professor Deporter, my co‐author, whose scientific insights, expertise, and global connections over the past decade have made this book possible. Working with him has been a privilege, pleasure, and true treasure.
My heartfelt gratitude also goes to Professors Mohammad Reza Talebi, Mehdi Valizadeh, Neda Moslemi, and Anahita Moscowchi for their generous support and assistance.
Publishing with a respected team like Wiley has been a rewarding experience, and I am grateful to their editorial team for their invaluable help with this my second book on immediate implantation.
I dedicate this book to all students, faculty, and especially the eager perio residents at IAU Dental School (Isfahan Branch), where I have spent nearly 27 years serving in various administrative and academic roles.
Finally, I present this book to my wonderful family—Saeedeh, Shiva, Sara, and Mahdi—for their unwavering support and understanding.
Mohammad Ketabi
1Introduction, History and General Principles
Douglas Deporter, Domenico Baldi, and Mohammad Ketabi
Background
In the 40 plus years since the first reports appeared from Professor P‐I Branemark and his colleagues of the clinical use and success of oral rehabilitation using endosseous, root‐form, titanium dental implants [1–3], exhaustive laboratory, animal and human clinical research has led to major advancements in their design and use to replace hopeless or missing teeth. Branemark originally used his implant design, a machine‐turned, commercially pure titanium screw, to restore long‐standing, fully edentulous patients with splinted fixed prostheses meant primarily to provide occlusal function with no great attention being given to esthetic outcomes. Implants were placed in healed edentulous sites and allowed submerged healing for 6 months or more before being uncovered and restored with suitable prostheses. Survival after 10 years was in the high‐90th percentile for mandible, but only in the mid‐80th percentile for maxilla, likely due to differences in bone density. Subsequent replication studies in university settings (e.g. Leuven, Belgium; Toronto, Canada) and elsewhere then began to define further the prerequisites, indications and contraindications for their use in partially edentulous cohorts. While no mention of any limitations in implant length or diameter were specified by Branemark, the replication studies [4, 5] reported that Branemark's original design had a high risk of failure (≥ 25%) when used in lengths of less than 10 mm in mandible and less than 13 mm in maxilla, a belief that even today remains in the minds of some clinicians. However, this elevated risk with “short” implants was most likely due to implant design (machined surface topology) and inexperience by the investigators involved, as would later be concluded [6, 7]. The move to implants with moderately rough surface topologies [8] and introduction of titanium alloys containing zirconium to improve material strength [9] was a major advance. Today, we have a wealth of well‐designed study results showing that both short (≤8 mm) [6] and even ultra‐short (< 6 mm) [10], moderately rough‐surfaced threaded implants can offer excellent performance when properly used and restored.
The essential need for submerged initial healing in achieving osseointegration of dental implants also came to be challenged since investigators later learned that non‐submerged implant placement in healed edentulous sites worked just fine, provided that initial implant stability was adequate [11]. Indeed, even limited, immediate loading in non‐submerged cases started to be reported [12], again if appropriate initial stability could be achieved [13].
The Timing of Implant Placement
The original cohort of patients treated by Branemark had long‐standing full edentulism and their implants were inserted into healed edentulous sites, often in primarily basal bone and with mature overlying soft tissues. However, we now know that other approaches can be taken including implant placement (IIP) at the time of tooth extraction (“immediate implantation”; type 1) or in some instances within the following 4–8 weeks (“early implantation”; type 2) after tooth removal, during which time initial soft tissue healing has occurred [14–16]. The advantage here is that an additional 3–5 mm of keratinized mucosa, including a significant mid‐facial thickening over thin or damaged facial bone walls, can result [17]. There will also be some new bone formation apically in the socket which may accommodate easier implant bed preparation compared with IIP. Both of these “non‐traditional” approaches, while challenging, can be suitable for replacement of non‐molar teeth [16,18–20]. As will be seen, however, immediate placement via flapless surgery and hard tissue gap grafting with immediate provisionalization is the more heavily researched approach [21, 22]. Type 3 implant placement (after 12–16 weeks of healing) can still be indicated in more challenging situations, such as when the tooth socket is so damaged that it needs to be reconstructed in advance with guided bone regeneration (GBR), while type 4 coincides with the original Branemark approach of placing implants in long‐standing, fully healed edentulous sites.
Current thinking is that “immediacy” (type 1) is often the preferred treatment if the condemned tooth or at least its root(s) remains to be extracted, and if so, two possible approaches have been suggested. In the ideal scenario with all socket walls intact, IIP with gap grafting is the usual choice (Figure 1.1). However, if the tooth has suffered extensive bone loss apically and/or buccally due to an endodontic failure or root fracture, provided that the IIP can be placed within the original boney housing with adequate stability, the principles of GBR can be used to regenerate the lost bone during the period of implant integration (Figure 1.2). Finally, if the damage to the bony walls is so extensive so that it is no longer possible to stabilize an implant within the original alveolar housing, immediacy will not be suitable, with the safer approach being socket preservation grafting [23] and delayed implant placement.
Figure 1.1 (a) This patient presented with a hopeless maxillary right central incisor. (b) Preoperative cone beam computed tomography showed the site to have a very thin buccal plate but adequate apical and palatal bone to place an immediate implant. (c) Flapless extraction was followed by implant insertion in a prosthetically ideal location for a screw‐retained restoration. A large buccal gap was intentionally left and packed with particulate bone substitute material. (d) Initially a stock, wide body healing abutment was inserted and the soft tissues sutured. (e) A customized transitional crown was placed. (f) The restored implant after 4 years in function showing stable soft tissue morphology. (g) A radiograph taken at the 4‐year recall confirming stable crestal bone levels.
Figure 1.2 (a) This patient presented with a failed endodontic treatment with chronic periapical infection and fenestration of the buccal plate at her maxillary right first premolar. (b) Because of the large buccal fenestration, a mucoperiosteal flap was raised to expose it. (c) After thorough debridement of the socket and periapical lesion, an immediate implant was inserted into the original bony housing. (d) Particulate bone substitute was used to graft the apical defect and buccal plate as well as the peri‐implant gaps. (e) A collagen membrane was placed over the graft material. (f) Following periosteal release of the flap it was repositioned and sutured. (g) A panoramic radiograph of restored implant 5 years following surgery. (h) The restored implant 5 years in function.
A second case of IIP requiring simultaneous GBR is shown in Figure 1.3a. The patient's maxillary central incisors were extracted revealing major loss of the buccal bone, but it was still possible to secure two implants within the original bony housing of their roots. After ensuring adequate stability of the implants, the large defects were filled with particulate bone allograft, covered with a membrane and allowed 6 months of submerged healing (Figure 1.3b). At that point, cone beam computed tomography (CBCT) revealed significant buccal bone regeneration (Figure 1.3c). To allow wound closure, the large flap had been coronally advanced, which left the buccal covered with alveolar mucosa. Soft tissue grafting was proposed but the patient declined this extra surgery. As a result, it was not possible to regenerate the midline papilla, making it necessary to use a two‐unit splinted prosthesis with the interimplant space masked with pink acrylic (Figure 1.3d).
Figure 1.3 (a) Two maxillary central incisors suffered endodontic complications and needed extraction. (b) After implant insertion, the defects were packed with particulate bone allograft material covered with a stabilized collagen membrane.
Source: Courtesy of Dr. Vahid Esfahanian and Dr. Sorena Abrishamkar, Faculty of Dentistry, Islamic Azad University (Isfahan Branch).
(c) Cone beam computed tomography at 6 months of healing revealed regenerated buccal bone and the implants were subsequently restored. (d) The final restoration including pink acrylic to mask the missing midline papilla.
Early Work with Immediate Implant Placement
The earliest report of IIP usage in humans was published in German in 1976 by Schulte and Heimke [24] using ceramic (aluminum oxide, Al3O2), press‐fit implants, but this implant design was soon overtaken by Branemark's titanium threaded concept. One of the earliest reports using threaded titanium designs for IIP was a case series published by Richard Lazzara [25], the original founder of the 3i Implant Company. He applied the principle of GBR [26] to allow osseointegration of machine‐turned threaded implants placed immediately after removing non‐molar teeth. After raising a conservative soft tissue flap, minimally traumatic tooth removal and socket debridement, he prepared osteotomies into socket native apical bone to achieve adequate initial implant stabilization, and to a depth so that the implant platform was seated at 2 mm below the crestal bone level. Following implant insertion, the extraction socket opening was draped over and isolated with a Gore‐Tex® (WL Gore & Assoc., Flagstaff, AZ) barrier membrane stabilized with sutures. The purpose of the barrier was to prevent connective tissue ingrowth into the socket allowing new bone to form by “distance osteogenesis” [27] arising from the socket walls with eventual implant osseointegration. The Gore‐Tex membrane was left exposed, but because of the risk of site infection [28] was removed at 6 weeks. By this time, the peri‐implant gaps had filled with new, albeit still remodeling, osseous tissue.
Akimoto et al. [29] subsequently conducted experiments in dogs in which machine‐surfaced (i.e. minimally rough [8]) implants were placed in healed mandibular edentulous osteotomy sites intentionally overprepared coronally (by 0.5 mm, 1.0 mm, and 1.4 mm) relative to the diameter of implants being used, but of appropriate diameter apically to achieve implant stability. None of the coronal peri‐implant gaps were grafted with bone substitute, nor were any barrier materials used to cover the implanted sites prior to soft tissue flap closure to allow undisturbed submerged healing. After 12 weeks of healing and animal euthanasia, the retrieved jaw segments were defleshed to reveal macroscopically that all gaps appeared to have healed with complete bone fill. However, subsequent histological assessment revealed that fibrous connective tissue had developed between newly formed bone and implant surface to variable depths such that the wider the initial gap, the more fibrous tissue found. Clearly, healing by “distance osteogenesis” [27] alone with no barrier protection had been too slow to avoid the invasion of fibroblasts, and the authors suggested that moderately rough‐surfaced implants [8] might have performed better by promoting “contact osteogenesis” [27]. Botticelli et al. [30] later confirmed this suggestion with a dog study using moderately rough [8], SLA (sand‐blasted large grit acid‐etched)‐treated (Straumann AG, Waldenburg, Switzerland) implants (length 10 mm; width 3.3 mm). Peri‐implant gaps of 1.25 mm width were created around the coronal‐most 5 mm of implant length. The gaps on one side of each mandible were filled with deproteinized cancellous bone mineral (Bio‐Oss®, Geistlich Sons Ltd., Manchester, UK) while those on the contralateral side were left ungrafted. Finally, all sites were covered with resorbable barrier membranes and allowed submerged healing. Four months later, histological assessment of retrieved specimens showed all gaps, grafted or not, to be filled with bone confirming the importance of guided healing using membranes, at least when implants were submerged using primary wound closure. Later, following work by others, the consensus became that moderately rough IIPs with peri‐implant gap distances greater than 1.5–2 mm most likely required placement of allograft or xenograft bone particles covered by some sort of membrane to allow complete submerged bone healing up to the implant surface [31, 32].
Later still, clinical opinions on the need for gap grafting changed once more, with influential clinicians claiming that, provided that flapless surgery and non‐submerged healing were employed for tooth extraction/IIP, any size gaps would fill with bone spontaneously as long as the blood clots occupying them were not disrupted during initial healing [33–35]. However, if grafted gaps left were small (≤ 2 mm), post‐extraction alveolar ridge shrinkage was seen to endanger sites with initially thin buccal bone [36]. So yes, peri‐implant gaps adjacent to moderately rough‐surfaced implants, regardless of their size, will fill with bone naturally, but gap grafting is still indicated to minimize buccolingual alveolar ridge shrinkage with IIPs [37], and especially in anterior maxilla, where buccal bone is commonly very thin. Failure to include gap grafting also has been linked to immediate implant failures. For example, Covani et al. [38] found that IIP survival at single‐rooted tooth sites after 10 years in function was 87.9% at non‐grafted compared with 94.1% at grafted sites.
Currently, as demonstrated in this book, the consensus with IIPs at sites with intact socket walls is to use flapless surgery, minimally traumatic tooth extraction, gap grafting with a particulate bone substitute and non‐submerged initial healing following placement of a wide‐diameter stock or customized healing abutment or temporary restoration to: (i) protect the added graft material; (ii) support the original socket soft tissue margins; and (iii) provide some degree of non‐occlusal loading to the implant to kickstart osteogenesis [39]. However, using IIPs is recognized by experts as being technically challenging [40], particularly for surgeons with limited experience, because of high risks of disastrous esthetic complications, especially in anterior maxilla [41, 42]. To provide successful IIP treatment in the esthetic zone, the clinician needs to have the essential skills of delicate soft tissue manipulation using flapless surgery, minimally traumatic extraction methods, familiarity with bone of different qualities and appropriate ways to compensate for them if need be, selection of appropriate implant designs, three‐dimensional (3D) prosthetically ideal implant positioning, well‐controlled site drilling, proper assessment of initial implant stability, and, of course, most importantly recognizing when IIP is inappropriate. In the end, success with “immediacy” at non‐molar sites for both clinicians and patients is now defined as a stable esthetically pleasing outcome replicating natural teeth. If this cannot be anticipated, IIP may not be the treatment of choice [43].
Biological Benefits of “Immediacy”
There are significant biologic advantages with IIPs since as already mentioned, with gap grafting they help to minimize the alveolar ridge bone shrinkage routinely seen following tooth extraction and unassisted healing [44–46]. Following tooth removal, periodontal ligament and “bundle bone” [47] are quickly lost due to the reduced functional forces received by the remaining alveolar bone. This leads to a dramatic buccolingual/palatal ridge shrinkage of up to 50% in the first 3 months or so [48]. The impact is particularly dramatic at maxillary anterior tooth sites where facial/buccal bone wall thickness is typically less than 1 mm and therefore can completely disappear within 6–8 weeks post‐extraction. Chappuis et al. [49, 50] reported that the average mid‐buccal loss in width at these sites was 7.5 mm. This drastic loss in healing ridge width can be significantly reduced by “socket preservation grafting” [51] at the time of tooth removal, but this adds expense and time to the implant treatment since a second series of appointments then become necessary for delayed implant insertion. It is, however, becoming increasingly apparent that IIP placement with grafting of peri‐implant buccal gaps using particulate bone allograft or xenograft can be an effective way to reduce this ridge shrinkage [52, 53]. Most clinicians elect to place the graft material after securing the implant, but an alternate approach can be to place the graft material before inserting the implant to ensure that it is well compacted [54]. This latter approach, however, requires redrilling of the osteotomy with the same bur used for the initial osteotomy, with the surgical guide in place, at a very slow speed and without saline, to keep the graft particles in place [54].
The larger the gap being grafted the better (Figure 1.4a, b). For example, Levine et al. [36] recently published CBCT findings up to 5 years after IIP treatment in anterior maxilla comparing buccal gaps of 2 mm or less with gaps greater than 2 mm. All were grafted with particulate xenograft, but where gaps of less than 2 mm had been left, there was significantly more buccal thinning and vertical bone loss, the ultimate result being significant loss of bony covering on buccal implant surfaces. While this may not result in complete denudation of bone from the buccal implant surface, it most likely will lead to some loss in crestal bone height and associated gingival recession. Buccal bone thickness needs to be at least 1.8 mm to accommodate the vasculature necessary for nutrients supporting appropriate remodeling and long‐term bone maintenance [55]. To reduce this risk with narrower gaps, it is prudent also to include contour grafting buccally under the periosteum [56]. Capelli et al. [57] went further, suggesting that if the distance from the implant surface to the outer aspect of the buccal plate is less than 4 mm, this “external grafting” should always be included. Xenograft particles covered with a resorbable membrane were used by Capelli for both gaps and for external grafting, although others believe that the barrier in unnecessary and that the particulate xenograft can simply be inserted in a surgically created buccal pouch [58, 59]. Others have proposed using autogenous connective tissue grafts to increase buccal soft tissue thickness to minimize soft tissue recession [60].
Figure 1.4 (a) A large (> 2 mm) buccal gap between implant and buccal bone wall needs to be left for grafting with slowly resorbing particulate bone substitute. (b) The gap left at the implant marked with the arrow was too small for effective grafting making buccal onlay grafting essential to avoid loss of buccal plate.
Indications for Immediate Implant Placement in Anterior and Premolar Sites
Proper case selection is crucial in proposing IIP treatment, including reasons for tooth extraction, which may be non‐restorable caries, root fractures, root resorption, questionable teeth in need of endodontic retreatment, teeth fractured at the gingival margin with unfavorably short roots, and especially when questionable teeth may be being considered as abutments for traditional fixed partial dentures. Placement of immediate implants has its longest history in maxillary anterior and premolar sites (i.e.: the “esthetic zone”) and documented findings have allowed considerable refinement of treatment approaches.
Maxillary incisor sites may seem to the uninitiated as the ideal sites for IIPs because of easy access, single‐rootedness, and patients' urgent needs of replacement for esthetic reasons. Indeed, the authors of one recent systematic literature review with meta‐analysis of immediate implant performance at different tooth locations suggested IIP to be the preferred approach for maxillary anteriors [61]. However, for many reasons, these sites may be the most difficult to obtain optimal or even acceptable long‐term outcomes [62]. The scallop of the periodontium, level of crestal and interproximal bone, expected tooth‐to‐implant interproximal distance, morphology of the gingival tissues, smile line and patient's esthetic expectations must be considered before initiating treatment. Box 1.1[63] shows a suggested list of essential diagnostic parameters needed for favorable treatment outcomes. The ideal scenario for IIP in the esthetic zone will be a healthy individual who is a non‐smoker, with a low lip line, a thick, low‐scalloped gingival phenotype, rectangular tooth shape, no infection, ≤ 5 mm distance from the future contact point with the adjacent teeth to the bone crest [64], adequate mesiodistal ridge width (≥ 7 mm), minimal buccal bone anatomical undercuts and an intact facial bone plate ≥ 1 mm in thickness at the crest [63, 65] (Figure 1.5
