Immediate Implant Placement and Loading – Single or Multiple Teeth Requiring Replacement E-Book

France Lambert

• Herausgeber: Quintessence Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 360

Veröffentlichungsjahr: 2023

Beschreibung

Dental implants are used routinely throughout the world to replace missing teeth. With the broadening of treatment options and an increasing number of clinicians that provide implant therapy, it is important to ensure that the treatment methods used meet the highest clinical standards. The ITI Treatment Guide series is a compendium of evidence-based implant-therapy techniques in daily practice. Written by renowned clinicians and supported by contributors from expert practitioners, the ITI Treatment Guides provide a comprehensive overview of the various indicated treatment options. The management of different clinical situations is discussed with an emphasis on sound diagnostics, evidencebased treatment concepts, and predictable treatment outcomes with minimal risk to the patient. Volume 14 of the ITI Treatment Guide series aims to provide a comprehensive overview on immediate implant placement and immediate loading protocols for replacement of single or multiple teeth requiring extraction. This volume outlines the current literature on immediate implant placement and immediate loading and elaborates on our understanding of the biology surrounding tooth extraction and osseointegration that underpin these treatment concepts. The importance of patient and site selection in conjunction with comprehensive treatment planning is highlighted and a risk assessment tool to aid decision making is provided. All key aspects of both the surgical and loading procedures are described in order to provide protocols that optimize the final treatment outcome. This volume also presents 9 step-by-step clinical cases performed by experts in the field, and typical complications of immediate implants are discussed, along with recommendations on how these can be prevented.

Leseprobe

ITI Treatment Guide

Volume 14

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ISBN 978-1-78698-127-1

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Illustrations:

Ute Drewes, Basel (CH),

www.drewes.ch

Copyediting:

Triacom Dental, Barendorf (DE),

www.triacom.com

Layout | Production:

Janina Kuhn, Berlin (DE)

Printer:

Grafički zavod HrvatskeMičevečka ulica 7HR-10000 Zagreb, Croatia

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ISBN: 978-3-86867-682-2

The materials offered in the ITI Treatment Guide are for educational purposes only and intended as a step-by-step guide to the treatment of a particular case and patient situation. These recommendations are based on the conclusions of the ITI Consensus Conferences and, as such, are in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors, or publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential, or incidental damages or loss of profits) caused by the use of the information contained in the ITI Treatment Guide. The information contained in the ITI Treatment Guide cannot replace an individual assessment by a clinician and its use for the treatment of patients is therefore the sole responsibility of the clinician.

The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in the ITI Treatment Guide does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.

All rights reserved. In particular, the materials published in the ITI Treatment Guide are protected by copyright. Any reproduction, whether in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.

Some of the manufacturer and product names referred to in this publication may be registered trademarks or proprietary names, even though specific reference to this fact is not made. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

The tooth identification system used in this ITI Treatment Guide is that of the FDI World Dental Federation.

The ITI Mission is …

“… to serve the dental profession by providing a growing global network for life-long learning in implant dentistry through comprehensive quality education and innovative research to the benefit of the patient.”

Acknowledgement

The authors would like to express their gratitude to Dr. Kati Benthaus for her excellent support in the preparation and coordination of this Treatment Guide. We would also like to thank Ms. Ute Drewes for the professional illustrations, Ms. Janina Kuhn (Quintessence Publishing) for the typesetting, Ms. Änne Kappeler (Quintessence Publishing) for the coordination of the production workflow, and Mr. Per N. Döhler (Triacom Dental) for the language editing. We also acknowledge Institut Straumann AG, the corporate partner of the ITI, for its continuing support.

Preface

The advantages of immediate implant placement and loading protocols are well documented and can be considered a desirable treatment approach if certain conditions are fulfilled.

A considerable body of literature supporting the use of immediate implant placement and loading protocols in partially edentulous patients has accumulated over the last two decades. However, a number of factors and procedures such as type of surgery, alveolar ridge preservation, and type of graft, among others, can make the clinical decisions involved challenging.

Referring to evidence-based methods, this volume of the ITI Treatment Guide series aims to provide a comprehensive overview of immediate implant placement and loading protocols for replacement of single or multiple teeth requiring extraction. It highlights the importance of patient and site selection in combination with comprehensive treatment planning and provides the reader with a risk-assessment table to aid in decision-making. The reader will also find a description of all key aspects of both surgical and loading procedures, providing clinical protocols for predictable treatment outcomes.

Step-by-step clinical cases performed by experts in the field underline the importance of careful patient selection in order to achieve successful outcomes, while also reducing patient treatment time. Overall, Volume 14 of the ITI Treatment Guide series will inform and support clinicians when faced with challenging cases of single and multiple tooth replacement.

Editors and Authors

EDITORS

Daniel Wismeijer, Professor, DMD, PhD

Referral Practice for Oral Implantology and Prosthetic Dentistry

De Veluwezoom

p/a Zutphensestraatweg 26

6955 AH Ellecom

The Netherlands

Email: [email protected]

Stephen Barter, BDS, MSurgDent, RCS

Specialist in Oral Surgery

Honorary Senior Clinical Lecturer / Consultant Oral Surgeon

Centre for Oral Clinical Research

Institute of Dentistry

Barts and The London School of Medicine and Dentistry

Turner Street

London E1 2AD

United Kingdom

Email: [email protected]

Nikolaos Donos, DDS, MS, FHEA, FDSRC, PhD

Director of Research

Professor and Chair of Periodontology and Implant Dentistry

Head of Clinical Research

Centre for Oral Clinical Research

Institute of Dentistry

Barts and The London School of Medicine and Dentistry

Turner Street

London E1 2AD

United Kingdom

Email: [email protected]

AUTHORS

Adam Hamilton, BDSc, DCD, FRACDS

Discipline Lead in Prosthodontics and Graduate Program Convenor

Division of Oral Restorative and Rehabilitative Sciences

University of Western Australia

17 Monash Avenue

Nedlands, WA 6009

Australia

Email: [email protected]

Division of Regenerative and Implant Sciences

Department of Restorative Dentistry and Biomaterial Sciences

Harvard School of Dental Medicine

188 Longwood Avenue

Boston, MA 02118

United States of America

Email: [email protected]

France Lambert, DDS, MSc, PhD

Professor and Head, Department of Periodontology, ­Oro-dental and Implant Surgery

Vice-director, Dental Biomaterial Research Unit

CHU of Liège

University of Liège

Domaine Universitaire du Sart Tilman B35

4000 Liège

Belgium

Email: [email protected]

Contributors

Mauricio G. Araújo, DDS, MSc, PhD

Professor, Head of Periodontics and Implant Dentistry Research Unit

Department of Dentistry

State University of Maringá

Av. Mandacaru 1550

87080-000 Maringá

Brazil

Email: [email protected]

Miljana Baćević, DDS, PhD

Centre for Oral Clinical Research

Institute of Dentistry

Barts and The London School of Medicine and Dentistry

Turner Street

London E1 2AD

United Kingdom

Email: [email protected]

Thomas Borer, Dr med dent

Oral Surgery and Prosthetics

Private Clinic Basel Switzerland

Missionsstrasse 1

4055 Basel

Switzerland

Email: [email protected]

Senior Doctor

Kantonsspital Aarau Switzerland

Haus 2a, Tellstrasse 25

5001 Aarau

Switzerland

Email: [email protected]

Andre Chen, DDS, MSc, PhD

Oral Surgery Specialist

Private Practice

International Advanced Dentistry

Academy Center for Continuing Dental Education

Av. da Liberdade 220, 1st Floor

1250-147 Lisboa

Portugal

Email: [email protected]

Stephen Chen, BDS, MDSc, FRACDS, PhD

Clinical Associate Professor

Melbourne Dental School

Faculty of Medicine, Dentistry and Health Sciences

The University of Melbourne

720 Swanston Street, Carlton, VIC 3053

Australia

Email: [email protected]

Krzysztof Chmielewski, DDS, MSc

SmileClinic Chmielewski & Karczewska Advanced Implant Center

Karola Szymanskiego 2

80-280 Gdańsk

Poland

Email: [email protected]

Karim Dada, Dr, DDS, MS

Private Practice

62 Bd de la Tour-Maubourg

75007 Paris

France

Email: [email protected]

Gary Finelle, DMD

Private practice Dental7Paris

59 Av de la Bourdonnais

75007 Paris

France

Email: [email protected]

German O. Gallucci, DMD, PhD

Raymond J. and Elva Pomfret Nagle Endowed

Associate Professor and Chair Department of

Restorative Dentistry and Biomaterials Sciences

Harvard School of Dental Medicine

188 Longwood Avenue

Boston, MA 02115

United States of America

Email: [email protected]

Luiz Gonzaga, DDS, MS

Clinical Associate Professor

Center for Implant Dentistry

Department of Oral and Maxillofacial Surgery

College of Dentistry

University of Florida

1395 Center Drive, Room D7-6

Gainesville, FL 32610-0434

United States of America

Email: [email protected]

Oscar Gonzalez-Martin, DDS, PhD, MSc

Private practice, Atelier Dental Madrid

C/Blanca de Navarra 10

28010 Madrid

Spain

Email: [email protected]

Visiting lecturer

Department of Restorative Dentistry and Biomaterials Sciences

Harvard School of Dental Medicine

188 Longwood Ave

Boston, MA 02115

United States of America

Email: [email protected]

Visiting lecturer

University Complutense Madrid

Department of Periodontology

Plaza Ramon y Cajal

28040 Madrid

Spain

Arndt Happe, PD, Dr med dent

Private Practice Dr. Happe & Kollegen

Specialist in Implantology, Oral Surgeon

Schützenstr. 2

48 143 Münster

Germany

Email: [email protected]

Clinic for Dental Prosthetics

Center for Dental, Oral and Maxillofacial Medicine

University Hospital Ulm

Albert-Einstein-Allee 11

89081 Ulm

Germany

Alejandro Lanis, DDS, MS

Director Advanced Graduate Education in Implant Dentistry

Assistant Professor in Restorative Dentistry and Biomaterials Sciences

Harvard School of Dental Medicine

188 Longwood Avenue

Boston, MA 02115

United States of America

Email: [email protected]

Amélie Mainjot, DDS, MSc, PhD

Professor and Head, Dental Biomaterials Research Unit

University of Liège

Head of Clinic, Department of Fixed Prosthodontics

University Hospital Center (CHU) of Liège

Department of Dentistry

Quai G. Kurth, 45

4000 Liège

Belgium

Email: [email protected]

William Martin, DMD, MS, FACP

Clinical Professor and Director

Center for Implant Dentistry

Department of Oral and Maxillofacial Surgery

College of Dentistry

University of Florida

1395 Center Drive, Room D7-6

Gainesville, FL 32610

United States of America

Email: [email protected]

Léon Parienté, Dr, DDS

Private Practice

62 Bd de la Tour-Maubourg

75007 Paris

France

Email: [email protected]

Stefan Röhling, DDS, PD, Dr med dent

Specialist in Oral Surgery

Senior Clinical Lecturer/Consultant Oral Surgeon

Private dental practice Gahlert & Röhling

Theatinerstraße 1

80333 Munich

Germany

Email: [email protected]

Senior Oral Surgeon and Associate Professor

Clinic of Oral- and Maxillofacial Surgery

Hightech Research Center

University Hospital Basel, Kantonsspital

Aarau

Tellstrasse 25

5001 Aarau

Switzerland

Björn Roland

Dental Design Björn Roland GmbH

Raiffeisenstraße 7

55270 Klein-Winternheim

Germany

Email: [email protected]

André Barbisan De Souza, DMD, MSc

Adjunct Professor

Nova Southeastern University College of Dental Medicine

3020 North Military Trail Ste 200

Boca Raton, FL 33431

United States of America

Email: [email protected]

Teresa Chanting Sun, DDS, MS

Specialist in Periodontology

Department of Periodontology

Mackay Memorial Hospital

92 Zhongshan North Road Section 2

104 Taipei City

Taiwan

Clinical Assistant Professor

School of Dentistry

National Defense Medical Center

and Tri-Service General Hospital

161 Minquan E Road Section 6

114 Taipei City

Taiwan

Email: [email protected]

Table of Contents

1 Introduction

A. Hamilton, F. Lambert

2 Evolution of Immediate Implant Placement and Loading

A. Hamilton, F. Lambert, M. Baćević, M. Araújo, S. Chen, G. Gallucci

2.1     Evolution of Implant Placement Protocols

2.2     Evolution of Implant Loading Protocols

2.3     Current Concepts and Definitions of Implant Placement and Loading Protocols

2.4     Proceedings of the 6th ITI Consensus Conference

2.4.1  Consensus Statements Regarding Implant Placement and Loading Protocols

2.4.2  Clinical Recommendations Regarding Implant Placement and Loading Protocols

2.5     Proceedings of the 7th ITI Consensus Conference

2.5.1  Consensus Statements Regarding Type 1A Immediate Implant Placement and Immediate Loading

2.5.2  Clinical Recommendations Regarding Type 1A Immediate Implant Placement and Immediate Loading

2.6     Evidence for Type 1A Protocols: Immediate Implant Placement + Immediate Loading

2.7     Evidence for Type 1B Protocols: Immediate Implant Placement + Early Loading

2.8     Evidence for Type 1C Protocols: Immediate Implant Placement + Conventional Loading

3 Preoperative Analysis and Treatment Planning

F. Lambert, A. Hamilton, A. De Souza, W. Martin

3.1     Patient Characteristics

3.1.1  Medical Status

3.2     Esthetic Analyses and Esthetic Challenges

3.3     Prosthodontic Planning

3.3.1  Diagnostic Wax-Up/Digital Diagnostic Set-Up

3.3.2  Occlusal Assessment

3.3.3  Alternative Provisional Restorations (Plan B)

3.4     Surgical Planning

3.4.1  Bone Conditions

3.4.2  Soft Tissue Status

3.4.3  Preoperative Infections

3.4.4  Virtual Implant Planning and 3D Positioning

3.4.5  Implant Selection

3.5     Risk Assessment Table with Indications and Contraindications

4 Clinical Procedures

F. Lambert, A. Happe, A. Hamilton, O. González-Martín

4.1     Immediate Implant Placement

4.1.1  Minimally Invasive Extraction

4.1.2  Socket Assessment and Debridement

4.1.3  Flapless vs. Flapped

4.1.4  Osteotomy Preparation

4.1.5  Socket Management

4.1.6  Biomaterial Selection

4.1.7  Connective Tissue Grafting and Alternatives

4.1.8  Alternative Socket Management: the Socket-Shield Technique

4.1.9  Postoperative Drug Administration and Instructions

4.2     Immediate Restoration

4.2.1  Clinical Criteria for Immediate Loading and Restoration

4.2.2  Prosthetically Guided Soft Tissue Healing

4.2.3  Contours of the Emergence Profile

4.2.4  Occlusal Considerations

4.2.5  Fabrication Techniques

4.2.6  Restoration Insertion

4.2.7  Alternatives to Immediate Loading

5 Clinical Case Presentations

5.1     Immediate Implant Placement and Immediate Provisionalization with a Prefabricated-Shell Provisional Crown

A. Happe

5.2     Immediate Implant Placement to Replace a Fractured Central Incisor in a Young Patient and Management of Long Term Implant Infraposition

A. Mainjot, F. Lambert

5.3     Immediate Implant Placement and Restoration of a Maxillary Left Central Incisor with a Provisional Crown

L. Pariente, K. Dada

5.4     Immediate Implant Placement with Static Computer-Aided Implant Surgery and Immediate Loading in the Esthetic Zone with Prefabricated CAD/CAM Provisional Implant Restorations

A. Lanis, L. Gonzaga, A. Hamilton

5.5     Replacement of a Maxillary Left Canine with a Cemented Crown on an Immediately Placed Bone-Level Tapered Implant Using a One-Abutment, One-Time Approach

K. Chmielewski, B. Roland

5.6     Guided Immediate Placement of a Ceramic Implant in a Maxillary Right Second Premolar and Immediate Restoration with a CAD/CAM-Fabricated Provisional Crown

A. Chen

5.7     Replacement of a Mandibular Central Incisor with an Immediately Placed Monotype Zirconia Implant

S. Röhling, T. Borer

5.8     Immediate Replacement of Four Mandibular Anterior Teeth with a Conventionally Loaded Implant-Supported Fixed Dental Prosthesis

G. O. Gallucci, A. Hamilton, T. C. Sun

5.9     Replacement of an Endodontically Compromised Mandibular Left First Molar with Immediate Implant Placement and a Sealing Socket Abutment (SSA)

G. Finelle

6 Complications

F. Lambert, A. Hamilton

6.1     Complications Related to Case Selection

6.1.1  Unfavorable Alveolar Bone Anatomy

6.1.2  Unfavorable Soft Tissue Quality or Quantity

6.2     Complications Related to Surgical Procedures

6.2.1  Implant Positioning

6.2.2  Complications Associated with Adjunctive Regenerative Procedures

6.3     Complications Related to Loading Procedures

7 Conclusions

F. Lambert, A. Hamilton

8 References

1

Introduction

A. Hamilton, F. Lambert

Once a tooth is indicated for extraction and immediate replacement with a dental implant, one of the first and most important clinical decisions to make is to select an appropriate protocol for implant placement and loading. The success of this protocol is determined by four main parameters: biological, prosthetic, and esthetic outcomes, as well as patient satisfaction (as per patient-reported outcome metrics). The selected protocol should combine the maximally predictable short- and long-term outcomes with the lowest surgical morbidity and highest efficiency (Buser and coworkers 2017a).

Our continuously better understanding of the biology of immediate placement has had a significant impact on the evolution of immediate placement and loading protocols and procedures. The advantages of immediate placement are well documented; they include shorter overall treatment times, limitation to a single surgical session, and maximum availability of potential bone volume (since the extraction socket will not yet have undergone the inevitable post-extraction resorption) (Hämmerle and coworkers 2004; Chen and Buser 2008). Immediate implant placement and loading is a desirable protocol—provided that the appropriate clinical indications are present.

However, several limitations have been reported for this approach. Immediate placement is made more complicated by the morphology of the socket and the surrounding alveolar bone. Achieving the ideal three-dimensional position of the implant while obtaining primary stability can be a challenge. Immediate placement does not limit the alveolar bone resorption associated with tooth extraction (Araújo and coworkers 2005). Unless addressed by proper patient selection and adjunctive regenerative procedures, this bone resorption may lead to midfacial recession and esthetic compromises (Chen and Buser 2014).

Considerable research into immediate placement and immediate loading in partially edentulous patients has been published over the last two decades. Overall, the literature reports this to be a predictable treatment approach, with implant survival rates comparable to delayed protocols using contemporary treatment approaches (Gallucci and coworkers 2018). However, the diversity of surgical and prosthetic techniques in terms of adjunctive procedures and factors can make clinical decisions difficult.

These adjunctive factors include:

Type of surgery (flapless versus open-flap procedures)

Alveolar ridge preservation (socket grafting versus no graft)

Type of graft (

autologous, allograft, or xenograft

)

Use of connective tissue graft (CT) for soft tissue augmentation

Simultaneous connection of a provisional prosthesis (immediate loading)

There seems to be a trend for studies of immediate (type 1A) implant placement that use adjunctive regenerative procedures to minimize and compensate for resorption of the facial tissues (flapless, bone graft, and CT graft) to exhibit less variability in terms of esthetic outcomes (Chen and Buser 2008; Seyssens and coworkers 2021)

The focus of the present Volume 14 of the ITI Treatment series is on modern treatment protocols for immediate implant placement following the flapless extraction of a tooth. The reduced surgical trauma and morbidity associated with this approach offer distinct biological advantages and provide greater patient benefits than more invasive approaches.

This volume therefore aims to provide a comprehensive overview of immediate implant placement and loading protocols for the replacement of single teeth requiring extraction. The current literature on immediate implant placement and immediate loading is outlined to provide the biological understanding that underpins these concepts, together with a review of the success of immediate tooth-replacement protocols (Chapter 2).

The main objective of this volume is to highlight the importance of patient and site selection in conjunction with comprehensive treatment planning, and to provide the reader with a risk assessment tool that will aid in decision-making (Chapter 3).

Even if the sites for immediate implant placement and loading are carefully selected, these interventions are technically complex, with many variations in proposed treatment protocols. The second objective of this volume is therefore to describe the key aspects of both the surgical and loading procedures, in order to provide protocols that optimize the final outcome (Chapter 4).

This volume also provides step-by-step reports of clinical cases performed by experts in the field, exploring a range of indications and applications for immediate implant placement and loading protocols (Chapter 5).

The final chapter discusses typical complications associated with immediate implants and provides recommendations on how to prevent them (Chapter 6).

2

Evolution of Immediate Implant Placement and Loading

A. Hamilton, F. Lambert, M. Baćević, M. Araújo, S. Chen, G. Gallucci

2.1 Evolution of Implant Placement Protocols

The original protocol for implant placement required a healed alveolar ridge and involved a two-stage surgical procedure (Schroeder and coworkers 1976; Brånemark and coworkers 1977). Even though the Tübingen immediate implant, which allowed implant placement into fresh extraction sockets, was introduced soon thereafter (Schulte and coworkers 1978), immediate implants presented a more challenging option to traditional (delayed) implants for decades to follow. Techniques based on the principles of guided bone regeneration (GBR) (Dahlin and coworkers 1988; Dahlin and coworkers 1989) were also investigated at that time and applied to peri-implant extraction defects of immediate implants in combination with open-flap procedures (Lazzara 1989; Becker and Becker 1990; Lang and coworkers 1994).

Early on, studies had shown that implants placed into fresh extraction sockets could successfully achieve osseointegration (Barzilay and coworkers 1988; Barzilay and coworkers 1991; Paolantonio and coworkers 2001), but higher implant failure rates were also reported (Schwartz-Arad and Chaushu 1997, Mayfield 1999). By the late 1990s, new studies had emerged to demonstrate that not only immediate implant placement was possible but also immediate loading (of the implants) (Wöhrle 1998). However, initial clinical results with immediate implants or immediate loading were not always satisfactory, particularly in regard to esthetic outcomes (Chen and coworkers 2004).

The introduction of implants with moderately rough surfaces provided a better understanding of the bone/implant interface and healing processes, as well as occlusion and proper prosthetic design. Along with the improvement of implant design, immediately placed and loaded implants slowly gained acceptance among the scientific community and among clinicians (Avila and coworkers 2007). Following the accumulation of an extensive body of evidence, both immediate implant placement and immediate loading have become accepted clinical procedures within the indicated conditions.

A widely adopted classification of 4 categories for the timing of implant placement after tooth extraction (type 1 to type 4) was first established at the 3rd ITI Consensus Conference (Hämmerle and coworkers 2004) and further modified in Vol. 3 of the ITI Treatment Guide series (Chen and Buser 2008), which classified immediate implant placement following tooth extraction as type 1 (Fig 1).

Fig 1 Timing of implant placement.

The main benefit of type 1 (immediate) implant placement lies in the reduced number of surgical procedures, shorter overall treatment times, reduced recovery times, and—in certain circumstances—the ability to immediately restore the implant, leading to high patient satisfaction as well as positive effects regarding the maintenance of the peri-implant softtissue architecture.

A biological understanding of immediate implant placement relies on the biology of socket healing. Post-extraction socket healing is a biological process where several processes develop continuously, despite being arbitrarily assigned to distinct phases, namely: hemostasis and coagulation, inflammatory, proliferative, and modeling and remodeling phases (de Sousa Gomes and coworkers 2019).

Immediately after tooth extraction, the socket is filled with blood; a blood clot is formed soon thereafter. The wound starts to attract inflammatory cells that infiltrate the clot and embark on phagocytosis—removing bacteria and clot structures—as well as on the production of different growth factors. At the same time, new blood vessels start to sprout, and loosely organized granulation tissue intensely infiltrated by inflammatory cells and fibroblasts replaces the initial blood clot, which undergoes coagulative necrosis (Cardaropoli and coworkers 2003).

The granulation tissue is progressively replaced by immature connective tissue (provisional matrix) rich in cells and collagen fibers organized in a woven pattern. Subsequently, undifferentiated mesenchymal cells penetrate the fibrous tissue and start differentiating into bone-forming cells, which promote the mineralization of the organic matrix to form the so-called woven bone. Woven bone progressively becomes replaced by mature lamellar bone tissue/bone marrow, and the alveolar ridge, at the socket wall, undergoes dimensional alterations (Figs 2a-b) (Araújo and Lindhe 2005).

Figs 2a-b Macroscopic histological images demonstrating the bone modelling 1 week (a) and 8 weeks (b) following tooth extraction demonstrating resorption of the thin facial bone visible on the right side of the images.

   Use this QR code to view a computer-animated 3D film on osseointegration.

   Use this QR code to view a 3D animation about socket healing.

Most dimensional changes following tooth extraction occur in the first three months after tooth removal (Schropp and coworkers 2003) and continue as long as the modeling phase takes place, although with lesser intensity. Post-extraction dimensional alterations seem to be related to several factors, such as the individual healing properties of a patient, anatomical or pathological site characteristics, and the extent of surgical trauma and tissue destruction induced during the extraction procedure (Araújo and coworkers 2015).

Although all these factors may vary, a mean hardtissue reduction of 3.8 mm (29–63%) in width and 1.24 mm (11–22%) in height during the first six months of healing was reported in a systematic review evaluating post-extraction hard and soft tissue dimensional changes (Tan and coworkers 2012).

The following resorption patterns have been observed:

Greater resorption in width than height (Johnson 1969)

The mandibular bone resorbs faster than the maxillary bone (Atwood 1971)

The molar area endures more resorption than the frontal area (Pietrokovski and Massler 1967)

Greater vertical changes occur in multiple adjacent extraction sites compared with single-tooth extraction sites (Lam 1960)

The buccal plate is resorbed first (Cawood and Howell 1988)

Thin buccal walls, intrinsically present in the anterior maxilla, are especially prone to resorption. Araújo and coworkers (2005) hypothesized that the coronal part of buccal bone plate was often made only of bundle bone, which is a part of the periodontium and thus a tooth-dependent structure. Removing a tooth renders this bone useless, and its resorption is a natural consequence. Studies have shown that thin facial bone (< 1 mm) at the socket is likely to resorb three times more in the apicocoronal plane than thick facial bone (≥ 1 mm) when immediate implants are placed (Ferrus and coworkers 2010).

Additionally, damaged facial bone with fenestrations or any kind of dehiscence in the bone walls will make the bone weaker and more prone to resorption (Kan and coworkers 2007), while sites presenting thick buccal bone exhibit less dimensional changes of the alveolar ridge after tooth extraction (Chappuis and coworkers 2013; Chappuis and coworkers 2015). Other risk factors include a thin periodontal phenotype (Evans and Chen 2008; Cordaro and coworkers 2009) and inadvertent facial malposition of the implant within the socket at placement (Chen and coworkers 2007; Evans and Chen 2008).

Once it had been demonstrated that the osseointegration of implants placed in fresh extraction sockets was a predictable outcome (Chen and coworkers 2004) and took place irrespective of the gap between the implant surface and the bony socket walls, studies proceeded to investigate the physiological process of socket healing combined with immediate implant placement. Initially, proponents of immediate implants as a novel therapeutic concept argued that it may counteract post-extraction buccal-bone resorption, benefiting from the supporting role of the tooth and hence providing better esthetic outcomes (Lazzara 1989; Denissen and coworkers 1993). However, subsequent studies yielded contradictory results, namely that resorptive changes after tooth extraction occur independently of the timing of implant placement and that immediate implants fail to prevent them (Botticelli and coworkers 2004; Araújo and coworkers 2005; Chen and coworkers 2007) (Figs 3a-c) (Araújo and coworkers 2006).

Figs 3a-c Resorptive changes after tooth extraction occur independently of the timing of implant placement and immediate implants fail to prevent them. Baseline (a), 4 weeks (b), and 12 weeks (c) after tooth extraction demonstrating resorption of the thin facial bone visible on the right side of the images adjacent to the immediately placed implants.

These findings led researchers to combine immediate implants with alveolar ridge preservation procedures that involve grafting the peri-implant socket defect with bone substitutes to limit post-extraction remodeling and to achieve a better long-term functional and esthetic outcomes of implant restorations (Chen and coworkers 2004).

Most evidence on immediate implants involves maxillary anterior teeth (Zhou and coworkers 2021), where esthetic outcomes play a key role for success. One of the early limitations of immediate placement was the use of coronally advanced full-thickness mucoperiosteal flaps to achieve submerged healing with or without concomitant bone grafting. Implants were also often placed in compromised sockets with thin or absent buccal plates. Although such procedures produce successful outcomes in terms of osseointegration and implant survival, esthetic limitations and—most commonly—midfacial recession were frequently reported with 20–30% of immediate implants at risk of midfacial mucosal recession of 1 mm or more (Chen and Buser 2009; Chen and Buser 2014).

Various alveolar-ridge preservation techniques and protocols have been described, aimed at minimizing dimensional changes and esthetic challenges. These include particulate bone grafts or substitutes and socket-sealing techniques using connective tissue grafts, a barrier membrane, or plugs. Among other opinions, the 2019 European Workshop in Periodontology Consensus statements indicated that alveolar ridge preservation via socket grafting limits horizontal and vertical post-extraction bone resorption, compared to tooth extraction alone (Avila-Ortiz and coworkers 2019; Tonetti and coworkers 2019). The same workgroup also concluded that socket grafting in conjunction with immediate implant placement is an integral component of the procedure in most cases.

Current evidence seems to indicate a trend toward better outcomes when implants are placed immediately in a flapless approach combined with socket grafting, plus connective-tissue grafting in patients with a thin soft tissue phenotype (Seyssens and coworkers 2020; Seyssens and coworkers 2021).

2.2 Evolution of Implant Loading Protocols

The biological process of osseointegration of a dental implant follows a pattern similar to that of bone fracture healing.

One prerequisite for direct bone fracture healing is wound stabilization and rigid fixation, with excessive loads at the wound interface leading to delayed healing or non-union (Marsell and Einhorn 2011). With dental implants, this stabilization is achieved through the insertion of an endosseous implant with a diameter slightly larger than that of the osteotomy. This provides primary stability, which is a requirement for osseointegration and long-term implant success.

The original loading protocols for endosseous implants proposed by Per-Ingvar Brånemark and André Schroeder required an undisturbed healing time of three to four months prior to loading (Schroeder and coworkers 1976; Adell and coworkers 1981; Buser and coworkers 2000). The protocols were proposed based on their understanding of osseointegration at the time, which involved a necrotic border zone around the implant due to the surgical trauma of the osteotomy preparation. It was suggested that the necrosis and replacement of the bone adjacent to the implant was inevitable, and it was recommended to leave the implant undisturbed throughout this process until osseointegration had occurred, as minor movements would inhibit osteogenesis and jeopardize osseointegration (Albrektsson and coworkers 1981; Schroeder and coworkers 1981).

Over the next few decades, our understanding of the physiology of the osseointegration process evolved, and clinical studies soon emerged to challenge this paradigm by demonstrating that implants in fully edentulous sites could be immediately loaded when four implants were placed with cross-arch splinting (Ledermann 1979; Babbush and coworkers 1986).

The concept of immediate loading continued to evolve (Schnitman and coworkers 1990). By the late 1990s, interest had turned to a challenging clinical scenario in which an immediate provisional prosthesis was connected to an implant placed in a fresh extraction socket in the anterior maxilla (Wöhrle 1998). Implant technology had improved to the point where the healing period prior to loading could be reduced, with immediate loading considered predictable given a proper indication, with results comparable to conventional loading protocols (Cochran and coworkers 2004; Gallucci and coworkers 2014; Gallucci and coworkers 2018).

This was underpinned by advances in two areas:

A research focus on the reduction of surgical trauma and subsequent necrosis to the surrounding bone during osteotomy preparation and insertion of a dental implant (Eriksson and Albrektsson 1983; Möhlhenrich and coworkers 2015; Bernabeu-Mira and coworkers 2021)

Research on the regeneration of bone adjacent to the implant during the osseointegration process, where surface technology was identified as a key component (Salvi and coworkers 2015; Bosshardt and coworkers 2017).

Osseointegration is now recognized as a dynamic process in which the resorption of damaged bone and the apposition of new bone through regeneration occur simultaneously. This follows current mechanobiological models of bone fracture healing, which recognizes that the physiologically complex healing process involves both biological and mechanical aspects (Ghiasi and coworkers 2017).

It is generally established that mechanical stability throughout the osseointegration process is required for short- and long-term clinical success (Listgarten and coworkers 1991; Albrektsson and Zarb 1993). Mechanical stability is required to limit micromovements from direct or indirect forces being applied to the implant that would result in fibrous encapsulation and implant failure. As osseointegration occurs, the initial primary mechanical stability—by which the implant resists movement from loading in the initial healing phase—is substituted for secondary stability (Fig 4) where the newly regenerated bone has matured to the point where it can contribute to the stability of the implant under loading conditions (Bosshardt and coworkers 2017).

Fig 4 Illustration of the gradual rise in secondary stability as the primary stability Is reduced. The rate of increase in secondary stability can be influenced by the implant’s surface characteristics, surgical trauma, and the biological capacity of the patient.

With this transition from primary to secondary implant stability, a dip in the overall mechanical stability of the implant occurs. This constitutes a risk factor for implant failure if excessive loads are applied at this point in the healing process (Raghavendra and coworkers 2005; Oates and coworkers 2007; Lang and coworkers 2011).

Immediate loading of dental implants may present some advantages, mainly in that it eliminates the need for removable transitional appliances, which are often inconvenient for the patient to wear and can be deleterious to the underlying surgical site if the transitional appliance is tissue-supported. An immediate implant-supported provisional restoration also provides an opportunity to provide prosthetically guided soft tissue healing, which can assist in maintaining the pre-extraction soft tissue architecture. While these objectives can also be achieved with alternatives (bonded bridges, custom healing abutments), immediate provisionalization of immediately placed dental implants provides the most efficient pathway.

Contemporary protocols for immediate implant placement recognize that the preservation of the soft tissue contours and architecture at the time of extraction can provide predictable results in the context of prosthetically guided soft tissue healing (Schubert and coworkers 2019). An immediately loaded provisional or custom healing abutment with an appropriately shaped emergence profile will support the marginal soft tissue while containing the grafting material and blood clot and minimizing contamination by saliva. With biocompatible materials, soft tissue adhesion can also promote soft tissue stability and help minimize post-extraction ridge alterations.

2.3 Current Concepts and Definitions of Implant Placement and Loading Protocols

The current classification of implant placement and loading protocols was defined in a 2018 systematic review by Gallucci and coworkers and adopted by the 2018 ITI Consensus Conference. In this new classification, the relationship between these two treatment concepts is combined into one classification system (Table 1) with the relative timelines illustrated in Figure 5. This approach recognizes that these two events occur for every implant that is placed and that they are not independent of each other, but rather co-dependent variables that influence success and outcomes. Twelve different combinations of implant placement and loading were described, as follows:

Type 1A: Immediate placement + immediate restoration/loading

Type 1B: Immediate placement + early loading

Type 1C: Immediate placement + conventional loading

Type 2A: Early placement with soft tissue healing + immediate restoration/loading

Type 2B: Early placement with soft tissue healing + early loading

Type 2C: Early placement with soft tissue healing + conventional loading

Type 3A: Early placement with partial bone healing + immediate restoration/loading

Type 3B: Early placement with partial bone healing + early loading

Type 3C: Early placement with partial bone healing + conventional loading

Type 4A: Late placement + immediate restoration/loading

Type 4B: Late placement + early loading

Type 4C: Late placement + conventional loading.

Fig 5 Timeline based on the definitions of implant placement protocols and implant loading protocols (after Zhou and coworkers 2021).

Table 1 Classification combining implant placement and loading time

Loading protocol

Immediate restoration/loading (type A)

Early loading (type B)

Conventional loading (type C)

Implant placement protocol

Immediate placement (type 1)

Type 1A

Type 1B

Type 1C

Early placement (type 2-3)

Type 2-3A

Type 2-3B

Type 2-3C

Late placement (type 4)

Type 4A

Type 4B

Type 4C

Gallucci, Hamilton, Zhou, Buser and Chen 2018. 6th ITI Consensus Report. Group 2. Article 2

In this classification, previous definitions of the timing of implant placement and loading were adopted from previous ITI Consensus Conferences, as follows:

Implant placement protocols

Late implant placement:

Dental implants are placed after completely bone healing, more than six months after tooth extraction

Early implant placement:

Dental implants are placed with soft tissue healing or with partial bone healing, four to eight weeks or twelve to sixteen weeks after tooth extraction

Immediate implant placement:

Dental implants are placed in the fresh socket on the same day of tooth extraction

(Chen and Buser 2009; Chen and coworkers 2004; Hämmerle and coworkers 2004).

Implant loading protocols

Conventional loading:

Dental implants are allowed a healing period of more than two months after implant placement with no connection to the prosthesis.

Early loading:

Dental implants are connected to the prosthesis between one week and two months after implant placement.

Immediate loading:

Dental implants are connected to the prosthesis within one week after implant placement.

This is in line with the publications of the previous ITI Consensus Conferences (Benic and coworkers 2014; Chiapasco 2004; Cochran and coworkers 2004; Gallucci and coworkers 2014; Gallucci and coworkers 2009; Ganeles and Wismeijer 2004; Grutter and Belser 2009; Morton and coworkers 2004; Papaspyridakos and coworkers 2014; Roccuzzo and coworkers 2009; Schimmel and coworkers 2014; Schrott and coworkers 2014; Weber and coworkers 2009).

Thus, for immediate implant placement, three subcategories were listed:

Type 1A:

Immediate placement + immediate restoration/loading

Type 1B:

Immediate placement + early loading

Type 1C:

Immediate placement + conventional loading

The analysis of the survival rates of each of these treatment protocols based on this new classification follows in the next section.

2.4 Proceedings of the 6th ITI Consensus Conference

2.4.1 Consensus Statements Regarding Implant Placement and Loading Protocols

The newly proposed classification assessing both the timing of implant placement and loading combinations allows for comprehensive treatment selection.

Type 1A (immediate placement + immediate resto­ration) is a clinically documented protocol. The survival rate was 98% (median: 100%; range: 87–100%).

Type 1B (immediate placement + early loading) is a clinically documented protocol. The survival rate was 98% (median: 100%; range; 93–100%).

Type 1C (immediate placement + conventional loading) is a scientifically and clinically valid protocol. The survival rate was 96% (median: 99%; range: 91–100%).

Type 2-3A (early placement + immediate restoration/loading) presents clinically insufficient documentation.

Type 2-3B (early placement + early loading) presents clinically insufficient documentation.

Type 2-3C (early placement + conventional loading) is a scientifically and clinically valid protocol. The survival rate was 96% (median: 96%; range: 91–100%).

Type 4A (late placement + immediate restoration/loading) is a clinically documented protocol. The survival rate was 98% (median: 99%; range 83–100%).

Type 4B (late placement + early loading) is a scientifically and clinically valid protocol. The survival rate was 98% (median: 99%; range: 97–100%).

Type 4C (late placement + conventional loading) is a scientifically and clinically valid protocol. The survival rate was 98% (median: 100%; range: 95–100%).

When considering placement/loading protocols, there are factors that can prevent achievement of the intended treatment. These factors include:

Patient-related factors

Lack of primary stability

The need for bone augmentation

2.4.2 Clinical Recommendations Regarding Implant Placement and Loading Protocols

Immediate implant placement and immediate restoration/loading is considered a complex surgical and prosthodontic procedure. Clinicians performing this procedure need to have sufficient training, experience, and clinical skill to be able to undertake the necessary diagnostic procedures and to perform the treatment.

The ITI recommends that the type 1A protocol should only be considered if there are demonstrable patient-centered advantages, such as esthetic requirements or a clinical indication to reduce surgical morbidity (Morton and coworkers 2018). For example, there seems to be little advantage in connecting an immediate provisional restoration to an immediately placed implant in a first-molar site. Although it has been clinically documented (Atieh and coworkers 2010), there is little patient-centered advantage to this approach over conventional placement and loading protocols.

The following clinical conditions are recommended for the type 1A protocol (Morton and coworkers 2014; Morton and coworkers 2018):

Intact socket bone walls.

In particular, the status of the facial bone wall is critical to esthetic outcomes. Diagnostic CBCT scans are often able to evaluate the condition of the facial socket wall; however, it can often be obscured by metal artifacts from a post within a root canal. The facial bone wall can also be damaged as a result of the extraction procedure. Therefore, the facial bone should be definitively evaluated following tooth extraction.

Facial bone at least 1 mm thick.

Clinical studies have demonstrated that thin facial bone (< 1 mm) is prone to significant vertical crestal resorption (Chen and coworkers 2007; Ferrus and coworkers 2010; Sanz and coworkers 2017). If this resorption is extensive, bone grafts placed into the facial peri-implant defect may not be fully contained within the bone walls and are therefore prone to resorption. This may result in incomplete bone fill within the peri-implant defect (van Steenberghe and coworkers 2000; Chen and coworkers 2007; Juodzbalys and Wang 2007), exposure of the rough surface of the implant crestally, and recession of the midfacial peri-implant mucosa.

Thick soft tissue phenotype.

Sites with a thin soft tissue phenotype run a greater risk of recession of the midfacial mucosa, which may have adverse implications for final esthetic outcomes (Evans and Chen 2008; Cordaro and coworkers 2009). Cases with a thin soft tissue phenotype should be avoided unless additional interventions promote thickening of the facial gingiva. Such additional interventions may include intentional decoronation and submergence of the root to promote gingival overgrowth, soft tissue thickening (Langer 1994) incorporating connective tissue grafts into the soft tissue marginal area on the facial aspect of the socket (Kan and coworkers 2005; Chen and coworkers 2009; Kan and coworkers 2009), or grafting of the supracrestal region with small-particle bone substitutes that promote soft tissue thickening (Chu and coworkers 2012; Chu and coworkers 2015).

No acute infection at the site.

Sites with acute infection should not be considered for the type 1A protocol as there is likely to be damage to one or more socket walls, and the inflammation of the soft tissues may lead to significant recession.

Sufficient bone volume apical and lingual to the socket.

This is to allow the implant to be placed with primary stability. This is an essential requirement to ensure that the implant can then be connected to a provisional resto­ration. CBCT scans provide essential information establishing this requirement.

Resistance to rotational torque.

The implant should resist the torque that is likely to be applied to the abutment screw of the provisional restoration. This largely depends upon the recommendations of the implant manufacturer, which with current implant systems should be in the range of 25-40 Ncm or ISQ value > 70.

Occlusal scheme that protects the provisional resto­ration

during function. Cases should therefore be selected where direct occlusal contact between the provisional res­toration and opposing dentition can be avoided.

Patient compliance.

The patient should be prepared to follow postoperative instructions. The critical factor is to avoid direct masticatory function on the provisional prosthesis.

2.5 Proceedings of the 7th ITI Consensus Conference

In the 7th ITI Consensus Conference in 2023, the literature specifically on type 1A immediate implant placement and immediate loading in the anterior maxilla (teeth 15 to 25) was assessed and new consensus statements as well as clinical recommendations were made as an update to those from the 6th ITI Consensus Conference, in which all implant placement and loading protocols were assessed.

2.5.1 Consensus Statements Regarding Type 1A Immediate Implant Placement and Immediate Loading

The following consensus statements were developed from the two systematic reviews that assessed selection criteria and implant survival (Hamilton and coworkers 2023) and clinical performance (Wittneben and coworkers 2023) of immediately placed and immediately loaded dental implants (type 1A) for single-tooth replacement in the anterior maxilla (teeth 15 to 25) (region of esthetic significance). All implants included in the two reviews exhibited a minimum of 12 months of follow-up.

SYSTEMATIC REVIEW PAPER 1

HamiltonA, Gonzaga L, Amorim K, Wittneben JG, Martig L, Morton D, et al. Selection criteria for immediate implant placement and immediate loading for single tooth replacement in the maxillary esthetic zone: a systematic review and meta-analysis. Clin Oral Implants Res. 2023; 34 [forthcoming].

Preamble

The following consensus statements are based on a systematic review that assessed implant survival with type 1A (immediate implant placement and immediate restoration/loading) protocol for implant replacement of single teeth in the anterior maxilla (teeth 15 to 25), with a minimum of 12 months of follow-up. The review also assessed the reported patient and site-specific selection criteria that may influence survival outcomes. The review is based on data from 43 prospective (11 randomized controlled trials, RCTs, and 6 clinical controlled trials, CCTs) and 25 retrospective studies with a total of 2,531 implants with a mean follow-up of 2.6 years.

Consensus statements

The type 1A protocol for replacement of a single tooth in the anterior maxilla (teeth 15 to 25) is predictable with high implant survival rates. This is based on studies with highly selective populations, with favorable patient and site-specific characteristics. When failures occur, the majority are within the first 6 months of implant placement. This statement is supported by 43 prospective (including data from 11 RCTs, 6 CCTs) and 25 retrospective studies.

Multiple patient and site-specific factors are relevant in the selection and completion of a type 1A protocol for the replacement of a single tooth in the anterior maxilla (teeth 15 to 25 FDI). These include:

General factors

–   Medical status (63 studies)

–   Periodontal disease (54 studies)

–   Occlusal scheme (57 studies)

–   Parafunction (26 studies)

Site-specific factors

–   Facial bone wall (60 studies)

–   Endodontic infection (42 studies)

–   Bone for anchorage (37 studies)

–   Soft tissue quality (25 studies)

–   Gingival margin position (22 studies)

Treatment factors

–   Mucoperiosteal flap (63 studies)

–   Damage during tooth extraction (59 studies)

–   Gap between the facial bone and implant (56 studies)

–   Primary implant stability (42 studies)