Chapter 6
Immediate Esthetic Implant Therapy Abd El Salam El Askary
The high clinical success rates that have been reported when implants placed in standard situations have encouraged efforts to improve esthetic success, especially for implants that are placed in more demanding esthetic situations. One of these improvements is the procedure for immediate tooth replacement with dental implants in fresh extraction sockets. Although the first clinical procedures for placing implants immediately following tooth removal were described long ago, it is only recently that the details of such clinical approaches have been studied thoroughly (Hammerle et al. 2004). Immediate esthetic implant therapy has a highly pronounced value. It has been developed to save time and preserve the condition of the alveolar ridge by avoiding postextraction bone resorption, thus maintaining original alveolar crest width and height, reducing surgical procedures and treatment time, and offering enhanced esthetic results. Paolantonio and others (2001) recently suggested that the placement of implants in fresh extraction sockets would prevent postextraction bone resorption and hence maintain the original shape of the ridge. They stated that early implantation may preserve the alveolar anatomy and that the placement of a fixture in a fresh extraction socket may help to maintain the osseous crest structure. Findings reported from a clinical study by Botticelli and others (2004) failed to support this hypothesis. An animal study (Araujo et al. 2005) that focused on determining the dimensional alterations of the alveolar ridge following implant placement in fresh extraction sockets using beagle dogs stated that placing an implant in the fresh extraction site obviously failed to prevent the remodeling that occurred in the walls of the socket. The resulting height of the buccal and lingual walls at three months was similar at implant and edentulous sites, and the vertical bone level change was more pronounced at the buccal than the lingual aspect of the ridge. Also, the height of the buccal hard tissue wall was reduced considerably more than that of the lingual wall of the same extraction socket. This was due to either the early disappearance of the bundle bone or the delicate nature of
the buccal bone rather than the lingual bone wall of the socket. Because the implant can be seated according to the existing natural tooth angulation, this minimizes the possibility for injury of the anatomical landmarks. This also limits postdrilling bone resorption, thus reducing heat generation, which in turn favors marginal soft tissue stability around dental implant-supported restorations. The overall procedure has proven to have a positive psychological impact on the patient (Gelb 1993, Cornelini et al. 2000, Kan and Rungcharassaeng 2000). Immediate implant placement offers success rates that are strongly evidenced in the literature; results are equal to that of the delayed implant placement modes (Becker 2005, Meredith et al. 1996). There are some clinical factors that should be considered prior to selecting an immediate implant placement protocol versus the other clinical approaches, such as: (1) bone topography, (2) level of crestal and interproximal bone, (3) smile line, (4) condition of the gingival tissues, (5) pathological and morphological condition of the alveolar socket, (6) soft tissue biotype, (7) the need for preservation of interdental papilla, (8) the need to prevent alveolar ridge resorption, and (9) patient demands. However, certain clinical requirements should be fulfilled to attain high success rates for immediate implant therapy, such as: (1) absence of any frank active infection, (2) good mechanical anchorage and primary stability of the implant fixture within the alveolar socket, (3) atraumatic removal of the unsalvageable tooth, (4) preservation of the labial plate of bone, (5) use of the appropriate implant design that corresponds to the socket’s configuration, and (6) proper implant position in terms of angulation and position. These requirements are important not only to achieve functional success, but also esthetic success. This is backed by strong literature support that indicates the high success rate of dental implant placement in the esthetic zone (Hammerle et al. 2004, Gelb 1993, Cornelini et al. 2000, Kan and Rungcharassaeng 2000). The basic 179