Diagnostic Considerations for Esthetic Implant Therapy
more accurate description of the status of the socket at the time of immediate implant placement (Tehemar 1999). An immediate implant procedure offers many advantages, including optimal implant placement (i.e., the original tooth place), which thus minimizes the need for severely angulated abutments, and alveolar ridge preservation due to prevention of the postextraction resorption, which permits the use of longer and wider implants. Other advantages are (1) minimizing the possibility for injury of anatomical landmarks, (2) limiting postdrilling bone resorption by reducing heat generation during drilling, and (3) reducing treatment time to almost half. There is also a positive psychological impact on the patient in relation to dental implants because immediate replacement of the extracted root/tooth takes place without a delay while the patient waits for socket healing. A nonsubmerged protocol for immediate implantation was proposed by Saadoun and La Gall (1998). In this protocol, the implant and healing abutment are connected at the time of implant placement without attempting any soft tissue modifications. This technique minimizes soft tissue trauma and plays a significant role in the maturation of the soft tissue around the site. Using an implant diameter that corresponds to the socket orifice will eventually reduce the need for bone grafting and prevent the in-growth of soft tissue along the socket walls (Wheeler et al. 2000). However, soft tissue closure is still questionable in terms of predictable osseointegration. Lack of direct visibility of the labial plate of the alveolar bone raises some serious concerns over this procedure and its clinical success. The immediate delayed protocol of implant placement, on the other hand, permits soft tissue granulation on the socket orifice. Soft tissue requires six to 10 weeks after tooth extraction to mature. This approach aids in developing a soft tissue seal on top of the socket by secondary intention, after which the implant is placed, as is the case of the standard delayed method. The newly formed keratinized tissue helps minimize soft tissue complications that might arise from excessive
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surgical manipulations made to achieve primary closure in cases of immediate implant placement. Interestingly, a study by Osigo and others (1995) described another method for delayed implantation. This technique employs an implant osteotomy followed by wound closure without actually inserting the implant. Two weeks later, the patient undergoes another surgery to place the implant. The authors found that many new thin trabeculae and capillaries formed around the osteotomy walls during the waiting period, and the surrounding fibrous tissue encapsulation appeared to a lesser extent, thus enhancing osseointegration. This approach makes the technique clinically and practically inapplicable. Another implant placement protocol is the one-stage implant placement technique. This refers to the insertion of a one-piece implant in a single surgical procedure, eliminating the second-stage surgery. The technique is similar to the nonsubmerged protocol of implant placement. The implant penetrates the soft tissue through the flared implant neck itself. The method can be used in both delayed and immediate cases. The use of nonsubmerged, one-piece implants has shown immense clinical success, especially at the functional level, with the ease of prosthetic management (Buser et al. 1997, Buser et al. 1999). The one-stage system eliminates the possibility of microgap formation between the abutment and the implant fixture at the level of the bone crest. These advantages certainly increase the popularity of this type of implant. It must be noted that the technique is restricted to areas where esthetics are not of chief concern (See Figures 2.53A–C) (Cornelini et al. 2000).
Diagnostic Checklist A complex decision-making process will influence the choice of treatment path, such as the clinician’s access to technology, level of skill, education, philosophy, evi-
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Figure 2.53. A. Healed osseous site that is scheduled for delayed implant placement protocol. B. Fresh extraction site that is scheduled for immediate implant placement. C. Partially healed site (i.e., the soft tissue is only healed but not the bone; the case is scheduled for delayed immediate implant therapy).