Preservation of Existing Soft‐Tissue Contours in the Transition from a Tooth to an Implant Restoration in the Esthetic Zone Using a Flapless Approach: A Clinical Report

Two‐stage placement of a dental implant is a well‐established method for restoring a missing anterior tooth; however, replacement of an anterior tooth by using two‐stage implant surgery may result in changes in the interdental papilla height and loss of alveolar bone with compromised esthetic results. Alternatively, the use of a one‐stage minimally invasive surgical technique followed by immediate provisionalization may facilitate achievement of esthetic and functional success with minimal discomfort and clinical time. This article presents a clinical case with a single anterior tooth replacement, illustrating ridge preservation with healing, delayed implant placement with immediate provisionalization of the implant to support the soft tissue, and a method of recording the soft‐tissue contour in the final impression to achieve an optimal esthetic result.     

Implant treatment of two failing or missing central incisors in the aesthetic region: a treatment protocol and 1-year prospective study

Implant treatment for two central incisors in the maxillary aesthetic region is complex due to concerns regarding inter-implant hard and soft tissue stability. A treatment protocol was therefore developed and implemented in a 1-year prospective case series study involving 16 patients with two failing or missing central incisors in the maxillary aesthetic region. The protocol consists of five options depending on whether teeth are still present (options 1–3) or not (options 4 and 5) and on the amount of bone available at the start of treatment: (1) extraction followed by immediate implant placement and provisionalization, (2) extraction followed by immediate implant placement and delayed provisionalization, (3) extraction followed by ridge preservation, delayed implant placement and immediate provisionalization, (4) delayed implant placement and guided bone regeneration with delayed provisionalization, (5) guided bone regeneration (extensive bone augmentation of the alveolar ridge), delayed implant placement, and delayed provisionalization. The patients were assessed regarding peri-implant hard and soft tissue parameters, aesthetic index score, and patient satisfaction. All treatment options showed good clinical and radiographic results and high patient satisfaction.     

Immediate Placement of Dental Implants in the Esthetic Zone: A Systematic Review and Pooled Analysis

Background: Research interest on immediate placement of dental implants has shifted from implant survival toward optimal preservation of soft and hard tissues. The aim of this study is to systematically assess the condition of implant survival, peri‐implant hard and soft tissue changes, esthetic outcome, and patient satisfaction of immediately placed single‐tooth implants in the esthetic zone. Methods: MEDLINE, EMBASE, and CENTRAL databases were searched for publications up to June 2013. Studies reporting on implant survival, changes in hard and soft peri‐implant tissues, esthetic outcome, and patient satisfaction were considered. A pooled analysis was performed to identify factors associated with survival and peri‐implant tissue changes after immediate implant placement. Results: Thirty‐four studies were considered eligible. Immediate placement of single‐tooth implants in the esthetic zone was accompanied by excellent 1‐year implant survival (97.1%, 95% confidence interval [CI]: 0.958 to 0.980). Mean marginal peri‐implant bone loss was 0.81 ± 0.48 mm, mean loss of interproximal peri‐implant mucosa level was 0.38 ± 0.23 mm, and mean loss of peri‐implant midfacial mucosa level was 0.54 ± 0.39 mm. Regression analysis revealed that delayed provisionalization (odds ratio [OR] 58.03, 95% CI: 8.05 to 418.41, P <0.000), use of a flap (OR 19.87, 95% CI: 10.21 to 38.66, P <0.000), and use of a connective tissue graft (OR 4.56, 95% CI: 1.72 to 12.08, P <0.002) were associated with marginal peri‐implant bone‐level change >0.50 mm. Because of underreporting, esthetic results and patient outcome did not allow for reliable analysis. Conclusion: Immediate placement with immediate provisionalization of dental implants in the esthetic zone results in excellent short‐term treatment outcome in terms of implant survival and minimal change of peri‐implant soft and hard tissue dimensions.     

Distraction osteogenesis: a treatment tool to improve baseline conditions for esthetic restorations on immediately placed dental implants--a case report

Replacement of two adjacent teeth in an anterior maxilla with deficient hard and soft tissues appears to be the utmost challenge in implant dentistry in the esthetic zone. In this case report, baseline conditions for implant placement were improved by alveolar distraction to enhance hard and soft tissues around the maxillary central incisors. Three months after the active phase of distraction, the roots of the central incisors were extracted and two screw-type dental implants were immediately placed into the extraction sockets. For immediate provisionalization, acrylic resin crowns were fabricated on UCLA abutments, providing the ideal emergence profile to support the periimplant soft tissue. Six months after implant placement, the prosthetic restoration of the case was finished with ceramic crowns cemented to individually fabricated zirconium oxide abutments. The described treatment strategy appears to have a great potential to restore natural esthetics in cases with major tissue deficiencies in the esthetic zone.     

Immediate single-tooth implants in the anterior maxilla: a 1-year case cohort study on hard and soft tissue response

Aim: The objective of the present study was to assess implant survival rate, hard and soft tissue response and aesthetic outcome 1 year after immediate placement and provisionalization of single-tooth implants in the pre-maxilla. All patients underwent the same strategy, that is mucoperiosteal flap elevation, immediate implant placement, insertion of a grafting material between the implant and the socket wall and the connection of a screw-retained provisional restoration.
Material and Methods: Thirty consecutive patients were treated for single-tooth replacement in the aesthetic zone by means of immediate implant placement and provisionalization. Reasons for tooth loss included caries, periodontitis or trauma. At 6 months, provisional crowns were replaced by the permanent ones. Clinical and radiographic evaluation was completed at 1, 3, 6 and 12 months to assess implant survival and complications, hard and soft tissue parameters and patient's aesthetic satisfaction.
Results: One implant had failed at 1 month of follow-up, resulting in an implant survival rate of 97%. Radiographic examination yielded 0.98 mm mesial, respectively, 0.78 mm distal bone loss. Midfacial soft tissue recession and mesial/distal papilla shrinkage were 0.53, 0.41and 0.31 mm, respectively. Patient's aesthetic satisfaction was 93%.
Conclusions: The preliminary results suggest that the proposed strategy can be considered to be a valuable treatment option in well-selected patients.     

Implant placement in fresh extraction sockets

Recent systematic reviews have shown that the survival rate of immediate implant placement is similar to those with a delayed approach. However, preclinical models and human studies have shown that immediate implant placement per se does not preserve the anatomy of the alveolus, mainly at the buccal bone crest, leading to bony dehiscences and subsequently to soft‐tissue recession, with a great impact on esthetic outcomes. On the other hand, preclinical and human studies have identified factors that may prevent bone resorption after immediate implant placement, such as anatomical/biological (alveolus, gingival biotype, periapical/periodontal pathology) and surgical/restorative ones (implant diameter and positioning, flap/flapless, bone and connective tissue grafts, immediate loading/provisionalization, antibiotics). Taking these factors together and with a critical treatment plan made by an expert professional, the immediate treatment approach could be possible and beneficial for the patient.     

上颌单颗前牙不翻瓣即刻种植修复的临床效果观察

目的评价即刻种植即刻修复联合不翻瓣技术在上颌单颗前牙位点的临床应用效果,并探讨其技术要点。方法选择上颌单颗中切牙无法保留的患者17例,采用不翻瓣技术,拔除患牙后即刻植入种植体,并即刻行种植体支持临时冠修复,术后2个月复诊调整临时冠外形,术后3个月行最终修复。最终修复后1、3、6、12、24个月复诊。最终修复即刻、12、24个月复诊时检测种植体周围边缘骨吸收量、软组织健康状况及红色美学指数(PES)。结果本研究共植入17枚种植体,随访期内所有种植体周围软组织健康状况良好,24个月复诊时平均边缘骨吸收量为0.59 mm;最终修复即刻、12、24个月复诊时的PES平均分别为8.88、9.12和8.94,3个时间点的红色美学指数差异无统计学意义。结论上颌单颗前牙位点采用即刻种植即刻修复联合不翻瓣技术可以获得良好的短期临床效果。     

Customized provisional abutment and provisional restoration for an immediately-placed implant.

The use of immediate implant placement and immediate provisionalization techniques are paramount to the maintenance for aesthetic hard and soft tissue structures. This is particularly important when implant-supported restorations are utilized in the aesthetic zone. A purpose of the custom-fabricated provisional abutment and restoration is to guide the hard and soft tissue response during healing. This case presentation depicts the prosthetic technique used by the author to create the final tissue contours and emergence profile for the final restoration.     

Rehabilitation of maxillary anterior esthetics by alveolar distraction osteogenesis with immediate implant placement: a case report

Esthetic reconstruction of severe soft and hard tissue deficiencies is the utmost challenge in implant dentistry. To prevent postoperative bone resorption and to control the amount of hard and soft tissue volume, distraction osteogenesis followed by immediate implant placement has been proven to be a promising combined technique. The aim of this report is to introduce a treatment strategy to maintain anterior esthetics and to control hard and soft tissue volume in a case, treated with the combined technique of vertical alveolar distraction and immediate implant placement. An osteotomy was performed by the use of an oscillating saw. Cut alveolar segment was mobilized, and a distractor device was inserted in between the segments. During the activation and consolidation periods of distraction, anterior esthetics was provided with removable acrylic provisional crowns placed on the distractor's rod. In 2 weeks of distraction period, vertically 10 mm of new bony segment was obtained, and 2 weeks after the removal of distractor, maxillary incisors were extracted. Four dental implants were placed according to the immediate placement protocol. In osseointegration period, provisional restorations were fabricated on abutments to form harmonious gingival contours and to maintain maxillary anterior esthetics until the fabrication of final restorations.     

Computer-guided implant placement with immediate provisionalization: a case report.

Placement of dental implants in the esthetic zone is challenging for clinicians because of patients exacting esthetic demands and preexisting anatomy. This article presents an option for highly demanding surgical cases with the use of computer-guided implant placement and immediate provisionalization. This technique optimizes implant placement and soft tissue esthetics while providing the patient with an immediate fixed restoration.     

Hard and soft tissue changes after crestal and subcrestal immediate implant placement

Background: The purpose of this study is to assess the influence of the placement level of implants with a laser‐microtextured collar design on the outcomes of crestal bone and soft tissue levels. In addition, we assessed the vertical and horizontal defect fill and identified factors that influenced clinical outcomes of immediate implant placement. Methods: Twenty‐four patients, each with a hopeless tooth (anterior or premolar region), were recruited to receive dental implants. Patients were randomly assigned to have the implant placed at the palatal crest or 1 mm subcrestally. Clinical parameters including the keratinized gingival (KG) width, KG thickness, horizontal defect depth (HDD), facial and interproximal marginal bone levels (MBLs), facial threads exposed, tissue–implant horizontal distance, gingival index (GI), and plaque index (PI) were assessed at baseline and 4 months after surgery. In addition, soft tissue profile measurements including the papilla index, papilla height (PH), and gingival level (GL) were assessed after crown placement at 6 and 12 months post‐surgery. Results: The overall 4‐month implant success rate was 95.8% (one implant failed). A total of 20 of 24 patients completed the study. At baseline, there were no significant differences between crestal and subcrestal groups in all clinical parameters except for the facial MBL (P = 0.035). At 4 months, the subcrestal group had significantly more tissue thickness gain (keratinized tissue) than the crestal group compared to baseline. Other clinical parameters (papilla index, PH, GL, PI, and GI) showed no significant differences between groups at any time. A facial plate thickness ≤1.5 mm and HDD ≥2 mm were strongly correlated with the facial marginal bone loss. A facial plate thickness ≤2 mm and HDD ≥3 were strongly correlated with horizontal dimensional changes. Conclusions: The use of immediate implants was a predictable surgical approach (96% survival rate), and the level of placement did not influence horizontal and vertical bone and soft tissue changes. This study suggests that a thick facial plate, small gaps, and premolar sites were more favorable for successful implant clinical outcomes in immediate implant placement.     

上前牙美学区即刻种植的研究现状

在牙齿拔除的同时将种植体立即植入新鲜拔牙窝的种植方式,其具有减少手术次数和整体治疗时间、充分利用现有骨量、具有理想的美学效果等优点。然而,即刻种植同样存在本身固有的缺点,由于拔牙窝的存在,创口的关闭较困难;由于种植体的尺寸与拔牙窝不匹配,较难达到良好的初期稳定性;并且存在软组织退缩的风险。本文就上前牙美学区即刻种植的成功率、适应证及其扩展、手术要求、并发症及其防治等方面作一综述。文献复习结果表明,即刻种植的5年成功率高于95%。其适应证包括:拔牙窝完整;唇侧骨壁厚度至少为1mm;厚龈生物型;种植位点无急性感染;根尖区足够骨量以提供良好初期稳定性。同时近年来随着种植外科技术的改良和骨替代材料性能的改善,即刻种植已成为口腔种植诊疗中的常规手段之一,并且其适应证有进一步扩大趋势。但其也有并发症,包括种植体植入位置不佳,牙龈退缩造成美学效果欠佳。此外即刻种植即刻修复和常规负荷表现出相似的结果,并有利于获得更好的美学效果,但关于即刻种植软组织美学的长期稳定性和患者满意度尚需进一步研究。     

Immediate Single‐Tooth Implant Placement in Bony Defects in the Esthetic Zone: A 1‐Year Randomized Controlled Trial

Background: This study aims to assess, with regard to marginal bone level (MBL), whether the outcome of immediate implant placement in bony defects in the esthetic zone was non‐inferior to delayed implant placement after 1 year. Methods: Forty patients with a failing tooth in the esthetic zone and a labial bony defect of ≥5 mm after removal of a tooth were randomly assigned for immediate (n = 20) or delayed (n = 20) implant placement. Second‐stage surgery and provisionalization occurred after 3 months of healing. Follow‐up was at 1 month and 1 year after definitive crown placement. The study was powered to detect a difference in MBL of >0.9 mm. Buccal bone thickness, soft tissue peri‐implant parameters, esthetic indices, and patient satisfaction were also assessed. Results: One year after definitive crown placement, MBL loss was 0.56 ± 0.39 mm mesially and 0.74 ± 0.51 mm distally for the immediate placement group and 0.51 ± 0.43 mesially and 0.54 ± 0.45 distally mm for the delayed placement group, respectively (not significant). Regarding differences in means, non‐inferiority was observed after 1 year (difference in mean for immediate versus delayed: mesially 0.04 mm [95% confidence interval (CI) = ?0.22 to 0.30 mm, P = 0.40]; distally 0.21 mm [95% CI = ?0.10 to 0.51 mm, P = 0.58]). No significant differences in the other outcome variables were observed. Conclusions: Immediate implant placement with delayed provisionalization was non‐inferior to delayed implant placement with delayed provisionalization in labial bony defects of ≥5 mm regarding change in MBL. Although not powered for other outcome variables, no clinically relevant differences were observed in these variables.     

The pediculated connective tissue graft: a novel approach for the "blown-out' site in the esthetic zone

Management of the soft-tissue framework around an implant is key to achieving ideal esthetics in the maxillary anterior esthetic zone. When a patient has a tooth with advanced bone loss and recession in the esthetic zone, removing that tooth and replacing it with an implant often requires multiple surgical procedures to restore the lost hard and soft tissue. This article will discuss a novel approach to this dilemma, by means of a case treated with a single-stage surgical procedure using the pediculated connective tissue graft. The extraction of an anterior tooth with advanced bone loss, placement of an immediate implant, and reconstruction of the hard and soft tissue with one surgery will be demonstrated. Finally, the 2-year follow-up of the final prosthetic restoration that shows the stability of the soft tissue also will be presented.     

Alveolar ridge preservation in the esthetic zone

In the esthetic zone, in the case of tooth extraction, the clinician is often confronted with a challenge regarding the optimal decision‐making process for providing a solution using dental implants. This is because, after tooth extraction, alveolar bone loss and structural and compositional changes of the covering soft tissues, as well as morphological alterations, can be expected. Ideally, the therapeutic plan starts before tooth extraction and it offers three options: spontaneous healing of the extraction socket; immediate implant placement; and techniques for preserving the alveolar ridge at the site of tooth removal. The decision‐making process mainly depends on: (i) the chosen time‐point for implant placement and the ability to place a dental implant; (ii) the quality and quantity of soft tissue in the region of the extraction socket; (iii) the remaining height of the buccal bone plate; and (iv) the expected rates of implant survival and success. Based on scientific evidence, three time‐periods for alveolar ridge preservation are described in the literature: (i) soft‐tissue preservation with 6–8 weeks of healing after tooth extraction (for optimization of the soft tissues); (ii) hard‐ and soft‐tissue preservation with 4–6 months of healing after tooth extraction (for optimization of the hard and soft tissues); and (iii) hard‐tissue preservation with > 6 months of healing after tooth extraction (for optimization of the hard tissues).     

Microbiologic evaluation of compromised periodontal sites before and after immediate intrasocket implant placement

This study aimed to elucidate the changes in subgingival microflora before the extraction of severely periodontally involved teeth and 1 year after immediate implant placement and provisionalization without flap elevation. Clinical parameters were recorded for 20 maxillary anterior teeth from 10 individuals before and after implant treatment. The clinically observed improvement in the soft tissues was found to be compatible with a less pathogenic flora. Concentrations of periodontopathogens in the periodontal sites were heavily reduced when transformed into peri-implant sites, whereas the relevant counts of the beneficial microorganisms were increased.     

Immediate implants at fresh extraction sockets: from myth to reality

In recent years, immediate implant placement has become a common clinical therapeutic protocol representing an alternative to the classical delayed surgical protocol of implant placement. This protocol, however, has not been fully validated, either in terms of fully understanding the influence of implant placement on the socket‐healing process or on the clinical outcomes. This narrative review evaluates the different experimental studies in humans and animals assessing the bone‐healing dynamics of the socket after tooth extraction and the dimensional changes occurring at the socket bone walls. These experimental studies describe, in detail, the hard‐ and soft‐tissue healing of implants placed into fresh extraction sockets, demonstrating that marked morphological changes of the alveolar ridge will occur, independently of the implant installation, thus demonstrating that postextraction bone loss is an inevitable biological process. This evidence has also been corroborated in clinical studies in humans, demonstrating the risk of significant peri‐implant tissue loss, mainly in the areas of high esthetic demand. There is a lack of long‐term evidence on the impact of this protocol on the preservation of the peri‐implant tissues. In conclusion, despite the obvious advantages of this surgical protocol, it also has limitations and is more technically demanding than placing an implant into a healed crest. When selecting this protocol, clinicians should always consider: (a) the gingival biotype of the patient; (b) the thickness and integrity of the socket bony walls; (c) the implant selection as well as the adequate vertical and horizontal position of the implant; and (d) the ideal patient (a nonsmoker with good plaque control).     

Maintaining and attenuating periodontal tissues for aesthetic implant placement

Alveolar ridge resorption and soft tissue recession after tooth extraction inevitably disrupted the harmonious pre-existing periodontal complex, compromising clinicians' ability to recreate successful aesthetic restorations. Although numerous surgical procedures had been advocated for the augmentation of both the alveolar ridge and its soft tissue to ideal contours, questions remain regarding viability and predictability of these procedures. This is especially critical in the maxillary anterior region, where a the condition of the soft tissue complex and its relationship to the implant restoration and its adjacent dentition often determines the implant's success. The described technique of retaining the root remnant and inducing the proliferation of the surrounding tissue in conjunction with immediate implant placement results in the preservation of existing soft and hard tissue, thus minimizing the necessity of grafting procedures and facilitating primary flap closure during implant placement.     

Protocol for immediate implant replacement of infected teeth

Extraction and immediate implant placement has become routine procedure due to reduced treatment time and the preservation of anatomical structures. However, in many cases, this technique involves teeth with different degrees of tissue compromise due to underlying infections. Until now, the degree of implant compromise has not been described, nor has a clinical management protocol been established for these cases. The aim of this article is to report the clinical results of a protocol used for immediate implant placement and provisionalization in infected extraction sockets. A classification of the implant surface compromise (in contact with previously infected tissue) is also described to facilitate the comparative analysis. It is possible to maintain the benefits of immediate implant placement and provisionalization in infected sites by applying a clinical protocol that considers antibiotic therapy, a thorough curettage of the infected tissue, antisepsis, and sufficient primary implant stability.     

Immediate maxillary lateral incisor implants with nonocclusal loading provisional crowns.

This clinical report series describes a treatment modality involving immediately placed dental implants in maxillary lateral incisor sites using noncemented immediate provisional crowns retained with calcinable copings (prosthetic complement used in preparing the metal for the definitive prosthesis). Ten implants were placed in eight patients for the replacement of maxillary lateral incisors: two immediate and eight corresponding to cases of agenesis. All were subjected to immediate rehabilitation with provisional acrylic resin crowns in nonocclusal loading. One implant failed 3 weeks after placement due to acute local trauma. The other nine remained functional within the mouth, with normal clinical and radiological characteristics after a minimum of 12-month follow-up. Immediate placement of implant fixed provisional restorations retained by friction in maxillary lateral incisors offers an esthetic solution, eliminates the need for a removable provisional restoration, and avoids implant failures associated with excess cement or screw loosening. Moreover, in the case of extractions, immediate placement and provisionalization of implants in maxillary lateral incisors can effectively optimize the peri-implant esthetic results by maintaining the existing hard and soft tissue architecture of the replaced tooth. As no cement or screws are required, and the provisional crowns are placed in nonocclusal loading, the risk of complications is minimized.