UBC Faculty Research and Publications

Immediate Implants: Clinical Guidelines for Esthetic Outcomes Javaid, Mohammad A.; Khurshid, Zohaib; Zafar, Muhammad S.; Najeeb, Shariq Jun 13, 2016

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dentistry journalReviewImmediate Implants: Clinical Guidelines forEsthetic OutcomesMohammad A. Javaid 1, Zohaib Khurshid 2, Muhammad S. Zafar 3 and Shariq Najeeb 4,*1 Department of periodontics, University of British Columbia, Vancouver, BC V6T 1Z3, Canada;mohammad.javaid2@alumni.ubc.ca2 Department of Dental Biomaterials, College of Dentistry, King Faisal University, P.O. Box 400,Al-Ahsa 31982, Saudi Arabia; drzohaibkhurshid@gmail.com3 Department of Restorative Dentistry, College of Dentistry, Taibah University,Madina Munawarrah 41311, Saudi Arabia; MZAFAR@taibahu.edu.sa or drsohail_78@hotmail.com4 Department of Restorative Dental Sciences, Al Farabi Colleges, Riyadh 361724, Saudi Arabia* Correspondence: shariqnajeeb@gmail.com; Tel.: +966-507-544-691Academic Editor: Bernhard PommerReceived: 2 April 2016; Accepted: 9 June 2016; Published: 13 June 2016Abstract: Research has shown that tooth loss results in morphological changes in alveolar ridge thatmay influence the subsequent implant placement. Immediate implant placement was introduced asa possible means to limit bone resorption and reduce the number of surgical procedures followingtooth extraction. Histological and clinical evidence from human clinical studies showing efficacy ofimmediate implants has come to light over the last decade or so. However, immediate implantplacement is a challenging surgical procedure and requires proper case selection and surgicaltechnique. Furthermore, there appears to be a lack of clinical guidelines for immediate implantplacement case selection. Therefore, the aim of this mini-review is to analyze critical evidence fromhuman studies in order to establish clinical guidelines which may help clinicians in case selectionwhen considering immediate implant placement protocol.Keywords: immediate implants; clinical guidelines; esthetic dentistry1. IntroductionDental implants are surgical devices made of titanium, zirconia or polymeric materials thatform a direct interface with the alveolar bone to support a prosthodontic or orthodontic appliance [1–4].Conventionally, following tooth extraction, the alveolar socket is allowed to heal fully prior to theinsertion of a dental implant [5]. However, pathological and environmental factors may prolong healingtime [6]. In addition to the prolonged treatment time, it is well documented that the physiologicalprocess leads to dimensional changes in the alveolar ridge following tooth extraction such asresorption [7] during the first 3 months of healing [8]. Local factors effecting peri-implant healinginclude tobacco usage, periodontal disease, surgical procedure and oral hygiene, while systemic factorsmay include presence of systemic disease, pregnancy, etc. [9]. Additionally, to improve osseointegration,surfaces of dental implants are modified to enhance their bioactivity [10]. Morphological changespromoted by systemic and/or local factors in alveolar ridge can potentially influence the prognosis ofimplant placement [11,12].In order to circumvent the problem of post-extraction and implant-related bone resorption, theconcept of immediate implants was introduced in the late 1970s [13,14]. It was suggested that thisapproach could not only limit physiological bone resorption leading to better esthetic outcomes butalso minimize the number of surgical procedures [15]. An initial histological study demonstratedosseointegration of immediate implants [15]. In addition, clinical evidence demonstrated the role ofDent. J. 2016, 4, 21; doi:10.3390/dj4020021 www.mdpi.com/journal/dentistryDent. J. 2016, 4, 21 2 of 5immediate implants in limiting physiological bone remodelling following tooth extraction [16,17].Researchers from the University of Goteborg demonstrated that alveolar bone resorbs independentof timing of implant placement and significant dimensional changes in buccal wall take place4–12 weeks following placement of immediate implants [7,18,19]. This was further supported byhuman clinical trials reporting up to 56% reduction in width of alveolar ridge following immediateimplant placement [20]. In contrast to these initial results, numerous other studies published duringthe last 5 years report excellent survival rate, degree of osseointegration and maintenance of interdentalbone levels with use of immediate implant protocol [21,22]. The immediate implant placement ininfected tooth sockets may also lead to successful osseointegration [23]. The aim of the present reviewis to analyze critical evidence from human clinical studies on the efficacy of immediate implantplacement and to provide important clinical guidelines for esthetically pleasing outcomes.2. Spontaneous Healing vs. Immediate Implant HealingVery limited research has been published comparing healing of extraction sockets with andwithout dental implants. One study reported similar reduction in bone height in implant andedentulous sites after 3 months of healing [24]. Vignoletti and coworkers [25] reported significantlygreater vertical bone loss in immediate implant sites compared to edentulous sites. These studiesclearly demonstrate that immediate implant placement protocol does not prevent bone resorptionfollowing tooth extraction.3. Hard Tissue Changes after Immediate Implant PlacementBotticelli and colleagues [20] reported that the buccal bone plate undergoes more than 50%reduction in horizontal dimensions following placement of single unit immediate implant in maxilla.Similar findings were observed in another clinical trial [26] where cylindrical and conical shapedimplants were placed in extraction sockets. Both groups showed 36% reduction in width in buccalbone wall. The authors also reported a mean vertical bone loss of 1 mm that was accentuated in thepresence of a thin buccal wall and placement of implants in anterior maxilla. Multivariate analysesrevealed that the thickness of buccal bone wall was a key factor influencing horizontal bone resorptionchanges. Similarly, vertical changes were significantly influenced by implant position and the thicknessof buccal bone wall [26].Various approaches have been proposed to counter these hard tissues dimensional changes.Most of these strategies involve combination of immediate implant placement with simultaneoususe of various grafting materials and barrier membranes [27]. Chen et al. [27] analyzed placementof immediate implants in maxilla. Bone grafts with or without membrane were used to fill the gapbetween implant and inner bone surface in test groups. No bone graft material was used in the controlgroup and the gap between implant and inner bone surface was left unfilled. The experimental groupsshowed significantly reduced horizontal resorption compared to the control group. Vertical resorption,however, was similar among the groups and was influenced by the thickness of the buccal boneplate [27]. Recently, clinicians have observed more stable placement of immediate non-functionalrestorations when combined with bone grafting [28,29]. A recent study by Romao et al., suggests thatlaser-induced biostimulation may improve bone repair post-extraction [30]. However, the effect ofbiostimulation has not been investigated in sites of immediate implant placement.4. Soft Tissue Changes Following Immediate ImplantsRecently, a systematic review analyzing recession associated with immediate implants has beenpublished [31]. Marginal tissue recession of at least 1 mm was reported in studies with observationperiod of 3 years or more. Such untoward clinical outcome was observed in 20% of the patients, butthis observation was made in just two studies with no control groups. Factors that influenced marginaltissue recession include [31]:Dent. J. 2016, 4, 21 3 of 5(a) Position of implant, with greater recession being a common occurrence when the implants werepositioned buccally.(b) Gingival biotype—increased recession was observed in cases with thin biotype.Similar results were reported by Chen et al. [27] demonstrating at least 1 mm recession in over30% of the sites after 18 months of follow up period. The authors also reported significant associationbetween marginal recession and position of implant in relation to buccal bone plate. Recessionwas seen in 16.7% of the implants placed lingually as compared to 58.3% of the buccally placedimmediate implants. Bianchi and Sanfilippo [32] assessed the added value of connective tissuegrafts in conjunction with immediate implant. They compared the mucosal marginal level followinginstallation of final restoration and compared the marginal level with adjacent teeth. They observedthat all patients who received connective tissue grafts with immediate implants showed less than 1 mmof marginal tissue discrepancy. This outcome was achieved only in 80% of the subjects who receivedimmediate implants alone. Canullo et al. [33] studied the use of platform switch implants in context ofmarginal tissue recession. They reported significantly less recession when platform switch implantswere used. However, a recent systematic review by Lee et al., has not found any significant advantageof using connective tissue grafts towards reducing gingival recession [34]. Hence, more studies arerequired to advocate the combined use of soft tissue grafts and immediate implants. Provisionalrestorations, following immediate placement of implants, may also improve soft-tissue healing [35].It has been observed that placement of provisional crowns on immediately placed implants maynot only improve preservation of buccal bone, but also improve esthetics by reducing gingivalrecession [36,37].5. Clinical Guidelines and ConclusionsThe clinical guidelines for immediate implant placement protocol are summarised in Table 1.Table 1. Clinical Guidelines for Esthetic Outcomes When Using Immediate Implant Protocol.Thick and Intact Buccal Bone WallThick gingival biotypeMinimal trauma in tooth extractionPresence of at least 3 socket walls—ideally 4 wallsImplant shoulder should be placed 2–3 mm apical to anticipated gingival marginPrimary implant stability with engagement of 3–4 mm bone apical to root apexSlight palatal/lingual positioning of implantFill the gap between implant and inner bone surface using a low resorbing bone graftmaterial with or without membraneBased on the evidence, thickness and integrity of buccal bone plate and gingival biotype are thecritical factors that play a pivotal role in success of immediate implants. When following immediateimplant protocol, buccal position of the implants should be avoided. Implants should be slightlypalatally/lingually placed. The gap between implant and inner bone surface should be filled withbone substitutes which have a low resorption rate [38]. In order to compensate for the expectedvertical resorption, implant should be placed at least 1 mm apical to buccal ridge or 2–3 mm fromgingival margin [27]. In addition, factors such as use of platform switch implants, flapless surgicalapproach, simultaneous placement of connective tissue grafts and immediate provisional restorationsmay also be considered. Success with immediate implant protocol requires advanced surgical skills,ideal extraction socket conditions and knowledge of local anatomy. It is recommended that whenideal conditions are not present, other implant timing protocols that have provided excellent clinicaloutcomes with regards to soft and hard tissues should be followed [39].Conflicts of Interest: The authors declare no conflict of interest.Dent. J. 2016, 4, 21 4 of 5References1. Brånemark, P.; Adell, R.; Albrektsson, T.; Lekholm, U.; Lindström, J.; Rockler, B. 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This article is an open accessarticle distributed under the terms and conditions of the Creative Commons Attribution(CC-BY) license (http://creativecommons.org/licenses/by/4.0/).

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