IMMEDIATE POST-EXTRACTION IMPLANTS WITH AESTHETIC RESTORATION
José Manuel Navajas Rodríguez de Mondelo
Full Professor of the Department of Stomatology, University of Granada
Rosa Mª Pulgar Encinas
Associate Professor of the Department of Stomatology, University of Granada
José Manuel Navajas Nieto
Dentist, Master in Implantology, Madrid Complutense University; Master in Oral Surgery, University of Granada
Cristina Lucena Martín
Associate Professor of the Department of Stomatology, University of Granada
Cristina Navajas Nieto
Dentist, “Expert” in Periodontics, University of Granada
Dr. José M. Navajas Rodríguez de Mondelo
Avd. del Dr. Oloriz 2. 10 ª
18012 Granada España
Abstract: This study addresses the present state of knowledge on immediate implantation in fresh extraction socket. The author’s selection of the single-piece Q Trinon R implant is explained, reporting clinical cases with a follow-up of around 5 yrs.
Key Words: Immediate post-extraction implants. Immediate post-extraction aesthetics. Q Trinon implants
Placement of an endosseous implant is the current treatment of choice for the prosthetic replacement of missing teeth, regardless of the cause of their loss.i ii Conventional recommended reposition protocols include an initial stage to achieve osseointegration and a second prosthetic stage for tooth replacement. This treatment sequence requires a waiting time that is functionally solved with a removable prosthesis, causing discomfort to the patient or with a temporary bonded crown, increasing the cost. Scientific evidence has demonstrated that immediate implant loading is a valid procedure with predictable success when indicated by the anatomo-functional conditions., 
Implants have been placed in oral sockets immediately after extraction since the very beginnings of implantology. Although the two-stage protocol has traditionally been recommended, clinicians are now performing the immediate loading and aesthetics of the immediate socket mplant in response to the aesthetic demands of their patients.,     
In this article, authors propose a variant of the conventional technique and present the outcomes obtained using this approach in clinical cases with 5 yrs of follow-up.
Indications and contraindications
Immediate socket implantation is indicated for anterior tooth losses due to accidental trauma or coronary or root fractures in endodontic teeth without active infectious disease. It is also indicated in cases of dentine cement or internal dentine resorption and advanced periodontal disease provided that there is adequate remnant bone for implant stabilization and aesthetic restoration is essential.
- Uncontrolled diabetes
- Coagulation disorders
- Allergies to any material used in the procedure
- Acute infection
- Heavy smoking
- Drug addiction
Impossible apical stabilization of implant
They are generally placed in the incisor-canine region and premolar group.
All types of commercially available implant have been used in immediate implantation. Two-piece implants (implant + transepithelial abutment) are generally used in two stages:
a) Immediate implantation in fresh socket
b) Prosthetic replacement and implant loading at least 6-8 weeks later. More recently, these implants have also been fitted with a temporary crown, but this procedure is complicated and requires impressions to be taken during surgery, the selection and placement of an abutment, manufacture of the crown and its cementation at least 24 h after implantation.
For this reason, the implant of choice in cases requiring immediate prosthetic replacement will undoubtedly be the one-piece implant, which incorporates both abutment and implant, allowing a temporary crown to be placed in the same surgical act without difficulty.
The main advantages are:
Axial transmission of forces
High primary stability
Possibility of immediate loading
Possibility of immediate aesthetics
Possibility of creating an adequate emergency profile
Impossibility of bacterial colonization between implant and external abutment: no micro-infiltration in the gap area.
Lower cost, since no special attachments are required for crown replacement
This type of implant also has some drawbacks:
Difficulty of abutment angulation.
Difficulty of recovering deteriorated prostheses
Difficulty of placing removable prostheses retained by these implants. However, this can also be done using telescopic crowns, and one-piece implants were recently developed that can be screwed to the abutment.
Almost all manufacturers (Fig. 1) offer one-piece implants, including the following (as examples)
|Fig. 1: Different designs of one-piece implants.|
Nobel BiocareR: Nobel Direct, Posterior Nobel Direct and Active Nobel
StraummanR: Monotyp e8º; this one-piece implant is recommended by the company for bar prostheses but can also be used for immediate implant due to its screw design
LifecoreR: Prima Solo, a conical, self-screwing implant with gold-coloured abutment to improve the aesthetics.
Apha-bio ImplantsR: ARRP, a one-piece implant available in several diameters
Zimmer DentalR: A recently-developed one-piece implant for immediate loading.
Trinon DentalR: Q implant, an implant tested for immediate loading.
Our group uses the TrinonR Q implant (Fig. 2) for this procedure This one-piece implant has a conical design with a wide spiral of blunt edges and a threaded part for self-screwing and condensation of bone between spirals. The apex has a blunt point to facilitate insertion. It has a 2-4-mm long polished neck and conical abutment with 8º convergence that bears four slots for insertion and to avoid crown rotation when only one tooth is replaced. As demonstrated by Shi et al., the conical design of the implant, which simulates a natural tooth root, provides a more homogeneous distribution of axial and tangent forces, reducing stress at the bone-implant interface.
|Fig. 2: Single-piece Trinon Q Implant R with polished neck of 2-mm height. Note: a) Space between spirals, b) Threaded part area; c) Blunt point; d) Surface treatment; e) Spiral design after the polished part, which minimises tensions in the cortical area (between arrows). The conical shape and space between spirals optimises the distribution of masticatory forces.||Fig.-2 bis- Scanning electron microscope image of implant surface: a).- Note the bluntness of the spirals, to release tension. b).- Image (1000 X) of the rough part of the implant surface (cavity diameter ranges from 1 to 4 microns).|
The surface is acid-etched and sand-blasted with aluminium-oxide (Fig. 2bis). It is manufactured in commercially pure titanium (alloy of titanium, aluminium and vanadium). It is available in three diameters at neck level (3.5 mm, 4.5 mm and 5.5 mm) and in lengths of 8, 10, 12, 14 and 16 mm.
The implant is first inserted by hand or with a drill at very low speed. A manual wrench is used to control, with one-eighth of a turn, insertion of the implant and condensation of the surrounding bone, allowing intraoperative modification of the insertion axis to achieve the optimal position and desired aesthetic outcome. Because of its design, it can be used as an osteotome, allowing the 3.5-mm width implant to be placed in very thin crests with no need for further surgery and achieving exceptional primary stability.
Insertion surgery requires the use of only two conical burs for the 3.5 mm implant and three for the 4.5 mm one. The conical design of the surgical socket and its small size offers important bone saving, minimizing stress and cutting temperature.
As in all titanium implants, osseointegration occurs. Given its high primary stability, a large amount of laminar bone is observed in close union with the treated surface of the implant (Fig. 3)
|Fig. 3: Environmental scanning electron microscope image of the transversal section of a recovered Trinon Q implantR. Note: a) Implant surface; b) Close implant-bone binding; c) Compact laminar bone; d) Trabecular bone; e) Osteoplast.|
Conditions of extraction previous to immediate implant
The success of immediate implantation in fresh socket and the achievement of favourable aesthetics are largely based on two essential conditions: alveolar bone integrity and absence of infection. The extraction procedure must therefore meet a series of requirements to have a minimal traumatic effect on the receptor tissue and ensure an optimal functional and aesthetic outcome. To this end, it is recommended that:
Locoregional or infiltration anaesthesia should be used but never interligamentous anaesthesia, which produces alveolar ischemia.
Circular periodontal fibres should be withdrawn with care, using a periosteotome or a 12-B scalpel blade.
The ligament space at tooth neck level should be enlarged before luxation. For this purpose, the use of ultrasound with special accessories (as used in PiezosurgeryR, from Mectron) helps to preserve alveolar bone integrity.
The root should be carefully luxated, applying axial pressure with new elevators, taking great care to avoid damage to the socket walls. It should be taken into account that the presence of lateral bone determines papillary integrity.
Full-thickness flaps should be avoided. Flap elevation causes major bone ischemia, since cortical irrigation takes place via the periosteum. Ischemia may cause the loss of vestibular cortex and threaten implant integration (Figs. 4-5)
|Figs. 4 and 5: Incorrect extraction of root remnant with exposure of cortex and immediate two-phase implantation. Note exposure of implant during the integration period due to loss of vestibular cortex.|
Implant insertion technique
There must be at least 3-4 mm of bone in the apical area of the fresh socket for the implant to be adequately secured. Larger apical areas for fixation are more favourable, since they provide greater primary stability. For this reason, manufacturers supply professionals with 16-mm and even 18-mm implants. After the extraction, and taking great care not to damage the alveolar bone crest or papillary area, a meticulous curettage of the whole socket is performed to remove any possible remnants of granulation tissue. It is recommended to produce a small haemorrhage to favour wound-healing.
|Fig. 6: Diagram of Trinon Q Implant R for immediate implantation in fresh socket, indicating the apical stability and space with no bone contact.||Fig. 7: Diagram showing the fitting of the implant to the size of the post-extraction socket|
The implant must be fixed with an insertion force of ≥ 60 Newton/cm2 (Fig. 6). The selection of implant size is determined by the characteristics of the extracted tooth. In general, 4.5-mm implants are used for central incisors and canines, whereas 3.5-mm implants are more commonly used for lower incisors and upper lateral incisors (Fig. 7).
|Figs. 8 and 9: Root remnant with internal dentin resorption and the selected implant (Trinon QR; 4.5 x 12 mm), exceeding the alveolar apex by 4 mm. Note how the implant spirals are anchored in the alveolar cortex thanks its conical design and the width of the spirals.|
Implant length is conditioned by the need for stabilization, which requires, as mentioned, at least 4 mm of bone to be available between the apical area of the socket and the anatomic limits (Figs 8 and 9). Implants of 3.5-mm require a greater length to be stable than do those with a larger diameter.
The placement procedure commences with perforation of the socket floor cortex using a pilot drill, initiating the preparation of the implant bed, which must be at the centre of the socket, as equidistant as possible from its distal and mesial walls. Given the high conicity of the implant design, it is not usually necessary to utilise the palatal wall for support, as recommended for cylindrical implants.
|Fig. 10: The direction of the bur can be change if desired.||Fig. 11: Preparation with internal irrigation bur. Note the palate/vestibule incline, centred and parallel to neighbouring teeth.|
The direction of the implant bed can be modified when aesthetically or anatomically required (Fig.10). Internal irrigation burs of suitable size for the selected implant are then used. The implant, which has a considerable self-screwing capacity, is first inserted manually, with the possibility of correcting its position if necessary (Fig.12). When more force is needed, we use the insertion wrench, especially designed to allow atraumatic fixing of the implant body (Fig. 13).
|Fig. 12: Manual insertion of implant. Perfect alignment with adjacent teeth, obtaining an excellent problem-free aesthetic outcome. Note the conicity of the implant, of great utility given the anatomical characteristics of the socket.||Fig. 13: The last turns of the screw are done with a manual wrench. The wrench is designed so that the handle must be taken off and put back at every eighth of a turn, allowing stress on the bone to diminish. Note the insertion axis and the design of the wrench.|
|Fig. 14: This X-ray provides a perfect image of the part of the implant that is covered by bone and the polished part next to soft tissues.|
The implant is inserted in the socket until its unpolished part is completely covered by bone. The polished part is in contact with soft tissue and, together with the temporary crown, will contribute to achieving a correct biological space, a good emergency profile and a good aesthetic outcome (Fig. 14).
Because of the conical shape of the implant, the free gap between implant and socket is minimal. It has been demonstrated that this space does not need to be filled because. thanks to the high wound-healing capacity of the socket, it will be closed with bone. However, if there is a large gap, a xenograft can be placed with plasma rich in growth factors and fibrin clot. This technique is especially useful in cases of immediate implants in the premolar area where, if there are two sockets, it can enhance wound-healing. When the implant is moistened in plasma rich in growth factors, it is endowed with an active surface that facilitates bone integration (Figs. 15 and 16).
|Fig. 15: Socket of upper first premolar with two roots. When the implant is inserted, there will be a large gap between the bone walls and the implant, which should be filled with a graft.||Fig. 16: Mixture of xenograft (Bio-Oss GeistlichnBiomaterials) and plasma rich in growth factors in the above case, before insertion of the implant.|
Manufacture of temporary crown
The temporary crown has a highly important role in the success of this type of treatment for the following reasons:
It re-establishes aesthetics immediately, one of the main demands of patients.
It facilitates soft tissue healing
It is essential to establish the emergency profile and allow gingival papilla formation.
|Fig. 17: Diagram of a Trinon Q implant R with socket and soft tissues in comparison to the tooth|
The relationship between inserted implant and soft tissue is similar to that between tooth and periodontium. Thus, bone tissue integrates with the treated (rough) area of the implant and conjunctive tissue adapts to the polished area and a small portion of epithelial insertion, while the remaining gingiva is shaped to the artificial crown that we place for creating an adequate emergency profile (Fig. 17). The two differences with natural teeth are: a) conjunctive tissue fibres are bound to the crestal bone and b) vessels that irrigate the internal part of the emergency profile are vertically aligned, since they come from the periosteum, whereas they form a circular plexus in natural teeth (Figs. 18 and 19).
|Fig. 18: Trinon Q implantR before fitting the definitive crown. Note the emergency profile, the physiologic exudate from the polished neck area, the vertical vascular network and the general state of health.||Fig. 19: The above case with the definitive crown in place|
With two-piece implants (implant with abutment), the aim is to avoid bone loss by eliminating abutment micromobility, reducing the gap or using an abutment with a diameter smaller than the implant platform.
Temporary crown adaptation procedure
Before extraction, alginate impressions are taken from the patient. The prosthetist cuts the tooth to be extracted from the model obtained, forming a slightly over-sized hollow acrylic crown with the colour and aesthetic characteristics indicated by the dentist. The more polished and aesthetic the temporary crown, the better is the outcome. This crown is adapted to the implant abutment using plastic materials for temporary bridges and crowns, followed by the removal of excess material.
After the material is cured, it is carefully polished with composite-polishing discs and wheels. For this purpose, it is very useful to place the crown on a replica of the implant. The degree of polish obtained determines the success of soft tissue healing and achievement of an emergency profile (see Fig 18.) After 8 weeks, an impression of the implant abutment is taken and the final crown is made.
Case nº 1
A 53-yr-old woman came to the clinic with a root fracture of 23 and active fistula at 2 mm above the gingival margin. Clinical examination demonstrated crown mobility and normality of gingival sulcus. X-ray revealed a well-sealed root treatment and a conical post in the shape of a screw that does not surpass the coronal third of the root. A horizontal fracture was observed at the end of the post.
Diagnosis: Horizontal root fracture with no apical infection (Fig. 20).
Treatment plan: Extraction and immediate prosthetic replacement with implant in fresh socket.
Alginate impressions were taken during the examination and the mould was sent to the dental prosthesis laboratory. Two prostheses were made: an acrylic crown of similar colour and shape to the tooth to be extracted, and a partial removable prosthesis. In cases of immediate post-extraction implantation, it is important to have a partial removable prosthesis prepared. This allows aesthetics to be restored if, after the extraction, it is decided that the implantation should be postponed.
Crown and root remnants were extracted, taking care not to damage alveolar bone structures (see above-mentioned recommendations). Examination of the socket interior with a blunt instrument ensured vestibular bone integrity.
The socket was curetted and a Q TrinonR implant of 4.5 mm width, 14-mm length and 2-mm polished neck was placed, ensuring that the rough part of the implant was completely covered by alveolar bone (Fig. 21). The socket-implant gap was filled with a clot of plasma rich in growth factors. Figures 22, 23, 24 and 25 show the clinical process and outcome, and Figure 25bis depicts the case at almost 5 yrs after treatment.
|Fig. 20: Appearance of area of 23. Active fistula at 2 mm from gingival sulcus.||Fig. 21: Recently inserted Trinon Q implant R. Note the pillar with the entire polished area subgingival and the orientation and equidistance from adjacent teeth. Also note the integrity of the gingival papillae and part of a fibrin clot of the plasma rich in growth factors placed during the implantation|
|Fig. 22: Provisional acrylic crown recently fitted on the implant.||Fig. 23 a and b: At three months, impressions are taken and the definitive crown is placed. Note the emergency profile and magnificent state of papillae (vertical vascular plexus can be seen)|
|Fig. 24 a and b: The crown when recently fitted (A) and at two years (B). Note periodontal health and good state of papillae. The small ischaemia seen in (B) was produced by pressure of the lip protector on the gingiva.||Fig. 25: Follow-up X-ray at three years. Note the total integration, absence of crestal bone loss, polished area for obtaining the biological space and the emergency profile.|
|Fig. 25 bis: Follow-up photograph and X-ray at more than four years: Note the total integration and stability of aesthetic outcome.|
Case nº 2
A 56-yr-old man came to the clinic for mobility in upper left lateral incisor. Clinical history showed a childhood traumatism on the tooth that had been symptom-free in the intervening years. Examination showed the incisor with high mobility to be reddish and to have virtually lost its natural colouring. The X-ray revealed absence of more than two-thirds of the length of the root (Fig.26).
Diagnosis: Severe cementum-dentin resorption.
Treatment plan: Extraction and immediate implantation.
Alginate impressions were immediately taken of both arches and despatched to the dental prosthesis laboratory where, as in the case above, two prostheses were made: a hollow resin crown, and a partial removable crown for immediate aesthetic restoration in case the implantation procedure proved impossible (note the date of the surgery!). Four hours later, extraction and implantation were performed, using plasma rich in growth factors (Fig. 27). Figures 28 and 29 depict the outcome.
|Fig. 26: Cement-dentin resorption. Note change in colour of the crown and mesial and distal diastemas.||Fig. 27: Occlusal view of recently placed Trinon Q implantR in the above case. Note the integrity of the papillae and the depth of its insertion.|
|Fig. 28: Recently placed provisional crown. Note the careful nature of the intervention.||
Fig. 29: The definitive crown at five months. The diastemas were preserved to match the original appearance, as expressly requested by the patient.
Case nº 3
A 53-yr-old woman came to the clinic for mobility of upper left incisor. Examination revealed a metal ceramic crown on 21, a small periodontal abscess, mobility and mild pain. The X-ray showed a well-performed root treatment, with no periapical lesion and reconstruction with a metal post, with tangential mesial fracture. It was decided to carefully extract the tooth and insert a Q Trinon implant (14 x 4.5 mm) for immediate aesthetic restoration. Figures 31, 32, and 33 illustrate the entire procedure.
|Fig. 30: Oblique root fracture of 21. Note the small periodontal abscess.||Fig. 31: Recently placed implant. Note its position, the fibrin clot and small remains of Bio–Oss GeistlichnBiomaterials.|
|Fig. 32: The provisional crown at one week of placement. The excellent appearance of the soft tissues demonstrates the care taken in the intervention.||Fig. 33: The definitive crown. Note the magnificent aesthetics and the good health of soft tissues.|
Case nº 4
It was decided to extract the lower incisors and place two immediate implants in 32 and 42 for immediate aesthetic restoration. During the implantation, a Bio-Oss GeistlichnBiomaterials graft was placed in sockets of 31 and 41 to maintain the alveolar crest.
Figures 35 and 36 depict the clinical sequence of implantation and prosthetic replacement. Figure 37 shows the outcome after 4 yrs after implanting.
|Fig. 34: Clinical and radiological situation of the patient. Note the appearance of the soft tissues, the opening of the diastemas and the loss of bone support, demonstrating the non-viability of the lower incisors.||Fig. 35 a and b: (a) The situation of two Trinon Q implantsR (3.5 mm x 14 mm) placed after extraction of the incisors. (b) The recently placed provisional fixed prosthesis. A Bio-Oss Geistlichn Biomaterials graft was placed in sockets of 31 and 41 to maintain the architecture of the crest.|
|Fig. 36 a and b: (a) Appearance of the implants and gingival tissue before placement of the fixed prosthesis. (b) The recently placed definitive prosthesis. The small irritated area of 32 was because the provisional acrylic crown was oversized.||Fig. 37 a and b: (a) Appearance of the definitive prosthesis at four and five months. (b) Radiographic appearance of implants at four and five months after their insertion. Note the good situation of the implants and area of the Bio-Oss Geistlichn Biomaterials graft in 31-41.|
The use of one-piece Q Trinon implants is a procedure of predictable success for immediate aesthetics restoration after extraction, providing that the indications reported in this paper are followed.
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