Immediate Implants

What Are Immediate Implants?

Immediate post-extractive implants are placed immediately after tooth extractions in fresh sockets. Immediately post-extractive implants have gained popularity over the years because they shorten treatment duration since patients do not have to wait for soft tissue healing (2 to 6 weeks) or bone healing (4 to 6 months), although they might be at higher risk of complications and failures.

Some evidence states that grafting at immediate post-extractive sites can improve the aesthetic outcome, whereas the use of large diameter implants at immediate post-extractive sites is to be avoided because of the poor aesthetic outcome. In order to obtain an improved aesthetic outcome at immediate post-extractive sites, implants should be placed in a slightly more palatal position as recommended by most implantologists (than placement at the ideal center of the socket).

How Does an Immediate Implant Heal?

Hansson et al. in 1983 and Ericsson in 2000- According to them, known theories proposed for post-extraction healing and bone growth show that the surgical trauma is considerably decreased when an immediate implant is placed. Also, immediate implants will decrease the risk of bone necrosis and permit the bone remodeling process to occur.

The healing period is rapid compared to the bone resorption that takes place after a tooth is extracted and heals naturally without any bone graft placement. The natural socket being rich in periodontal cells and matrix makes the healing fast-paced and also predictable. Small osseous defects that may be found adjacent to implants can be grafted with autogenous bone obtained from intraoral bony sites or edentulous ridges to preserve the bone volume and height.

When Should Tooth Be Extracted for an Immediate Implant?

• Weak periodontal attachment levels.

• Tooth mobility.

• Periodontal furcation involvement.

• Poor periodontal health status of teeth adjacent to the proposed implant site.

• Insufficient crown to root ratio.

• Deep carious lesions.

• Root fractures.

• Teeth with endodontic posts that have fractured.

• Failed endodontic retreatment.

Very minimal preparation is needed while placing the immediate implants since the extracted tooth socket preserves the anatomy of the tooth root which mimics the root form implants. To gain the initial stability, the implant should be placed a minimum of 3 mm apical to the extraction site and 3 mm apical to the crestal bone. The initial stability of the implant is the main factor determining the success of the immediate placement.

Biotype And Antibiotic Prophylaxis:

Patients receive a single dose of prophylactic antibiotics 1 hour before the intervention: 2g of Amoxicillin or 600 mg of Clindamycin if allergic to penicillin. Patients rinse with chlorhexidine mouthwash 0.2% for 1 minute prior to the intervention. Patients are treated under local anesthesia using articaine with adrenaline 1:100,000.

After crestal incision and flap elevation, teeth are extracted atraumatically as possible, attempting to preserve the buccal alveolar bone. Sockets are carefully cleaned from any remains of granulation tissue. The wider diameter of the extraction socket is then measured using a granulated periodontal probe in millimeters, rounded to 0.5 mm.

The sockets are divided into:

• Nicely preserved- when the buccal plate is intact.

• Partially preserved- when up to 4 mm of buccal bone is missing.

• Poorly preserved- when more than 4 mm of buccal bone is missing.

Implant sites are thus categorized into two groups according to the treating dental practitioners, as having:

• Thick biotype.

• Thin biotype.

How Is the Procedure for Implantation Surgery?

The implant insertion torque is measured with the motor set at 25 Ncm and reported as superior at 25 Ncm or up to 25 Ncm (as an insertion torque less than 25 Ncm can lead to primary instability). Once the implant is placed, periapical radiographs and clinical pictures should be taken. If needed, the area is grafted and then covered with a resorbable collagen membrane. Flaps are sutured, but the wound can be left partially open when complete soft tissue coverage is not easy to achieve. Patients are instructed to use 0.2% chlorhexidine mouthwash for 1 minute twice a day for two weeks and to avoid brushing and possible trauma on the surgical sites.

Postoperative antibiotics were prescribed: Amoxicillin 1 g three times a day for seven days. Patients allergic to penicillin were prescribed Clindamycin 300 mg three times a day for seven days. After one week, patients are checked, and sutures are removed. After one month, implants need to be manually tested by the dentist for stability; temporary abutments are placed, and provisional acrylic crowns are then cemented on the same day. Periapical radiographs of the study implants can be taken. If the marginal bone levels are not readable, the radiograph is to be retaken.

Oral hygiene instructions are delivered. With a 20 Ncm torque using a manual wrench able to deliver a variable tightening torque from 10 to 35 Ncm. Clinicians almost universally recommended placing implants slightly more palatally to achieve a better aesthetic outcome. However, the ability to achieve the best aesthetics is probably mostly dependent on the manual skills and the experience of the individual operator.

What Are the Exclusion Criteria for Immediate Implants?

Sufficient bone is also required to allow the placement of one single implant at least 10 mm long with a 3.3 mm diameter.

Exclusion criteria were: ·

• General contraindications to implant surgery.

• Immunosuppressed or immunocompromised.

• Irradiation in the head or neck area.·

• Uncontrolled diabetes.

• Pregnancy or lactation.

• Untreated periodontitis.

• Poor oral hygiene and motivation.

• Substance abuse.

• Psychiatric disorder or unrealistic expectations.

• Acute infection (abscess) or suppuration in the site intended for implant. placement.

• Undertreatment or had previous treatment with intravenous amino bisphosphonates.

Conclusion:

Immediate implants are the preferred modality following extraction of a tooth unless it is not recommended by the dentist due to certain exclusion criteria. Improved bone remodeling and preservation, along with manual operator skills, ensure the long-term success of immediate implants.