Modern dentistry seeks to prevent tooth loss have a safe and attractive smile that is accompanied by a relaxed and functional occlusion. However, there are situations in which extraction is the only course of treatment. Among the various options to provide functional occlusion dental implants are the most preferred one nowadays. Clinical replacement of lost natural teeth by osseointegrated implants has represented one of the most significant advances in dentistry. In fact, over the last three to four decades, dental implants have become the benchmark and established themselves as the gold standard for replacing missing teeth.
Following years of basic research and fundamental studies on the principle of osseointegration, the replacement of a tooth with a dental implant is the product of the advancement of principles, technology, and clinical applications. Bone resorption occurs both buccolingually and apicocoronally after tooth extraction, and the first six months after extraction are crucial, with the highest rate of bone resorption in either direction.
Immediate Dental Implant
Immediate dental implant placement, known as placing a dental implant into a fresh extraction socket site immediately after tooth extraction. Immediate implant placement in an extraction socket in humans was first reported by, Lazzara in 1989. Since then, this treatment modality has acknowledged much attention in the literature.
The rationale of placement immediate dental implants
In cases where teeth had to be extracted, the original protocol (gold standard) recommended waiting 6 to 12 months for the site to heal before placing dental implants to allow for complete ossification of the extraction socket. As a result, patients have had to wear removable dentures or live with missing teeth for an extended period of time while waiting for their dental implants to be placed. Over the last decade, the initial procedure (gold standard) has been questioned by shorter time intervals between tooth extraction and dental implant placement, as well as shorter time intervals between dental implant placement and implant loading. Dental implants can now be inserted at the time of tooth extraction or shortly afterward, before major bone resorption occurs, according to new protocols. Immediate dental implants refer to a modified procedure in which dental implants are inserted at the time of tooth extraction. However, even for immediate implants, to attain consistent and esthetic outcomes, careful selection of patients, precise treatment planning, and meticulous immediate implant placement are paramount.
Location of placement of immediate dental implants
Although its placement in a fresh extraction socket is advised, a lot of debate has been surfaced on the status of the fresh extraction sockets. Initially, researchers advised a healthy extraction socket for the success of immediate implants which has been challenged by many others who found similar success in implants placed in fresh extraction sockets with periapical or peri-radicular pathology. Fugazzotto et al compared dental implants immediately placed into sites with periapical pathology with those without in the same patient. Both therapies have been found to achieve similar outcomes with no statistically significant difference in survival rates. In absence of any periapical radiolucency, Bell and colleagues put 285 immediate implants in sockets with chronic periapical infections (with seven failures) and 637 dental implants in extraction sites (with eight failures). The discrepancy between the control group and the periapical radiolucent group was not statistically important.
Immediate loading of dental implants:
Immediate loading of dental implants involves loading or placement of prosthetic restoration within 24-48 hours of implant placement. It is also known as immediate function. It may be used if adequate primary stability is achieved – this is known as immediate provisionalization for single-tooth restoration. The technique was created in response to the increasing demand from patients for faster care and shorter tooth-to-teeth times. While Ledermann was the first to report effective healing of immediately loaded implants inserted in the mandible’s anterior region, Schnitman et al. were the first to investigate the possibility of successfully attaching a partial prosthesis to these implants. High cumulative survival rates, such as about 97 percent – 100 percent, have been identified for immediately loaded implants placed in extraction sites for some indication in several long-term studies conducted with 5-10 years of follow-up.
Diagnosis and treatment planning of immediate implants:
- Diagnosis and meticulous investigations are the crucial aspects for successful treatment outcomes in the case of immediate implant
- The investigation includes: IOPA (intraoral periapical radiographs), OPG (orthopantomography), and CBCT (cone-beam computerized tomography)
Determinants of treatment planning for immediate dental implants:
The most important step in treatment planning includes:
Prognosis of the tooth in question
- Crown to root ratio
- Remaining root length and root resorption
- Periodontal attachment level
- Furcation involvement
- Periodontal health status of teeth adjacent to the proposed implant site
- Presence of root fractures with large endodontic posts
Criteria for a favorable and successful treatment outcome for immediate implant placement:
- Absence of any strict contraindications to treatment in patients such as systemic diseases (e.g. diabetes, cancer)
- Patients preferably not on any bisphosphonate medications or recreational drugs
- Adequate bone status of the buccal and lingual plate of the extraction socket must be present
- Absence of overhanging or insufficient restoration margins of the teeth adjacent to the extraction socket
- The patient should ideally be non-alcoholic and non-smoker
- Wide and intact inter radicular septum following the tooth extraction
Indications of immediate dental implants:
- Atraumatic loss of teeth with the minimal amount of bone loss
- Loss of tooth due to gross decay not accompanied with purulent discharge or spreading infection
- Failure of teeth to undergo complete endodontic therapy
- Presence of severe periodontal bone loss without purulent exudates
- Presence of adequate soft tissue for primary wound closure
Contraindications for immediate dental implants:
- Profuse presence of purulent exudates at the time of extraction
- Presence of cellulitis and granulation tissue at the extraction site
- In-adequate bone support apical to the extraction socket
- Closed proximity with the mandibular neurovascular bundle and other vital sinuses
- Poor anatomical configuration of remaining bone
Advantages of immediate dental implants:
- The key advantage of immediate implant placement over the delayed placement of implants into the extraction sockets is that there is no need to wait for 4–6 months after extraction
- Less crestal bone loss as compared to delayed placed implants
- Shorter treatment time
- Better patient compliance
- Decreased surgical trauma which leads to decrease risk of bone necrosis and formal bone remodeling process and faster and more predictable healing
Patients, on the whole, want to be handled quickly and efficiently. When looking for a cure, they want a safe and successful procedure that can be completed in the shortest amount of time with the least amount of pain and discomfort. Immediate implant placement and loading are useful methods for the clinician to use, but their expertise, experience, and case selection are also important factors in achieving long-term performance.