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Implant Treatment Sequencing Gregori M. Kurtzman, DDS Private Practice Silver Spring, Maryland Lee H. Silverstein, DDS, MS Private Practice Marietta, GA Associate Clinical Professor Department of Periodontics Medical College of Georgia Augusta, Georgia Marc E. Moskowitz, DDS Private Practice Marietta, GA Consultant Periodontal and Prosthetic Residency Programs US Army Visiting Faculty Department of Oral Rehabilitation Medical College of Georgia Augusta, Georgia Periodontal or endodontic related osseous infections of natural teeth may complicate implant treatment. Staging of the surgical aspects of the treatment is important to achieve the desired restorative objectives. Additionally, when cosmetic correction of adjacent natural teeth is required as part of the overall treatment, the final result will be influenced

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of 9Compendium of Continuing Education in Dentistry

06/01/2007http://www.compendiumlive.com/nlarticle.php?ida=3181

by proper sequencing. Implant surgical placement in immediate extraction sites has been well documented in the literature as a successful treatment option, and the direction of implant treatment is

advancing toward immediate placement at the time of extraction.1-4 But, in the presence of active infection, osseous healing surrounding the newly placed implant may lead to a failure to fully integrate. Inflammation associated with endodontic infections, chronic periodontal infections, or acute infections with exudate creates a local environment that does not favor osseous healing and subsequent integration of the immediately placed

implant.5

The presence of a fistula, moderate periapical radiolucency, obvious exudate or lack of a facial plate in the presence of a moderate level of inflammation may warrant delaying implant placement after extraction (Figure 1). Inflammatory changes at the localized site associated with infection can trigger osteoclastic activity leading to bone resorption. It is prudent that when infection is visibly present at extraction, thorough curettage of the socket to remove any remnants of the cystic tissue be performed. Socket preservation is recommended to aid in the stabilization of the facial plate and implant placement is delayed until the soft tissue has healed fully and evidence of infection and inflammation have resolved (Figure 2). Systemic antibiotics administered during the first week after extraction will aid the body in clearing bacteria and inflammatory cells from the site.

Figure 1—Maxillary central incisor (No.9) presents with a periodontal abscess apical to the gingival margin facially and class III mobility.

Figure 2—Central incisor has been extracted and the socket curetted, followed by socket preservation using an autogenous graft. Site was covered by a collagen membrane and shown 1 week after extraction and grafting. Initial healing will normally occur within 4 to 6 weeks after extraction of the source of the infection (the failed tooth). The presence of keratinized tissue with closure of the extraction site indicates the site is probably ready for the next step in the surgical treatment—implant placement (Figure 3). The authors would recommend at this juncture



that a radiograph be taken to ascertain whether bone has regenerated or if an additional bone regeneration procedure should be performed.

Figure 3—Site shown 4 weeks after extraction and grafting. A cast fabricated from an impression is taken after extraction of the tooth to be replaced by the implant. The facial contours of the anterior teeth are built out in composite to ideal contours and a surgical stent is fabricated, allowing positioning of the implant in the best position based on the contours of the final restorations (Figures 4 and 5).

Figure 4—Composite mock-up was performed on the cast to position the facial of the central incisors in an ideal position.

Figure 5—A surgical stent was fabricated and a pilot hole placed to guide surgical placement of the implant. A crestal incision is made at the healed extraction site and extended as an intrasulcular incision mesial and distal to the site. The incision should be extended wide enough to allow visualization of the facial osseous plate after implant placement. If vertical releasing incisions are required for visualization, they should be located far enough from the site that they do not lie over the implant or any graft placed. The implant placement guide (surgical stent) previously fabricated is tried in and stability verified.



A pilot drill is introduced into the guide hole in the stent and taken to the desired depth. Angulation and position are verified with respect to the osseous triangle that will house the implant. Changes to the final position may be performed at this stage without resulting overpreparation of bone at the osteotomy. Subsequently larger osteotomy drills are used with the surgical stent until the final diameter and depth of the site are achieved (Figure 6).

Figure 6—Surgical stent shown intraorally after implant placement. The site should be examined to determine if any loss of facial plate or a thin crestal margin will require grafting. The implant is introduced into the site to its proper depth and examined for any thread exposure on the facial plate. Should a dehiscence be present or a thin crestal margin, osseous grafting will be required before site closure. An appropriate osseous graft material is packed on the facial to cover any exposed thread and thicken the facial plate (Figure 7). Primary closure of the site is critical to ensure stability of the crestal bone after healing. Elevation of the palatal aspect of the flap will allow harvesting of connective tissue to be relocated over the crestal aspect of the site (Figures 8 through 11). If more connective tissue is required than harvestable palatally, Alloderm (LifeCell Corporation, Branchburg, NJ, www.alloderm.com) may be used.

Figure 7—Osseous graft has been placed to cover dehiscence on coronal facial aspect of the implant. Palatal flap has been elevated to allow harvesting of connective tissue.

Figure 8—Connective tissue harvested from the palate.



Figure 9—The harvested connective tissue is relocated to cover the osseous graft over the facial aspect of the implant.

Figure 10—Illustration demonstrating positioning of connective tissue graft over osseous graft. Osseous graft is shown in purple and connective tissue graft in green. Illustration courtesy of David Kurtzman, DDS.

Figure 11—Illustration demonstrating positioning of connective tissue graft over osseous graft. Connective tissue graft in green. Illustration courtesy of David Kurtzman, DDS. The connective tissue is placed under the flap margins and tacked apically with a resorbable suture to stabilize the soft-tissue graft (Figure 12). Flap margins are overlaid in a tension free manner and the site closed with resorbable sutures. The connective tissue graft need not be completely covered by the flaps. Periacryl (N-butyl-2-cyanoacrylate; Salvin Dental Specialties, Charlotte, NC, www.salvin.com), a tissue adhesive, is applied



over the site to cover the flaps and any exposed connective tissue creating a water tight barrier (Figure 13). This barrier will prevent bacteria or plaque penetration into the site through the soft tissue and improve healing.

Figure 12—Surgical site closed with resorbable sutures, ensuring a tension free closure.

Figure 13—Surgical site has been closed with Vicryl (Ethicon, Cincinnati, OH, www.jnjgateway.com) suture and sealed with Periacryl (N-butyl-2-cyanoacrylate). After a 3- to 4-month healing period (Figure 14), the implant is exposed with a crestal incision similar to the incision used to place the implant. An abutment fabricated from an impression taken at the time of surgical placement is positioned on the implant and torqued to the manufacturer’s recommended Newton centimeters (ncm). A prefabricated temporary crown is placed with temporary cement and the restoration is removed from any occlusal contact. Temporization of adjacent teeth that will receive crowns or veneers to the desired facial contours is performed.

Figure 14—Implant site shown 6 months after surgery. At this stage soft-tissue recontouring of the adjacent teeth is accomplished. The soft tissue is sutured in the desired position with a resorbable suture material and the patient



dismissed (Figure 15). The soft tissue is allowed to heal and mature for 4 weeks before final impressions (Figure 16).

Figure 15—Implant has been uncovered and soft-tissue crown lengthening has been performed on teeth Nos. 7 through 10. Implant abutment was placed with a temporary crown and the site closed with Vicryl suture.

Figure 16—Sutures removed at 10 days after crown lengthening. Conclusion Complications may arise at extraction sites where implants are planned, making treatment staging challenging. When combined with cosmetic treatment on adjacent teeth, sequencing of the surgical phase of implant treatment can simplify multi-aspect planning and provide predictable results (Figures 17 through 20).

Figure 17—Maxillary anterior following completion of restorative treatment consisting of feldspathic porcelain veneer on tooth No. 7, and individual all-ceramic crowns on teeth Nos. 8 and 9.



Figure 18—Lateral view showing emergence and contour of the facial surfaces of the final restorations.

Figure 19—Radiograph 3 years after treatment, demonstrating stability of the osseous structure surrounding the implant.

Figure 20—Finished result after completion of surgical and prosthetic treatment. Acknowledgments Prosthetic treatment courtesy of Marc E. Moskowitz, DDS, Marietta, Georgia. The authors would like to thank David Kurtzman, DDS, for his contribution to the illustration demonstrating connective tissue placement.

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