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The first patients receivingBränemark implants werecompletely edentulous

and received multiple (5-6)implants placed in the anteriormandible between the mentalforamina, then later in the maxil-lary anterior region. All of theseimplants were the “two-stage” vari-ety which classically required threeto six months to complete the bone

Winter

Immediate Placementof Single Tooth Implants

From Our Officeto Yours...

Implant dentistry has steadilyevolved since Bränemark firstapplied orthopedic principles toendosseous dental implants.

In this issue of ThePerioDontaLetter, we review the his-tory of implants and current newtechnologies which have broughtus from two-stage implants withlengthy healing times to the imme-diate placement of implants with opti-mum function and cosmetics undercertain favorable circumstances.

As these new proceduresbecome increasingly well-docu-mented, we may be able to providemore immediate placement, imme-diate loading and immediate func-tion of implants. As a result, yourpatients may enjoy shortened treat-ment times, less invasive proce-dures and the elimination of theneed for interim prostheses.

As always, we will continue towork with you to select the mostappropriate method for each indi-vidual situation and patient. Welook forward to your commentsand suggestions and our continu-ing teamwork with your office toincrease your patients’ satisfactionwith their implant treatment.

fusion process named osseointegra-tion. Then a second surgical proce-dure to expose the implant head forabutment connection and restora-tion was performed.

Although there were limitationsimposed by Bränemark’s system,including the design and cosmeticsof the prostheses they supported, formany “dental cripples” the return ofadequate function was nothing short

Figure 1. A fractured lateral incisor was removedatraumatically using a flapless technique. Figure 2. Theimplant osteotomy was extended beyond the apex of the socketfor initial implant stability. (See Figures 3 and 4.)

I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300, Philadelphia, PA 19102 (215) 735-3660

The Brown

I. Stephen Brown, D.D.S., Periodontics & Implant Dentistry

healing? Can provisional restorationsbe placed on immediate implants andalso into immediate, occlusal (loaded)function?

Answers to these questions arestill “a work in progress.” It isimportant to be mindful of the objec-tives -- maximizing successful func-tion and esthetics while minimizinginvasive surgical procedures in theface of public demand for singletooth implants with optimum results.

Palantonio et al addressed theissue of bone augmentation within asocket with adjoining immediately-placed implants. Their studyshowed similar osseointegrationwithout bone grafts or membranes ifthe microgap between implant andsocket wall was 2mm or less, and theflaps were closed over the implant.

It is recommended that imme-diate implants be placed slightlylingual to the original socket so asnot to engage the labial plate. Bynot following the exact confines ofthe socket shape and placing the

of a miracle which significantlyimproved their quality of life.

As a means of treating areas ofbone with less than adequate densityand volume, alternative implantdesigns and geometry and the use ofosteotomes, sinus augmentation andonlay grafts were developed toincrease the predictability and clinicalsuccess of dental implants.

The Single ToothImplant

Beginning in the mid-90's, sin-gle tooth implants and reduction intreatment time became a primarygoal for implant clinicians.Patients were dissatisfied withmerely achieving a stable implantin alveolar bone and demandedfunctional and cosmetically-acceptable tooth replacements. Asa result, the single tooth implanthas become the treatment of choiceAND the standard of care in manytooth replacement situations.

Daunting clinical obstacles wereovercome, in particular the reproduc-tion of lost alveolar bone and theoverlying soft tissue which almostalways accompanies tooth extraction.However, because attempts to regainlost tissues often subject the patient tomultiple surgical procedures, whichare often unpredictable in producingthe desired clinical results, preserva-tion of tissue became a primary objec-tive. Placing an implant immediatelyinto a fresh extraction site provided atreatment method with the potential ofreducing the amount of invasive sur-gical care, minimizing treatment time,and providing the best opportunity forpreservation of a normal periodontaltissue complex, especially in the inter-dental papilla.

Several pivotal questions becameapparent: Will an implant osseointe-grate if portions of the implant surfaceare not in intimate contact with thebony socket walls? Can a provisionalrestoration be placed immediately onan implant to enhance esthetics during

Figure 3. Following implant placement, a customhealing abutment was fabricated to shape thegingival architecture.

Figure 4. The temporary healing abutment canbe used for placement of an immediate temporaryfixed restoration or reduced for the placement of atemporary partial.

PerioDontaLetter, Summer

implant slightly lingual, long-termstability of the labial plate seems tobe maintained.

In both studies, the implants wereextended apically and/or laterally tothe anatomic socket apex to gainfavorable initial stabilization. Usingthis “native” bone when available api-cally ensures initial implant stability.Elimination of any micromovementhas long been considered a basic prin-

ciple of implant success. This is ofparamount importance in the designof the interim provisional restoration.

Immediate Loadingof Implants

Although somewhat controver-sial, some clinicians are advocatingimmediate loading of implants. This

involves placing a temporary crownon the implant at the time of implantsurgery.

When treatment planning apatient for immediate loading, onemust first consider patient-related andenvironmental factors.

• The healing potential of thepatient is a critical issue.

• Systemic conditions includingdiabetes, compromised immunologi-

Figures 5 and 6. The upper lateral incisor was decayed and fractured subgingivally.

Figure 7. The root was removed and, using a guide stent, theimplant was placed into and beyond the socket for initial stability.

Figure 8. The radiograph confirmsthe implant has osseointegratedwith the socket bone.

cal status and life stresses do notfavor immediate loading.

• Smoking and the presence ofextensive periodontal disease arealso contraindications to immediateloading.

• The character and quality ofbone in the implant site may dictatea more conventional approach.

• Provisional prostheses whichcannot be protected from overload-ing during function or from para-functional habits such as bruxism,are best treated in a more traditionalmanner.

• Large sockets in maxillary andmandibular molar regions whichhave the potential for defining lessthan ideal implant positioning favorbone regeneration and delayedimplant placement.

In summary, it is important toremember that the concepts forimmediate placement, restoration andloading are completely dependentupon the availability of alveolar bone.

The long-term success of anydental implant is predicated on thequality and quantity of the bone intowhich it is being placed. If the boneis wide, tall and dense, chances for asuccessful implant, which will last alifetime, are very good indeed. If thebone is deficient in any one of thesedimensions, bone modification orsupplementation may be requiredprior to implant placement. Inpatients presenting with inadequatebone, it is ill-advised to attempt anytype of immediate implant procedure.

One Miracle at a Time

Dennis Tarnow, a leader inimplant research and development,has said: “The fact that we canreplace a tooth with an implant is amiracle, and that we can grow bonewhich has been destroyed due todisease or atrophy is a miracle.Let’s only try to perform one mira-cle at a time.”

What is most important is thatimplants be placed in the most favor-able position for optimal functionand cosmetics. It is here that weneed the restoring doctor’s assis-tance in determining this position.This is where a pre-surgical diagnos-tic waxup and surgical guide show-ing the implant position in threeplanes -- buccal-lingual, mesial-dis-tal and apical-coronal -- is critical.

This is our philosophy in treatingyour patients because we want thebest long-term results possible.

We strive to make sure the bone isadequate and healthy prior to implantplacement, and that the implant hashad sufficient time to fully integrateprior to restoring it with a prosthetictooth replacement.

Allowing sufficient time for prop-er healing or regeneration of bone andensuring that the implants placed willlast a lifetime is a small price to payfor a miracle.

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Figures 9 and 10. The clinical photograph and the radiograph confirm the appearance of the final restoration of the implant.

I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300, Philadelphia, PA 19102 (215) 735-3660