Topic: Implant insertion after tooth extraction: Clinical outcomes with different approaches

Presented by Edith Groenendijk & Tristan Staas

References

Conclusion

Introduction

PROTOCOL FOR IMMEDIATE TOOTH REPLACEMENT IN THE ESTHETIC REGION

MINIMAL INVASIVE, MAXIMAL EFFECTIVE

Immediately placed front tooth implants 1 : Analysis with Cone Beam Computed

Tomography after remodelling of the buccal plate

Staas TA, Groenendijk E, Graauwmans FEJ, Verhamme L, Maal T, Meijer GJ

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Abstract Results

Material & Method

The aim of this retrospective research was to study the stability of the buccal bone

using a protocol for immediate tooth replacement described by Staas & Groenendijk.

In the period 1 January 2008 to 1 January 2012, in 186 patients an implant was installed

immediately after the removal of a maxillary incisor. Subsequent to placement of the

implant, a 2 mm gap between implant and buccal plate was filled with a bone

substitute. In addition to a pre-operatively and per-operatively cone beam computer

tomogram (CBCT), also a late-postoperative cone beam computer tomogram was

produced in 16 cases. Per-operative, the buccal plate thickness increased by 1.5 mm

(mean) from 0.9 mm to 2.4 mm (mean). During the evaluation period of 1 to 4 years a

reduction took place resulting in a final buccal plate thickness of 1.8 mm on average.

Surprisingly, the buccal plate bone height increased by 1.6 mm (mean), to an average

of 1.2 mm above the implant shoulder. In these cases it was crucial that the implant

was placed in such a way that a gap of a minimum of 2.0 mm was created between the

original buccal plate and the implant, and that this gap was filled with a bone

substitute. With this minimal invasive treatment protocol, costs and treatment time

are minimized, while patient comfort and esthetics are optimized. Although the results

are promising, further research on this topic is necessary.

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In a period from 1 January 2008 to 1 January 2012 186 patients were treated with an

immediate implant to replace a lateral or central maxillary incisor. Patients were

treated by one practitioner. After some time another CBCT was indicated for diagnostic

reasons in 16 cases (4 men; 12 women). This made it possible to use this CBCT for late

postoperative evaluation. The ages of the 16 patients included ranged from 17 to 72

years with an average age of 44 years. A standard protocol described by Staas &

Groenendijk was followed in all patients. Using this protocol a pre-operative CBCT is

made for diagnostic reasons and planning of the implant treatment, while a per-

operative CBCT is made to capture the three dimensional position of the implant after

the flapless surgery. The pre-operative CBCT shows the natural tooth in situ or an

empty socket immediate after avulsion.

Two implants were at position 11, four at position 21, eight at position 12 and two at

position 22. In 9 cases persistent periapical pathology was reason for extraction, four

cases had a crown - or root fracture and three cases were found to a recent trauma

related avulsion. NobelActive ™ Internal implants were placed using the

manufacturers drill protocol: 1 X Ø 3.0 mm x length 13.0 mm; 4 X Ø 3.5 mm x length

13.0 mm; 6 X 3.5 Ø x length 15.0 mm; and 5 X Ø 4.3 mm x length 15.0 mm. In 15

patients Geistlich Bio-Oss ® was used as bone substitute with a grain size between

0.25-1.0 mm. The torque at immediate placement varied between 40 to 110 NCm with

an average of 65 NCm.

The time lag between implant placement and the manufacture of the late-postoperative

CBCT was between 43 and 202 weeks, with an average of 103 weeks after implant

placement. Based on ‘voxel-based alignment’ using software (version 2.3.0.3 Maxilim

®) the pre-operative, post-operative, and late-postoperative CBCT of each patient was

superimposed. As orientation the palate and the spina nasalis anterior was detained.

Three sagittal cuts were appointed; central of the placed implant (the mid-buccal cross

section), as well as 1 mm to the mesial and 1 mm to the distal. The width of the buccal

plate was measured 1 mm below the most coronal point . In this way the thickness of

the buccal plate was measured before implant placement, directly after and on average

103 weeks (range 43-202) after the surgery. By comparing the preoperative thickness,

the direct-postoperative thickness and late postoperative thickness the change in

buccal plate thickness was measured. The data were reviewed with a paired t-test. In

analogy of the bone thickness also the height of the buccal bone was determined in

the middle of the implant, 1 mm to the distal and 1 mm to the mesial. The difference in

bone-height can be described by reducing the late-postoperative height with the

preoperative height. For all provisions the mean and standard deviation and

dispersion were calculated. Differences were tested with a paired t-test and the

reliability, the duplo errors and structural measurement error were determined. A intra

reviewers-and inter-assessors check was carried out on the basis of repetition of all

measurements in 4 cases.

The success rate and esthetic outcome of implant treatment in the esthetic region

depends on multiple factors. In various studies on the topic of immediate replacement

key factors, such as the initial condition of the alveolar ridge before extraction,

surgical and prosthetic technique, surgical and prosthetic components and implant

position are either not well defined or not comparable to each other. Colleagues Staas

& Groenendijk defined a protocol for immediate tooth replacement in the esthetic

region. A retrospective research was performed in order to study the stability of the

buccal bone outcome using this protocol.

Per-operative, the buccal plate thickness increased by 1.5 mm (mean) from 0.9 mm to

2.4 mm (mean). During the evaluation period of 1 to 4 years a reduction took place

resulting in a final buccal plate thickness of 1.8 mm on average. The buccal plate bone

height increased by 1.6 mm (mean), to an average of 1.2 mm above the implant

shoulder. The observed increase in height ( ΔH values in the table) were at review

statistically significant (p < 0.001) on all measured cross sections. Both in thickness

(ΔD) as in height (ΔH) no differences were measured in the sagittal section created by

the mid-facial, 1 mm to the mesial and 1 mm to the distal.

With this minimal invasive treatment protocol, in which a gain in the buccal plate

thickness is seen of on average 1.5 mm and an increase in buccal bone height of on

average 1.6 mm in the mid-facial , costs and treatment time are minimized, while

patient comfort and esthetics are optimized. Although the results are promising,

further research on this topic is necessary.