Abstract

Since the first report describing the placement of dental implants into fresh extraction sockets, there has been an increasing interest in this technique. The advantages of immediate implant placement have been reported to include a reduction in the number of surgical interventions, potentially decreased alveolar bone resorption after tooth loss, and shorter treatment time. Appropriate indications, good surgical technique, eand the use of a prosthetic protocol have resulted in success for immediate loading and immediate implantation. Adverse patient-related factors, such as systemic health, a smoking habit, poor oral hygiene, presence of a thin biotype, or an infection in the region of the extraction, are contraindications for this treatment. Patient satisfaction is very high, and some difficulties related to the implantation site in late implantations may be eliminated. This article reports on three cases of immediate loading with up to 30 months of clinical follow-up.

Introduction

Immediate implantation and immediate loading protocols are becoming more common. Immediate loading in the mandibular interforaminal region has been routinely performed for more than a decade and success rates of 90% to 100% have been reported.1 The goal of immediate implantation and immediate loading is to decrease the number of surgical interventions, thereby reducing costs and patient discomfort. Furthermore, such an approach has led to immediate implant placement after tooth extraction and immediate loading of implants with fixed restorations. Studies showing long-term results of these two methods are scarce, and the number of cases is limited.2,3 This article presents three different immediate loading cases and shows clinical and radiographic status after short-term functional loading.

Case Reports

Case 1: Immediate Implantation and Immediate Loading

An 18-year-old female patient was sent by her dentist to the Department of Prosthodontics of the Faculty of Dentistry at Istanbul University for evaluation of her maxillary right central incisor. Clinical and radiographic examinations showed external root resorption (Figures 1a and b), with slight mobility and a negative vitality test. The adjacent left central incisor also showed external root resorption (Figure 1a), but it was still vital. The patient's dental history included orthodontic treatment. Endodontic consultation led to a decision to retain the left central incisor and extract the right one. After atraumatic extraction (Figure 2), a dental implant (4.5 × 13 mm, Astra Tech Osseospeed, Astra Tech AB, Mölndal, Sweden) was placed in the fresh extraction socket in a 3-dimensionally correct position (Figure 3). After primary stability was affirmed, an abutment (Direct Abutment, Astra Tech) was mounted, upon which a temporary acrylic (Dentalon Plus, Heraeus Kulzer GmbH & Co KG, Dormagen, Germany) crown was fabricated chair-side. The marginal fit was finished and controlled on a laboratory analogue and then temporarily cemented (Temp Bond, Kerr Corp, Romulus, Mich) (Figures 4a and b). Occlusal contact was eliminated to protect the provisional crown. A final periapical radiograph was taken to evaluate the marginal fit (Figure 5a). After 3.5 months, minimal bone loss was observed radiographically (Figure 5b). A crown of porcelain fused to zirconium oxide, ZrO2 (Cercon, Degudent, Hanau, Germany), was fabricated and cemented permanently (Panavia 21, Kuraray, Tokyo, Japan) after a 10-day period of temporary cementation. A 27-month follow-up radiograph (Figure 6a) showed a clinically stable situation around the implant, peri-implant bone resorption appeared comparable to results with delayed loading protocols, and the soft tissue showed excellent pink esthetics (Figure 6b).

Figures 1–4. Figure 1. (a) External resorption of maxillary central incisor roots. (b) Intraoral clinical view of implant site before treatment. Figure 2. The extracted tooth and the implant immediately placed into the extraction site. Figure 3. 3-dimensionally correct implant placement. Figure 4. (a) The marginal fit was finished on a laboratory analogue. (b) The acrylic provisional crown in situ.

Figures 1–4. Figure 1. (a) External resorption of maxillary central incisor roots. (b) Intraoral clinical view of implant site before treatment. Figure 2. The extracted tooth and the implant immediately placed into the extraction site. Figure 3. 3-dimensionally correct implant placement. Figure 4. (a) The marginal fit was finished on a laboratory analogue. (b) The acrylic provisional crown in situ.

Figures 5

and 6. Figure 5a. Case 1. Figure 5 (a) The final result and marginal fit were evaluated on a periapical radiograph. (b) Minimal bone loss was seen radiographically after 3.5 months of functional loading. Figure 6. (a) The clinical view showed excellent pink esthetics. (b) The 23-month follow-up radiograph.

Figures 5

and 6. Figure 5a. Case 1. Figure 5 (a) The final result and marginal fit were evaluated on a periapical radiograph. (b) Minimal bone loss was seen radiographically after 3.5 months of functional loading. Figure 6. (a) The clinical view showed excellent pink esthetics. (b) The 23-month follow-up radiograph.

Case 2: Immediate Loading

A 22-year-old female patient who had lost her maxillary left central incisor in a car accident several months earlier, applied to the Department of Prosthodontics of the Faculty of Dentistry at Istanbul University for evaluation (Figure 7). A dental implant (4.5 × 13 mm, AstraTech Osseospeed) was placed in a 3-dimensionally correct position. After primary stability was affirmed, an abutment (AstraTech) was mounted, upon which a temporary acrylic (Dentalon Plus, Heraeus Kulzer GmbH & Co KG) crown was fabricated chair-side. The marginal fit was finished on a laboratory analogue and then temporarily cemented (Temp Bond, Kerr Corp). The provisional crown was protected from occlusal contact. This was easy to accomplish because the patient had an open bite. Final seating of the crown was verified by a periapical radiograph. The marginal fit was very good, as in case 1. Three months later, the final restoration (a porcelain fused to metal crown) was fabricated and cemented (Figure 8) with polycarboxylate cement (Adhesor Carbofine, SpofaDental, Praha, Czech Republic). Clinical follow-up after 38 months of functional loading showed a stable clinical (Figure 9) and radiographic (Figure 10) outcome.

Figures 7–10. Figure 7. Case 2. Figure 7. Preoperative radiograph. Figure 8. The periapical radiograph of the final restoration 3 months after the procedure. Figure 9. Stable clinical outcome 38 months after immediate loading. Figure 10. Follow-up 38 months after functional loading showed a radiographically stable situation.

Figures 7–10. Figure 7. Case 2. Figure 7. Preoperative radiograph. Figure 8. The periapical radiograph of the final restoration 3 months after the procedure. Figure 9. Stable clinical outcome 38 months after immediate loading. Figure 10. Follow-up 38 months after functional loading showed a radiographically stable situation.

Case 3: Immediate Loading

A 27-year-old male patient who had lost his mandibular right central incisor because of a trauma several months earlier, applied to the Department of Prosthodontics of the Faculty of Dentistry at Istanbul University for evaluation (Figure 11). A dental implant (3.5 × 15 mm, AstraTech) was placed in the missing tooth location in a 3-dimensionally correct position (Figure 12). After primary stability was affirmed, an abutment (AstraTech) was mounted, upon which a temporary acrylic (Dentalon Plus, Heraeus-Kulzer) crown was fabricated chair-side. The marginal fit was finished on a laboratory analogue and then temporarily cemented (Temp Bond, Kerr Corp). The provisional crown was protected from occlusal contact with the opposing teeth. At that time, the patient's adjacent mandibular left central incisor was also prepared and provisionalized. The patient was lost to follow-up but eventually returned for definitive restoration 18 months later. The radiograph taken in this session showed that the crestal bone level had been well maintained (Figure 13).

Figures 11–13. Figure 11. Preoperative panoramic radiograph shows a missing mandibular right central incisor. Figure 12. Radiograph after implant placement. Figure 13. Follow-up radiograph 18 months after immediate loading.

Figures 11–13. Figure 11. Preoperative panoramic radiograph shows a missing mandibular right central incisor. Figure 12. Radiograph after implant placement. Figure 13. Follow-up radiograph 18 months after immediate loading.

Discussion

Since the first reports demonstrating successful implantation into fresh extraction sockets,4 this technique has gained frequent, widespread use.5,6 Immediate implantation has several advantages, such as reducing the number of surgical interventions and the total treatment time. Furthermore, the alveolar bone at the extraction site may be more resistant to resorption,7,9 and the soft tissue esthetics can be better maintained.10 

It has been reported that the buccolingual alveolar crestal width shrinks 5 to 7 mm, which is approximately 50% of the original volume, in the first year after tooth loss; the largest resorption appears within the first 4 months.11,12 Parallel to that resorption, a vertical bone loss of 2 to 4.5 mm tends to continue simultaneously.13,14 Extraction of several neighboring teeth may cause an even greater volume loss in the bone.11,14,15 

Immediate implantation should be avoided in the following situations: infection at the extraction site,16,18 significant discrepancies in a smaller size (ie, diameter) of the implant relative to the alveolar socket, and absence of primary stability of the placed dental implant. Studies with animals have shown that the distance of the implant surface to bone is important for clot stabilization.19,22 Distances >2 mm should be covered by a membrane.23,26 

If the requirements for immediate loading are met after implantation, this treatment option is valuable for fulfilling the esthetic and functional expectations of patients. A fixed provisional crown is more comfortable and less vulnerable to fracture or loss than a temporary removable denture.

The implant should be positioned 3-dimensionally in the correct position,12,27,29 and primary stability must be obtained. Additionally, the socket walls where the implant will be placed must be intact to warrant later soft tissue esthetics.30 Insufficient bone support and a thin biotype often lead to disastrous results.31,36 If bony support is defective or if a dehiscence or a thin biotype is detected before or during the surgery, a grafting procedure that will delay the loading time is indispensable. Another important risk factor is a history of aggressive periodontitis, especially combined with cigarette smoking.37,38 These cases can show unpredictable soft tissue recession.

The provisional crown is a key factor in the success of immediate loading of single implants, patient satisfaction, and soft tissue and interproximal papilla shaping. The provisional crown should not cause extensive pressure on the gingiva, which could lead to recession. Furthermore, the crown should be fabricated in a manner to avoid contact in laterotrusion or protrusion.

Proper indications, good surgical technique, and the use of a prosthetic protocol are very important for the success of immediate loading and immediate implantation. Patient satisfaction is very high, and difficulties related to the implantation site in late implantations are eliminated. Nevertheless, there are also contraindications for these treatment modalities. If even one of the following patient-related factors, such as poor systemic health, a heavy smoking habit, poor oral hygiene, a thin biotype, or an infection in the extraction region is present, this treatment option should not be considered.

All three cases presented herein showed a relatively good soft tissue response and a physiologically normal crestal bone loss after up to 30 months of functional loading. Periapical radiographs showed clearer and more accurate details than panoramic radiographs.39 

Conclusion

Based on our clinical experience, we suggest that if correct surgical techniques are applied and the indication and planning of the case is done meticulously, good clinical results can be achieved in immediate loading or immediate implantation combined with immediate loading when compared to delayed loading protocols. To be able to draw clinically meaningful conclusions, larger case numbers with longer observation periods must be achieved.

References

References
1
Attard
,
N. J.
and
G. A.
Zarb
.
Immediate and early implant loading protocols: a literature review of clinical studies.
J Prosthet Dent.
2005
.
94
:
242
258
.
2
Barone
,
A.
,
L.
Rispoli
,
I.
Vozza
,
A.
Quaranta
, and
U.
Covani
.
Immediate restoration of single implants placed immediately after tooth extraction.
J Periodontol.
2006
.
77
:
1914
1920
.
3
Hoffmann
,
O.
,
C.
Beaumont
, and
G. G.
Zafiropoulos
.
Immediate implant placement: a case series.
J Oral Implantol.
2006
.
32
:
182
189
.
4
Schulte
,
W.
,
H.
Kleineikenscheidt
,
K.
Linder
, and
R.
Schareyka
.
The Tübingen immediate implant in clinical studies [in German].
Dtsch Zahnärztl Zeitschr.
1978
.
33
:
348
359
.
5
Mayfield
,
L. J. A.
Immediate, delayed and late submerged and transmucosal implants.
In: J. Lindhe, eds.
Proceedings of the 3rd European Workshop on Periodontology: Implant Dentistry.
Berlin: Quintessenz;
.
1999
.
520
534
.
6
Schwartz-Arad
,
D.
and
G.
Chaushu
.
The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review.
J Periodontol.
1997
.
68
:
915
923
.
7
Denissen
,
H. W.
,
W.
Kalk
,
H. A.
Veldhuis
, and
M. A.
van Waas
.
Anatomic consideration for preventive implantation.
Int J Oral Maxillofac Implants.
1993
.
82
:
191
196
.
8
Shanaman
,
R. H.
The use of guided tissue regeneration to facilitate ideal prosthetic placement of implants.
Int J Periodontics Restorative Dent.
1992
.
124
:
256
265
.
9
Watzek
,
G.
,
R.
Haider
,
N.
Mensdorff-Pouilly
, and
R.
Haas
.
Immediate and delayed implantation for complete restoration of the jaw following extraction of all residual teeth: a retrospective study comparing different types of serial immediate implantation.
Int J Oral Maxillofac Implants.
1995
.
105
:
561
567
.
10
Werbitt
,
M. J.
and
P. V.
Goldberg
.
The immediate implant: bone preservation and bone regeneration.
Int J Periodontics Restorative Dent.
1992
.
12
:
207
217
.
11
Johnson
,
K.
A study of the dimensional changes occurring in the maxilla following tooth extraction.
Aust Dent J.
1969
.
14
:
241
244
.
12
Tarnow
,
D. P.
and
R. N.
Eskow
.
Considerations for single-unit esthetic implant restorations.
Compend Contin Educ Dent.
1995
.
16
:
782
784
.
13
Iasella
,
J. M.
,
H.
Greenwell
, and
R. L.
Miller
.
et al
.
Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: a clinical and histologic study in humans.
J Periodontol.
2003
.
74
:
990
999
.
14
Lam
,
R. V.
Contour changes of the alveolar processes following extraction.
J Prosthet Dent.
1960
.
10
:
25
32
.
15
Tarnow
,
D. P.
,
S. C.
Cho
, and
S. S.
Wallace
.
The effect of interimplant distance on the height of inter-implant bone crest.
J Periodontol.
2000
.
71
:
546
549
.
16
Grunder
,
U.
,
G.
Polizzi
, and
R.
Goene
.
et al
.
A 3-year prospective multicenter follow-up report on the immediate and delayed immediate placement of implants.
Int J Oral Maxillofac Implants.
1999
.
142
:
210
216
.
17
Polizzi
,
G.
,
U.
Grunder
, and
R.
Goene
.
et al
.
Immediate and delayed implant placement into extraction sockets: a 5-year report.
Clin Implant Dent Relat Res.
2000
.
22
:
93
99
.
18
Rosenquist
,
B.
and
B.
Grenthe
.
Immediate placement of implants into extraction sockets: implant survival.
Int J Oral Maxillofac Implants.
1996
.
112
:
205
209
.
19
Akimoto
,
K.
,
W.
Becker
,
K.
Donath
,
B. E.
Becker
, and
R.
Sanchez
.
Formation of bone around titanium implants placed into zero wall defects: pilot project using reinforced e-PTFE-membrane and autogenous bone grafts.
Clin Implant Dent Relat Res.
1999
.
12
:
98
104
.
20
Botticelli
,
D.
,
T.
Berglundh
,
D.
Buser
, and
J.
Lindhe
.
The jumping distance revisited: an experimental study in the dog.
Clin Oral Implants Res.
2003
.
141
:
35
42
.
21
Knox
,
R.
,
R.
Caudill
, and
R.
Meffert
.
Histologic evaluation of dental endosseous implants placed in surgically created extraction defects.
Int J Periodontics Restorative Dent.
1991
.
11
:
365
376
.
22
Stentz
,
W. C.
,
B. L.
Mealey
,
J. C.
Gunsolley
, and
T. C.
Waldrop
.
Effects of guided bone regeneration around commercially pure titanium and hydroxyapatite-coated dental implants. II. Histologic analysis.
J Periodontol.
1997
.
68
:
933
949
.
23
Cornelini
,
R.
Immediate transmucosal implant placement: a report of 2 cases. Int J Periodont.
Restorative Dent.
2000
.
20
:
199
206
.
24
Goldberg
,
P. V.
,
F. L.
Higginbottom
, and
T. G.
Wilson
.
Periodontal considerations in restorative and implant therapy. Periodontol 2000.
2001
.
25
:
100
109
.
25
Paolantonio
,
M.
,
M.
Dolci
, and
A.
Scarano
.
et al
.
Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in man.
J Periodontol.
2001
.
72
:
1560
1571
.
26
Wilson
Jr,
T. G.
,
J.
Carnio
,
R.
Schenk
, and
D.
Cochran
.
Immediate implants covered with connective tissue membranes: human biopsies.
J Periodontol.
2003
.
743
:
402
409
.
27
Belser
,
U. C.
,
J. P.
Bernard
, and
D.
Buser
.
Implant-supported restorations in the anterior region: prosthetic considerations.
Pract Periodontics Aesthet Dent.
1996
.
8
:
875
883
.
28
Belser
,
U. C.
,
D.
Buser
,
D.
Hess
,
B.
Schmid
,
J. P.
Bernard
, and
N. P.
Lang
.
Aesthetic implant restorations in partially edentulous patients—a critical appraisal. Periodontol 2000.
1998
.
17
:
132
150
.
29
Parel
,
S. M.
and
D. Y.
Sullivan
.
, eds.
Esthetics and Osseointegration.
Dallas: Osseointegration Seminars;
.
1989
.
30
Choquet
,
V.
,
M.
Hermans
,
P.
Adriaenssens
,
P.
Daelemans
,
D. P.
Tarnow
, and
C.
Malevez
.
Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region.
J Periodontol.
2001
.
2
:
1364
1371
.
31
Berglundh
,
T.
and
J.
Lindhe
.
Dimension of the periimplant mucosa. Biological width revisited.
J Clin Periodontol.
1996
.
23
:
971
973
.
32
Block
,
M. S.
and
J. N.
Kent
.
Factors associated with soft and hard tissue compromise of endosseous implants.
J Oral Maxillofac Surg.
1990
.
48
:
1153
1160
.
33
Buser
,
D.
,
H. P.
Weber
,
K.
Donath
,
J. P.
Fiorellini
,
D. W.
Paquette
, and
R. C.
Williams
.
Soft tissue reactions to non-submerged unloaded titanium implant in beagle dogs.
J Periodontol.
1992
.
63
:
225
235
.
34
Cochran
,
D. L.
,
J. S.
Hermann
,
R. K.
Schenk
,
F. L.
Higginbottom
, and
D.
Buser
.
Biologic width around titanium implants. A histometric analysis of the implanto-gingival junction around unloaded and loaded nonsubmerged implants in the canine mandible.
J Periodontol.
1997
.
68
:
186
198
.
35
Hermann
,
J. S.
,
D.
Buser
,
R. K.
Schenk
,
F. L.
Higginbottom
, and
D. L.
Cochran
.
Biologic width around titanium implants. A physiologically formed and stable dimension over time.
Clin Oral Implants Res.
2000
.
11
:
1
11
.
36
Todescan
,
F. F.
,
F. E.
Pustiglioni
,
A. V.
Imbronito
,
T.
Albrektsson
, and
M.
Gioso
.
Influence of the microgap in the peri-implant hard and soft tissues: a histomorphometric study in dogs.
Int J Oral Maxillofac Implants.
2002
.
17
:
467
472
.
37
Ellegaard
,
B.
,
V.
Baelum
, and
T.
Karring
.
Implant therapy in periodontally compromised patients.
Clin Oral Implants Res.
1997
.
8
:
180
188
.
38
Karroussis
,
I. K.
,
G. E.
Salvi
,
L. J.
Heitz-Mayfield
,
U.
Bragger
,
C. H.
Hämmerle
, and
N. P.
Lang
.
Long-term implant prognosis in patients with and without a history of chronic periodontitis: a 10-year prospective cohort study of the ITI Dental Implant System.
Clin Oral Implants Res.
2003
.
14
:
329
339
.
39
Reddy
,
M. S.
,
T.
Mayfield-Donahoo
,
F. J.
Vanderven
, and
M. K.
Jeffcoat
.
A comparison of the diagnostic advantages of panoramic radiography and computed tomography scanning for placement of root form dental implants.
Clin Oral Implants Res.
1994
.
5
:
229
238
.

Hakan Bilhan, Dr Med Dent, Emre Mumcu, Dr Med Dent, and Tayfun Bilgin, Dr Med Dent, are at Istanbul University, Faculty of Dentistry, Department of Prosthodontics. Address correspondence to Dr Bilhan at University of Istanbul – Faculty of Dentistry, Department of Prosthodontics, 34390- Çapa, Istanbul, Turkey. (bilhan@istanbul.edu.tr) Esma Sönmez is a PhD student at Istanbul University, Faculty of Dentistry, Department of Prosthodontics.