Immediate Implants

What Are Immediate Implants?

Immediate post-extractive implants are placed immediately after tooth extractions in fresh sockets. They have gained popularity over the years because they shorten treatment duration. Patients do not have to wait for soft tissue healing ( to six weeks) or bone healing (four to six months). However, they might be at higher risk of complications and failures.

Some evidence states that grafting at immediate post-extractive sites can improve the aesthetic outcome. In contrast, using large-diameter implants at immediate post-extractive sites should be avoided because of the poor aesthetic outcome. To obtain an improved aesthetic outcome at immediate post-extractive sites, implants should be placed in a slightly more palatal position as recommended by most implantologists (than placement at the ideal center of the socket).

How Does an Immediate Implant Heal?

Hansson et al. in 1983 and Ericsson in 2000- According to them, known theories proposed for post-extraction healing and bone growth show that surgical trauma considerably decreases when an immediate implant is placed. Also, immediate implants will decrease the risk of bone necrosis and permit the bone remodeling process to occur.

The healing period is rapid compared to bone resorption after a tooth is extracted and heals naturally without any bone graft placement. The natural socket is rich in periodontal cells and matrix, which makes healing fast-paced and predictable. Small osseous defects that may be found adjacent to implants can be grafted with autogenous bone obtained from intraoral bony sites or edentulous ridges to preserve the bone volume and height.

When Should the Tooth Be Extracted for an Immediate Implant?

• Weak periodontal attachment levels.

• Tooth mobility.

• Periodontal furcation involvement.

• Poor periodontal health status of teeth adjacent to the proposed implant site.

• Insufficient crown-to-root ratio.

• Deep carious lesions.

• Root fractures.

• Teeth with endodontic posts that have fractured.

• Failed endodontic retreatment.

Very minimal preparation is needed while placing the immediate implants since the extracted tooth socket preserves the anatomy of the tooth root, which mimics the root from implants. To gain initial stability, the implant should be placed a minimum of three mm apical to the extraction site and 3 mm apical to the crestal bone. The initial stability of the implant is the main factor determining the success of the immediate placement.

Biotype And Antibiotic Prophylaxis:

Patients receive a single dose of prophylactic antibiotics one hour before the intervention: two grams of Amoxicillin or 600 mg of Clindamycin if they are allergic to penicillin. They rinse with chlorhexidine mouthwash 0.2% for one minute before the intervention. Patients are treated under local anesthesia using articaine with adrenaline 1:100,000.

After crestal incision and flap elevation, teeth are extracted as atraumatically as possible to preserve the buccal alveolar bone. Sockets are carefully cleaned from any remains of granulation tissue. The wider diameter of the extraction socket is then measured using a granulated periodontal probe in millimeters, rounded to 0.5 mm.

The sockets are divided into:

• Nicely preserved- when the buccal plate is intact.

• Partially preserved- when up to four mm of buccal bone is missing.

• Poorly preserved- when more than four mm of buccal bone is missing.

Implant sites are thus categorized into two groups, according to the treating dental practitioners, as having:

• Thick biotype.

• Thin biotype.

Who Can Choose for Immediate Implants?

Immediate dental implants may be suitable for individuals who:

• Have Good Overall Oral Health: Patients should have healthy gums and adequate bone density to support the implant.

• Are Non-smokers or Willing to Quit: Smoking can impair healing and increase the risk of implant failure.

• Have a Stable Medical Condition: Individuals with well-controlled medical conditions, such as diabetes or heart disease, may be candidates for immediate implants with proper medical clearance.

• Require Single-Tooth Replacement: Immediate implants are often used for single-tooth replacement, although they can also be used for multiple teeth or full arch restorations.

Ultimately, the suitability of immediate dental implants depends on various factors and a thorough evaluation by a dental professional.

What is the Procedure for Implantation Surgery?

The implant insertion torque is measured with the motor set at 25 Ncm and reported as superior at 25 Ncm or up to 25 Ncm (as an insertion torque less than 25 Ncm can lead to primary instability). Once the implant is placed, periapical radiographs and clinical pictures should be taken. The area is grafted and then covered with a resorbable collagen membrane if needed. Flaps are sutured, but the wound can be left partially open when complete soft tissue coverage is not easy. Patients are instructed to use 0.2% chlorhexidine mouthwash for 1 minute twice daily for two weeks and avoid brushing and possible trauma on the surgical sites.

Postoperative antibiotics were prescribed: Amoxicillin one gram three times a day for seven days.

Patients allergic to penicillin were prescribed Clindamycin 300 mg three times a day for seven days. After one week, patients are checked, and sutures are removed. After one month, implants need to be manually tested by the dentist for stability; temporary abutments are placed, and provisional acrylic crowns are then cemented on the same day. Periapical radiographs of the study implants can be taken. If the marginal bone levels are not readable, the radiograph is to be retaken.

Oral hygiene instructions are delivered. With a 20 Ncm torque, using a manual wrench able to deliver a variable tightening torque from 10 to 35 Ncm. Clinicians almost universally recommended placing implants slightly more palatally to achieve a better aesthetic outcome. However, the ability to achieve the best aesthetics is probably mostly dependent on the manual skills and the experience of the individual operator.

What Are the Exclusion Criteria for Immediate Implants?

Sufficient bone is also required to allow the placement of one single implant at least 10 mm long with a 3.3 mm diameter.

Exclusion criteria were: ·

• General contraindications to implant surgery.

• Immunosuppressed or immunocompromised.

• Irradiation in the head or neck area.

• Uncontrolled diabetes.

• Pregnancy or lactation.

• Untreated periodontitis.

• Poor oral hygiene and motivation.

• Substance abuse.

• Psychiatric disorder or unrealistic expectations.

• Acute infection (abscess) or suppuration in the site intended for implant placement.

• Undertreatment or had previous treatment with intravenous amino bisphosphonates.

Conclusion:

Immediate implants are the preferred modality following extraction of a tooth unless the dentist does not recommend it due to certain exclusion criteria. Improved bone remodeling and preservation, along with manual operator skills, ensure the long-term success of immediate implants.