Immediate implant placement - Handling

Thick gingivae, an intact facial bone wall, sufficient bone volume on the apical aspect, no infection – ideal conditions for immediate implant placement. How to do it?

Ass. Prof. Stephen Chen | Australia

Immediate implant placement is a planned procedure and not something that should be done spontaneously without the proper pre-treatment diagnostic steps. With good planning, it is almost always possible to proceed with immediate implant placement unless complications occur as a consequence of the tooth extraction.

Extracting the tooth

If the root is ankylosed or part of the facial plate is damaged as a result of the extraction, then the implant placement may need to be delayed until additional healing has taken place. The extraction should be done carefully with fine luxators and root forceps.

Once the tooth has been extracted, the internal part of the socket should be carefully examined visually and with the use of a periodontal probe to look for defects and bony contours. The extraction should be done without flap elevation to reduce surgical trauma. This will also allow subsequent placement of the implant without a flap being raised to minimize surgical trauma.¹

Placing the implant

A surgical guide is recommended to ensure that the implant is placed in the correct three-dimensional position. Due to the dense bone on the lingual aspect of the socket, there is a risk that the implant could deflect towards the facial side when it is inserted. This malposition can result in recession of the facial bone wall. The implant should be placed with the shoulder approximately 0.5 to 1 mm apical to the facial bone crest to compensate for the resorption that will occur.

Filling the gap

If the implant is placed correctly, a marginal gap of at least 2 mm will be present between the implant and the internal aspect of the facial wall. This marginal defect should be grafted with a bone substitute that has a low replacement rate, such as deproteinized bovine bone mineral (DBBM). Once the implant has been placed, the clinician has the option of attaching an immediate restoration to the implant. If this is done, care needs to be taken not to disturb the DBBM graft and to minimize the risk of bacterial contamination.

The crown of the maxillary left central incisor has fractured. The gingival phenotype is thick. In addition, the gingival margin is more coronal to that of the adjacent central incisor, a favorable situation for immediate implant placement.

A CBCT view of the maxillary left central incisor. The facial bone is 1 mm thick.

The tooth has been extracted without elevation of a flap. The walls of the socket can be inspected directly and with the use of a periodontal probe to ensure that all bone walls are intact.

The implant has been placed without flap elevation into an ideal 3-D position.

The marginal gap has been grafted with Geistlich Bio-Oss® to the level of the facial bone crest. The collagen matrix Geistlich Mucograft® Seal has been inserted into the gap between the healing abutment and the gingiva.

After 10 weeks of healing, the soft tissues healed uneventfully and were healthy.

At the two-year recall, the peri-implant tissues were healthy.

At the two-year recall, the radiograph showed ideal bone conditions.

At the two-year recall, the CBCT showed stable crestal bone at the neck of the implant plus the maintenance of a thick facial bone wall with the bone crest located coronal to the implant abutment interface (Photos: Stephen Chen).

Ass. Prof. Stephen Chen | Australia

Melbourne Periodontal Specialists
Clinical Associate Professor at The School of Dentistry
University of Melbourne