RESEARCH ARTICLE
Immediate Placement and Restoration of Dental Implants in the Esthetic Region: Clinical Case Series NABIL KHZAM, BDS, MPhil, DClinDent*, NIKOS MATTHEOS, DDS, MASc, PhD†, DAVID ROBERTS, BDSc, MDSc‡, WILLIAM L BRUCE, BDSc, MDSc§, SASO IVANOVSKI, BDSc, BDentSt, MDSc, PhD¶
ABSTRACT Aim: The objective of this study was to assess the hard and soft tissue changes following immediate placement and provisional restoration of single-tooth implants in the aesthetic zone. Methods: Thirteen patients with immediately placed and restored implants were included in this study. All participating patients underwent the same treatment strategy that involved removal of the failed tooth, flapless surgery, immediate implant placement, and connection of a screw-retained provisional restoration. Three months following implant placement, the temporary crowns were replaced by the definitive restorations. Implant survival rates, and hard and soft tissue changes were measured using periapical X-rays and photographs. The range of the observation period was between 12 and 37 months with a mean period of 23.2 ± 7.6 months. Results: At the time of follow-up, all implants were present with no complications. Radiographic evaluation revealed a mean mesial bone gain of 1.20 ± 1.01 mm and a mean distal bone gain of 0.80 ± 1.14 mm, which reached statistical significance. The mean mid-buccal recession was 0.20 ± 0.78 mm, whereas the mesial and distal papillae height loss was 0.50 ± 1.26 mm and 0.30 ± 0.82 mm, respectively. The changes in the soft tissues did not reach statistical significance. Conclusion: Notwithstanding the limitation of a small sample size, this study shows that immediate implant placement and provisional restoration in the maxillary aesthetic zone can result in favorable treatment outcomes with regards to soft and hard tissues changes over a follow-up period of 23.2 ± 7.6 months.
CLINICAL SIGNIFICANCE Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zone have focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissues changes. However, this study assesses the soft tissue changes associated with this procedure, which is an important area of study given the esthetic demands of implant therapy in the maxillary anterior region. (J Esthet Restor Dent 26:332–344, 2013)
INTRODUCTION Single tooth replacement with an implant supported crown is often the treatment of choice for missing teeth in the anterior maxilla. The original implant treatment protocol described by Branemark involved 3 months of
healing following extraction of a failed tooth, and an additional 3 to 6 months of a load-free period following implant placement.1,2 In the last 20 years, implant dentistry has evolved dramatically, with the original two-stage protocol modified to include one-stage surgery,3 immediate implant placement into a fresh
*Specialist Periodontist, Private Practice, University of Tripoli, Libya † Associate Professor, The University of Hong Kong, Hong Kong ‡ Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia § Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia ¶ Professor of Periodontology, School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia
332
Vol 26 • No 5 • 332–344 • 2014
Journal of Esthetic and Restorative Dentistry
DOI 10.1111/jerd.12083
© 2013 Wiley Periodicals, Inc.
IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.
extraction socket and immediate implant restoration.4,5 These three approaches have been combined in an attempt to further expedite the restorative process.6 Clinical trials have shown high levels of implant survival and success for single tooth implants placed directly into fresh extraction sockets.6,7 Furthermore, it has been shown that immediately placed implants may be provisionally restored with a temporary crown that is placed out of occlusion (immediate provisional restoration). This one-stage surgical and restorative procedure has the advantage of an immediate esthetic outcome with a fixed restoration, while eliminating the need for temporary fixed and/or removable partial dentures, and potential second-stage surgical intervention. It also allows for shorter treatment times as post-extraction socket-healing events coincide with implant osseointegration. However, case selection is critical for this treatment approach, with multiple contraindications such as the presence of infection at the extraction site, inadequate soft tissue profile, and the requirement for sufficient bone apical to the socket in order to achieve appropriate primary stability. From a surgical point of view, good primary stability appears to be critical for the one-stage surgical procedure, as it has been shown that there is a strong relationship between the placement torque and the survival of single tooth-implants.8 Adequate primary stability is of additional importance in cases where the implant is provisionally restored in order to withstand various forces that may be exerted on the restored implant during the early stages of healing. From a restorative point of view, the implant temporary crown must be out of occlusion in both centric and eccentric positions of the lower jaw.6 Indeed, the immediate implant placement and restoration protocol is technically challenging and can be considered a “technique sensitive” procedure.9 A major consideration in the maxillary anterior region is the loss of buccal tissue contour following tooth extraction. In order to minimize this loss of buccal tissue, the placement of a grafting material in the space between the implant and the buccal socket wall has been advocated and is supported by histological
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12083
evidence that this approach significantly decreases bone loss following immediate implant placement.10–13 The use of antibiotic prophylaxis in patients undergoing routine implant placement to minimize complication is supported by the literature and hence are indicated in more challenging clinical protocols such as that described in this study.14 Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zone have focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissues changes. However, few studies have assessed the soft tissue changes associated with this procedure, although this is an important consideration given the esthetic demands of implant therapy in the maxillary anterior region. Therefore, the objectives of the current study were to assess the soft and hard tissue dimensional changes associated with immediately placed and provisionally restored implants replacing single teeth in the anterior maxillary region after a minimum follow-up of 12 months.
METHODS The research protocol was reviewed and granted ethical approval by the Griffith University Human Research Ethics Committee (DOH/09/09/HREC).
Patient selection Thirteen patients who received 15 immediately placed and provisionally restored implants in the esthetic zone between March 2007 and December 2008 were included in this study. Two of the patients had two implants each. Patients were included in this study based on their willingness to attend 6 monthly review visits following their treatment. The sample included four males and nine females, mean age 44.7 ± 18.7 years, with 15 implants (13 incisors, 1 canine, and 1 premolar) (Table 1). None of the patients were smokers. No patients were lost at the final follow-up.
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 5 • 332–344 • 2014
333
IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.
TABLE 1. Tooth types and reason for tooth extraction Tooth type/ reason for extraction
Endodontic
Fracture
Root resorption
Total
Incisors
6
6
1
13
Canines
0
1
0
1
Premolars
0
1
0
1
Total
6
8
1
15
Inclusion and Exclusion Criteria The decision to progress with immediate implant placement and provisional restoration was determined following a comprehensive clinical and radiographic examination (using a cone-beam computed tomography [CBCT] scan), and detailed consultation between the surgical and restorative clinician. Aside from the usual contraindications for routine implant therapy (untreated periodontitis, uncontrolled diabetes, medical conditions that contraindicate elective surgery), specific contraindications for the immediate implant placement and restoration protocol included the presence of any pathological bone loss around the tooth or any gingival margin pathology or irregularity. Furthermore, the immediate implant placement and provisional restoration protocol was not implemented unless the tooth socket walls were completely intact (no fenestrations or dehiscences) following extraction, and a minimal implant torque insertion of 30 Ncm (maximum of 40 Ncm) was obtained.
334
placement followed, according to the instructions of the implant manufacturer (Astra Tech®, Mölndal, Sweden) (Figure 1C). Primary stability was achieved to a minimum insertion torque of 30 Ncm using a motor-driven surgical handpiece. In all implants sites, the buccal space between the implant and the socket wall was filled using a xenogenic particulate bone grafting material (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland). Postoperative instructions included chlorhexidine mouthwash (20 mL) use for 2 minutes twice daily for 2 weeks. Patients were instructed to not brush the implant site for at least 2 weeks. For pain control, patients were advised to use either 1 g of Paracetamol or 400 mg of Ibuprofen as needed.
Restorative Protocol After connection of a temporary abutment (Figure 1D), a prefabricated screw-retained temporary crown was adjusted and placed (Figure 1E). Appropriate adjustment of the occlusal scheme was carried out in order to ensure that the temporary restoration was free of any contact in both centric and eccentric excursions (Figure 1F). Final finishing of the provisional crown was carried out with rubber cups and pumice. The patients were advised to avoid placing any pressure on the provisional restoration, especially during eating. After 3 to 4 months, the temporary restoration was replaced with a custom zirconia abutment (Procera, Nobel Biocare, Göteborg, Sweden) and a permanent all-ceramic restoration by a prosthodontist.
Surgical Protocol
Hard Tissue Measurements
All surgical procedures were conducted under local anesthesia. Preoperative antibiotics were given to all patients. This prophylactic dose was 500 mg Amoxicillin three times daily (20 caps) for 1 week, starting 1 day before surgery. Diagnostic evaluation of the site of placement included clinical examination, radiographic analysis using a cone-beam CT scan and occlusal analysis with study models. After informed consent was obtained from the patient, atraumatic tooth extraction using a periotome without flap elevation was performed (Figure 1B). Surgical implant
Periapical X-rays were used to measure the changes in alveolar bone height surrounding the implant from the time of placement of the temporary restoration (baseline) to the follow-up assessment, which was at least 12 months later. The parallel technique was used in order to obtain comparable X-rays, and standardization was carried out by using the known implant length to calibrate the baseline and follow-up measurements. The implant shoulder was used as a reference level from which mesial (Mbc) and distal (Dbc) lines were drawn in an apical direction to the
Vol 26 • No 5 • 332–344 • 2014
Journal of Esthetic and Restorative Dentistry
DOI 10.1111/jerd.12083
© 2013 Wiley Periodicals, Inc.
IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.
A
B
C
D
E
F
G
FIGURE 1. A, Failed tooth due to improper root canal treatment (12) before the extraction. B, Minimal traumatic tooth extraction. C, Implant placed in final position. D, E, and F, Temporary crown in place. G, A radiograph.
first point of contact between bone and the implant (Figure 2). Computer software (Image J 1.43u; National Institute of Health, Bethesda, MD, USA) was used to calculate the length of these lines (Mbc and Dbc) and express it as an absolute measurement in millimeters.
Soft Tissue Measurements The soft tissue data were collected from photographs taken with a fixed angle and zoom ratio prior to tooth extraction (baseline) and at the follow-up visit (at least 12 months later). The crown length of the tooth mesial to the implant measured from the margin of the gingiva was set as the reference length. This allowed comparisons of the changes that occurred before and after the treatment with regard to the position of the gingiva and the amount of recession. A line extending from the incisal edges of the teeth adjacent to the implant (Ocl) was the starting point for the measurements. From this line, perpendicular lines were drawn extending to the tip of the mesial (Mp) and distal (Dp) papilla, as well as the middle of the mid-buccal gingival margin (Bm) (Figure 3). The length
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12083
of these lines was calculated based on the clinical photographs using a software program (Image J 1.43u), and variations over time were calculated in millimeters.
Other Measurements Implant survival rate: defined as the percentage of implants that were present at the final follow-up. Implant success rate: defined as the percentage of symptom and pathology free implants at the final follow-up. Assessment of interdental papilla: The triangular interdental papillae occupying the space between the implant retained restoration and the adjacent teeth were assessed using Jemt’s index.15 Jemt’s Index comprises of: score 0 (no papilla present), score 1 (
Immediate Placement and Restoration of Dental Implants in the Esthetic Region: Clinical Case Series NABIL KHZAM, BDS, MPhil, DClinDent*, NIKOS MATTHEOS, DDS, MASc, PhD†, DAVID ROBERTS, BDSc, MDSc‡, WILLIAM L BRUCE, BDSc, MDSc§, SASO IVANOVSKI, BDSc, BDentSt, MDSc, PhD¶
ABSTRACT Aim: The objective of this study was to assess the hard and soft tissue changes following immediate placement and provisional restoration of single-tooth implants in the aesthetic zone. Methods: Thirteen patients with immediately placed and restored implants were included in this study. All participating patients underwent the same treatment strategy that involved removal of the failed tooth, flapless surgery, immediate implant placement, and connection of a screw-retained provisional restoration. Three months following implant placement, the temporary crowns were replaced by the definitive restorations. Implant survival rates, and hard and soft tissue changes were measured using periapical X-rays and photographs. The range of the observation period was between 12 and 37 months with a mean period of 23.2 ± 7.6 months. Results: At the time of follow-up, all implants were present with no complications. Radiographic evaluation revealed a mean mesial bone gain of 1.20 ± 1.01 mm and a mean distal bone gain of 0.80 ± 1.14 mm, which reached statistical significance. The mean mid-buccal recession was 0.20 ± 0.78 mm, whereas the mesial and distal papillae height loss was 0.50 ± 1.26 mm and 0.30 ± 0.82 mm, respectively. The changes in the soft tissues did not reach statistical significance. Conclusion: Notwithstanding the limitation of a small sample size, this study shows that immediate implant placement and provisional restoration in the maxillary aesthetic zone can result in favorable treatment outcomes with regards to soft and hard tissues changes over a follow-up period of 23.2 ± 7.6 months.
CLINICAL SIGNIFICANCE Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zone have focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissues changes. However, this study assesses the soft tissue changes associated with this procedure, which is an important area of study given the esthetic demands of implant therapy in the maxillary anterior region. (J Esthet Restor Dent 26:332–344, 2013)
INTRODUCTION Single tooth replacement with an implant supported crown is often the treatment of choice for missing teeth in the anterior maxilla. The original implant treatment protocol described by Branemark involved 3 months of
healing following extraction of a failed tooth, and an additional 3 to 6 months of a load-free period following implant placement.1,2 In the last 20 years, implant dentistry has evolved dramatically, with the original two-stage protocol modified to include one-stage surgery,3 immediate implant placement into a fresh
*Specialist Periodontist, Private Practice, University of Tripoli, Libya † Associate Professor, The University of Hong Kong, Hong Kong ‡ Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia § Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia ¶ Professor of Periodontology, School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia
332
Vol 26 • No 5 • 332–344 • 2014
Journal of Esthetic and Restorative Dentistry
DOI 10.1111/jerd.12083
© 2013 Wiley Periodicals, Inc.
IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.
extraction socket and immediate implant restoration.4,5 These three approaches have been combined in an attempt to further expedite the restorative process.6 Clinical trials have shown high levels of implant survival and success for single tooth implants placed directly into fresh extraction sockets.6,7 Furthermore, it has been shown that immediately placed implants may be provisionally restored with a temporary crown that is placed out of occlusion (immediate provisional restoration). This one-stage surgical and restorative procedure has the advantage of an immediate esthetic outcome with a fixed restoration, while eliminating the need for temporary fixed and/or removable partial dentures, and potential second-stage surgical intervention. It also allows for shorter treatment times as post-extraction socket-healing events coincide with implant osseointegration. However, case selection is critical for this treatment approach, with multiple contraindications such as the presence of infection at the extraction site, inadequate soft tissue profile, and the requirement for sufficient bone apical to the socket in order to achieve appropriate primary stability. From a surgical point of view, good primary stability appears to be critical for the one-stage surgical procedure, as it has been shown that there is a strong relationship between the placement torque and the survival of single tooth-implants.8 Adequate primary stability is of additional importance in cases where the implant is provisionally restored in order to withstand various forces that may be exerted on the restored implant during the early stages of healing. From a restorative point of view, the implant temporary crown must be out of occlusion in both centric and eccentric positions of the lower jaw.6 Indeed, the immediate implant placement and restoration protocol is technically challenging and can be considered a “technique sensitive” procedure.9 A major consideration in the maxillary anterior region is the loss of buccal tissue contour following tooth extraction. In order to minimize this loss of buccal tissue, the placement of a grafting material in the space between the implant and the buccal socket wall has been advocated and is supported by histological
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12083
evidence that this approach significantly decreases bone loss following immediate implant placement.10–13 The use of antibiotic prophylaxis in patients undergoing routine implant placement to minimize complication is supported by the literature and hence are indicated in more challenging clinical protocols such as that described in this study.14 Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zone have focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissues changes. However, few studies have assessed the soft tissue changes associated with this procedure, although this is an important consideration given the esthetic demands of implant therapy in the maxillary anterior region. Therefore, the objectives of the current study were to assess the soft and hard tissue dimensional changes associated with immediately placed and provisionally restored implants replacing single teeth in the anterior maxillary region after a minimum follow-up of 12 months.
METHODS The research protocol was reviewed and granted ethical approval by the Griffith University Human Research Ethics Committee (DOH/09/09/HREC).
Patient selection Thirteen patients who received 15 immediately placed and provisionally restored implants in the esthetic zone between March 2007 and December 2008 were included in this study. Two of the patients had two implants each. Patients were included in this study based on their willingness to attend 6 monthly review visits following their treatment. The sample included four males and nine females, mean age 44.7 ± 18.7 years, with 15 implants (13 incisors, 1 canine, and 1 premolar) (Table 1). None of the patients were smokers. No patients were lost at the final follow-up.
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 5 • 332–344 • 2014
333
IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.
TABLE 1. Tooth types and reason for tooth extraction Tooth type/ reason for extraction
Endodontic
Fracture
Root resorption
Total
Incisors
6
6
1
13
Canines
0
1
0
1
Premolars
0
1
0
1
Total
6
8
1
15
Inclusion and Exclusion Criteria The decision to progress with immediate implant placement and provisional restoration was determined following a comprehensive clinical and radiographic examination (using a cone-beam computed tomography [CBCT] scan), and detailed consultation between the surgical and restorative clinician. Aside from the usual contraindications for routine implant therapy (untreated periodontitis, uncontrolled diabetes, medical conditions that contraindicate elective surgery), specific contraindications for the immediate implant placement and restoration protocol included the presence of any pathological bone loss around the tooth or any gingival margin pathology or irregularity. Furthermore, the immediate implant placement and provisional restoration protocol was not implemented unless the tooth socket walls were completely intact (no fenestrations or dehiscences) following extraction, and a minimal implant torque insertion of 30 Ncm (maximum of 40 Ncm) was obtained.
334
placement followed, according to the instructions of the implant manufacturer (Astra Tech®, Mölndal, Sweden) (Figure 1C). Primary stability was achieved to a minimum insertion torque of 30 Ncm using a motor-driven surgical handpiece. In all implants sites, the buccal space between the implant and the socket wall was filled using a xenogenic particulate bone grafting material (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland). Postoperative instructions included chlorhexidine mouthwash (20 mL) use for 2 minutes twice daily for 2 weeks. Patients were instructed to not brush the implant site for at least 2 weeks. For pain control, patients were advised to use either 1 g of Paracetamol or 400 mg of Ibuprofen as needed.
Restorative Protocol After connection of a temporary abutment (Figure 1D), a prefabricated screw-retained temporary crown was adjusted and placed (Figure 1E). Appropriate adjustment of the occlusal scheme was carried out in order to ensure that the temporary restoration was free of any contact in both centric and eccentric excursions (Figure 1F). Final finishing of the provisional crown was carried out with rubber cups and pumice. The patients were advised to avoid placing any pressure on the provisional restoration, especially during eating. After 3 to 4 months, the temporary restoration was replaced with a custom zirconia abutment (Procera, Nobel Biocare, Göteborg, Sweden) and a permanent all-ceramic restoration by a prosthodontist.
Surgical Protocol
Hard Tissue Measurements
All surgical procedures were conducted under local anesthesia. Preoperative antibiotics were given to all patients. This prophylactic dose was 500 mg Amoxicillin three times daily (20 caps) for 1 week, starting 1 day before surgery. Diagnostic evaluation of the site of placement included clinical examination, radiographic analysis using a cone-beam CT scan and occlusal analysis with study models. After informed consent was obtained from the patient, atraumatic tooth extraction using a periotome without flap elevation was performed (Figure 1B). Surgical implant
Periapical X-rays were used to measure the changes in alveolar bone height surrounding the implant from the time of placement of the temporary restoration (baseline) to the follow-up assessment, which was at least 12 months later. The parallel technique was used in order to obtain comparable X-rays, and standardization was carried out by using the known implant length to calibrate the baseline and follow-up measurements. The implant shoulder was used as a reference level from which mesial (Mbc) and distal (Dbc) lines were drawn in an apical direction to the
Vol 26 • No 5 • 332–344 • 2014
Journal of Esthetic and Restorative Dentistry
DOI 10.1111/jerd.12083
© 2013 Wiley Periodicals, Inc.
IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.
A
B
C
D
E
F
G
FIGURE 1. A, Failed tooth due to improper root canal treatment (12) before the extraction. B, Minimal traumatic tooth extraction. C, Implant placed in final position. D, E, and F, Temporary crown in place. G, A radiograph.
first point of contact between bone and the implant (Figure 2). Computer software (Image J 1.43u; National Institute of Health, Bethesda, MD, USA) was used to calculate the length of these lines (Mbc and Dbc) and express it as an absolute measurement in millimeters.
Soft Tissue Measurements The soft tissue data were collected from photographs taken with a fixed angle and zoom ratio prior to tooth extraction (baseline) and at the follow-up visit (at least 12 months later). The crown length of the tooth mesial to the implant measured from the margin of the gingiva was set as the reference length. This allowed comparisons of the changes that occurred before and after the treatment with regard to the position of the gingiva and the amount of recession. A line extending from the incisal edges of the teeth adjacent to the implant (Ocl) was the starting point for the measurements. From this line, perpendicular lines were drawn extending to the tip of the mesial (Mp) and distal (Dp) papilla, as well as the middle of the mid-buccal gingival margin (Bm) (Figure 3). The length
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12083
of these lines was calculated based on the clinical photographs using a software program (Image J 1.43u), and variations over time were calculated in millimeters.
Other Measurements Implant survival rate: defined as the percentage of implants that were present at the final follow-up. Implant success rate: defined as the percentage of symptom and pathology free implants at the final follow-up. Assessment of interdental papilla: The triangular interdental papillae occupying the space between the implant retained restoration and the adjacent teeth were assessed using Jemt’s index.15 Jemt’s Index comprises of: score 0 (no papilla present), score 1 (
