Immediate verse delayed/ laser dentistry courses in india

Immediate implantsImmediate implants
VsVs
Delayed implantsDelayed implants
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

• Contents
Introduction
Terminologies
Conventional implants
- two stage
- one stage
- flapless(direct)
Factors to be considered when implant is placed in
esthetic zone

Immediate implants
- indication
-Contraindication
-Clinical requirements
-Protocols for implant placement in extraction
sockets
-guidelines for extraction when planning for
immediate implants

-Advantages and disadvantages of immediate
implants
-Note on implant loading
-Summary
-conclusion
-References

• Introduction
 Traditional implant surgical protocols advocated
complete healing and maturation of bone.
 However , the resorption of bone over the
extended period of time led to insufficient bone for
routine implant placement.
 Therefore Protocols have been developed in
which implant are placed at the time of extraction
of tooth ,before significant resorption occurs.www.indiandentalacademy.com

Terminologies

• Two stage – Implant heals under the soft tissue
and is , after a healing period ,accessed through
a second stage surgery.
• One stage - The implant heals without
protection of the oral mucosa and is accessible
through the mucosa during healing.

• Immediate implants – placement of implants into
fresh extraction sites.
• Early placement - implant placement 2-6 weeks
following tooth extraction

• CONVENTIONAL OR DELAYED IMPLANTS
PLACEMENT

• Reflects the flap directly observes the bone
Two stage surgery

• Osteotomy is prepared
- 2mm end cutting
starter
- linderman bur
- 2mm pilot drills

• - sequential drills 2.5,3,3.2
- side cutting crestal bone drill
- bone tap

• Implant is inserted at or slightly below the crest of
bone
• slow speed high torque handpiece is usually used
to thread the implant into the bone at 30 rpm or
less

• low profile cover screw is then inserted

• tissue are then approximated over implant for
primary closure

• Healing period is about 4-6 months and longer on
D4 bone and Grafted areas.
• Technique requires a second stage surgery to
uncover the implant body

• Advantages of the two stage surgery
• observation of crestal bone before osteotomy
• observation during osteotomy preparation
• Ability to bone graft the site at the time of implant
placement
• Implant body healed at or below the crest of bone
• Bacterial infiltration are not critical during healing

 one stage surgery uses a similar incision and
reflection technique to observe crestal bone
One stage surgery

• At the conclusion of implant surgery Permucosal
healing abutment is placed into the implant .

 Implant is also placed slightly above the crest of
the bone
 Soft tissue is then sutured around the PME

• Advantages one stage surgery
• Soft tissue matures while bone interface is healing
• Surgical appointment is reduced
• Higher location of implant abutment connection
may reduce some of the early crestal bone loss
• Higher profile implant body also allows the
prosthetic abutment with greater ease

Modification of one stage surgery
Doesn’t reflect the crestal soft tissue
Direct(flapless) one stage surgery

• Core of keratinized tissue( size of the implant
crest modules diameter) is removed over the
crestal bone

Implant osteotomy is performed in the centre of the
core exposed bone
Technique doesn’t require sutures
Advantages of flapless surgery
Less soft tissue trauma coz tissue are not reflected

• Disadvantages of flapless surgery
• Inability to assess the bone volume before or
during implant osteotomy or insertion
• Only be used when the bone width is abundant
• (>6-8mm)

• Factors to be considered when implant
is placed in esthetic zone

 When an implant is placed in esthetic zone
 The site must be thoroughly evaluated
 Garber has proposed a classification for such site

 Vertical and horizontal level of both soft tissue
and bone
implant placement is a straight forward
 Thin gingival biotype soft tissue
augmentation
Garber class I

 Normal vertical bone and slight horizontal bone
deficiency about 1 to 2 mm
 Expanded using serial osteotomes instead of drilling
( described by summers)
 slight expansion of bony ridge horizontally
Garber class II

• No vertical bone loss and horizontal bone loss
greater than class II
• Implant placement can be attempted
• Initial stability is achieved
• GBR is necessary
Garber class III

• No vertical bone loss but significant horizontal
bone loss
• staged approach is necessary
• Implant is placed after suitable healing period
• Block bone graft or GBR technique
Garber class IV

 Extensive apicocoronal bone loss

Garber class V

• PRINCIPLES OF IMPLANT BODY POSITION-

• Vertical positioning
• Midcrestal positioning of the edentulous site
• 2-3 mm below the facial CEJ of the adjacent
teeth

• Mesiodistal position
• Implant should be at least 1.5-2 mm from an
adjacent tooth and 3 mm to adjacent implants.

• Labiopalatal positioning
• Should be 2mm greater than the implant diameter
• The crestal bone should be 1.5 mm on labial
aspect
• 0.5mm on palatal aspect .

• Implant angulation

• Facial implant body angulation
• An implant is in the position of natural root of the
tooth
• It places the implant too facial and angled
abutment is usually necessary.

• Incisal edge of the final restoration
Centre of the implant is located directly under the
incisal edge of the crown
Straight abutment for cement retention emerges
directly below the incisal edge
Decreases the crestal stresses
to the bone .

• Cingulum Implant body angulation
• Emerges under the cingulum of the crown
• Indicated for screw retained crown
• Facial projection of the crown ,facing away from
the implant body.
• Facial ridge lab must extend 2 to 3mm.

Immediate
implants

Certain clinical requirement for immediate
implants

• Implant placement immediately following tooth
extraction
• Part of same surgical procedure
• Advantages
• Reduced no of surgery
• Reduced overall treatment time
• Optimal availability of existing bone
Type 1

• Disadvantages
• Site morphology
• Thin tissue biotype
• Lack of keratinized mucosa
• Technique sensitivity
International journal of oral and maxillofacial implant 2004 .19

 Complete soft tissue coverage of the sockets
(typically 4-8 weeks)
• Advantages
• Increased soft tissue area and volume
• Resolution of local pathology
Type 2

• Disadvantages
• Varying amount of resorption
• Increased treatment time
• Adjunctive surgical procedure

Substantial clinical or radiographic bone fill of the
socket.(typically 12 – 16 weeks)
Advantages
• Bone fill facilitates implant placement
• Mature soft tissue facilitates flap management
Disadvantages
• Same as type 2
Type 3

• Healed site ( typically >16 weeks )
Advantages
• Healed ridges
• Matured soft tissue
• Facilitates flap management
Type 4

• Histology and clinical trials
Most reports on immediate implants placement
describe small peri-implant osseous defects
resulting in a gap.
Horizontal defect dimension or jumping distance
(DCNA 2006 50 )www.indiandentalacademy.com

These small defects heal with bone fill
Defect less than 2mm in width , no augmentation
or membrane is required
Dehiscence or fenestration defects required bone
grafting and barrier membrane
(DCNA 2006 50 )

• Guideline for extraction when planning for
immediate implant placement
Preoperative evaluation
Antibiotic therapy initiation
Preservation of bony receptor site
Procedural delays
Avoidance of excessive pressure

Osteotomy preparation
Improvements of placement
 bone graft
Soft tissues closure
Successful osseointegration

Thoroughly evaluated
Acute situation may not allow for preliminary
evaluation
Any sign of potential acute infection
Antibiotic therapy should be initiated before
surgery
Preoperative evaluation
Antibiotic therapy initiation

 Use periotome for removal of teeth in atraumatic
manner
Preservation of bony receptor site

 If any purulent is discovered after removing the
tooth
 placement of the implant should be delayed
 Affected area should be irrigated and closed .
 Tissue is then allowed to heal for several weeks
until soft tissue closure is complete .
Procedural delays

 Socket consists of thin, dense layer of cortical
bone.
 During socket preparation care must be taken not
to create any force or pressure
Avoidance of excessive pressure

• In maxilla palatal wall is thicker than the buccal
wall
• denser palatal bone will cause the drill to forced
to the labial
• Bone resorption ,leading to failure

 The best position of implant is under incisal edge
 This doesn’t coincide with root apex position
Osteotomy preparation

 Once correct position is confirmed
 Standard drilling procedures are performed
2mm twist drills prepare the osteotomy to the
opposing landmark side cutting drills

The osteotomy is kept in an angulation aligned
with the incisal edge of the adjacent teeth

 incremental drills prepare to the final length and
diameter
 .

 Bone tap is used
to its final depth
 Implant is threaded into position using slow
speed, high torque handpiece.

 Bone cell will damaged if temp is raised in the
bone to 47 degree for more than 1 mins.
 Careful cooling with copious sterile saline
 Use of sharp drills
 Control of the cutting speed

 Implant should be seated two third in the host
bone.
 The apex should be 1mm or 2mm longer than
tooth being replaced
 Implant diameter at the cervical area should be
wide as possible to prevent soft tissue ingrowths.
 Totally immobilized .
Improvements of placement

 The gap between the osseous walls of the socket
and the implant fixtures is filled with the bone
grafting materials
 bone graft

Complete soft tissue closure on top of implants
might present for the overall success of dental
implants therapy( Lekholm et al. 1993)
Protect bone grafting materials from the oral
environment
Prevent the migration of epithelial tissue along the
socket wall
Soft tissues closure

 Successful osseointegration can be increased by
a stress free nonfunctional healing period
 Successful osseointegration

Advantages

disadvantages

• Esthetic outcome of immediate implant
bone resorption during the first six months post
extraction esthetic defect
IMP allows maintenance of gingival form
• facilitates peri-implant gingival tissue esthetic
{ Douglass and Merin (2002)}

Achieving esthetic success is suggested to be
dependent on ideal 3 dimensional implant position
(Buser et al 2004)
Maintenance of adequate buccal bone over the
implant surface ( Grunder et al 2005)

• NOTE ON IMPLANT LOADING
 Immediate occlusal loading protocols- is an
implant supported temporary or definitive
restoration in occlusal contact within 2 weeks of
the implant insertion .
 Early occlusal loading – refers to an implant
supported restoration in occlusion between 2
weeks and 3 months after implant placement.

• Delayed or staged occlusal loading – refers to an
implant prosthesis with an occlusal load after
more than 3 months after implant insertion .
• Nonfunctional immediate restoration- an implant
prosthesis with no direct occlusal load within 2
weeks of implant insertion.
• Nonfunctional early restoration – a restoration
delivered between 2 weeks and 3 months after
implant insertion.www.indiandentalacademy.com

SUMMARY

immediate VS conventional
Indication
Alignment
esthetic
Surgery session
Soft tissue n bone

• Immediate conventional
Psychological
Cost
Bacterial infiltration

CONCLUSION
• Although each of the 2 modalities has its own pros
and cons , the ultimate choice depends upon the
patients local and systemic condition and proper
diagnosis and treatment planning by the dentist .

REFERECES
Contemporary implant dentistry – Carl E.
Misch , 2nd
and 3rd
edition.
Dental implants art and science – Charles A
Babbush.
Implants in clinical dentistry – Martin Dunitz
Oral implantology – Kakar
Fundamental of esthetic implant dentistry

DCNA 2006 ,50,375-389
BDJ 2006 , VOL 201 NO 4

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Immediate verse delayed/ laser dentistry courses in india

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