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2001 immediate implant

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Yinpin Wang

Various studies have examined immediate implants versus delayed implants. Immediate implants have the advantages of preserving alveolar bone and providing esthetics by maintaining tooth alignment, but risks include unfavorable implant angulation if the extracted tooth was misaligned or inadequate bone beyond the apex. Delayed implants allow primary soft tissue healing for 6-10 weeks before placement and have benefits like adequate soft tissue and minimized microorganisms, as well as highly osteogenic bone filling in of defects. Studies found high survival rates for both immediate and delayed implants, though immediate implants showed slightly deeper pockets and more membrane exposure on average.

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Various studies of implant Ö¸Œ§ÀÏŽŸ …ÇÒÝÃñátŽŸ 2001/2/4 perio-prostho seminars
Topic Immediate implant vs delayed immediate implant ( ÍõÓ¢±ó ) Wide-diameter implant vs standard-diameter implant ( ÌK¾êƒx ) Single-stage vs Two-stage ( üSÎÄ»Û ) Immediate loading vs progressive loading ( ÁÖ‚¥ì÷ )
Br ?nemark group ¨C traditional protocol recommends a 12-month healing period between tooth extraction and placement of implants. (Adell R et al 1981 Int J Oral Surg) Preserve alveolar bone concept ? immediate implant concept
Schulte(1984) Tuebinger implant Frialit-2 implant Stepped-tapered root analog
Immediate implant Advantage Preservation of the alveolar bone Esthetic (extracted tooth has a desirable alignment) ideal implant position natural scalloping and distinct papillae are easier to achieve maximal soft tissue support Fewer surgical interventions Reduction in treatment time & cost
Immediate implant Disadvantages Misalignment of the extracted tooth may lead to unfavorable angulation of the fixture Stabilization may require more bone than is available beyond the apex Localized peri-implant bone defect Primary soft tissue closure ( submerged vs transmucosal implant)
Indication for Immediate implant Root fracture Trauma not affecting the alveolar he alveolar bone Decay without purulence Endodontic failure Severe periodontal bone loss Residual root
Contraindication for Immediate implant Presence of pus Lack of bone beyond the apex or close relationship to the anatomical vital structures
Extraction site defects Residual defect morphology and the regenerative potential at the extraction sites Salama H & Salama M 1993 IJPRD
Extraction site defects Type I ¨Cideal site for immediate implant 4-/3-wall socket with minimal bone resorption (<5mm apico-coronal defect) Sufficient bone available beyond the apex Acceptable discrepancy between the fixture head & neck of the adjacent teeth Manageable gingival recession or esthetics is not essential.
Extraction site defects Type II ¨C need orthodontic extrusion Dehiscence > 5mm Substantial discrepancy between the fixture head & neck of the adjacent teeth Significant gingival recession or esthetics .
Extraction site defects Type III ¨Cnot suitable for immediate implant inadequate vertical &B-L bone dimension Recession and severe loss of labial bone Severe circumferential and angular defect
The decision to submerge should base on the following factors Plaque control Smoking Periodontal conditions The degree of stability The presence of provisional removable denture
Submerged implant Primary closure Bowers & Donahue(1988) Edel (1995) ,Chen & Dahlin(1996) Rosenquist(1997)
Rotated palatal flap for immediate implant Nemcovsky CE 2000 COIR
Transmucosal immediate implant Cochran & Douglas(1993);Br ?gger et al (1993) Schultz(1993) ;Lang(1994) Br ?gger et al (1996);H?mmerle et al (1998) Evidences emphasize the importance of infection control for a successful tx. of outcome following immediate implant of transmucosal implants
Transmucosal immediate implant Original peri-implant defect was the most critical factor relating to the final amount of bone-to-implant contact Horizontal defect dimensions of >4mm resulted in a lower bone-to ¨Cimplant contact than dimension of 1.5mm or less Wilson et al 1998 JOMI
Conclusion about immediate implants High survival rate : 93.9%-100% Implants must placed 3-5mm beyond the apex in order to gain a maximal degree of stability Implant should be as close as possible to the alveolar crest(0-3mm) Schwartz-Arad D et al 1997
Conclusion about immediate implants There is no consensus regarding about the need for gap filling and the best graft materials The use of membrane does not imply better results ¨Con the contray ,membrane exposure may carry complications The absolute need for primary closure Schwartz-Arad D et al 1997
Immediate vs non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth : A retrospective comparative study Schwartz-Arad D et al 2000 JP
Results 5-year cumulative survival rate(CSR) Immediate implant (96%) non-immediate(89.4%) Mean potential contact area(PCSA) 230mm 2 Significant differences in CSR in maxilla(96.6% vs 82.9%) Posterior Max. Immediate implant (100%) non-immediate(72%)
Conclusions Survival rates of implants placed to support full-arch ceramo-metal prosthesis can be ranked as follows : bone quality , immediate implant,PCSA Immediate implantation exerts its effect through higher PCSA values by a compensatory effect for bone quality Immediate implant does not carry additional morbidity
Delayed Immediate implant To allow primary soft tissue healing following tooth extraction for a period of 6-10 weeks ,prior to implant placement Advantages 1) adequate soft tissue 2) minimized the effect of microorganism associated with the failed tooth or wound healing (Gher 1994) 3) highly osteogentic activity
Spontaneous in situ gingival augmentation Burton Langer IJPRD 1994;14:525-535
Delayed immediate implant Alveolar bone changes during the healing period Strong tendency for the defects to fill-in in the horizontal plan and bone growth to occur in the vertical plane of the height of the cover screw . Good short-term prognosis with bone regeneration occurring around the defect without the use of barrier membranes or bone substitutes Nir-Hadar O et al (1998)
After an average follow-up of 12.4 months, peri-implant pocket depth, the gingival index, the hygienic index, and the degree of bone resorption were examined. A life-table approach (Kaplan-Meier) was applied for statistical analysis, and showed no difference between primary and secondary immediate implants . Also, none of the parameters examined demonstrated a statistically significant difference between the two groups. Mensdorff-Pouilly et al 1994 JOMI
However, compared with the groups of secondary immediate implants, the group of primary immediate implants showed a tendency towards deeper pocket formation and an increased frequency of membrane dehiscences that may be due to the poorer quality of the soft tissue covering. Mensdorff-Pouilly et al 1994 JOMI
3-year Prospective Multicenter Follow-up No clinical difference with respect to socket depth or when comparing the different placement methods. Higher failure rate was found for short implants in the posterior region of maxilla .(extracted for periodontitis) Mean marginal bone resorption : (from loading to 1yr F/U) Max.(0.8mm),mand(0.5mm) Implant survival : Max(92.4%);Mand(94.7%) Grunder U et al 1999 JOMI
Generally, primary immediate implant ¨C max. anterior secondary immediate implant ¨C mandible,posterior maxilla Mensdorff-Pouilly et al 1994 JOMI
Thanks for your attention!!
Evidence for osseointegration of immediate implant Experimental animal studies (Kohal et al 1997) Controlled human studies(Palmer et al 1994)
Evidence for osseointegration of immediate implant Root-analogue titanium implants Lundgren et al (1992) beagles dog study Kohal et al(1997) monkeys
Evidence for osseointegration of immediate implant Conventional screw- or cylinder-type implant Experimental animal studies Parr et al (1993) dog study Barzilay et al (1996) controlled monkey Similar result for immediate and late implant ( Clinical,radiography,histology)
Evidence for osseointegration of immediate implant Clinical studies Becker et al(1998) prospective clinical human trials of 47 immediate implants without bone augmentation cumulative success rate of 93% followed between 4 to 5 years
Bone augmentation in combination with immediate implant GBR-barrier membranes Experimental animal studies Dahlin(1989)¨C rabbits Becker et al (1991) ¨C barriers enhance predictability of bone fill in immediate extraction sockets when compared with a mucoperiosteal flap
Bone augmentation in combination with immediate implant GBR-barrier membranes e-PTFE membrane Lazarra(1989) Becker &Becker(1990) Nyman(1991) Hammerle(1998)
Bone augmentation in combination with immediate implant GBR-barrier membranes e-PTFE membrane Becker (1994) 49 immediate implant with e-PTFE alone --- 93.6% bone fill ,1-year functional loading success rate 93.9%
Bone augmentation in combination with immediate implant GBR-barrier membranes e-PTFE membrane Gher et al (1994 ) influence of original defect morphology on bone fill with e-PTFE at immediate implant sites Dahlin et al (1995) prospective multicenter study 2-year cumulative survival rate Max.(84.7%) mand(95%)
Bone augmentation in combination with immediate implant GBR-barrier membranes Collagen membrane( Cosci&Cosci 1997) polyglactin (balshi 1991) Polylactic acid (Lundgren 1994) Fascia lata (Callen & Rohrer 1993) Autogenous gingival grafts(Evian & Cutler 1994)
Bone augmentation in combination with immediate implant GBR-barrier membranes Zitzmann et al (1997) e-PTFE vs collagen ( deproteinized bovine bone ) no significant difference in average percentage bone fill for collagen (92%) and e-PTFE(78%) But, 44% wound dehiscence and premature membrane removal in the e-PTFE group was reported.
Barrier membrane exposure Compromised results Simion (1994) bone fill (97% vs 42%) Augthun(1995) Successful bone regeneration & complete bone filling ,but strict infection control is followed Mellonig (1993) Shanaman(1994) Rominger & Triplett (1994) 96.8%
GBR and bone grafts DFDBA ( negative ) animal study Becker (1992) dogs study Becker (1995) dogs study Kohal(1998) dogs study Clinical study Gelb(1993)
GBR and bone grafts DFDBA ( positive ) Callan (1990) Mellonig (1993) Landsberg (1994) combined with Tc Gher (1994)
GBR and bone grafts Hydroxyapatite Wachtel et al (1991) biopsies taken on 3M showed enhanced bone regeneration than non-grafted sites. Knox (1993) Novaes & Novaes (1993)
GBR and bone grafts Simion(1994) Cosci & Cosci(1997) Fugazzotto (1997) Schwartz-Arad & Chaushu(1997)
Compromised sites ¨Cinfection Pecora(1996) 32 teeth due to root fx.,perforation,endo-perio complication ,F/u 16M Rosenquist & Grenthe(1996) periodontal disease (92%) trauma,root fx.,endodontic failure (95%) Novaes(1995,1998)
Compromised sites ¨Cinfection ¡° Immediate implantation at chronically infected sites may be successful,the extent of the defect ,the implant primary stability,and esthetic consideration of future restoration must be considered.¡±
Biologically active bone-differentiating substances Cook (1995) recombinant human osteogenic protein-1(rhOP-1) Cochran et al(1997) recombinant human bone morphogenetic protein-2(rhBMP-2) Hedner & Linde(1995) membrane + BMP ? compromised blood supply
Future about biologically active bone-differentiating substances Identification of the ideal carrier substrate Dose application The effect of combination
Late implants A period of >6 months for healing of the extraction site is recommendation prior to implant placement

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2001 immediate implant

  • 1. Various studies of implant Ö¸Œ§ÀÏŽŸ …ÇÒÝÃñátŽŸ 2001/2/4 perio-prostho seminars
  • 2. Topic Immediate implant vs delayed immediate implant ( ÍõÓ¢±ó ) Wide-diameter implant vs standard-diameter implant ( ÌK¾êƒx ) Single-stage vs Two-stage ( üSÎÄ»Û ) Immediate loading vs progressive loading ( ÁÖ‚¥ì÷ )
  • 3. Br ?nemark group ¨C traditional protocol recommends a 12-month healing period between tooth extraction and placement of implants. (Adell R et al 1981 Int J Oral Surg) Preserve alveolar bone concept ? immediate implant concept
  • 4. Schulte(1984) Tuebinger implant Frialit-2 implant Stepped-tapered root analog
  • 5. Immediate implant Advantage Preservation of the alveolar bone Esthetic (extracted tooth has a desirable alignment) ideal implant position natural scalloping and distinct papillae are easier to achieve maximal soft tissue support Fewer surgical interventions Reduction in treatment time & cost
  • 6. Immediate implant Disadvantages Misalignment of the extracted tooth may lead to unfavorable angulation of the fixture Stabilization may require more bone than is available beyond the apex Localized peri-implant bone defect Primary soft tissue closure ( submerged vs transmucosal implant)
  • 7. Indication for Immediate implant Root fracture Trauma not affecting the alveolar he alveolar bone Decay without purulence Endodontic failure Severe periodontal bone loss Residual root
  • 8. Contraindication for Immediate implant Presence of pus Lack of bone beyond the apex or close relationship to the anatomical vital structures
  • 9. Extraction site defects Residual defect morphology and the regenerative potential at the extraction sites Salama H & Salama M 1993 IJPRD
  • 10. Extraction site defects Type I ¨Cideal site for immediate implant 4-/3-wall socket with minimal bone resorption (<5mm apico-coronal defect) Sufficient bone available beyond the apex Acceptable discrepancy between the fixture head & neck of the adjacent teeth Manageable gingival recession or esthetics is not essential.
  • 11. Extraction site defects Type II ¨C need orthodontic extrusion Dehiscence > 5mm Substantial discrepancy between the fixture head & neck of the adjacent teeth Significant gingival recession or esthetics .
  • 12. Extraction site defects Type III ¨Cnot suitable for immediate implant inadequate vertical &B-L bone dimension Recession and severe loss of labial bone Severe circumferential and angular defect
  • 13. The decision to submerge should base on the following factors Plaque control Smoking Periodontal conditions The degree of stability The presence of provisional removable denture
  • 14. Submerged implant Primary closure Bowers & Donahue(1988) Edel (1995) ,Chen & Dahlin(1996) Rosenquist(1997)
  • 15. Rotated palatal flap for immediate implant Nemcovsky CE 2000 COIR
  • 16. Transmucosal immediate implant Cochran & Douglas(1993);Br ?gger et al (1993) Schultz(1993) ;Lang(1994) Br ?gger et al (1996);H?mmerle et al (1998) Evidences emphasize the importance of infection control for a successful tx. of outcome following immediate implant of transmucosal implants
  • 17. Transmucosal immediate implant Original peri-implant defect was the most critical factor relating to the final amount of bone-to-implant contact Horizontal defect dimensions of >4mm resulted in a lower bone-to ¨Cimplant contact than dimension of 1.5mm or less Wilson et al 1998 JOMI
  • 18. Conclusion about immediate implants High survival rate : 93.9%-100% Implants must placed 3-5mm beyond the apex in order to gain a maximal degree of stability Implant should be as close as possible to the alveolar crest(0-3mm) Schwartz-Arad D et al 1997
  • 19. Conclusion about immediate implants There is no consensus regarding about the need for gap filling and the best graft materials The use of membrane does not imply better results ¨Con the contray ,membrane exposure may carry complications The absolute need for primary closure Schwartz-Arad D et al 1997
  • 20. Immediate vs non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth : A retrospective comparative study Schwartz-Arad D et al 2000 JP
  • 21. Results 5-year cumulative survival rate(CSR) Immediate implant (96%) non-immediate(89.4%) Mean potential contact area(PCSA) 230mm 2 Significant differences in CSR in maxilla(96.6% vs 82.9%) Posterior Max. Immediate implant (100%) non-immediate(72%)
  • 22. Conclusions Survival rates of implants placed to support full-arch ceramo-metal prosthesis can be ranked as follows : bone quality , immediate implant,PCSA Immediate implantation exerts its effect through higher PCSA values by a compensatory effect for bone quality Immediate implant does not carry additional morbidity
  • 23. Delayed Immediate implant To allow primary soft tissue healing following tooth extraction for a period of 6-10 weeks ,prior to implant placement Advantages 1) adequate soft tissue 2) minimized the effect of microorganism associated with the failed tooth or wound healing (Gher 1994) 3) highly osteogentic activity
  • 24. Spontaneous in situ gingival augmentation Burton Langer IJPRD 1994;14:525-535
  • 25. Delayed immediate implant Alveolar bone changes during the healing period Strong tendency for the defects to fill-in in the horizontal plan and bone growth to occur in the vertical plane of the height of the cover screw . Good short-term prognosis with bone regeneration occurring around the defect without the use of barrier membranes or bone substitutes Nir-Hadar O et al (1998)
  • 26. After an average follow-up of 12.4 months, peri-implant pocket depth, the gingival index, the hygienic index, and the degree of bone resorption were examined. A life-table approach (Kaplan-Meier) was applied for statistical analysis, and showed no difference between primary and secondary immediate implants . Also, none of the parameters examined demonstrated a statistically significant difference between the two groups. Mensdorff-Pouilly et al 1994 JOMI
  • 27. However, compared with the groups of secondary immediate implants, the group of primary immediate implants showed a tendency towards deeper pocket formation and an increased frequency of membrane dehiscences that may be due to the poorer quality of the soft tissue covering. Mensdorff-Pouilly et al 1994 JOMI
  • 28. 3-year Prospective Multicenter Follow-up No clinical difference with respect to socket depth or when comparing the different placement methods. Higher failure rate was found for short implants in the posterior region of maxilla .(extracted for periodontitis) Mean marginal bone resorption : (from loading to 1yr F/U) Max.(0.8mm),mand(0.5mm) Implant survival : Max(92.4%);Mand(94.7%) Grunder U et al 1999 JOMI
  • 29. Generally, primary immediate implant ¨C max. anterior secondary immediate implant ¨C mandible,posterior maxilla Mensdorff-Pouilly et al 1994 JOMI
  • 30. Thanks for your attention!!
  • 31. Evidence for osseointegration of immediate implant Experimental animal studies (Kohal et al 1997) Controlled human studies(Palmer et al 1994)
  • 32. Evidence for osseointegration of immediate implant Root-analogue titanium implants Lundgren et al (1992) beagles dog study Kohal et al(1997) monkeys
  • 33. Evidence for osseointegration of immediate implant Conventional screw- or cylinder-type implant Experimental animal studies Parr et al (1993) dog study Barzilay et al (1996) controlled monkey Similar result for immediate and late implant ( Clinical,radiography,histology)
  • 34. Evidence for osseointegration of immediate implant Clinical studies Becker et al(1998) prospective clinical human trials of 47 immediate implants without bone augmentation cumulative success rate of 93% followed between 4 to 5 years
  • 35. Bone augmentation in combination with immediate implant GBR-barrier membranes Experimental animal studies Dahlin(1989)¨C rabbits Becker et al (1991) ¨C barriers enhance predictability of bone fill in immediate extraction sockets when compared with a mucoperiosteal flap
  • 36. Bone augmentation in combination with immediate implant GBR-barrier membranes e-PTFE membrane Lazarra(1989) Becker &Becker(1990) Nyman(1991) Hammerle(1998)
  • 37. Bone augmentation in combination with immediate implant GBR-barrier membranes e-PTFE membrane Becker (1994) 49 immediate implant with e-PTFE alone --- 93.6% bone fill ,1-year functional loading success rate 93.9%
  • 38. Bone augmentation in combination with immediate implant GBR-barrier membranes e-PTFE membrane Gher et al (1994 ) influence of original defect morphology on bone fill with e-PTFE at immediate implant sites Dahlin et al (1995) prospective multicenter study 2-year cumulative survival rate Max.(84.7%) mand(95%)
  • 39. Bone augmentation in combination with immediate implant GBR-barrier membranes Collagen membrane( Cosci&Cosci 1997) polyglactin (balshi 1991) Polylactic acid (Lundgren 1994) Fascia lata (Callen & Rohrer 1993) Autogenous gingival grafts(Evian & Cutler 1994)
  • 40. Bone augmentation in combination with immediate implant GBR-barrier membranes Zitzmann et al (1997) e-PTFE vs collagen ( deproteinized bovine bone ) no significant difference in average percentage bone fill for collagen (92%) and e-PTFE(78%) But, 44% wound dehiscence and premature membrane removal in the e-PTFE group was reported.
  • 41. Barrier membrane exposure Compromised results Simion (1994) bone fill (97% vs 42%) Augthun(1995) Successful bone regeneration & complete bone filling ,but strict infection control is followed Mellonig (1993) Shanaman(1994) Rominger & Triplett (1994) 96.8%
  • 42. GBR and bone grafts DFDBA ( negative ) animal study Becker (1992) dogs study Becker (1995) dogs study Kohal(1998) dogs study Clinical study Gelb(1993)
  • 43. GBR and bone grafts DFDBA ( positive ) Callan (1990) Mellonig (1993) Landsberg (1994) combined with Tc Gher (1994)
  • 44. GBR and bone grafts Hydroxyapatite Wachtel et al (1991) biopsies taken on 3M showed enhanced bone regeneration than non-grafted sites. Knox (1993) Novaes & Novaes (1993)
  • 45. GBR and bone grafts Simion(1994) Cosci & Cosci(1997) Fugazzotto (1997) Schwartz-Arad & Chaushu(1997)
  • 46. Compromised sites ¨Cinfection Pecora(1996) 32 teeth due to root fx.,perforation,endo-perio complication ,F/u 16M Rosenquist & Grenthe(1996) periodontal disease (92%) trauma,root fx.,endodontic failure (95%) Novaes(1995,1998)
  • 47. Compromised sites ¨Cinfection ¡° Immediate implantation at chronically infected sites may be successful,the extent of the defect ,the implant primary stability,and esthetic consideration of future restoration must be considered.¡±
  • 48. Biologically active bone-differentiating substances Cook (1995) recombinant human osteogenic protein-1(rhOP-1) Cochran et al(1997) recombinant human bone morphogenetic protein-2(rhBMP-2) Hedner & Linde(1995) membrane + BMP ? compromised blood supply
  • 49. Future about biologically active bone-differentiating substances Identification of the ideal carrier substrate Dose application The effect of combination
  • 50. Late implants A period of >6 months for healing of the extraction site is recommendation prior to implant placement