Recently we presented an immediate implant case outlining what we feel is a predictable, efficient method for achieving a high success rate and excellent esthetics. Rather than cherry picking a beautiful and completed case, we have chosen to present this method as the therapy progresses so you can see what you can expect on a regular basis. Here we are reporting on the immediate implant case as it progresses through the integration period, but we are adding an early implant case for comparison.
The primary purpose of these case studies is to follow the changes in the gingiva when comparing the SteinerBio immediate implant protocol to the SteinerBio early implant protocol. However, we will also discuss why we decided on an immediate implant or an early implant in the two cases.
Immediate vs Early Implant
#7 was determined to be unrestorable and treated with immediate implant protocol. In this case, the immediate implant protocol was chosen because the entire socket was intact. (See how the surgery was performed: Perfecting Immediate Implants)
#7 planned immediate implant. The loss of the clinical crown has resulted in loss of the interdental papilla but the gingival margin has been maintained.
#7 day of extraction and immediate implant placement. Oral Bond is used to bond the gingiva to the healing abutment.
Early implant case presentation of tooth #10
This case was treated with our early implant protocol. This tooth presented with two roots, a furcation defect, and a lateral periodontal abscess. The tooth was extracted and grafted with Socket Graft Injectable. A dense PTFE membrane was used to cover the graft material. No sutures were used in this case or the previous case for tooth # 7. Oral Bond was used to seal and cover the membrane. The early implant protocol was used in this case because of the bone defect between 9 and 10 might prevent complete bone fill in this area with an immediate implant.
(see early implant protocol: Early Implant Protocol)
The goal of any implant method is to produce 100% bone to implant integration with normal bone that will last the life of the patient. Because there is something mineralized on the radiograph does not ensure that the tissue is normal bone and does not ensure it is integrated to the implant. If what you see on a radiograph is anything other than normal bone integrated to the implant surface, the health of the tissue and the longevity of the implant is in doubt.
The ability to produce normal bone integrated to the implant surface requires the presence of osteoblasts or the regenerative cells that produce osteoblasts. The vast majority of these cells are located in the apical area of the alveolar ridge where a large amount of cancellous bone exists. Comparatively, there are very few osteoblasts or regenerative cells found in the narrow bony septum that separate teeth.
In an extraction socket, the vast majority of bone formation is produced by cells that migrate from the apical region of the socket and this is the reason that the last area to mineralize in an extraction socket is the center of the alveolar crest.
The problem with immediate implants is that with the implant in place, the vast majority of bone forming cells are blocked from mineralizing the crest, which can result in bony defects around the coronal area of the implant. The only way to know if you have produced normal bone around an immediate implant is to use a resorbable synthetic.
As the graft material is resorbed, and if normal bone fills the grafted site, it will be evident on the radiograph. As the graft material is resorbed, and if bone formation does not occur, a radiographic defect will be evident on the radiograph. You should know how long it takes to resorb the synthetic graft material you are using so you can understand when the graft material is gone and bone has formed. Cadaver bone graft granules are never fully resorbed and do not produce integration; however, they produce great looking radiographs, but do not support the implant.
Is a bone graft successful if it fills the defect but does not integrate?
As long as the graft is in place and no pathogens are present, this is definitely an improvement over no grafting, but these grafts have been shown to breakdown over time. This is a long and wordy explanation as to why we chose an immediate implant for #7 and an early implant for tooth #10.
Tooth #7 had an intact socket. The defects around the immediate implant should be able to acquire the needed regenerative cells from the adjacent bony septum to resorb the graft material and fill the defect with normal bone.
For #10, however, due to the furcation involvement on the second root and periodontal abscess, it is questionable whether it would have enough regenerative cells to fill the defect and integrate to an immediate implant.
A benefit of the early implant technique is that after one month, regenerative cells migrate into the coronal portion of the socket. When the implant is placed, it is surrounded by bone regenerative cells that can fill a coronal defect.
Let’s now review the early implant case for tooth #10.
4-weeks after extraction (buccal view)
The membrane will be removed during this visit. The yellow staining is residual Oral Bond after using the sutureless membrane technique.
Crestal view
4-weeks after extraction and day of membrane removal. The membrane is removed with cotton pliers. The implant is placed with the top of a 3.5 mm healing abutment flush with the gingival margin.
The implant is placed 4 weeks after extraction when the membrane is removed. The defect at the mesial coronal margin of the implant where the second root was located has mineralized. At this time, the majority of graft material is resorbed.
Now let’s compare the two cases at 6 weeks after implant placement.
At 6 weeks after placement, the immediate implant on #7 has not lost any gingival height as the healing abutment is still level with the gingival margin.
The radiograph of # 7 immediate implant at 6 weeks shows good mineralization with the appearance of some remaining βTCP particles mesial to the healing abutment.
Tooth #10, 6 weeks after implant placement.
This crestal view shows the lasting gingival enlargement that results from the gingival regeneration that is produced with the early implant protocol.
Tooth #10
Early implant placement buccal view shows the production of gingival tissue at the gingival crest. The early implant protocol results in more gingiva than was present at the time of extraction.
Tooth #10
6 weeks after implant placement using the early implant protocol. The early implant protocol was introduced over two years ago and has undergone regular evaluations and periodic improvements. One significant improvement to the protocol is filling the osteotomy with BioDensification prior to implant placement.
In previous cases, we found that occasionally there would be minor areas at the coronal portion of the implant that would not appear to be integrated. This was determined to be a result of tissue damage in the area of the crest during the drilling process when creating the osteotomy. Going off center of the osteotomy is what causes the damage to the surrounding tissues. We solved this problem by injecting BioDensification into the osteotomy prior to implant placement, which acts as a bride for osteoblasts in the coronal region, resulting in excellent integration found in this radiograph.
A closer look at #10 shows complete coverage of the implant surface and maintenance of the bone along side #9 and #11, providing support for the interdental papilla.
- At 6 weeks after immediate implant placement, there is no recession noted on #7.
- At 6 weeks after early implant placement, #10 shows the gingiva has regenerated with additional gingiva formed throughout the crestal area.
#7 using immediate implant protocol
#10 using early implant protocol
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