Predictable Immediate Implant Esthetics

Immediate implants are a terrific service to the patient. However, achieving ideal esthetics and 100% bone integration to the surface of the implant has been challenging. Immediate implant placement with temporization can produce ideal esthetics but the production of an esthetic temporary is time-consuming and the incidence of failure to integrate is much higher.

The following cases illustrate excellent esthetic results when an immediate implant is placed without temporization.

3 months after implant placement

When an immediate implant is placed and there is nothing in the gingiva, there is no purpose for the gingiva to remain and recession of the gingiva occurs. As seen in the image above, significant recession has occurred producing an unacceptable esthetic result.

The following cases illustrate a predictable method for achieving predictable immediate implant esthetics.

Preop

Preop radiograph

The tooth is sectioned buccal lingual and a small elevator is used to enter the cut and crack the two pieces apart. The halves are collapsed and removed. All forces are in the horizontal direction and the buccal wall is preserved.

The implant is placed, grafted with Immediate Graft, and a healing abutment is placed level with the gingival margin.

Finger pressure is used to compress the gingiva against the healing abutment and Oral Bond is applied. The hex driver slot if filled with teflon tape before bonding in order to facilitate healing abutment removal.

Day of implant placement. Arrows show grafted portion of socket.

2.5 months post op. No buccal bone resorption has occurred.

2.5 months post op. No recession has occurred.

2.5 months after placement. The bone has regenerated to the collar of the implant. The patient is referred for crown restoration.

A magnification of the implant site shows complete fill of the osseous defects. This case shows excellent bone regeneration in a 100-year-old patient. A future post will discuss the difference between the bone of young vs old patients.

Using the same technique, this case is three months after immediate implant placement. No buccal bone resorption has occurred.

No recession of the gingival margin has occurred and the patient is referred for restoration.

3 months after immediate implant placement in a young patient. When the papilla are present at extraction, the papillae are maintained during the integration phase.

No buccal bone resorption has occurred.

Immediate Implant Placement: Step by Step

The following case is a step by step process of how to achieve the new immediate implant placement.

Preop

Caries with porcelain crowns and adjacent implants complicate the extraction.

The root is sectioned buccal lingual and the roots are separated with a small elevator.

The roots are collapsed with the ability to remove the mesial portion of the root, but the distal portion was not able to be removed without damaging the socket.

A pilot drill is used to drill through the remaining root tip.

When a larger drill is used, the root is engaged and pops out of the socket. Because there is a difference in bone height between the mesial and distal walls, the bone on the mesial needs to be trimmed or the implant will be displaced to the distal. A side cutting bur is used to remove mesial bone.

The implant is placed 3 mm subgingival and the cover screw is placed.

Immediate Graft is used to graft the site. The material is frozen. Cover the graft and use a spatula to break off pieces of the graft.

The graft is delivered to the site with a #7 wax spatula or cotton pliers and placed in over the implant.

The spade end of the spatula is used to work the graft material alongside of the implant without rubbing the implant.

Sterile cotton gauze is placed over the socket and the spade end of the spatula is used to pack and dry the graft material.

Grafting complete with cover screw still in place.

Cover screw is removed.

The healing abutment is placed. Care is taken to not pick up the graft material as the healing abutment is placed.

The gingiva is compressed against the healing abutment.

Oral Bond is applied.

Case complete.

The implant is encased in graft material up to and surrounding the healing abutment. The arrows indicate the socket defect adjacent to he implant. This area was relieved with a side cutting bur in order to prevent distal displacement of the implant. The amount of implant in native bone is not important when using SteinerBio graft materials.

What are the critical factors for success of this immediate implant method and why does this method produce superior bone and esthetic results? There are two main factors one is the graft and the other is the application of Oral Bond.

For long term success, bone must form in the area of the graft and the bone must integrate to the surface of the implant. If no graft is used, the defect may appear to fill with bone, but the bone will not integrate to the implant surface. Also, if cadaver bone is used, the defect will appear to filled with bone, but again the bone will not integrate to the surface of the implant. This has been proven by a study done by Becker and Urist from USC:

Histologic findings after implantation and evaluation of different grafting materials and titanium micro screws into extraction sockets: case reports

The study found that allografts, xenografts, and autografts all failed to produce integration to the implant surface.

Most dentists don’t care because the post op radiograph looks good. However, they should care because a study of a very large patient pool found that when an immediate implant is grafted with cadaver and autografts, marginal bone loss occurs progressively over time:

The red line shows that after four years of function, immediate implants grafted with cadaver bone grafts and autografts produced progressive dramatic marginal bone loss. The chart is from a study published in the Journal of Periodontology.

Retrospective cohort study of 4,591 dental implants: Analysis of risk indicators for bone loss and prevalence of peri‐implant mucositis and peri‐implantitis.

SteinerBio graft materials are the only graft materials proven to produce integration in the grafted site. The complete resorption of the graft material producing normal bone that is integrated to the implant surface is critical to the long term success of this immediate implant methodology.

Another factor is bone graft particle size.

Immediate Graft contains pure phase beta tricalcium phosphate granules 250 to 500 microns in diameter. Particle size in an important factor in healing around immediate implants. With a particle size of 250 to 500 microns, the particles in the gingiva can migrate out of the sulcus over time. However, larger granules become lodged around the abutment producing inflammation in the gingiva and possible bone loss.

The second critical factor for this implant methodology is the use of Oral Bond. For gingiva to maintain its position and shape, it must be in contact with what it thinks is a tooth. But we all know that it is the presence of a physical object that is needed and the physical composition is not a factor. In this case, a metal healing abutment is a functional substitute for the tooth. Another critical factor is the gingiva must be in physical contact with the object and that is why it is necessary to compress the gingiva against the healing abutment before it is bonded in place. Any gaps between the healing abutment and gingiva will result in recession.

Another critical factor is the properties of Oral Bond. Many dentists are converting from Periacryl to Oral Bond because they find the tissue remains in contact longer when using Oral Bond. Why is that if they are both cyanoacrylates? True, but they are composed of different types of cyanoacrylate. Oral Bond is composed of sterile medical grade 2-octyl cyanoacrylate. Periacryl is composed of a combination of n-butyl cyanoacrylate and 2-octyl cyanoacrylate in a nonsterile formulation. While both are considered biocompatible, n-butyl cyanoacrylate continues to leach formaldehyde after setting while 2-octyl cyanoacrylate does not.

However, the main characteristic that separates the two products is that Oral Bond is flexible and Periacryl is not. The n-butyl cyanoacrylate in Periacryl produces a rigid structure and it is this difference in properties that allows Oral Bond to remain functionally attached to the gingiva for a longer period of time. The flexibility of Oral Bond allows for minor changes in the gingiva to occur without losing its bond.

Over the last two years, SteinerBio has been developing its early implant protocols. We have gone through many minor modifications to arrive at the methodology we have today. Our early implant protocols are as follows:

Immediate implants in the esthetic zone grafted with Immediate Graft with a healing abutment bonded with Oral Bond.
When immediate implants are not possible in the esthetic zone but with all walls in place, implants are placed 4 weeks post extraction.
Bicuspids: Graft with Socket Graft with implants placed 4 weeks post extraction.
Molars: Graft with Socket Graft with implant placed 6 weeks after extraction.
When socket walls are missing, graft with Socket Graft Plus and place implants in 3 months.

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American Society for Bone and Mineral Research (ASBMR)

Tissue Engineering and Regenerative Medicine International Society (TERMIS)