Immediate Results by Dr. Emil M. Verban Jr.

Categories: Implant Dentistry;
Immediate Results 

Immediate implant placement poses challenges, particularly in the anterior


by Dr. Emil M. Verban Jr.


Over the past 20 years, implant dentistry has progressed faster than many other disciplines in dentistry. The success of implant dentistry is no longer judged by osseointegration of the implant but also by aesthetics when the patient smiles.

In the U.S., more than 150 million people are missing at least one tooth, yet slightly more than 1 million are treated each year (corresponding to 2.5 million implants). From the patient’s point of view, treatment should be done as quickly as possible with the least amount of pain and the least amount of cost, providing an excellent outcome. One way to reduce the time between tooth extraction and implant placement is with immediate placement. Some studies suggest that if the socket is thoroughly cleaned and still bleeding, the healing capacity of the socket provides an improved opportunity for osseointegration.

In the anterior maxilla, implant therapy requires comprehensive preoperative planning and precise surgical execution. Patient selection is essential, and high-risk patients identified through site analysis should be undertaken with caution. With immediate placement, there can be an unpredictable positioning of hard- and soft-tissue margins, so the clinician must have technical skills and experience to manage any unlikely complications.


Immediate anterior placement
Immediate anterior placement is not simple and straightforward; success depends on treatment planning, evaluation of imaging and the ability of the surgeon. Figs. 1–3 show an example of an aesthetic failure. (Fortunately for this patient, the smile line gives some protection.) Patients need to understand that implants in the aesthetic zone require more time and extra steps to make the restoration lifelike and create the illusion of reality.

Immediate Implant Results
Fig. 1
Immediate Implant Results
Fig. 2
Immediate Implant Results
Fig. 3


The rationale for immediate implant placement includes:
  • Reduced total treatment time.
  • Preservation of hard- and soft-tissue architecture.
  • Optimal soft-tissue outcomes.
  • Reduced costs for patient and clinician.
  • Fewer appointments.
Implant placement in a correct three- dimensional position is one of the keys to an aesthetic outcome, regardless of the implant system used (Figs. 4–6). The “3D position” refers to the buccolingual, mesiodistal and apicocoronol axes.

Immediate Implant Results
Fig. 4
Immediate Implant Results
Fig. 5
Immediate Implant Results
Fig. 6


Selecting the correct implant relative to the mesiodistal dimensions of the tooth to be replaced is also critical. An interproximal distance of at least 1–1.5 mm should be between the implant and the periodontal attachment of the adjacent tooth. The orofacial position of the implant shoulder should be located 1.5–2 mm palatal of the point of emergence of the future implant crown, and the coronoapical positon of the implant platform should be 3 mm apical to the future crown margin.

Prosthetically driven implant placement allows for the natural emergence with proper support of the surrounding gingiva. For immediate placement, a minimum distance of 2 mm between the implant platform and the inner surface of the facial socket wall should be present. To compensate for postextraction resorption, a bone graft to fill the space should be used. Placing implants too far labially often contributes to a higher incidence of hard- and soft-tissue recession.

Adhering to the guidelines of three-dimensional placement will provide the foundation for long-term success. Minimally invasive procedures without flap elevation make it difficult to visualize the bone, but have the advantages of less scarring and bone loss with no sutures. Here are a few examples of flapless cases:
  • In 2007, the patient shown in Figs. 7–12 had #8 extracted and immediate placement of a Straumann tissue-level implant and an immediate provisional. In 2023, a 16-year follow-up photo and X-rays (Figs. 13–15) demonstrate the continued illusion of reality.
    Immediate Implant Results
    Fig. 7
    Immediate Implant Results
    Fig. 8
    Immediate Implant Results
    Fig. 9
    Immediate Implant Results
    Fig. 10
    Immediate Implant Results
    Fig. 11
    Immediate Implant Results
    Fig. 12
    Immediate Implant Results
    Fig. 13
    Immediate Implant Results
    Fig. 14
    Immediate Implant Results
    Fig. 15
  • The patient in Figs. 16–20 presented in 2003 with endo post cores and a fracture of #8. Extraction and immediate placement of #8 with immediate provisional was performed, following the guidelines of 3D placement. Ten years later, #9 fractured, followed with immediate implant placement (Figs. 21–28). There was a difference in abutment fabrication for each site: A stock abutment was used in #8, while a custom abutment was used in #9. This demonstrates that with proper 3D placement, there can be many ways to restore a case. The 20-year follow-up images (Figs. 29–32) show the 3D placement was good in that the peak of bone was preserved between the implants, but I overlooked the distance from the peak of bone to the contact of the teeth. The contact of the teeth was greater than 5 mm. (Notice the black triangle and lack of papilla fill.)
    Immediate Implant Results
    Fig. 16
    Immediate Implant Results
    Fig. 17
    Immediate Implant Results
    Fig. 18
    Immediate Implant Results
    Fig. 19
    Immediate Implant Results
    Fig. 20
    Immediate Implant Results
    Fig. 21
    Immediate Implant Results
    Fig. 22
    Immediate Implant Results
    Fig. 23
    Immediate Implant Results
    Fig. 24
    Immediate Implant Results
    Fig. 25
    Immediate Implant Results
    Fig. 26
    Immediate Implant Results
    Fig. 27
    Immediate Implant Results
    Fig. 28
    Immediate Implant Results
    Fig. 29
    Immediate Implant Results
    Fig. 30
    Immediate Implant Results
    Fig. 31
    Immediate Implant Results
    Fig. 32

Challenges and approaches
For me, the challenge of immediate placement in the anterior is because of bone anatomy. A CBCT image should always be taken to assess bone availability and the palatal angulation. With the development of the angled screw channel, it is now possible to fabricate a screw-retained crown in almost all cases (Figs. 33–36). The palatal bone wall should be prepared to place the implant 2–3 mm away from the facial wall, creating a gap for grafting. Burs tend to skip on the palatal, making it difficult to control the osteotomy, but a 2 mm round bur can be used to create a flat area in the socket, while other burs are used to prepare the bone accurately (Figs. 37–39).
Immediate Implant Results
Fig. 33
Immediate Implant Results
Fig. 34
Immediate Implant Results
Fig. 35
Immediate Implant Results
Fig. 36
Immediate Implant Results
Fig. 37
Immediate Implant Results
Fig. 38
Immediate Implant Results
Fig. 39

Another technique is to use a lance pilot, angled as the bur is started, then correcting the angulation as the bur is advanced (Figs. 40–42). There is a tendency for the implant to drift to the buccal during placement; to compensate for this, the change in positioning the osteotomy should be slightly palatal.
Immediate Implant Results
Fig. 40
Immediate Implant Results
Fig. 41
Immediate Implant Results
Fig. 42

After implant placement, the use of immediate provisional restorations aids in developing and contouring periimplant tissue. There can be a higher risk of implant failure because of lack of patient cooperation, and after experiencing some failures, I now rarely use immediate provisionals with single-implant placements. Instead, custom healing abutments greatly aid in tissue development and reduce the risk of implant failure (Figs. 43–45).
Immediate Implant Results
Fig. 43
Immediate Implant Results
Fig. 44
Immediate Implant Results
Fig. 45

After integration, the custom healing abutment can be replaced to further develop the emergence profile (Figs. 46 and 47). Screw-retained provisionals are preferred, because they allow removal and changes to be made in contour to control the gingival zeniths. The provisional can be made directly in the patient’s mouth or indirectly in the laboratory. (The disadvantage of laboratory fabrication is that another clinical session is necessary to deliver the restoration.)
Immediate Implant Results
Fig. 46
Immediate Implant Results
Fig. 47

The contour of the provisional will influence the soft-tissue support. Tissue compression can increase the length of the crown, and reduction of contour can allow the tissue to move coronally to make the crown shorter. An example of changing contour is shown in Fig. 48: Initial placement of the provisional with excessive contour created a long tooth. Changing the subgingival contour allowed a coronal movement of the gingival zenith and a more aesthetic result (Fig. 49). It is critical to transfer the subgingival space to the laboratory for fabrication of the abutment and crown. Fabrication of a custom impression coping will allow the transfer of the emergence profile space (Fig. 50).
Immediate Implant Results
Fig. 48
Immediate Implant Results
Fig. 49
Immediate Implant Results
Fig. 50


Posterior approach
The recipe for success in the posterior is the same as the anterior. The patient in Figs. 51–62 presented with a failed endo treatment and was treated with extraction, curettage, implant placement following 3D principles, grafted membrane tissue and a custom abutment. The result was optimal, with a reduction in the number of appointments.
Immediate Implant Results
Fig. 51
Immediate Implant Results
Fig. 52
Immediate Implant Results
Fig. 53
Immediate Implant Results
Fig. 54
Immediate Implant Results
Fig. 55
Immediate Implant Results
Fig. 56
Immediate Implant Results
Fig. 57
Immediate Implant Results
Fig. 58
Immediate Implant Results
Fig. 59
Immediate Implant Results
Fig. 60
Immediate Implant Results
Fig. 61
Immediate Implant Results
Fig. 62


In summary, the surgery sequence for immediate placement must follow certain principles:
  • Perform minimally invasive extraction.
  • Perform socket curettage and irrigation.
  • Prepare the lingual wall of socket with round bur or lance bur.
  • Leave a labial gap of 2–3 mm in an intact socket and 3-4 mm in defective sockets.
  • Use custom healing abutments and custom impression copings.
I hope this has been educational and informative!

Author Bio
Dr. Emil M. Verban Jr. Dr. Emil M. Verban Jr. earned his DDS from Loyola University School of Dentistry. He practices general dentistry full time in Bloomington, Illinois, with a special interest in cosmetic and implant dentistry. Verban is a nationally recognized leader, lecturer and educator in implant dentistry, and has developed and patented surgical products that increase safety and precision for implant surgery. He is a member of the American Dental Association, the Academy of General Dentistry, the International Team of Implantology and the American Academy of Implant Dentistry.


Sponsors
Townie Perks
Townie® Poll
Do you show patients images during or after treatment/consultation?

  
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2024 Dentaltown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450