Deciding Between Immediate Versus Delayed Implant Placement
Q: For failing central incisors, how do you decide on extraction sequencing and immediate vs. delayed implant placement?
A: Dr. Bakeman
Deciding between immediate versus delayed implant placement hinges on establishing whether ideal peri-implant tissue architecture currently exists and can be maintained or whether tissue deficiency indicates a need to first optimize tissue architecture.
Approaches that aim to preserve favorable tissue architecture and prevent tissue collapse include atraumatic extraction, immediate implant placement, flapless surgical approaches, and immediate support of facial and interproximal architecture. Grafting thin gingival biotypes, which are prone to recession, at the time of implant placement helps in preserving existing architecture. Injectable fillers show promise in helping to further preserve the contours of the interdental papillae during the transitional phases of reconstruction. Neither implant size nor position should encroach on the buccal or interproximal osseous architecture, as encroachment can lead to bone loss and subsequent soft-tissue loss. Exaggerated prosthetic contours must also be avoided, as they can negatively impact soft-tissue contours.
The loss of two or more adjacent teeth poses increased challenges in preserving osseous and tissue architecture. Use of an alternative approach to extraction, implant placement, and reconstruction that avoids simultaneous extraction of adjacent teeth can provide greater control. With such an approach, tooth extraction, implant placement, and provisionalization are completed on one site prior to proceeding with similar procedures on an adjacent site.
When preoperative gingival or osseous architecture is suboptimal, treatment approaches should strive to reestablish ideal tissue contours prior to implant placement. These include orthodontic extrusion and hard- and soft-tissue grafting. In situations requiring osseous augmentation, delayed implant placement is preferable. Collapsed tissue architecture remains challenging to recreate, but it is best approached prior to implant placement.
Ultimately, clinicians must strive to preserve tissue architecture with proven techniques and employ augmentation procedures as required. Pre-surgical planning and meticulous execution of treatment protocols remain paramount when approaching the replacement of failing teeth with implant-supported restorations.
A: Dr. Dompkowski
Dentistry has evolved to a point where patients expect treatment to be completed in a fast, timely fashion. As such, it is often expected that a lost tooth be replaced as quickly as possible. One treatment option may include immediate placement of an implant at the time of extraction, followed by immediate temporary crown placement. The advantages of immediate implant placement include fewer surgical procedures, a shorter treatment timeframe, a fixed temporary prosthesis, and preservation of both crestal bone height and buccal/lingual bone width. The placement of an implant at the time of extraction, combined with the use of a bone-grafting ridge preservation technique, will prevent the crestal bone loss associated with tooth extraction. This bone will provide more support for the gingival contour and improved esthetics.
In cases where an anterior tooth will be lost, placement of a temporary crown on an immediate implant not only preserves bone but also supports gingival contour and preserves the papillae, leading to a natural-looking crown. In my experience, patients typically are grateful to have the lost tooth replaced with a fixed prothesis instead of a removable one. The temporary crown must be fabricated such that it is not being loaded, is totally out of occulsion, and has light to no interproximal contacts. The temporary crown can be screwed-retained (the author’s preferred technique) or cemented and should be delivered within 24 hours of implant placement. The patient must be instructed to avoid using the tooth to bite or chew food during the first 3 months of healing. Care must be taken during osteotomy site prepararation so that the buccal plate is not engaged and the implant is placed lingual to it by at least 2 mm.
For the patient, the benefits of immediate implant placement are fewer surgical procedures with implant abutment/crown placement in 4 to 5 months. Condraindications to immediate implant placement at time of extraction include advanced bone loss precluding the achievement of primary stability or the presence of a painful endodontic lesion. Immediate implant placement at time of extraction offers both the patient and dentist a treatment option to meet the demand for tooth replacement as early as possible.
A: Dr. Kurtzman
Immediate versus delayed implant placement is dictated by both how much facial osseous support is present and the condition of the surrounding periodontal structures. In the absence of frank infection or the presence of failing endodontically treated teeth, placement of the fixtures at the time of extraction preserves the crestal bone, specifically the facial/buccal, which resorbs first following extraction. This also allows the practitioner to avoid trying to recapture lost hard and soft tissue. When periodontal issues have led to the loss of the facial plate and, thus, a lack of bone to provide primary stability to the implant when placed, grafting becomes necessary to reconstruct the site before an implant can be placed.
Allowing the osseous and soft-tissue grafts to heal together prior to implant placement gives the surgeon and restorative dentist a better indication of the support the soft tissue will have when the restoration is placed. When considering a connective tissue graft, it is best to either place it when osseous grafting is performed before implant placement or concurrently with implant placement.
Following extraction, the lack of support for the papilla frequently leads to a flattening of the interproximal anatomy, an issue that becomes more problematic when adjacent teeth are being extracted. Soft-tissue architecture, specifically the papilla, is most predictably maintained when implants are placed at the time of extraction and provisionalization can be achieved at the time of surgery.
A papilla that is lost during site healing may be difficult or impossible to recreate, thereby compromising the final esthetic result. Preservation and maintenance of the papilla requires not only the correct distance between the crestal bone and contact between the restorations but also a 3-dimensional volume to be predictably maintained. With this in mind, when both central incisors are slated for extraction, the clinician must decide whether to place an implant into each of the two extraction sites or a single implant with a cantilever pontic. If the distance between the fixtures will allow greater than 3 mm of bone, then the clinician can place two fixtures and replicate natural soft-tissue architecture. However, when this distance is less than 3 mm, it may be wiser to use a single fixture with a cantilever pontic to allow maintenance of a papilla at the midline.
About the Authors
Betsy Bakeman, DDS
Adjunct Faculty, Kois Center, Seattle, Washington;
Private Practice, Grand Rapids, Michigan
Douglas F. Dompkowski, DDS
Dean’s Faculty Member, University of Maryland School of Dentistry, Baltimore, Maryland;
Course Director, Advanced Surgical Implant Course, AIC Education; Private Practice limited to Periodontics and Implant Dentistry, Bethesda, Maryland
Gregori M. Kurtzman, DDS, MAGD
Private Practice, Silver Spring, Maryland;
Former Assistant Clinical Professor, University of Maryland School of Dentistry, Department of Endodontics, Prosthodontics, and Operative Dentistry, Baltimore, Maryland