Extraction, Immediate implant placement and loading in the maxilla incisor sector. Management of a fenestration with guided bone regeneration (GBR). 28 September 2016
Extraction, Immediate implant placement and loading in the maxilla incisor sector. Management of a fenestration with guided bone regeneration (GBR).
An extraction and immediate implant placement is a treatment development prescribed in implantology. It brings together function and aesthetics through a rigorous immediate temporisation which relies on precise and necessary protocols for the implant integration. When this solution is chosen for anterior sectors, it shows a reassuring and elegant approach for the patient thus respecting their physical and moral well-being.
In this publication, we discuss a clinical case which requires an incisor restoration - implant and tooth - with immediate temporisation, associated with the treatment of a large vestibular fenestration treated with guided bone regeneration (GBR).
Mrs D., the 32-year-old patient, is in good general health, does not smoke, and is affected by recurrent infections of the upper incisors. The patient has a high aesthetic demand and wishes to replace the crowns of teeth 11 and 21 which have a “history of fractures”.
The exobuccal examination shows that the patient has a regular and straight oral aperture, a high smile line revealing the maxillary gum line which is important to take into consideration from the outset. We also note a lack of harmony between the form and the volume of the incisors and the oval shape of the face (Fig. 1A and b).
Figure 1a and 1b : Exobuccal views exhibiting the large gingival smile including the molars, spoiled by an unbalanced relative amount of white and pink. The volume and the shape of the teeth do not match the oval shape of the face.
The endobuccal examination shows a left canine class 1 occlusion and a right mandible canine, in crossbite. To this day, this situation does not generate any muscle or joint issues. In dynamic occlusion, the patient shows functional anterior guidance, left canine function and right group function. Furthermore, there is a clinical absence of cavities.
The periodontal observation (Fig. 2) shows a generalised moderate to severe gingival inflammation at temporary crowns on teeth 11 and 21, a thick biotype and a flawed plaque control. Tooth 11 has deep periodontal pockets on probing.
Figure 2: Endobuccal view with the topographical survey of the pockets. There is a Miller Class II recession on tooth 13, a deep pocket on tooth11 and a thick maxillar gingival biotype.
The aesthetic check-up of the maxillary anterior sectors shows a large gingival smile displaying inharmonious proportions between incisors, irregular dental necks and inelegant and turgescent papilla (Fig. 3).
Figure 3: The centred view on the incisivo-canine maxillary sector displays a red and edematous gingiva, a short and turgescent papilla, but a significant keratinised gingiva highlighting the dotted “orange peel” effect. The analysis of these elements is important for the predictability of the final results.
On the panoramic X-ray (Fig. 4), we see regular and continuous maxillary and mandible bone levels displaying the absence of any periodontal disease. However, we note a periradicular inflammatory lesion of endodontic origin in relation to tooth 11. It is objectified in the retroalveolar X-ray (Fig. 5). We also note the presence of recurrent caries on teeth 26 and 27.
Figure 4: In the initial panoramic X-ray, we note several coronal and corono-radicular restorations as well as dental continuity under the arches. Teeth 18 and 28 are included. The bone level is regular. On tooth 11, we note the presence of an apical image.
Figure 5: The retroalveolar X-ray confirms the apical lesion on tooth 11; its root is short and has significant osseous volume beyond the apical lesion. Teeth 11 and 21 have been restored with temporary crowns with apical anchorage. The interdental osseous septum are present.
The 3D tomography examination, CBCT (Fig. 6), confirms the periradicular inflammatory lesion of endodontic origin and displays sufficient osseous volume for an immediate implant following the extraction of tooth 11 despite a certain discontinuity in the V table, which is extremely thin
Figure 6: The CBCT examination displays the partial loss on the higher level of the extremely thin vestibular bone plate. However, the cervical surface is intact allowing an extraction and immediate implant placement to be performed under good conditions.
The patient shows:
- Generalised moderate gingivitis caused by plaque at the periodontal level.
- A retocurrent abscess at the dental level on tooth 11 with an incorrect prognosis on this tooth. However, there is residual osseous volume which allows for an extraction and immediate implant placement.
- Aesthetically, disharmony at the level of the dental necks and papilla disrupts the appearance of the smile.
- J 0: Initial periodontal therapy
This stage aims to reduce the plaque and the inflammation to zero thereby ensuring the stability of the gingival soft tissue. The implementation of advanced hygiene techniques with help from the patient in their application is essential before undertaking any implant treatment. Once the goal is reached, a scaling / root planning session is scheduled.
- At 2 months: Extraction, immediate implant placement and temporisation + GBR + connective tissue graft
Extraction of tooth 11 is performed using an atraumatic approach (Fig. 7a and 7b). The area is then thoroughly curetted, opened up, deepithelialized with a diamond bur and irrigated with Betadine. A Nobel Active NP 3.5 x 15 mm implant (Nobel Biocare) is put in place by anchoring most closely to the palatal wall leaving a vestibular space between the cortical bone and the vestibular side of the implant allowing for filling with allogeneic bone (BioBank) (Fig. 8). This approach creates stable vestibular bone thickness for a long-term satisfactory outcome. The use of a small diameter implant with a conical connection, the platform-switching concept, and the addition of soft tissue generate local morphological stability and facilitate the control of the prosthetic emergence profile for a better aesthetic result.
Figures 7 a and b: Tooth 11 is removed by fragmentation in order to avoid fractures of residual osseous walls
Figure 8: The implant on tooth 11 is placed in an ideal position at 3mm below the gum line and glued to the palatal wall for an emergence profile on the future cingulum and so a screwed prosthesis can be used. The remaining vestibular space is filled with allogeneic bone (BioBank).
The second stage of the operation focuses on the treatment of apical fenestration. A full-thickness flap is lifted away from the dental neck after performing a para-marginal incision in order not to create any gingival recession (Fig. 9) and a guided bone regeneration is performed (Fig. 10).
Figure 9: View of the incision made beyond the marginal gingiva showing the apical fenestration and exposing the osseous wall in cervical.
Figure 10: The filling guarantees a complete filling of the missing osseous volume and, to keep the particles in place, a resorbable membrane (Bio-Gide Geistlish) is fixed apically with a nail.
Finally, for the remodelling phase of soft tissue, a connective tissue graft (Fig. 11) is sampled on the right tuberosity and is placed against the inner wall of the marginal gingiva on the vestibular and proximal sides. Simple and discontinued sutures with a resorbable non monofilament 6/0 thread (Surgipro, PPI Pharma) help fix the graft and seal the flap.
Figure 11: Occlusal view of the provisional composite connected to the implant and protruding slightly palatially in the buccal corridor for the use of a screwed prosthesis. The connective tissue graft, higher in vestibular, creates a consequently thick mucosal relief for aesthetic results.
The implant was placed under good conditions with sufficient primary stability, allowing for screw-retained immediate provisional prosthesis to be placed after the operation. It is tightened at 20Ncm and strictly put in static and dynamic under occlusion (Fig. 12 and 13). This exclusively secures the aesthetic temporisation. The patient is instructed not to chew on the provisional tooth for at least two months.
Figure 12: The retroalveolar control X-ray displays the conical morphology of the implant and its centred position respecting the osseous septa, future support for the papillae.
Figure 13: Vestibular clinical view two weeks after, during the removal of the sutures. The remodelling phase of soft tissue is well under way. The patient has dramatically improved her plaque control and hygiene.
- Check-up appointments and aesthetic adjustments
The patient is asked to come back for a check-up at one week, at two weeks for the removal of the sutures, and then at 3 months for an intermediate check-up with a gingivoplasty and a refitting of the provisional prosthesis in order to guide maturation of the mucous membrane and to obtain an emergence profile with aesthetic papillary development (Fig. 14).
Figure 14: Vestibular clinical view
at 6 months with the modified provisional crowns. Tissue integration is
almost completely in the apical zone. The papillae are still remodelling.
- At 6 months, making of the final prostheses for teeth 11 and 21.
The final prostheses are made at 6 months after the implant placement. The emergence profile achieved (Fig. 15) thanks to the provisional prosthesis will be recorded in order to achieve optimal aesthetic integration of the final prosthesis.
Figure 15: The emergence profile obtained through
guiding with the provisional arrangement ensures progressive and attractive emergence
in the transgingival area. We note the achieved vestibular curving contour.
For the reproduction of the achieved emergence profile, the “indirect method” will be used. The form of the provisional prosthesis and the emergence profile are recorded in silicone. Then, a personalised impression coping with Duralay resin is made from the mould. After disinfection, it is put in the mouth and set on the implant (Fig. 16). A double mix impression is taken (Fig. 17). The prosthetist has now all the elements required to create the final crown for the alveolar bed and perfectly mould the peri-implant mucous membrane (Fig. 18, 19, 20, 21a, 21b, 21c).
Figure 16: The impression coping attached to the implant with the resin Duralay moulds the emergence profile. It prevents the collapse of soft tissue during the impression.
Figure 17: The pick-up impression of the complete arch in double mix, with coping in place, allows presetting of the dynamic movements and their horizontal components on the articulator to minimise the constraints imposed by these forces at the implant level.
Figure 18: The final prostheses on 11 and 21 in the mouth. We note good tissue integration, however, a gingival fistula persists leaving a slightly inelegant aspect.
Figure 19: Retroalveolar X-ray with the final prostheses in place.
Figure 20: The gingivoplasty performed with a bur eliminates the surface epithelium and establishes wound colonisation by the migration of peripheral cells. A chromatic tissue blend is obtained. It improves the appearance of gingival tissue.
Figures 21 a, b and c: The final result shows satisfactory tissue integration creating visually pleasing proportions of white and pink. Viewed from the side, the lines of the larger crown contour show the convexity of the dental surfaces. (prosthesis: Dr Richard Massihi).
The extraction, immediate implant placement and loading for single restorations is a technique with a proven track record. The implant survival rate and the aesthetic results are equivalent to conventional techniques (Benic et al. 2014, Chen et al. 2014, Chen et al. 2013).
In order to guarantee better aesthetic results and reduce the risks of vestibular tissue recession, in a systematic review performed by Lin et al. (2013), they recommend placing the implant more in the palatal / lingual area, using platform-switching connections, taking a flapless approach, bridging the gap between the implant and the vestibular osseous wall, performing a connective tissue graft and immediately placing the provisional prosthesis.
Antoun et al. in a forthcoming study, presented to the Congress of the Academy of Osseointegration in 2015, on the evaluation of extraction, immediate implant placement and loading in the aesthetic sectors shows that it is a reliable technique which, associated with a connective tissue graft, seems to maintain, or even improve, the aesthetic results of soft tissue.
Key words: Extraction, Immediate implant placement, Immediate temporisation, Implant
Recommended reading :
Benic G.I, Mir-Mari J, Hämmerle C.H.F. Loading Protocols for Single-Implant Crowns: A Systematic Review and Meta-Analysis. Int J Oral Maxillofac Implants 2014;29(suppl):222–238.
Chen S.T, Buser D. ￼ Esthetic Outcomes Following Immediate and Early Implant Placement in the Anterior Maxilla—A Systematic Review. Int J Oral Maxillofac Implants 2014;29(suppl):186–215.
Cosyn J, De Bruyn H, Cleymaet R. Soft Tissue Preservation and Pink Aesthetics around Single Immediate Implant Restorations: A 1-Year Prospective Study. Clinical Implant Dentistry and Related Research,2013, Volume 15, Number 6, 847-857.
Lin G.H, Chan H.L, Wang H.L . Effects of Currently Available Surgical and Restorative Interventions on Reducing Midfacial Mucosal Recession of Immediately Placed Single-Tooth Implants: A Systematic Review. J Periodontol 2014;85:92-102.
Karouni M., Antoun H. Evaluation and comparaison of soft tissues before and after immediate post-extraction single implant placement and provisionalization in the anterior maxillae. Poster session presented at the. Academy of Osseointegration Annual Meeting, 2016 Feb 17-20, San Diego, CA.
Doctor of Dental Surgery, Paris University
Doctor in Dental Surgery
Private practice limited to Periodontology and Implantology
Paris, Founder of the IFCIA Insitute.