2001 immediate implant

Various studies of implant

指導老師吳逸民醫師

2001/2/4 perio-prostho seminars

Topic

Immediate implant vs delayed immediate implant ( 王英斌 )

Wide-diameter implant vs standard-diameter implant ( 蘇娟儀 )

Single-stage vs Two-stage ( 黃文慧 ) Immediate loading vs progressive

loading ( 林偉祺 )

Bränemark group – traditional protocol recommends a 12-month healing period between tooth extraction and placement of implants.(Adell R et al 1981 Int J Oral Surg)

Preserve alveolar bone concept

immediate implant concept

Schulte(1984) Tuebinger implant Frialit-2 implant

Stepped-tapered root analog

Immediate implant

Advantage Preservation of the alveolar bone Esthetic (extracted tooth has a desirable alignment) ideal implant position natural scalloping and distinct papillae are easier to achieve maximal soft tissue support Fewer surgical interventions Reduction in treatment time & cost

Immediate implant

Disadvantages Misalignment of the extracted tooth may lead to

unfavorable angulation of the fixture Stabilization may require more bone than is

available beyond the apex Localized peri-implant bone defect Primary soft tissue closure

( submerged vs transmucosal implant)

Indication for Immediate implant

Root fracture Trauma not affecting the alveolar he

alveolar bone Decay without purulence Endodontic failure Severe periodontal bone loss Residual root

Contraindication for Immediate implant

Presence of pus Lack of bone beyond the apex or close

relationship to the anatomical vital structures

Extraction site defects

Residual defect morphology and the regenerative potential at the extraction sites

Salama H & Salama M

1993 IJPRD


Type I –ideal site for immediate implant 4-/3-wall socket with minimal bone

resorption (<5mm apico-coronal defect) Sufficient bone available beyond the apex Acceptable discrepancy between the

fixture head & neck of the adjacent teeth Manageable gingival recession or

esthetics is not essential.


Type II – need orthodontic extrusion Dehiscence > 5mm Substantial discrepancy between the

fixture head & neck of the adjacent teeth Significant gingival recession or

esthetics .


Type III –not suitable for immediate implant

inadequate vertical &B-L bone dimension Recession and severe loss of labial bone Severe circumferential and angular defect

The decision to submerge should base on the following factors

Plaque control Smoking Periodontal conditions The degree of stability The presence of provisional removable

denture

Submerged implant

Primary closure

Bowers & Donahue(1988)

Edel (1995) ,Chen & Dahlin(1996)

Rosenquist(1997)

Rotated palatal flap for

immediate implant

Nemcovsky CE 2000 COIR

Transmucosal immediate implant

Cochran & Douglas(1993);Brägger et al (1993) Schultz(1993) ;Lang(1994) Brägger et al (1996);Hämmerle et al (1998)

Evidences emphasize the importance of infection control for a successful tx. of outcome following immediate implant of transmucosal implants

Transmucosal immediate implant

Original peri-implant defect was the most critical factor relating to the final amount of bone-to-implant contact

Horizontal defect dimensions of >4mm resulted in a lower bone-to –implant contact than dimension of 1.5mm or less

Wilson et al 1998 JOMI

Conclusion about immediate implants

High survival rate : 93.9%-100% Implants must placed 3-5mm beyond the

apex in order to gain a maximal degree of stability

Implant should be as close as possible to the alveolar crest(0-3mm)

Schwartz-Arad D et al 1997

Conclusion about immediate implants

There is no consensus regarding about the need for gap filling and the best graft materials

The use of membrane does not imply better results –on the contray ,membrane exposure may carry complications

The absolute need for primary closure Schwartz-Arad D et al 1997

Immediate vs non-immediate

implantation for full-arch fixed reconstruction following extraction of all residual teeth : A retrospective comparative

study

Schwartz-Arad D et al 2000 JP

Results

5-year cumulative survival rate(CSR)

Immediate implant (96%) non-immediate(89.4%) Mean potential contact area(PCSA) 230mm2

Significant differences in CSR in maxilla(96.6% vs 82.9%)

Posterior Max.

Immediate implant (100%) non-immediate(72%)

Conclusions

Survival rates of implants placed to support full-arch ceramo-metal prosthesis can be ranked as follows : bone quality , immediate implant,PCSA

Immediate implantation exerts its effect through higher PCSA values by a compensatory effect for bone quality

Immediate implant does not carry additional morbidity

Delayed Immediate implant

To allow primary soft tissue healing following tooth extraction for a period of 6-10 weeks ,prior to implant placement

Advantages 1) adequate soft tissue 2) minimized the effect of microorganism

associated with the failed tooth or wound healing (Gher 1994)

3) highly osteogentic activity

Spontaneous in situ gingival augmentation

Burton Langer IJPRD 1994;14:525-535

Delayed immediate implant

Alveolar bone changes during the healing period Strong tendency for the defects to fill-in in the

horizontal plan and bone growth to occur in the vertical plane of the height of the cover screw .

Good short-term prognosis with bone regeneration occurring around the defect without the use of barrier membranes or bone substitutes

Nir-Hadar O et al (1998)

After an average follow-up of 12.4 months, peri-implant pocket depth, the gingival index, the hygienic index, and the degree of bone resorption were examined. A life-table approach (Kaplan-Meier) was applied for statistical analysis, and showed no difference between primary and secondary immediate implants. Also, none of the parameters examined demonstrated a statistically significant difference between the two groups.

Mensdorff-Pouilly et al 1994 JOMI

However, compared with the groups of secondary immediate implants, the group of primary immediate implants showed a tendency towards deeper pocket formation and an increased frequency of membrane dehiscences that may be due to the poorer quality of the soft tissue covering.


3-year Prospective Multicenter Follow-up

No clinical difference with respect to socket depth or when comparing the different placement methods.

Higher failure rate was found for short implants in the posterior region of maxilla .(extracted for periodontitis)

Mean marginal bone resorption : (from loading to 1yr F/U) Max.(0.8mm),mand(0.5mm)

Implant survival : Max(92.4%);Mand(94.7%) Grunder U et al 1999 JOMI

Generally,

primary immediate implant –

max. anterior

secondary immediate implant –

mandible,posterior maxilla


Thanks for your attention!!

Evidence for osseointegration of immediate implant

Experimental animal studies (Kohal et al 1997)

Controlled human studies(Palmer et al 1994)


Root-analogue titanium implants

Lundgren et al (1992) beagles dog study

Kohal et al(1997) monkeys


Conventional screw- or cylinder-type implant

Experimental animal studies

Parr et al (1993) dog study

Barzilay et al (1996) controlled monkey

Similar result for immediate and late implant ( Clinical,radiography,histology)


Clinical studies Becker et al(1998) prospective clinical

human trials of 47 immediate implants without bone augmentation

cumulative success rate of 93% followed between 4 to 5 years

Bone augmentation in combination with immediate implant

GBR-barrier membranes

Experimental animal studies

Dahlin(1989)– rabbits

Becker et al (1991) – barriers enhance predictability of bone fill in immediate extraction sockets when compared with

a mucoperiosteal flap


GBR-barrier membranes e-PTFE membrane

Lazarra(1989)

Becker &Becker(1990)

Nyman(1991)

Hammerle(1998)


GBR-barrier membranes e-PTFE membrane Becker (1994) 49 immediate implant

with e-PTFE alone

--- 93.6% bone fill ,1-year functional loading success rate 93.9%


GBR-barrier membranes e-PTFE membrane Gher et al (1994 ) influence of original defect morphology on bone

fill with e-PTFE at immediate implant sites Dahlin et al (1995) prospective multicenter study 2-year cumulative survival rate Max.(84.7%) mand(95%)


GBR-barrier membranes Collagen membrane( Cosci&Cosci 1997) polyglactin (balshi 1991) Polylactic acid (Lundgren 1994) Fascia lata (Callen & Rohrer 1993) Autogenous gingival grafts(Evian & Cutler

1994)


GBR-barrier membranes Zitzmann et al (1997)

e-PTFE vs collagen ( deproteinized bovine bone )

no significant difference in average percentage bone fill for collagen (92%) and e-PTFE(78%) But, 44% wound dehiscence and premature membrane removal in the e-PTFE group was reported.

Barrier membrane exposure

Compromised results

Simion (1994) bone fill (97% vs 42%)

Augthun(1995) Successful bone regeneration & complete bone

filling ,but strict infection control is followed

Mellonig (1993)

Shanaman(1994)

Rominger & Triplett (1994) 96.8%

GBR and bone grafts

DFDBA ( negative ) animal study

Becker (1992) dogs study

Becker (1995) dogs study

Kohal(1998) dogs study Clinical study

Gelb(1993)

GBR and bone grafts

DFDBA ( positive )

Callan (1990)

Mellonig (1993)

Landsberg (1994) combined with Tc

Gher (1994)

GBR and bone grafts

Hydroxyapatite

Wachtel et al (1991) biopsies taken on

3M showed enhanced bone regeneration

than non-grafted sites.

Knox (1993)

Novaes & Novaes (1993)

GBR and bone grafts

Simion(1994)

Cosci & Cosci(1997)

Fugazzotto (1997)

Schwartz-Arad & Chaushu(1997)

Compromised sites –infection

Pecora(1996)

32 teeth due to root fx.,perforation,endo-perio complication ,F/u 16M

Rosenquist & Grenthe(1996)

periodontal disease (92%)

trauma,root fx.,endodontic failure (95%) Novaes(1995,1998)

Compromised sites –infection

“ Immediate implantation at chronically infected sites may be successful,the extent of the defect ,the implant primary stability,and esthetic consideration of future restoration must be considered.”

Biologically active bone-differentiating substances

Cook (1995) recombinant human osteogenic protein-1(rhOP-1)

Cochran et al(1997) recombinant human bone morphogenetic protein-2(rhBMP-2)

Hedner & Linde(1995) membrane + BMP compromised blood supply

Future about biologically active bone-differentiating substances

Identification of the ideal carrier substrate Dose application The effect of combination

Late implants

A period of >6 months for healing of the extraction site is recommendation prior to implant placement

2001 immediate implant

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