Extraction, immediate-load implants, impressions and final restorations in two patient visits JOSEPH C.

LEARY and MUNEKI HIRAYAMA J Am Dent Assoc 2003;134;715-720

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ABSTRACT
Background. Since the advent of immediately loaded implants, patients have experienced shorter treatment times, reduced amount of surgical therapy, preserved gingival esthetics and the comfort and security of fixed prostheses. Practitioners have experienced less expense in the form of chair time and greater patient satisfaction. Case Description. The authors present two cases in which, at the first clinical visit, they extracted maxillary incisors, placed hydroxyapatite-coated implants, took impressions for final restorations and stabilized the implants immediately with a fixed interim prosthesis. At the second clinical visit, the authors placed the final restorations. All of the implants were integrated clinically, and gingival esthetics appeared to have benefited from preservation of papillary form, which was made possible with fixed interim anterior restorations. The patients expressed satisfaction with the results particularly because the treatment was accomplished in two clinical visits. Clinical Implications. The cases presented demonstrate a technique that may be of value to therapists who place immediate-load implants. The long-term effectiveness of immediate-load implants requires further evidence to ensure their long-term usefulness and safety.

CASE REPORTS

Extraction, immediate-load implants, impressions and final restorations in two patient visits
JOSEPH C. LEARY, D.M.D.; MUNEKI HIRAYAMA, D.M.D.

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itanium has a long history as a biocompatible material.1 Since its introduction as a dental implant material,2,3 we have witnessed a gradual movement toward decreasing treatment time, which not only benefits the patient, but the dentist as well. The success of immediate implant placement,4,5 one-stage implants6 and immediate-load implants,7 each under The goal was certain circumstances, offers the advantages of decreased treatment time, to show the improved clinical results and greater potential to patient satisfaction. reduce It is common for patients to be reluctreatment tant to use removable interim prostime and theses, and the possibility of micromovethe potential for implant improve ment increases failure.8 Our objective in the cases prepatient sented in this article was to take satisfaction impressions for the final prosthesis within the immediately after extractions and the time between placement of implants so that the prosthe placement thesis would be available at the and integration patients second clinical visit. In addition to having the final prosthesis availof the implant. able at the second clinical visit, we hoped that having it be available sooner than usual would preserve the patients papillary form and enhance the gingival esthetics.

CASE REPORTS

Case 1. A 42-year-old woman had a fractured maxillary left central incisor, an ill-fitting crown with gingival recession on the right central incisor and the loss of pap-

illary form between the central incisors (Figure 1). We discussed the restorative options with her, and she elected to have both central incisors extracted. At the initial treatment visit, we gave the patient a preoperative mouthrinse of 0.12 percent chlorhexidine and had her premedicate with 1 gram of amoxicillin. In placing the implants, we used the sterile technique, as described by Brnemark and colleagues.9 Then the surgeon (J.C.L.) extracted the maxillary right and left central incisors while the patient was under local anesthesia. He carefully curetted the sockets to remove any soft-tissue remnants and inspected them for integrity. He determined that the site
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Figure 1. Case report 1: preoperative view of poorly fitting crowns, loss of gingival and papillary form and the fractured root of the left central incisor. Image reproduced with permission of Bicon.

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was appropriate for placement and stabilization of an immediate implant.10 He placed two 5- 8millimeter hydroxyapatite-, or HA-, coated implants (Bicon Dental Implant, Bicon, Boston) into the freshly prepared sockets (Figure 2). Using a 2-mmdiameter pilot drill, he penetrated the apical aspect of the socket to a depth of 2 to 3 mm. This osteotomy plus the lateral aspect of the socket wall, which is engaged by using increasingly wider diameter drills, is designed to reshape the socket sufficiently to ensure stabilization of the implant. The surgeon applied water externally to cool the pilot drill; he did not use coolant for the subsequent drills, which rotate at 50 rotations per minute or less and are configured to increase the width of the osteotomy by 0.5 mm with each successive drilling until the osteotomy width is the same as that of the chosen implant width. The surgeon placed the head of the implant 1 to 2 mm below the most coronal aspect of the socket. Gaps that remain between the implant and socket wall have been seen to fill with bone during the healing period. With the implant in place, the restorative dentist (M.H.) used a shoulder depth gauge to determine which abutment height would provide for subgingival placement of the abutment shoulder. The depth gauge, which is similar to a periodontal probe, is placed so that its tip is at the base of the implant well and the distance from the base of the implant well to the crest of the overlying gingiva is measured. This distance is used to select the abutment that will allow the abutment shoulder to be 1 to 2 mm subgingival. In the implant system we used, the abutments
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Figure 2. Case report 1: implant being placed into a fresh extraction site. Image reproduced with permission of Bicon.

are available in several heights to provide for variations in the depth of implant placement and overlying tissue thickness; they also are available in angulations of 0 degrees and 10 degrees. The restorative dentist then snapped a onepiece acrylic sleeve onto the selected shouldered abutment; the acrylic sleeve assists in the impression taking, as well as in forming the base of the temporary crowns. He inserted the abutments with acrylic sleeves into the implants (Figure 3) and applied composite transitional material to the acrylic sleeve. The restorative dentist added additional composite to a vacuum-formed template that he made before the extractions and placed a strip of fiber-reinforcement ribbon in the vacuum-formed template to provide extra strength to the composite temporary crowns. He then fabricated and polished the temporary crowns. He removed the shouldered abutments from the implants and placed impression posts into the implants. The restorative dentist took full upper and lower arch impressions for the final crowns. He used a polyester impression material with impression posts for an implant-level impression and poured a soft-tissue stone model. He inserted implant analogs onto the impression posts in the impression. The dental technician made the final all-ceramic crowns using aluminum oxide sleeves. The restorative dentist placed and bonded the temporary crowns to adjacent teeth for stabilization (Figure 4).

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Figure 3. Case report 1: abutment with acrylic sleeve being placed into the implant well. Image reproduced with permission of Bicon.

Figure 4. Case report 1: temporary crowns being bonded to adjacent teeth to provide stabilization for the implants. Image reproduced with permission of Bicon.

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At the conclusion of the first clinical visit, we had extracted the teeth, placed implants, taken impressions for the final restorations, and placed and immobilized temporary crowns. Because we made the final impressions at the time of implant placement, the final prostheses were ready to be inserted 13 weeks later during the patients second clinical visit at which time the implants were to be clinically integrated. At the second clinical visit 13 weeks later, we removed the temporary crowns. The sulci appeared clinically healthy (Figure 5). We cleaned the shouldered abutments with an aluminum oxide abrasive and applied an adhesive system metal coupler to the abutments. We then applied a ceramic coupler to the internal aspect of the allceramic final restorations. This was followed by the application of a bonding agent on both the abutment and internal crown surfaces. We cemented the crowns to the abutments extraorally to eliminate the problem of residual cement being left subgingivally. We placed the abutments with the crowns cemented into the implants (Figure 6) using an acrylic jig to verify proper orientation and checked the contacts with floss. Once we verified the contacts, we tapped the crowns into the implant to activate the locking taper. We then checked the contacts again with floss. (If it becomes necessary to remove the crown/abutment for any reason, the locking taper can be inactivated by applying a rotational coronal force with an extraction forceps.) We verified occlusion again and took a radiograph (Figure 7). Six months after the restorations were placed, the patient had a postoperative evaluation. The

Figure 5. Case report 1: 13 weeks later, temporary crowns were removed, and the soft-tissue sulci appeared healthy. Image reproduced with permission of Bicon.

Figure 6. Case report 1: a crown was cemented to the abutments extraorally and is placed into the implant site. Image reproduced with permission of Bicon.

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Figure 8. Case report 1. six-months postplacement, soft tissue exhibits slight marginal inflammation. Image reproduced with permission of Bicon.

Figure 7. Case report 1: radiograph of the crowns in place. Image reproduced with permission of Bicon.

Figure 9. Case report 2: the maxillary right central incisor could be probed 7 millimeters on the distofacial aspect, and there was suppuration and marginal inflammation. Image reproduced with permission of Bicon.

tissue exhibited slight marginal inflammation that was consistent with mild plaque accumulation (Figure 8). The gingiva was otherwise stable and healthy. We reviewed and reinforced plaque control with the patient and took a radiograph. The patient made an appointment for further evaluation in six months. Case 2. In the second case, a 41-year-old woman had an area of severe root resorption on
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the distal aspect of the maxillary right central incisor. We were able to probe the distofacial aspect to 7 mm and found that it was suppurative and that the marginal gingiva exhibited inflammation (Figure 9). Her general dentist had suggested that she have the tooth removed and have an implant placed. The patient expressed a great deal of anxiety about the esthetics and felt that she could not wear a removable interim prosthesis. After discussing the alternatives with the patient, we decided to place an immediately stabilized implant. As in the first case, we gave the patient a preoperative mouthrinse of 0.12 percent chlorhexidine and had her premedicate with 1 gram of amoxicillin. We used the sterile technique, as described by Brnemark and colleagues.9 We removed the tooth and placed a 5- 8-mm HA implant (Bicon Dental Implant, Bicon). After implant placement, the restorative dentist fabricated a temporary restoration and took an impression for the final restoration, as described in case 1. The restorative dentist then placed and stabilized the temporary crown (Figure 10). At the patients second visit seven weeks later, we removed the temporary crown and cemented the final crown extraorally, as in case 1. Using an acrylic jig to verify proper position, we placed the abutment with the crown cemented into the implant well and checked contacts, as in case 1. We tapped the crown/abutment into place, activating the locking taper (Figure 11).

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Figure 11. Case report 2: crown/abutment in place on the maxillary right central incisor and locking taper activated; the gingival esthetics appear to be healthier than adjacent natural tooth and crown. Image reproduced with permission of Bicon.

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Figure 10. Case report 2: implant in place with abutment and stabilized temporary crown. Image reproduced with permission of Bicon.

DISCUSSION

In many instances, we can use the immediateload, or stabilization, procedure to provide patients with a fixed interim restoration. Not only is the fixed-interim restoration desirable for the patients comfort and security, but it also has been shown to achieve a greater bone-to-implant contact than controls,11 as well as more mature bone around the implant.12 Although some investigators have found more crestal bone loss with immediate-load implants13 than with unloaded implants, other investigators4,12,14 found that immediate-load implants were as successful as or more so than unloaded implants. The advantages of taking impressions for the final restorations at the initial visit are obvious; however, the technique we describe requires that both the surgeon and the restorative dentist be present or be the same person, or that coordination take place to enable the restorative dentist to have access to the patient immediately after the surgeon places the implant. It also is of paramount importance that the implant site be

inspected for any residual impression material. Failure to remove all remnants of this material may result in the failure of the implant to integrate. In addition, it is imperative that the patient contact the dentist immediately if movement should develop in the interim restoration. Although we produced the results in these cases in two treatment visits, we advise scheduling brief postoperative visits at one week, three weeks and five weeks, so the dentist can inspect the integrity of the interim prosthesis, as well as take a radiograph at the five-week point. It has been demonstrated that micromotion often will lead to fibrous encapsulation and implant failure.8,15 In the cases we report, we were pleased with the gingival esthetics. Studies have confirmed that immediate temporization will produce excellent gingival esthetics.16,17 Although in this study only two patient visits were needed to achieve these results (as seen at the six-month postplacement visit in case 1 [Figure 8] and at the time the restoration was placed in case 2 [Figure 11]), our real goal was to show the potential to reduce treatment time and improve patient satisfaction within the time between the placement and integration of the implant and not simply the insertion of the final restoration at the second patient visit. We have seen many cases of immediate-load placement involving multiple implants, including cross-arch stabilization; however, we selected these two cases to show the potential for taking impressions for the final prosthesis at the time of extraction, placement and immediate load of the implants.
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CONCLUSION

and Paolo Perpetuini, C.D.T., and John Murray, C.D.T., for fabricating the prostheses. For additional information about the cases reported in this article, go to www.bicon.com/d_cases-ISL.html and click on cases 2 and 6. 1. Levanthal G. Titanium: a metal for surgery. J Bone Joint Surg 1951;33:173-4. 2. Brnemark PI, Hansson BI, Adell R, et al. Osseointegrated implants in the treatment of the edentulous jaw: experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1-132. 3. Adell R, Lekholm U, Rockler B, Brnemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416. 4. Parel SM, Triplett RG. Immediate fixture placement: a treatment planning alternative. Int J Oral Maxillofac Implants 1990;5:337-45. 5. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol 1997;68(10):915-23. 6. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants, part 1: 8-year life table analysis of a prospective multi-center study with 2,359 implants. Clin Oral Implants Res 1997;8:161-72. 7. Schnitman PA, Wohrle PS, Rubenstein JE, DaSilva JD, Wang NH. Ten-year results for Brnemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12:495-503. 8. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Time of loading and effect of micromotion on bone-dental implant interface: review of experimental literature. J Biomed Mater Res 1998;43:192-203. 9. Brnemark PI, Zarb GA, Albrektsson T, eds. Tissue-integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence; 1985:211-4. 10. Lazzara RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:333-43. 11. Piattelli A, Corigliano M, Scarano A, Costigliola G, Paolantonio M. Immediate loading of titanium plasma-sprayed implants: an histological analysis in monkeys. J Periodontol 1998;69:321-7. 12. Henry P, Tan AE, Leavy J, Johansson CB, Albrektsson T. Tissue regeneration in bony defects adjacent to immediate load titanium implants placed in extraction sockets: a study in dogs. Int J Oral Maxillofac Implants 1997;12:758-66. 13. Sagara M, Akagawa Y, Nikai H, Tsuru H. The effects of early occlusal loading on one-stage titanium alloy implants in beagle dogs: a pilot study. J Prosthet Dent 1993;69:281-8. 14. Barzilay I, Graser GN, Iranpour B, Natiella JR, Proskin HM. Immediate implantation of pure titanium implants into extraction sockets of Macaca fascicularis, part II: histologic observations. Int J Oral Maxillofac Implants 1996;11:489-97. 15. Brunski JB, Moccia AF Jr, Pollack SR, Korostoff E, Trachtenberg DI. The influence of functional use of endosseous dental implants on the tissue-implant interface, I: histological aspects. J Dent Res 1979;58:1953-69. 16. Werbitt MJ, Goldberg PV. The immediate implant: bone preservation and bone regeneration. Int J Periodontics Restorative Dent 1992;12:207-17. 17. Gelb DA. Immediate implant surgery: three-year retrospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 1993;8:388-99.

These cases demonstrate that it is possible to achieve Dr. Leary is in private Dr. Hirayama is in even greater practice limited to private practice, efficiency in our periodontics, Norwood, Implant Dentistry Mass., is in part-time Centre, Faulkner efforts to give practice at the Implant Hospital, Boston. patients sound, Dentistry Centre, Faulkner Hospital, timely and economical treatBoston, and an assistant ment. While we acknowledge clinical professor, Department of that this procedure still is Periodontology, Tufts technique-sensitive, it is clear School of Dental Medicine, Boston. that with continued innovations Address reprint in the prosthetic capabilities of requests to Dr. Leary at 89 Access Road, Unit implant systems, we should be 30, Norwood, Mass. able to enhance the service and 02062, e-mail joeleary@attbi.com. treatment offered to our patients in regard to treatment time, patient comfort, cost and esthetics. In the cases described in this article, we cannot claim success in the sense of many years, particularly in view of the abbreviated times involved. Although the technique we used appears to be promising, additional time and evaluation are required to establish whether the soft-tissue results will remain stable over time. s
Drs. Leary and Hirayama are faculty members at the Bicon Institute, Boston, which is owned by Bicon, the manufacturer of the Bicon Dental Implant. Both of the cases presented in this article were completed in a fee-for-service setting at the Implant Dentistry Centre at Faulkner Hospital, Boston. This practice is operated by one of the principal owners of Bicon, the manufacturer of the Bicon Dental Implant. The authors are in part-time practice in this center. The cases presented in this article represent their efforts. Bicon assisted in preparing the photographs presented in the article.

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The authors would like to express their gratitude to Allison Shea, Erin Chae and Deirdre Murdock for their assistance in preparing this manuscript; Dr. Drauseo Speratti for the photographic documentation;

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