Immediate Implantation and Immediate Loading Protocol: Up to 18-month follow up of three cases Hakan BİLHAN1, Emre MUMCU1, Tayfun Bilgin2 1 Dr.med.dent., Istanbul University, Faculty of Dentistry, Department of Prosthodontics 2 Prof.Dr. med.dent., Istanbul University, Faculty of Dentistry, Department of Prosthodontics Correspondence address: Dr.med.dent. Hakan Bilhan University of Istanbul – Faculty of Dentistry, Department of Prosthodontics, 34390- Çapa Istanbul-TÜRKIYE e-mail: firstname.lastname@example.org Immediate Implantation and Immediate Loading Protocol: Up to 18-month follow up of three cases Abstract Since the first report describing the placement of dental implants into fresh extraction sockets, there has been an increasing interest in this technique. The advantages of immediate implant placement have been reported to include a reduction in the number of surgical interventions, decreased alveolar bone resorption following tooth loss, and less treatment time. Appropriate indications, good surgical technique, and the use of a prosthetic protocol have resulted in success for immediate loading and immediate implantation. If even one of the patient-related factors is negative, such as systemic health, a smoking habit, poor oral hygiene, presence of a biotype, or an infection in the region of the extraction, this treatment option should not be considered. Patient satisfaction is very high and difficulties related to the implantation site in late implantations are eliminated. The clinical course of a patient with immediate implantation and immediate loading and two other patients who underwent immediate loading only, over an 18 month interval, is the subject of the current report. Key words: immediate implantation, immediate loading, crestal bone loss around dental implants, anterior implant esthetics, immediate loading of lower incisors Immediate implantation and immediate loading protocols are becoming more and more popular. Immediate loading in the mandibular inter-foraminal region has been performed for over a decade and success rates of 90-100 % have been reported (1). The goal of immediate implantation and immediate loading is to decrease the number of surgical interventions, in turn reducing costs and patient discomfort. Furthermore, such an approach has led to immediate implant placement after tooth extraction, as well as immediate loading of implants with fixed restorations. Studies showing long-term results of these two methods (2, 3) are scarce and the number of cases is limited . The purpose of this case presentation involving two different immediate loading cases was to show the clinical and radiographic status after as many as 18 months of functional loading. Case 1: immediate implantation and immediate loading An 18 year old female patient was sent by her dentist for evaluation of tooth #11 to the Department of Prosthodontics of the Faculty of Dentistry at Istanbul University. Clinical and radiographic examinations showed external resorption of the roots of tooth #21, and even more so, tooth #11 (Figures 1a and b). Tooth #11 had slight mobility and a negative vitality test, whereas tooth #21 was still vital. The dental history included orthodontic treatment. The endodontic consultation led to the decision to retain tooth #21 and extract tooth #11. After an atraumatic extraction of tooth #11 (Figure 2), an AstraTech® implant with an Osseospeed® surface, 4.5 mm in diameter and 13 mm in length, was placed in the fresh extraction socket in a 3-dimensionally correct position (Figure 3). After primary stability was affirmed, a ―Direct Abutment®‖ was mounted, upon which a temporary acrylic (Dentalon® /Heraeus-Kulzer®) crown was fabricated chair side. The marginal fit was finished and controlled on a laboratory analogue and then temporarily cemented (Kerr ®, Temp Bond®; Figures 4a and b). The provisional crown was protected from contact by any excursive movement of the mandible. The final result was controlled by a periapical radiograph, where the marginal fit was also demonstrated (Figure 5a). Three and one-half months later, minimal bone loss was observed radiographically (Figure 5b). Porcelain fused to ZrO2 (Cercon®; Degudent, Hanau, Germany) was fabricated and cemented permanently (Panavia 21®; Kuraray, Tokyo, Japan) following a 10-day period of temporary cementation. The 16 month control x-ray (Figure 6a) showed a stable situation around the implant and a resorption rate comparable with delayed loading protocols, whereas the clinical view showed excellent pink esthetics (Figure 6b). Case 2: immediate loading of an implant in the upper incisor position A 22 year old female patient who had lost tooth #21 in a car accident several months earlier, applied to the Department of Prosthodontics of the Faculty of Dentistry at Istanbul University for consultation (Figure 7). An AstraTech® implant with an Osseospeed® surface, 4.5 mm in diameter and 13 mm in length, was placed in the #21 position in a 3-dimensionally correct position. After primary stability was affirmed, a ―Direct Abutment®‖ was mounted, upon which a temporary acrylic (Dentalon® /Heraeus-Kulzer®) crown was fabricated chair side. The marginal fit was finished and controlled on a laboratory analogue and then temporarily cemented (Kerr®, Temp Bond®). The provisional crown was protected from contact with any excursive movement of the mandible; since the patient had an open-bite, this was easy to accomplish. The final seating of the crown was controlled by a periapical radiograph where the marginal fit was very good, as in case 1. Three months later, the final restoration (porcelain fused to a metal crown) was fabricated and cemented (Figure 8) with polycarboxylate cement (Adhesor® Carbofine–SpofaDental/A Kerr Company, Praha - Czech Republic). The control session 18 months after functional loading showed a stable clinical (Figure 9) and radiographic (Figure 10) outcome. Case 3: immediate loading of an implant in the lower incisor position A 27 year old male patient who had lost tooth #41 due to a trauma several months earlier, applied to the Department of Prosthodontics of the Faculty of Dentistry at Istanbul University for consultation (Figure 11). An AstraTech® implant with an Osseospeed® surface, 3.5 mm in diameter and 15 mm in length, was placed in the #41 position and 3-dimensionally correct (Figure 12). After primary stability was affirmed, a ―Direct Abutment®‖ was mounted, upon which a temporary acrylic (Dentalon® /Heraeus-Kulzer®) crown was fabricated chair side. The marginal fit was finished and controlled on a laboratory analogue and then temporarily cemented (Kerr®, Temp Bond®). The provisional crown was protected from contact with the opposing teeth again; in the meantime a provisional crown for the already prepared #31 was fabricated, too. The patient disappeared and came for definitive restoration 8 months later. The radiograph taken in this session showed a well kept crestal bone level (Figure 13). Results and Discussion IMMEDIATE IMPLANTATION Since the first reports demonstrating successful implantation into fresh extraction (4) (5, 6) sockets , this technique has gained frequent, widespread use . Immediate implantation has several advantages, such as reducing the number of surgical interventions and the total treatment time. Furthermore, the alveolar bone at the extraction site is protected against resorption (7, 8, 9) and the soft tissue esthetics can be better maintained (10). It is well-known that the bucco-lingual alveolar crestal width shrinks 5-7 mm, which is approximately 50% of the original volume, in the first year after tooth loss and the largest (11, 12) resorption appears within the first 4 months . Parallel to that resorption, a vertical bone (13, 14). loss of 2-4.5 mm continues simultaneously The extraction of several neighboring teeth (11, 14, 15) causes an even greater volume loss in the bone . Immediate implantation should be avoided in the following situations: infection at the (16, 17, 18) extraction site , significant discrepancies in the size (i.e., diameter) of the implant and the alveolar socket, and absence of primary stability of the placed dental implant. Studies with animals have shown that the distance of the implant surface to bone is important for clot stabilization (19, 20, 21, 22). Distances > 2 mm must be covered by a membrane (23, 24, 25, 26). IMMEDIATE LOADING If the requirements for immediate loading are met after an implantation, this treatment option is valuable in the fulfillment of the esthetic and functional expectations of patients. A fixed provisional crown in comparison to a temporary removable denture is more comfortable and less vulnerable to fracture or loss. (12, 27, 28, 29) The implant should be positioned 3-dimensionally in the correct position and primary stability must be secured. Additionally, the socket walls where the implant will be (30) placed must be intact to warrant later soft tissue esthetics . Insufficient bone support and a (31, 32, 33, 34, 35, 36) thin biotype often lead to disastrous results . If bony support is defective, a dehiscence, or a thin biotype is detected prior or during the surgery, a grafting procedure which will delay the loading time is indispensable. Another important risk factor is a history of (37, 38) aggressive periodontitis, especially combined with cigarette smoking . These cases can show unpredictable soft tissue recessions. The provisional crown is a key factor in the success of immediate loading of single implants, patient satisfaction, and soft tissue and inter-proximal papilla shaping. The provisional crown should not cause an extensive pressure on the gingiva, which could lead to recession. Furthermore, the crown should be fabricated in a manner to avoid contact in laterotrusion or protrusion. Proper indications, good surgical technique, and the use of a prosthetic protocol are very important for the success of immediate loading and immediate implantation. Patient satisfaction is very high and difficulties related to the implantation site in late implantations are eliminated. Nevertheless, there are also contraindications for these treatment modalities. If even one of the following patient-related factors, such as poor systemic health, a heavy smoking habit, poor oral hygiene, a thin biotype, or an infection in the extraction region is present, this treatment option should not be considered. All three cases presented herein showed a relatively good soft tissue response and a physiologically normal crestal bone loss after up to 18 months of functional loading. Periapical radiographs showed clearer and more accurate details than panoramic radiographs (39). 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