Immediate Loading In Implant Dentistry OCR Surgical, Prosthetic, Occlusal, and Laboratory Aspects Vicente JimenezLopez

1 Introduction and General Considerations for Immediate Implant Loading 1 2 Surgical Technique for Immediate Loading of Single Implants 1s Ricardo Fernandez Gonzalez Implant Placeme

Madrid, Spain

Translated by Thomas P Keogh, Jr ret1red USAGS, and Thornas P Keogh Ill MD, DDS

Editorial Quintessence, S.L

Barcelona Chicago, Berlin, Tokyo, Copenhagen, London, Paris, Milan,

Dedication

To my rnends Ramon Mendoza and Vicente Jimenez (my rather): My thanks tor having let me learn trom your age and experience, your illness, your suffering, your knowledge and love of life your tempered bravery, your company your always sage advice your insistence your patience your not-always-understood humanity, your personal charisma and generosity, your always timely criticism your sense of humor your engaging smile your self-discipline your joy at my successes and sadness at my failures your understanding, your involvement, your lnendship and affection You were friends who will live as long as I exist

To my wife Pepa and my children Jaime Silvia, David, and Pepa, for your love, sense ot family

alfect1on unconditional support, and For being the way you are

Torres Trade (Torre Suri

Gran Via Carles Ill 84

All nghts reserved This book or any part thereof may not be reproduced

stored '" a retneval system, or transmitted 1n any form or by any means

electronic mechafllcal photocopymg, or oth0fWIS0 Without pnor written

permlSSlon of the publrsher

1 Introduction and General Considerations for

Immediate Implant Loading 1

2 Surgical Technique for Immediate Loading of Single Implants 1s

Ricardo Fernandez Gonzalez

Implant Placement 1n the Alveolar Process with Adequate Bone Height and Width

Implant Placement Following Tooth Extraction

Implant Placement 1n the Alveolar Process with Width and/ or Height L1m1tations

Implant Placement Immediately Alter Extraction of an Impacted Tooth

3 Prosthetic Features of Immediate Implant Loading

in Single Teeth 49

Extracted Tooth and Well-Preserved Alveolus or Alveolus with M1n1mal Bone Loss

Tooth Not Extracted and Well-Preserved Alveolus, or Alveolus with M1n1maJ Bone Loss

Nonextracted Tooth and Alveolus with Substantial Bone Loss

Extracted Tooth and Substantial Bone Loss

Single Tooth Replacement 1n the Posterior Areas

lnterrelat10nsh1p Between Ill and OrthodontJcs

5 Immediate Implant Loading for Overdentures

and Mandibular Hybrid Prostheses 89

Overdentures

Fixed Hybnd Prostheses

6 Branemark Novum: Surgical and Prosthetic Procedure

Jose Manuel Navarro Alonso Begona Fernandez Ateca, and Ramon Martinez Corria

Preoperatrve Evaluation

Procedure

Patients Treated with Branemark Novum

Conclusions

Surgical and Prosthetic Protocol for Immediate Provisional Prosthesis

Postoperative Protocol and Rehab11itat1on Program

Vicente J1menez-L6pez and Santiago Dalmau Bejarano

Achieving a Good Master Cast

Achieving a Blueprint of the End Product

Design QI the Alloy Structure and Selection of the Recovering Material

The Milled Titanium System: Procera Implant Prosthesis

The Procera Titanium Abutment System

The Procera Ceramic Abutment System

Technique for Luling Crowns over a Metal Structure

Technique for Screw-Retained Suprastructures and Infrastructures

Single-Tooth Replacement

Partial Prostheses

Maxillary or Mandibular Complete Fixed Rehabilitation

Maxillary and Mandibular Fixed Rehabilrtation

Occlusal Ad1ustment in Complete Implant.Supported Rehabilitations

Nightguards

B1b11ography 267

Index 275

Chapter 1

Introduction and General Considerations

for Immediate Implant Loading

The Idea of shortening the waiting time to

solve a patient's esthetic and functional

con-cerns with a fixed prosthesis has led many

authors to address the issue of reducing the

pre-established waiting periods while

follow-ing the principles of osseointegration

devel-oped by Professor Br~nemark

Early studies focused on reducing the lime

between extraction ·and implant placement

One to 2 months of healing were considered

suff1cien1 in comparison to the 9-to 12-month

waiting period previously required to allow for

bone healing

The next step under scrutiny was the time

that elapsed between the hrst surgery

(im-plant placement) and the second surgery

(uncovering the implants and placing

abut-ments) Upon observation clinicians

deter-mined that, with a suitable quality and

quan-tity of penalveolar bone the wa1t1ng penod

could be decreased to 2 months

Interest then developed regarding what

would happen If the first and second

surger-ies were combined into one step Becker et

al evaluated quality and quantity of bone in

Vicente Jimenez-Lopez

1997 This 1-year study analyzing these rameters provided qurte an acceptable suc-cess rate-95.6%

pa-The next unknowns to be resolved cluded not only lhe single surgical proce-dure but also the 1mmed1ate provision of a temporary acrylic restoration without func-tion or tooth loading which only partially re-solved the esthetic problem Within a vari-able time period this prosthesis would be substituted for a final ceramic restoration Why not 1n the posterior dentillon? Why not for fixed partial prostheses?

in-Schnitman et al (1997) found 1n a 10-year study that immediate loading of implants was successful in 84 7% of cases The au-thors mentioned an unknown prognosis for immediate loading 1n areas distal to the 1nc1-sors

Clin1c1ans who are involved with implant cases that involve extraction of lhe entire mandibular dentition followed by an Interim complete denture have encountered esthetic problems while trying to maintain these pa-

Chapter 1 • Introduction and General Considerations for Immediate Implant Loading

prosthesis The usual scenario was to wait

for 2 months after extraction until implant

surgery could be performed, wait at least 1

week unul the patient could use the

provi-sional prosthesis and then wall for 4 months

unltl second-stage surgery_ Meanwhile this

scenano caused enormous patient

discom-fort, with an Interim prosthesis that was

al-most always unstable because or a lack of

good soft and hard tissue support

Never-theless 1t was believed that the final goal of

reaching a fixed prosthesis after a E>- to

7-month waiting period would make the

pa-tient's discomfort worthwhile

Pract1t1oners next doubted whether 11 was

possible to place implants and a fixed pros·

thesis 2 months after the extractions 1n a

one-stage protocol The more optimistic

cl1-n1c1ans thought that perhaps this could all be

done in 1 day

The obiect of this book 1s to present the

basic ideas about immediate implant loading

(Ill) as of 2003 The fast pace of changes in

the field of implant dentistry to reduce the

walling times and thereby benefit patients

re-quires us to be careful 1n using this new form

Fig 1-1 Panoramic rad1ograph

show-ing fracture of !he two most distal

mandibular implants This forced the

chnictan 10 readapt lhe prosthetic

ex-lenS<On All 1mplan1S had bicort1cal

ftx-a11on tease presented by Dr Fran=

Martinez Calorno)

of implant therapy It 1s certain that 1n the near future the realm of implant dentistry will focus on immediate loading once new re-search and technologic advances have made their breakthrough

Providing Ill requires a great deal of rience, along with advanced knowledge of implant dentistry A thorough radiologic eval-uatlon 1s required to obtain three-dimen-sional data or the bone 1n the area to be treated Information on the quality of the bone and significant surgical and proslho-dontic skills are also needed The patient's medical, psychologic and dental history is very important parllcularly with regard to the presence of parafunctions or habits that might make the prognosis less favorable For Ill purposes, those patients affected by a compromised 1mrnunolog1c system coagu· lat1on problems uncontrolled diabetes mellt-tus, or psychiatric illness must be re1ected- In the case of complete maxillary rehabilrtallon, this procedure as also contra1nd1cated be-cause of a poor prognosis (see chapter 7) Patients who smoke more than 10 cigarettes

expe-a dexpe-ay expe-are poor cexpe-andidexpe-ates for Ill, since most

I

I

I

I

Introduction and General Conslderauons for lmmed1a1e Implant Loading

clinical failures appear in this group,

al-though the present authors have generally

had remarkable results

From a surgical point of view the main goal 1s to obtain primary stabihty of implants:

this is necessary for the achievement of

os-seo1ntegrat1on in cases involving II L Several

research papers have shown that both short·

and long-term prognoses are enhanced with

implants fixed to one cortical bone layer

versus bicort1cal bone fixation (Fig 1-1 J The

authors advocate following this

recommen-dation although ii may be necessary,

partic-ularly 1n the maxilla to provide bicortical

bone implant fixation

Another requirement is good bone quality 1e bone that will withstand a1 least 32 N/cm

for implant placement Adequate bone

quan-tity 1s also needed to place implants that are

at least 10 mm long which should provide

excellent primary stability

An important factor to consider 1s implant diameter Ivanoff et al (1999) reported an

18% failure rate with 5-mm-diameter implants

when employing the conventional two-stage

surgery technique The failure rate after 5

years was reported to be 27% in the

poste-rior area of the mandible The reason for

these results is still debatable, but several

factors such as overheating, implant design

prolonged bene instrumentation due to

larger implant diameter poor preparatory di·

agnosis and case selection and bone width,

could be to blame For these reasons, the

use of Implants that are 3 75 to 4 mm 1n

di-ameter 1s recommended as long as pnmary

stability is obtained

Regarding the nature of implant surfaces, there seems to be no objection to a smooth

surface if just the hrst three threads are

smooth and the rest are provided with

rough-ness or Irregularities via some sort of surface

treatment According to Davies (2001 ), this is

probably related to keeping the coagulum 1n

close contact with the prepared bone sur·

threads should be smooth to preclude terial invasion through this area to the os-seous area surrounding the implant As a general rule the use of smooth-surface im-plants or implants with partial surface treat· ment (ie smooth first three threads Figs 1-2

bac-to 1-6) On the other hand Lozada et al have reported that Implants with the entire surface treated have achieved good results

From a functional and prosthetic point, the goal 1s to splint the various 1m· plants with a provisional restoration that will not allow for flexural forces since such forces could generate negative tension on the structure endanger the splinting (1n both the short term and the long term), and inter· fere with passive fit of the prosthesis Distal cantilevers from the implants must be avoided and if the need arises the teeth on the cantilevers must be left out of occlusion

view-A current unknown is whether the teeth need

an acrylic or a cast structure (see chapter 5)

to prevent fractures Re1nforc1ng ribbon may

be useful but 1t seems logical to assume that

a rigid framework provides a safer solution The solutions provided 1n Fig 1-7 are recom· mended In the case or a complete maxillary acrylic resin denture methylmethacrylate can used If lhe opposing arch is natural den-t1t1on: or an implant-supported prosthesis (ISP) can be used where an increased risk of fracture exists and where the use of a cast frame is recommended In any even! the metal-framework ISP can be considered de-finitive since there is no need to construct a new one later Figure 1-7 presents a patient who required rehabilitallon of the maxilla with a complete denture as the antagonist (rehabllrtation performed by Dr Urs Belser) The solution Illustrated provides good es-thetics and low risk of fracture but such prostheses should be reinforced with fiber-glass nbbon or polyethylene

Another important aspect to consider is occlusion All lateral contacts in the posterior

Chapter 1 • Introduction and General Considerations for Immediate Implant loading

Fig 1-2 OssE!Ollle implant (31ftmplant vationsJ The first three 1mpran1 threads are smooth while ll>e rest of lhe implant sur- face has bean roughened

lnno-Figs 1-3 and 1-4 The T Un11e implant (Nobel BiocareJ The shoulder has standard fabnca11on The thickness of the oxide T10 ) and 11s rugos11y increase gradually Joward the apex of the implant ( 1oox m39mf1cato0nJ

•

Fig 1-5 The Twist M AX MP-I implant (Zimmer) Fig 1-6 Comparafl'IB study of the surface roughness

ol three dtfferent tmplants at 5.000x magn1hca11on

Introduction and General Considerations for Immediate Implant Loading

Fig 1-7a The patients comp!ete denture IS duplicated

and the same color acrylic 1s used for Ille teeth The

Ideal positions for the implants are established and lhlS

duplicate can be used as a surgical template

Fig 1·7c The duplicate IS placed 1n the mouth and

re-bel os p10Y1ded 1n the acryhc resin until the implants

and copmgs can be seen through them These will be

fixed directly to the denture With acryt.c resm of the

same color Ad~uate parallelism must exist to allow

removal of the denture once the acrylic resin has set

and the retaining screws have been remcJ\led

Fig 1-7b Ten maxlllary implants ($traumann) have just been placed

Fig 1-7d Once the denture ts remOlled, the full palate

is cut back and pressure points of the acrylic on the soh tissue are vem1ed using Fit.Checker Another op- tion 1s to take a silicone 1mpress1on using the denture

as a customized tray: the denture IS then adJosled on the cast model Fmal resutt of slent wrth acrylic placed 1n mouth (Rehabihtalion by Dr Urs Belser.)

Chapter 1 • lntrOduction and General Cons1derat1ons for Immed i ate Implant Loading

forces on the implants (see chapter 9)

Para-functional contacts must be prevented and

watched for; thus nightguards or splints are

advocated

Several options for the use of Ill are

avail-able as long as they comply with the

recom-mendations previously described:

1 Single maxillary or mandibular 1nc1sor

restorations with placement 2 months

after extraction or with extraction of the

tooth and placement of implant and

tem-porary crown at the same appointment

2 Fixed partial prostheses in the maxilla or

the mandible, with the same

considera-hons as 1n point 1

3 Single premolars, with the same

consider-ations as 1n point 1

4 Single first molars; with placement of two

implants splinted together with a 2-month

wailing period after extraction

5 Fixed parllal prostheses in postenor areas

6 Fixed mandibular hybrid partial prostheses

(implant-supported alloy structures with

acrylic soft tissues and teeth, sometimes

made of porcelain, that are used for fixed

mandibular full rehabilitation)

7 Complete maxillary rehabilitation

8 Overdentures • especially in the mandible

Al the present time, following the

condi-tions described, Ill 1s preferred for fixed

mandibular partial prostheses mandibular

overdentures single tooth replacement In

anterior areas and both maxillary and

mandibular fixed partial dentures in anterior

areas (Figs 1-8 to 1-13) According to

sev-eral authors those cases involving complete

maxillary rehabllitat1ons and fixed partial

prostheses 1n the posterior areas reflect the

worst prognosis with a failure rate ranging

from 5% to 25% The reason for this high

failure rate 1s the spongy nature of the

max-Illa, which has a greater amount of lar bone than the mandible, making primary stability more difficult to obtain On the other hand, the mandible has dense cortical bone with fewer trabeculae The optimal area for placement Is located between the mental foramina, where greater bone density exists Just distal to the foramina, implant place-ment can be risked, but teeth must be shaped like canines and kept out or occlu-sion The purpose of such restora!Jons is

trabecu-only esthelic Because of the high risk invol

v-ing the posterior region addressv-ing this area

is not recommended Standard implant

placement is recommended here, unless a patient recogni7es the risks and agrees that treatment planning of this area can be enter-tained Romanos et al reported that Ill in this area could be successful with sphnhng The bone formation here was similar to that seen

in standard protocols ( histolog1c study of

Macaca fasciculans) and a satisfactory amount of early bone deposition was seen around the implants

Beginning in late 1997 when the present authors began to use Ill the following re-sults were obtained in a 3-year study:

1 Single tooth replacement in the anterior area: Eighteen implants were placed ( 12 1n the maxilla and six in the mandible) and one failed, for a success rate of 94.5% In most cases, the extraction of the tooth and the placement of the Implant and a provi-sional resin crown were carried out s1mul-1aneously All the patients had natural teeth in the opposing arch

2 Mandibular fixed partial prostheses: teen prostheses were placed tolahng 92 implants Four ol the 14 patients had the natural dentrtion in the opposing arch, four had complete Implant-supported rehabilita-tions 1n the opposing arch and six were

Four-Introduction and General Cons i derations for Immediate Implant Loading

Fig 1-8 Preoperahve panoramic radt09raph

Fig 1-10 V1f!N of lhe soft tlSSues 10 days after UL

Fig 1-12 The temporary P<OSlhaszs iS placed 1ntraomlly

Fig 1-9 lntraoral rad11>

graph foll0W1ng non of the four man- dibular 1nc1sors and placement of two im-

ei<trac-plants on the same ai:r po1ntment Ill was ear-

ned ou1 on the same day

Fig 1·11 Design of the four-unrt temporary proslhes•S supported by two implants

Fig 1-13 The defirnll\<e prosthesis 1s made of fused-to-metal with aruf1coa.J papillae 1n pink

porcela1n-Chapler 1 • lnlfoducUon and General Considerations for Immediate Implant Loading

completely edentulous Four implants

failed (two patients with the natural denti·

lion as the antagonist lost one implant

each while another patient, who smoked

and had an implant-supported maxillary

re-habilitation In the opposing arch, lost two

implants), for a success rate of 95 7% In all

cases the original prosthesis was

main-tained which represented a 100% success

rate in this aspect, making this mode of

therapy a good option of treatment

Two groups comprised this study:

1 In group 1, tooth extractions were

per-formed and Ill was earned out 2 months

later Four patients with 26 screw4ype

im-plants made up this group No failures

were encountered (half of the patients had

opposing natural dentition while the other

half had implants) resulting in a 100%

success rate

2 In group 2 Ill was performed (implants

were placed and loaded right after tooth

ex-tractions, in a single appointment) Ten

pa-tients (66 implants) made up this group

Four implants failed: two in patients with

op-posing natural dentition and the other two in

patients with implants 1n the opposing arch

The patients with complete dentures as the

opposing dentition dtd not expenence any

failures The total success rate was 94%

These results are very similar to those

pre-sented by other authors such as Henry and

Rosenberg ( 1994 ) Salama et al ( 1995 ) and

Tarnow et al ( 1997) From these studies 11

can be stated that:

• In cases of a coronal root fracture, rather than subjecting the patient to endodontics and reconstruction (these restorations often present wrlh less than 8 mm in length) it is preferable to extract the tooth and place an Implant with a provisional crown 1n the same appointment This will provide adequate soft tissue contours for the final restoration and a better long-term prognosis, since the post in many cases debonds or the root fractures This option

is also advocated for any anterior toolh or premolar 1n a similar situation

• In a full-mouth rehabihtat1on maxillary tractions must be performed first to com-ply with the length and disposition of the anterior teeth and provide for good future canine guidance against the opposing dentition adequate occlusal plane 1nchna-t1on, function, etc (see chapter 5) Shortly thereafter the mandibular dentition 1s ex-

ex-tracted and Ill is performed according to the pa1ient's needs: a 1nin1mum of 5 to 7

mm of extra-alveolar bone is mended The prosthesis is placed in the same appointment After 3 to 6 months and depending on the quantity and quality

recom-of bone, the maxillary ISP is placed This will provide the patient w1tl1 a fixed denture beginning on the first day of treatment avoiding the discomfort of a mandibular complete denture The prognosis 1s excel-lent for these cases, and the success rate 1s near 100%

• It is advisable to add an extra implant to the total number planned to be placed 1n case of a failure

I ntroduction and General Cons1dera1Jons for Immediate Imp l ant Loading

• In the presence or extensive alveolar bone

destruction, there is no other esthetic solu

-tion but bone grafting In these cases,

par-ticularly those involving the buccal aspect,

Ill 1s not recommended Instead alveolar

regeneration 1s done through grafting and

implants are placed 4 to 6 months

after-ward thus allowing for llL This reduces the

waiting time by 2 months and less bone

re-sorption occurs because osseo1ntegration

begins sooner In those cases of minimal

bone loss that require autologous bone

grafting fro1n neighboring sites Ill can be

performed 1n the same appointment

Another factor to be considered 1s: What

is the period of time that can be considered

Ill? ln1t1ally, 6 to 8 hours after implant

place-ment could be suitable but, as will be seen

throughout this book there are different

protocols and depend111g on the

prostho-donhc work needed, more lime may be

re-quired According to several authors, this

time frame can increase from 1 or 2 days 10

a maximum of 4 days Nevertheless, this

pe-riod of time 1s still short enough to be sidered Ill

con-In the case of single-tooth substitution where the provisional restoration is left out of occlusion 1t 1s d1ff1cult to consider 11 Ill How-ever, 1t must be taken Into account that the lips tongue and chewing provide some sort

ol loading

Ill 1s defined as an implant-supported restoration that is In function beginning the day of placement and depending upon the location of the implant Function remains a variable consideration; therefore 1n the ante-rior area we are addressing esthetic con-cerns only When dealing with premolars two concerns exist: esthellcs and function Nonetheless 1t is d1ff1cult to provide both from the first moment In the case of molars

a true functional load is 111votved, so its achievement will be more complicated and

so w1ll 1ts prognosis The following study was

performed by Dr Paulo Malo It focuses on Ill

111 its dffferent forms as discussed above

Study of Immediate Implant Loading (Ill)

Ill IN SINGLE TOOTH REPLACEMENT

•

Chapter 1 • Introduction and General Considerations for Immediate Implant Loading

llL IN ANTERIOR PARTIAL PROSTHESES

·Cases followed for 5 years

•

llL IN POSTERIOR PARTIAL PROSTHESES

(PREMOLAR TO PREMOLAR)·

·Cases followed for 5 years

·Cases followed for 33 months

lntroductton and General Considerauons for Immediate Implant Loading

~~~~~~~~~~~~~~~~~~~~-Ill IN REHABILITAT I ONS O F C OMPLETELY EDENTULOUS MANDIBLE S U S ING

• ALL ON FOUR " S YSTEM•

Chapler 1 • Introduction and General ConS1derat1ons for Immediate Implant Loading

The following tables hst studies available on Ill for those not familiar wrth this field For complete details please refer to the list of references at the end of the book

Introduction and General Considerations for lmmechale Jmplanl L oading

Chapter 2

Surgical Technique for Immediate Loading

of Single Implants

Replacement of a tooth with a single

implant-supported prosthesis is currently considered

a predictable and effective alternative, with

ample research to support its use (Jemt et al

1990, 1991; Jemt and Pettersson 1993;

Schmitt and Zarb 1993; Ekfeldt et al 1994;

Engquist et a~ 1995; Palmer et al 1997;

An-dersson et al 1998; Scheller et al 1998) In all

these studies a two-stage surgical protocol

was followed to ensure implant

immobiliza-tion Single-tooth restoration in one surgical

phase has proven to be successful (Buser et

al 1997), even 1f a healing cap is placed after

implant placemen! (Becker et at 1997) In

these cases the implant receives very little

load transfer

The replacement of a lost tooth through

conventional prosthodon11cs requires the

preparation of neighboring teeth This

treat-ment Is not well received by patients

Possi-ble endodontic periodontic, and esthetic

complications are true risks that can be

Ricardo Fernandez Gonzalez

avoided if preparation of the abutment teeth

for the prosthesis is not performed-ie, with placement of an implant-supported crown

Nonetheless the patient must wear a able partial denture for several months until the process of osseointegration 1s completed and the temporary and final restorations can

remov-be placed This disadvantage can remov-be overcome by the immediate placement of a crown after surgical placement of the im-plant The literature available regarding these kinds of cases 1s scant (Malo et al 2000 Er-

-icsson et al 2000b, Chaushu et al 2001 Hui

et al 2001 ) To achieve success in a

s1ngle-tooth replacement using implants two major factors must be considered: the capacity of

the bone surrounding the implant to avoid

movement and the direction and magnitude

of forces that will be loaded onto the implant

through the prov1s1onal restoration

If the implant is surrounded by trabecular

bone with wide medullary spaces and the

Chapter 2 • Surgical Technique for 1mmed1a1e Loading of Single Implants

crown receives occlusal loads implant

macromovement is certain to occur This will

lead to fibrous encapsulation of the implant,

which will hinder osseointegratlon On the

other hand JI the implant 1s anchored to

dense bone and minimal lorces are applied

dunng the healing period, a favorable sJtua·

t1on exists for osseointegration of the

im-plant

The 1nd1cations for single implants must

be limited to SJtuatJons where oplimum

pri-mary slabihty and httle load transfer exist

According to the Lekholm and Zarb

classifi-cation b1cort1ca1 anchorage 1s 1mposs1ble 1n

type 3 and J bone With molars the risk of

failure 1s high If there are doubts about the

adequacy of the surrounding bone a

diag-nostic evalualion using the Penotest System

(Sien1ens) can be performed once the

im-plant abutn1en1 is 1n place If the result IS

un-satisfactory, the abutment is removed and a

cover screw is placed Crown placement 1s

therefore delayed until the implant has os·

seo1ntegrated If the crown 1s placed load

transler must be controlled by the ehmina·

t1on of occlusal contacts with the opposing

dent11ion during maximum intercuspa\ion

and all excursions Chewing with the con·

tralateral side is also recommended to avoid

interposition of the food bolus and

genera-tion of unroward loading or the implant

When replacing a premolar, for example a

1-mm clearance space 1s left: preferably the

lin-gual cusp is removed on the provisional

restoration

According lo the fcatu res monlloncd

above the following s1tuat1ons can be

re-stored Immediately with a single implant and

crown:

• The patient ·s tooth has been extracted but

a conventJonal prosthesis cannot be

adapted

• A tooth was extracted for periodontal or

endodonllc reasons or because of a

lls-• A tooth has experienced intense external resorption, rad1cular caries or coronocervi-cal rracture and cannot be reconstructed

• A tooth is avulsed and cannot be planted

reim-• A primary tooth JS present but the nent tooth IS not present

perma-• A canine 1s involved that cannot be tioned orthodonllcally and the primary tooth 1s present 1n patients at least 17

reposi-years old

• The patient 1s an adult with lateral sis and is undergoing orthodontic treat-ment Once the required space 1s gained lhe Immediate implant loading (Ill) tech· nique 1s perlormed This will also serve to

agene-maintain the space gained and allow the orthodontist to perform the hnal ahgn111ent

of the dentrt1on which should reduce ment time

treat-Implant Placement in the AJveolar Process with Adequate Bone Height and Width

This problem is probably the simplest and easiest to solve and requires no complicated surgical techniques This s1tuat1on occurs when the tooth has been extracted well in ad· vance and the bone Is healed and regener-ated· where a primary tooth with a resorbed

root exists: or where the permanent tooth is congenitally absent This last scenario is soon froquontty in pationts who are 17 or 18 years old with agenesis of the maxillary lat-eral Incisors while the clinician is wa1t1ng for

the bone to mature to enable placement of the implant Placement of a prov1s1ona1 crown will help ma1nta1n the space and thus

reduce orthodontic treatment lime

The first incision should be made slightly toward the lingual, almost adjacent to the line angles of the neighboring teeth This will prcr

Implant Placement in the Alveolar Process with Adequate Bone Height and Width

Fig 2-1 Twenty-Sfl\len-year-Old pauent whose pnmary

canine was mobile an<J had expet1enceo lull root

re-sorptlOfl The impacted canine had been extracted

several years belore

the nap toward the buccal and achieve

ade-quate esthel1cs When a pnmary tooth 1s

present, the 1ncis1on is made within the

sul-cus (Fig 2-1 ) It 1s preferable to extend the

in-cisions toward the neighboring teeth, rather

than making vertical incisions (Fig 2-2) This

will reduce bleeding during the adaptation

and cementat1on of the temporary crown

However, to achieve good visualizatron of the

alveolar process one or two vertical

1nc1-s1ons along the height of the line angles of

the nerghbonng teeth are needed

In the presence of type 1 or 2 bone, surgical

preparations are standard round bur,

2-mm-diameter drill, pilot drill (2 to 3 mm) 3-mm dnll,

and countersink (Fig 2-2) In the maxilla bone

depth preparation should reach the cortical

bone of the nasal floor or the maxillary sinus

f

Fig 2-2 SituatJOn alter extractJOn ot the prnnary

ca-nine The implant bed is prepared with a round bur IOI lowed t7>J a 2 ·mm dnll a 2-10 3-mm pilot dnll and a countersink A directional 1nd1cator has been placed 10 determine wht:lher the preparatJOn w111 allow lhe im- plant head 10 be buned 3 mm deep

so as to anchor the implant here and thereby obtain enhanced implant stab11rzallon In the mandible, when the bone is dense it 1s un-necessary to drill the full length of the basal as-pect of the mandible The preferred depth is

13 to 15 mm This will reduce the nsk of heating the bone When dealing with type 3 bone, rt 1s possible to vary the angle of prepa-ration to allow lor implant anchorage to either the buccaJ or lingual cortical plate With effec-tive planning this change 1n angle should not compromise the final esthelic results To achieve cortical stabihzation, use of a 2 7-mm drill is recommended for the final dnlhng, fol-lowed by placement of a 4-mm implant

over-When Implants are placed 111 esthetic areas it is important to calculate the final po-sition of the head of the implant to allow for a

Chap1er 2 • Surgical Technique for Immediate Loading of Single Implants

Fig 2-3 Overview after placing a Slandard 4 x 15-mm

1mp1an1 (Nobel Biocare) The probe tCP12) shows that

lhere are 3 mm between the implant and the most

coronal 1n1erprox1mal bone If 1he implant were not

tluned 10 an adequate depth after the appbcauon of 45

N rem of torque 11 would have oeen necessary 10

re-move 11 anct complete me depth preparm1on

good emergence profile II the bone 1s fully

preserved and a cen1ral incisor or maxillary

canine must be placed the head of the

im-plant should allow for a 3-mm inlerprox1mal

osseous n1argin (Fig 2·3) When the tooth

in-volved 1s a maxillary lateral 1nc1sor or

prerno-lar the osseous ·margin width is 2 mm These

limits shoulcl be observed because natural

bone resorption occurring down to the first

implant thread could reduce bone height

and result in a partia! loss of the g1ng1val

papillae

The implant is placed with a torque of 45

N/cm to ensure correct pnmary stab1hty If Iii·

tie resistance is encountered and the implant

rotates under torque Ill iS contra1nd1cated

and the classical two-phase surgical protocol

is recommended Nevertheless this s1tuat1on

rarely occurs 1f treatment planning and

drilling are adequate

The use of external-hex implants permrts

the use of definitive crowns {CeraOne Nobel

Fig 2-4 The Cera01ie 1-mm abutment ( Nobel care1 has been placed Thanks 10 me 1ntrasulcular 1n- CtS10ns very htlle bleeding is present, this makes con- s1ruct1on and ceme11tatt0n of the crown eas.er

B10-tions); al the same ltme, a temporary crown

can prepared in just a few minutes using an abutment for the CeraOne {Fig 2-5) as de-tailed in chapter 3 It 1s recommended that the crown be fitted and cemented before Su·

luring the flap to reduce soft tissue damage; this also allows the pract1t1oner to examine

the fit and ascertain that no cement residue

is left behind subgingivally Gin91val adapla·

lion allows for a good crown emergence file and thus results in very favorable eslhel·

pro-ICS (Figs 2·6 to 2-8)

Occasionally the natural size of the tooth

to be replaced does not allow for use of 1m·

plants that are 3 75 to 4 mm in diameter with CeraOne abutments In these s1luattons a 3.25-mm-diameter implant (31/lmpfant Inno-vations) is selected with a UCLA-type abut· ment and a cemented crown This will not compromise the papillae and will provide enough space for good periodontal health of the adjacent teeth The interim restoration ts

I

•

I mplant Placement In the Alveo l ar Process with Adequate Bone Height and Width

Fig 2·5 Adaplahon of the provisional seating for the

abu1men1 Nore !hat the coronal porhon required a cut

back 10 allow for a draw of the acrylic resin crown

•

Fig 2·7 Clrn1cat View 2 months after surgery The e x ·

ceflent esthebcs and good pen-Implant soft tlSSue

health can readily be seen

Fig 2-6 Postsurgical view after 7 days Note the lacK of inflammation and the good adaptation of the hssues to the crown I ~ was necessary 10 gnnd !he mes1al aspec1

or the canine to <NOid tareral con1acts Group func!Jon

was maintained, wh1Cll was 1he d•sclusion scheme

when the primary 10011'1 was 1n placa

Fig 2-8 The patient shows g1ngM1 when smiling The substJtubon of a pl'O'llsmnal canine for an implant-sup- ported crown has no! caused a single day of esthellc compromise

Chapter 2 • Surgical Techmque for Immediate Loading of Single Implants

1mpress1on must be taken A healing cap 1s

then placed The laboratory constructs the

provisional crown and on the day of the

sur-gery the healing cap is removed, the

UCLA-type abutment 1s screw-tightened, and the

acrylic crown is cemented (Figs 2·9 to 2-15)

The sutures that are used are 4-0 or 5-0

and 11 necessary individual sutures are

placed on the papillae and the vertical

inci-sions The tooth is then checked ror

oc-clusal contacts during opening and lateral

excursions After 7 days the sutures are re

moved

Implant Placement Following

Tooth Extract io n

Extraction of a tooth for periodontal or

en-dodonllc reasons or because of a fissure

vertical fracture, intense external resorption,

rad1cular canes or a coronocervical fracture

that cannot be reconstructed are frequent

scenarios in the office In these

circum-stances the Ill procedure follows the

extrac-tion of the tooth

Fig 2-9 This patient with advanced chronic

penodon-t~1s ne<!ded lhe mandibular nght lateral 1nosor e>t ·

tracli!d The root was sectioned and the tooth was

splinted to the other mandibular antenor teeth

-In the presence of a chronic infectious process (penap1cal granuloma rad1cular fis-

sure etc; see Fig 2-16) antibiotic therapy

must be commenced 5 days prior to surgery using a comb1nat1on of amoxicilhn and clavu-lanate potassium (875 mg/125 mg) every 8 hours and continued for 14 days Patients ex· hibiting allergies to penicillin 1nay be man· aged with chndamycin (300 mg every 8 hours) If no infection is present 10 days of antib1ot1c therapy beginning the day prior to surgery, 1s adequate The first 1nc1s1on will be 1ntrasulcular at the tooth to be extracted The

extractton must be performed carefully, preferably before raising the flap to reduce the chances of buccal cortical fracture Once

this 1s completed and the alveolar process 1s

exposed the alveolus is curetted carefully The surgeon should avoid leaving tissue there, which can interfere with the process of osseointegration and promote 1nfect1on

Achievement of primary stab1lrty along wrth preservation of the cortical plates and minimal bone loss enhances the chances for success However, if a defect 1s present along the cortical plate or 1f a large defect af-

Fig 2·10 Preopera1ove VlfNI aller sect10n1ng the spllnl and before implant pkleemenr

Implant Placement Following Tooth Extraction

-Fig 2 · 11 Implant bed preparation with 2 7-mm dnll

I av.i 1bl1" sp;ice does not allow tor a

standard-d.ar11Qter tn1pJ311 t

Fig 2·13 Th• reduc<!d Wld1h or 1he mandibulat lateral

n osor "' 1 nvl a low burymg of the implan1 head This

st "°Id be avoided 10 •edU<:t> 1he nSk ol 1nterproiumaJ

bone toss adJacent ·io 1he natural dent.lion The

coro-nal portion 01 th·' implanl has 11 diameter ot 3.3 mm,

'

which permits a Oistance of 1.5 mm between 1he 1m·

plant and each of lhe adiacen1 teeth

Fig 2-15 Occlusat y,ew afler removal ol sutures A

screw·rma1ned proV1S1onat crown was placed 1 hours

aHvr surg1<ry This op1100 does not allow cement

residue 10 pcncllillC under 1ho llap

Fig 2-12 Procedur<: lor placemem of the m1crom1n1· implant 3.25 mm 10 d ame1er by 15 mm rn teng1t1 (Os- seolite 3,,1mplan1 lnnovationsl

Fig 2· 14 a1nical s1tuahon 7 dayS AllPr surgery

Chapter 2 • SurglCSI Technique for Immediate Loading of Single Implants

fecting the trabecular bone 1s present Ill

procedures can become complicated and

may require complex surgical procedures

The situation may even contraindicate the

performance or regenerative procedures and

implant placement in the same appointment

One of the most important problems when

dealing with Ill procedures in the anterior

maxilla 1s !hat the ideal direction of the

im-plant axis does not necessarily coincide with

lhat or the tooth root For lh1s reason 11 is

rec-Fig 2 - 17 Alter extraction of the 1nc1SOr the loss of

buc-cal COflical bone can be seen The perforation of lhe

Internal cortJcal plale, whlCh surrounded the ltngual as·

peel of the root, IS done with a round bur If d11lbng fo~

lowed roo1 posillornng there would be an esthetic

problem and a more drf11cuH regeneraliw procedure

ommended that the bone be perforated with

-a round bur pl-aced -at the height or the dle third of the internal cortical plate (Fig 2-17) Since the inner cortical plate Is stronger,

mid-it is likely that during implant placement, 1t will slide toward the weaker buccal cortical plate Making a palatal approach with this preparation allows seating of lhe implant 1n the center of the crest (Fig 2-18)

During the drilling process, a bone filter is advocated so that as much autologous bone

F ig 2- 1 6 This patient presented with a vertical fissure

on the maxillary nght central incisor with a fistula

Fig 2- 1 8 A standard 3.753t5-mm rmplant is placed along with a CeraOne abutment Note that even thoogh the implant bed is far toward the palatal, lhe implant has

its head at lhe cen1er of lhe crest

as possible may be saved and then used to

fill osseous voids around the implant This

bone can be enriched with plasma

contain-ing growth factors (GF) from the patient and

activated using calcium chloride This allows

for perfect particle cohesion and favors the

regenerative process through the large

amounts of platelet and plasmatic GF (Arntua

1999) The techniques illustrated in Figs 2-16

to 2-25 show that much of the gingival level

has been preserved, although the buccal

Fig 2-20 Alter 1he crown is cemented the nao 1s

su-tured, and a buccal graft of aurologous bone mixed

Wt!h plasma rich in GF is obtained from the pauent

Fig 2·21 Postsutunng VIE!w The 91ng1val prominence

that resutted from use of the grafung material ca11 be

Chapter 2 • Surgical Technique for Immediate Loading of Singl e Implants

t F_,

Fig 2-24a Cl meal situation at 6 months Th<> g1ngival

Fig 2-23 Periapocal radiogra.pll 3 nionthS iill"r sur gery

Fig 2·24b Occlusal viev 6 months alter suraerv The

de,,~tJOn is ready ror 1mpressoons lo be made lor the construction ol the def1n1tl\/8 crown The prOVlsoonal

Alveolar process volume has been maintained

cortical plate was destroyed as a cons&

quence of a radicular fissure The technique

of creating plasma rich 1n GF is explained

later 1n this section

When a canine 1s replaced through Ill 1t 1s

necessary to employ wider-diameter

im-plants to achieve enhanced stabllrty and

re-duce the volume of the osseous defect

be-tween the implant and the cortical plates

(Figs 2-26 to 2-32)

Fig 2-27 Placement or a 5 x 15-mm Osseot>te implant

after root exlractJOn The use of a w1de-doamete< implant

allows for full bony CO\'erage along me lengtti of the

im-plant except for a rh1nu1e defecl on the distobuccal

area

•

•

Implant Placement Following Tooth Extraction

Fig 2-26 Patient with a crowrvroot fracture at the illary leh canine

max-Fig 2-28 Penapical rad109raph Showing Placement ot

a STA 453 abuiment 13 v lmp1an1 Innovations) This is

used with srandarckliameter 1mplams Its use here a ~ lows for good marginal adama11on and an increased distance from the neighbonng denht1or l

Fig 2 · 29 The crown IS cemenlad pnor to sutunng the

wound

Chapter 2 • Surgical Technique for Immediate Loading ol Single lmplanlS

Fig 2-30 View of the area 6 clays alter surgery The

su-ture had become loose, probably as a result of

trau-matic 1001hbrush1ng alter surgery

Figure 2-33 depicts a horizontal fracture of

the coronal third of the root on a maxillary left

central 1nc1sor with 2 mm of g1ngival

reces-sion However the buccal depth was 6 mm,

which may have 1nd1cated that the buccal

plate was destroyed Tooth mobility was

pen-F ig 2 - 32 Palatal view 1 month alter surgery The

g1n-g1val rnargm has been maintained because the cortical

bone 1n the palate was p<eserved

marked but the position was retained thanks

to splinting with ribbon fibers and cornposite;

as seen 1n Fig 2-34, the splint was fractured

To avoid the use of a removable prosthesis

an immediate implant and crown were placed To achieve favorable esthelics and

regenerate part of the lost tissues, a

regener-ative technique using plasma rich 1n GF was

• Solullon of calcium chloride ( 10%)

Before surgery blood 1s extracted through

a peripheral vein, usually 1n the forearm (Fig

2-36) The Venofix System (Terumo) permits

fill-ing of the vacuum tubes containing the

sodium citrate as an anticoagulant solution

Fig 2-35 Venofix System for blood extraction

Im p lant P lacement Fo llow ing Too t h Extraction -

Fig 2-33 Paltem wtlh honzontal fracture of 1he coronal third of the root on the maxillary left central Incisor Note the 1Qllammat1on and buccal r001 recess!OO The probing deplh here W<IS 6 mm

Fig 2-34 The tooth was kept in place thanks to splint· 1ng which had fractured

Fig 2-36 Venous ex1taetJOn at the rorearm

Chapte r 2 • Su r gica l Techn i que for I mmediate Loading of Si ngle I m plants

Fig 2-37 A vacuum tube cs filled with 0.5 mL sodium

crtrate (3.B'lb)

Fig 2-38 The four necessary tubes of btood are

ob-tained for the regeneralM! process ( 18 ml of blood)

(Flg 2-37) Four tubes must be obtained with 4.5 ml o f blood in each (Fig 2-38) The blood samples are then loaded on the centnfllga- tion device at 280G for 8 minutes at room tempera t ure Once the process is concluded the tubes are carefully removed from the ma- chine always kept 1n the vertical position Two clearly differentiated zones can be observed

in the tubes: one w i th red blood cells and the

o t her with plasma (Fig 2-39) Through the use

of t he pipettes plasma is obtained from the different fractions (Figs 2-40 and 2-41 ) First, with the 50G- µl pipette, the third fraction Is obtained from the four tubes and immediately drscarded Wrth the same instrument 0.5 m l

is removed from the plasma that corresponds

to the second fraction {nch with GF); this 1s deposrted in a sterile tube designated as no 2

Finally, with t he 10G- µ l microp1pette 0.3 ml tram the plasma that corresponds to the first fraction, which will be extremely nch in GF, is obtained It is then placed 1n tube no 1 (Flg 2-

42) The tubes are lef t on the rack and the surgical procedure 1s begun

Fig 2-39 View of the tubes after centrifugation at

280G for 8 minutes

-·

Fig 2-40 Different fractions ol plasma

-

Fig 2-41 Separation of the fractions with a pipette Firs!, the 0.5 ml (nch in platelets and GF) 1s separated out fol- lowed by the 0.3 ml nearest the red blood sa-

nes cells (very nch 1n pla1elets and GF)

Implant Placement Following Tooth Extraction

Fig 2-42 Two tubes are obtained· one w11h 2

ml of plasma nch 1n GF (0.5 ml from each of the rour tubes) and another with 1.2 ml of

plasma that is 110ry rich 1n GF (0.3 ml from each tube)

Chapter 2 • Surgical Technique for Immediate Loading of Single lmplams

In Fig 2-43 the root has been extracted

and the defect can be readily seen During

the drilling phase a bone filter is used to

re-cover bone obtained from the drilling site

This material can then be used to fill a defect

(Flgs 2-44 and 2-45) Once lhe implant is

placed, along with the CeraOne abutment, a

number of implant threads are left exposed

(Fig 2-46) While the temporary crown is

being constructed, the plasma Is activated

(see Fig 2-40) by adding 60 µL of calcium

Fig 2-43 Af1er ex1ract1on or the tooth rt was apparent

tha1 the bone destructo0n had reached the level of the

fracture

Fig 2-44 A bone filter IS used to collecl the bone lost

dunng dnlhng

chloride to tube no 1 and 100 µL to tube

no 2 (ie 50 µL/ml plasma) Tube no 1

con-taining the plasma that is highly rich in GF and platelets, is mixed with the autologous bone obtained in the bone filter (Fig 2-47), and the remainder is added to tube no 2

Once the crown has been cemented the riched grafting material 1s packed carefully

en-so as not to leave voids Platelet aggregation and the change from fibrinogen to fibrin

within the graft will permit excellent cohesion

of lhe bone particles; the mixture acquires a stable and rubbery consistency (Fig 2-48)

Now the clinician must wait until the extract

in tube no 2 completes the formation of the autologous fibrin coagulum (Figs 2-49 and 2-

50); this substance is then placed over the

graft Figure 2-51 illustrates how the defect has been filled with bone and plasma It is

necessary to raise a spht-thickness coronally

displaced flap to cover the temporary crown

margin with g1ngiva (Fig 2-52) Figure 2-53 shows the result 6 months later, following the healing process and placement of the final

crown

Fig 2-45 Aulotogous bone is obtained from the filter

Fig 2-46 Placement or a 4-mm<liame l e1' implant and

a CeraOne abutment

Fig 2-4a The graft achieves cons.stency after platelets

are added and hbnnogen converts into l1bnn

Fig 2·50 Formation of autolOgous f1bnn coagulum

Implant Placement F o llowing T oo th Extract i on

Fig 2-47 The autologous graf t ing matenaf is mixed with the plasma which was prav1ousty treated with cal- cium chfonde

Fig 2-49 The p l asma has achieved consistency 1n tube no 2, 10 minutes alter actMltton wrth calclum chloride

Fig 2-51 Situation alter placement of the prOV1s1onal crown au 1 ologous bone graft mixed with plasma nch 1n GF and fibrin coagulum

Chapter 2 • Surg i cal Technique lor Immediate Loading or Single Implants

Fig 2-52 The wound 1s sutured aher the coronally

dis-placed nap 1s raised

When the osseous defect surrounding the

tooth to be extracted 1s too large thereby

preventing primary implant stability

regener-ative procedures are done first and Ill is

de-layed for several months, especially where

there are esthetic demands

Several therapeutic options are available

for large defects when Ill is not possible:

1 Regenerative procedures can be carried

out, as described above, and once

os-seo1ntegrat1on of the implants is obtained,

the crown can be placed

2 The regenerative grafting and implant

placement can be performed in one

surgi-cal stage The crown can be placed once

osseointegration and tissue maturity are

achieved

3 The graft can be placed and allowed to

mature followed by another surgery, in

which the implant and crown are placed in

Fig 2 - 53 Clinical view alter final crown placemen!

The first option requires three surgical phases which will considerably delay com-pletion of the case The second option re-duces both the number of surgical stages and the timelrame Placemen! of the implant

in a narrow alveolar process however creases the possibility that optimal stability and a good emergence profile will not be achieved It should also be considered that the implant itself may serve as a bamer and delay revascularization of the graft In the au-thors' opinion the third option provides sev-eral advantages that the other treatment methods do not: It requires only two surger-

in-ies and tissue maturity will be appropriate for adequate implant stabilization and direc-tion

Several techniques have been suggested

to try to regenerate an osseous defect alter tooth extraction; each has advantages and disadvantages Nonetheless it 1s not known

1

studies examining the predictability of each

are not yet available The authors will describe

a simple and successful way of addressing

this problem, obtained through clinical

expe-rience that they have been following for the

past 2 years

This technique combines the use of an tologous bone gratt or a resorbable osteo-

au-conducttve b1omatenaJ with GF-nch plasma,

and the hard tissue gratt is covered with a

free g1n91val gratt or an autologous fibrin

co-agulum The protocol follows the same

guidelines described in the previous case

(see Figs 2-35 lo 2-42)

When the regenerative process has been completed the implant surgical stage can be

earned out Figures 2-54 to 2-56 illustrate a

case 1n which because of a large bony

de-fect the implant could not placed after tooth

extraction For the extraction an 1ntrasulcular

incision was performed along the tooth

perimeter without involving the papillae Atter

careful extraction the alveolus was curetted

Fig 2-55 Extraction without the pertomiance of

re-generative procedures would create an alveolar defect

compromJSmg esthe1ics because this paflent has a

Fig 2-56 The buccal corucat plate has been lost

com-pletely collapsing the g1ng1va

Chap1er 2 • Surgical Technique lor Immediate loading of Single Implants

without ra1s1ng a flap To fill in the defect au·

tologous bone can be obtained from the

chin retromolar area mandibular ramus or

any other area along the maxilla To obtain

this grafting material a small flap is raised

and perforations are made with a ?- to

3-mm-diameter drill un!ll enough material is col·

lected: the bone 1s recovered from the bone

filler 1n the suction hose

In this case the patient did not wish to

un-dergo autologous bone-grafting procedures

so resorbable bovine hydroxyapat11e material

(81o-Oss Spong1osa Geislhch Pharma) was

used as filling matenal Two tubes containing

plasma were activated With a 50-µl

m1-cropipette (0.05 ml) of 10% calC1um chlonde

(0.05 ml/ 1 ml plasma) Enough grafting

material was then mixed in tube no 1 that It

was completely soaked The defect was filled

(Fig 2-57) and covered with an autologous hbnn coagulum (Fig 2-58) To ensure primary wound closure a free g1ng1val graft and ep-ithelium can be obtained from the retromolar zone or from the palatal fibrous mucosa These are then stabilized with 6-0 or 7-0 su-tures (Fig 2-59) Reconstruction or the hs· sues of the area involved can be observed 1n

Ftg 2·60

To avoid pressure on the surgical wound from a removable partial denture 1t 1s possi-ble to sphnt the extracted crown of the in-volved tooth to the ad1acent tee1h (Fig 2·61 )

After 5 to 6 months a second surgery 1s car· ned out to place the implant and crown as descnbed previously (Figs 2 62 to 2-67) II autologous grafting material 1s used the wailing time 1s reduced to 3 months since bone maturation occurs more rapidly

Fig 2-57 Aftet caretul curetton<J the al\/CQlus IS filled

""''h resorbable b<Mne hydroxyapa11w rBoo-Oss

Spoo-goosa) maxed w1tn GF ,ch plasma

Fig 2-58 Note lhe consistency ol tho l'br'n co:igulum

Fig 2.5g To achieve primary wound closure a tree ep

tlhei1al and connectiw tissue graft is obtained from the

palatal fibrous mucosa

Fig 2-61 Alter the tooth root iS sectioned the tooth 1s

splinted 10 the ad1acent teeth with composite and

fiber-glass This will result 1n impr<M!d esthellCS and will

pre-vent the trauma that could be caused by a removable

partial denture

•

Fig 2-62 Postoperative Vl8W 15 days af1er surgery

Note rhe excellent healing of the wound probably

re-sulting from the use of GF-ennched plasma

I mplant Placement Following Tooth Extracti on

Fig 2-60 Diagram showing placement of Iha osseous graft and g1ngMl

Fig 2-63 Surgery lo place an implant was earned Olll

6 months after the grafting procedure Note the crestal width achieved

C ha pter 2 • Surg i cal Technique for Immediate load i ng of Single Imp l ants

Fig 2-64 The regeneration that was achieved permits

ideal implant placement

•

Fig 2-65 Postaperalrve Vlf!W 1 week after placement

of the implant and tne immediate crown

Fig 2-66 Clinical srtuauon alter the healing process has concluded The esthe11cs displayed pnor lo the ex- tractJon have been mamtamed

Fig 2-67 Pe n ap1cal rad1ograph laken 6 moothS after