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Dental Tribune Middle East & Africa Edition | May-June 2015 31referral clinic Immediate implant placement long term success: a case report > Page 32 ByDr.BernardAlliotDDS,DOS, PhD, CES, DU, UAE S ummary Immediate implant place- ment is sometimes a risky procedure particularly when we are replacing front teeth, patients are always expecting quick aesthetic results. This case report will try to show you how this procedure can be provided with a reduced risk for the pa- tient. Key words Immediate implant placement, patient selection, aesthetic re- sults, long term success, case report. Introduction In case of immediate implant placement, the selection of the patient and the site are of pri- marily importance. This selec- tion will have to integrate ana- tomical and pathological factors. The following factors will have to be taken in consideration as it has been recommended by the ITI consensus (EVANS & CHEN / 2009): - medical status - smoking habits - patient’s aesthetic expectations - lip line - periodontal biotype - shape of teeth crowns - infection at implant site - bone level at adjacent sites - restorative status of neighbour- ing teeth - width of edentulous space - soft tissue anatomy - bone anatomy of alveolar crest One of the most important con- siderations will be the difficult detection of the patient peri- odontal biotype! Soft tissue biotype was previ- ously called gingival biotype or morphotype (OLSSON & LINDHE / 1991), but since the advent of implants, this has been renamed to encompass tissue around both teeth and implants (KAN & al / 2003). The term re- fers to a composite or aggregate of four features of the soft tissues and the teeth they surround that build up to a specific picture: - gingival width (keratinised tis- sue width) - gingival thickness (thick or thin) - papilla height and proportion - crown width and height ratio. Thin scalloped periodontal bio- types (Fig. 1 & 2) are character- ized by: - highly scalloped soft tissues and bone contours - delicate and friable soft tissues - narrow band of keratinized tis- sue - thin bone with dehiscences and fenestrations - long pointy papilla - long tapered teeth whereas thick flat periodontal biotypes (Fig. 3 & 4) are present- ing: - relatively flat soft tissues and bone contours - dense and fibrotic soft tissues - wide band of keratinized tissue - bone thick with ledges - short blunted papilla - short square teeth This detection is important more particularly to prevent aesthetic complications. Inflammation generated by accumulation of plaque on the root surface ex- tends into the tissue for a dis- tance of 2 mm in all directions (KAN & al /2010): - concerning thin biotypes, the distance from the root surface to the oral epithelial surface can be less than 2mm, inflammation will involve all the structures (cementum, periodontal liga- ment, bone and gingiva) rapidly resulting in a recession. Bundle bone (lamina dura) is very likely to be the buccal plate; we can expect considerable collapse of the socket, resulting in a contour deficiency; bone grafting and compromised position / angula- tion of the implant, especially if patient is getting implant treat- ment in the aesthetic zone. - concerning thick biotypes, due to a thick alveolar housing around the teeth, the 2mm ra- dius of inflammation will dam- age cementum, ligament and bundle bone only, producing a periodontal pocket. Patients may end up with less alveolar deficiency; restorative treatment can be viewed as being more predictable and less demanding. Peri-implant tissue health seems to depend to there being immo- bile keratinized tissue around the emergent restoration: - thin peri-implant soft tissues seems to be more prone to re- cession and less likely to develop nicely formed papillae around implant restorations. - tissue recessions around im- plants seems to result in ab- sence of immobile keratinized tissue more quickly that around natural teeth, possibly because the shoulder of most implants are placed more apical to the cemento-enamel junction of the teeth they replace. - mobile tissue around an im- plant is associated with in- creased risk of development of peri-implant diseases and au- thors recommend an augmenta- tion of the keratinized tissue as one of the treatment strategies in managing peri-implantitis. A thick soft tissue biotype is a desirable characteristic that will positively affect the aesthetic outcome of an implant sup- ported restoration because thick soft tissue is more resistant to mechanical and surgical insults, is less susceptible to mucosal recession and has more tissue volume for prosthetic manipula- tion (COOK & al / 2011). There- fore, although tissue biotype is an inherent trait that varies from patient to patient, it can be trans- formed through precise man- agement of the implant position, implant design and prosthetic design such that a desired aes- theticoutcomeisachieved(FU& al / 2010). Most of the literature on implant success rates has not identified a correlation with the gingival biotype, although it is increasingly accepted that the biotype and tissue volume have an important impact on the aes- thetic outcome and minimizing the risk for post-restoration tis- sue instability. Case report Patient is a man, 45 years old; he is presenting good health, he is non-smoker and his oral hygiene is good. He complained five years ago (in 2010) about the presence of a recent dias- tema between 11 and 21, and about a slight mobility tooth 21 (Fig. 5) After complete examination, we detected the presence of a root resorption (Fig. 6), so it has been decided to extract this central in- cisor and to replace it by a dental implant. A complete aesthetic risk assessment of the patient and the site has been done and the results are presented in red inside of Table 1. An extraction without incisions has been done using periotome in order to preserve the sur- rounding bone and soft tissues. A Straumann® bone level im- plant (length 12mm / diameter 4.1mm) has been placed inside the socket in a palatal position and the remaining gap (around 1.5mm) between the implant and the buccal bony wall has been filled with a bone graft Bio Oss®, and the top of the socket has been protected with a Colla- cone® without sutures (Fig. 7 & 8) (CORDARO / 2014). Then at the end of the same ap- pointment, the extracted tooth (full crown and 3 mm of the root) has been used as tempo- rary restoration and fixed to the adjacent teeth using a metal grid. The presence of this pre- vious tooth was of primarily importance in order to support the surrounding soft tissues and more particularly the papilla on both sides of the implant (Fig. 9 & 10). Before to restore the implant with a final crown we took in consideration the latest recommendations concern- ing cementation on dental implants (I.T.I. / 5th Consensus 2013): - after bone level implants place- ment, if the depth of the mucosa margin is deeper than 1.5mm, screw-retained prosthodontics are highly recommended, - reduce the quantity of cement used to cement prosthetic resto- rations, - if the patient has been treated previously for periodontal dis- eases, use only temporary ce- ment, you will have the possibil- ity to remove the superstructure in order to treat an eventual peri-implantitis. At the time of the final restora- tion, it is also very important to keep in mind predisposing fac- tors leading to cement retention around dental implants: - the soft tissue connection around dental implants (epi- thelial adhesion with hemi- desmosomes and absence of connective tissue attachment) which is different from natural teeth (epithelial attachment and connective tissue attachment), - the sub-gingival placement of the implant more or less deep than the cemento enamel junc- tion of the natural teeth, - the abutment selection: abut- ment with a fixed restorative margin 2-3 mm to the implant neck or one-piece implant with a built-in restorative margin, - the radiographs are unable to show the presence of retained cement on buccal and palatal / lingual sides, - the cementation issues: ex- cessive quantity and unsuitable type of cement used, - the maintenance controls not always respected by a majority of patients. At the end of a period of heal- ing of 10 weeks, you can see the very good positioning of the soft tissues (Fig. 11), the implant has been exposed (Fig. 12), the depth of the sulcus was more Dr. Bernard ALLIOT - GMC Clinics / Dubai - U.A.E. Management of aesthetic risk AESTHETIC RISK FACTORS LEVEL OF RISK LOW MODERATE HIGH Medical status Healthy, cooperative patient with an intact immune system Reduced immune system Smoking habits Non smoker Light smoker (< 10 cigarettes / day) Heavy smoker (> 10 cigarettes / day) Patient’s aesthetic expectations Low Medium High Lip line Low Medium High Periodontal biotype Low scalloped, thick Medium scalloped, medium thick High scalloped, thin Shape of tooth crowns Rectangular Triangular Infection at implant site None Chronic Acute Bone level at adjacent teeth ≤ 5 mm to contact point 5.5 to 6.5 mm to contact point ≥ 7 mm to contact point Restorative status of neighbouring teeth Virgin Restored Width of edentulous space 1 tooth (≥ 7 mm) / 1 tooth (≥ 5.5 mm) 1 tooth (< 7 mm) / 1 tooth (< 5.5 mm) 2 teeth or more Soft tissue anatomy Intact soft tissue Soft tissue defects Bone anatomy of alveolar crest Alveolar crest without bone deficiency Horizontal bone deficiency Vertical bone deficiency Table 1 Fig. 1. Thin periodontal biotype Fig. 5. Patient at first consultation Fig. 2. Triangular teeth, long pointy papilla & thin periodontal biotype Fig. 6. Radiograph at first consulta- tion Fig. 3. Thick periodontal biotype Fig. 7. Extracted tooth with root re- sorption Fig. 4. Square teeth, short papilla & thick periodontal biotype Fig. 8. Implant and bone graft cov- ered with collagen sponge Dr. Bernard Alliot, UAE