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ePaper created 2018-04-05, 09:17:31 | version 1.38.0
I m m e d i a t e i m p l a n t s i n t h e e s t h e t i c a r e a Fig. 1 Fig. 2 Fig. 1 Root remnant of first maxillary left premolar, occlusal view. Fig. 2 Root remnant of first maxillary left premolar, lateral view. 2 . T o o t h e x t r a c t i o n The atraumatic extraction of the tooth to be replaced with an immediate implant is essential to prevent damage to the buccal bone plate and to preserve the interproximal papillae and labial soft tissue. Flapless extraction should be pre- ferred or only a minimal mucoperiosteal flap ele- vation14 to preserve the integrity of the vascular supply from the periosteum and avoid alveolar bone resorption in the exposed area (Fig. 3). 15, 16 Several measures or instruments can be adopted to aid in an extraction that is the least traumatic as possible, including sectioning the tooth to carefully remove the fragments and the use of a piezoelectric device or microsurgical instrumentation, such as periotomes. After the extraction, the socket should be thoroughly degranulated by careful curettage. Then, the integrity of the buccal bone and soft tissue should be checked to determine whether it is favorable for immediate implant placement. 3 . S o f t - t i s s u e m a n a g e m e n t The maintenance of soft-tissue contour and dimension is one of the most challenging aspects of immediate implant placement. Indeed, mid- facial mucosa recession around immediate implants has been reported to occur in a high percentage of cases (40%),8, 17, 18 and almost one- third of unsatisfactory esthetic outcomes have been associated with several factors, such as tissue biotype, thickness of facial bone wall and implant positioning.14, 19 It should also be taken into consideration that most of the soft-tissue changes can continue after implant surgery, even on a long-term basis.15 Today, it is well known that the surgical technique influences the soft tissue around immediate implants.16, 20 The surgical procedure is usually performed flapless,21 and it has been shown that it enhances esthetics and decreases gingival recession,22 as previously discussed. The soft tissue at the facial level needs to be supported by a buccal bone wall of sufficient height and thickness. There- fore, a volume augmentation through grafting at the time of implant surgery seems to be strongly recommended7, 23, 24 to maintain the bone volume at the facial level on a long-term basis25, 26 and thus to avoid a soft-tissue collapse, which can be responsible for some negative esthetic effects.27, 28 Otherwise, the soft tissue can be managed by a provisional crown, and there is evidence to support that immediate implant placement with temporary restorations can provide stable esthetic results and limited recession.29 In fact, it has been shown that it is advantageous to avoid manipulation of soft tissue during and after initial healing because such an intervention may disrupt the soft-tissue seal.30 This manipulation is unavoidable when implants are placed according to the traditional two-stage protocol. Thus, the idea is that 18 Volume 4 | Issue 1/2018 Journal of Oral Science & Rehabilitation