Preserving the tissue profile with immediate implant placement and immediate provisionalization technique

Adityo Widaryono; Sunny Indriani Kurnia; Fatimah Maria Tadjoedin

doi:10.4103/SDJ.SDJ_42_22

CASE REPORT

Year : 2022 | Volume : 6 | Issue : 3 | Page : 156-160

Preserving the tissue profile with immediate implant placement and immediate provisionalization technique

Adityo Widaryono¹, Sunny Indriani Kurnia², Fatimah Maria Tadjoedin¹
¹ Department of Periodontology, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia
² Private Practice, Jakarta, Indonesia

Date of Submission	09-Jul-2022
Date of Decision	12-Aug-2022
Date of Acceptance	28-Aug-2022
Date of Web Publication	15-Nov-2022

Correspondence Address:
Adityo Widaryono
Department of Periodontology, Faculty of Dentistry, Universitas Indonesia, Jl. Salemba Raya No. 4, Jakarta Pusat 10430
Indonesia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_42_22

Abstract

Background: Single-tooth replacement in the esthetic zone with a dental implant remains a challenge for clinicians. One challenge is the difficulty of creating a natural tissue profile in the cervical of the implant restoration. In a healed edentulous ridge, multiple surgeries along with hard- and soft-tissue augmentation will be required to gain sufficient tissue volume, thus significantly increasing the patient morbidity. Immediate implant placement, combined with a customized healing abutment, can potentially overcome these difficulties. Case Report: This case report describes the treatment of a patient with a subgingival fracture of the upper central incisor with an implant placement immediately after tooth extraction, xenograft gap filling, and nonfunctional provisional restoration to seal the extraction socket. The incisor had previously undergone root canal treatment and had been restored using a fiber post and ceramic crown. Conclusions: The use of the immediate implant placement with a nonfunctional provisional restoration (immediate implant placement and immediate provisionalization) technique preserves the tissue profile and volume during the implant healing period. This provides the clinician with a natural soft-tissue profile for implant restoration, without the need for an additional surgery.

Keywords: Emergence profile, immediate implant placement, immediate provisionalization

How to cite this article:
Widaryono A, Kurnia SI, Tadjoedin FM. Preserving the tissue profile with immediate implant placement and immediate provisionalization technique. Sci Dent J 2022;6:156-60

How to cite this URL:
Widaryono A, Kurnia SI, Tadjoedin FM. Preserving the tissue profile with immediate implant placement and immediate provisionalization technique. Sci Dent J [serial online] 2022 [cited 2023 Mar 20];6:156-60. Available from: https://www.scidentj.com/text.asp?2022/6/3/156/361160

Key Messages:

Reports and clinical studies have demonstrated that the survival rates for immediate implant placement are equal to, if not slightly higher than, those for delayed implant placement.^[1],[2],[3]

Background

When the tooth structure is severely compromised, a prosthetic replacement is required, and an extraction is recommended. Implant-supported prostheses are one of the most reliable options available for tooth replacement today. A single-tooth implant-supported restoration represents about one-half of all implant cases seen in the clinical practice on a daily basis, with many of these implants in the esthetic zone.^[1] Despite the high survival rates of dental implants, changes, such as gingival recession or spontaneous rebound of the receded mucosa margins, have been observed after a few years of function.^[1] It was postulated that these changes in the peri-implant mucosa were an attempt to establish a stable biological width of the implant. An understanding of the dentogingival complex and its implant counterpart (i.e., the peri-implant mucosa) allows clinicians to balance biological/physiological requirements and esthetic demands of single-implant restorations in the esthetic zone.^[2]

The latest concept in implant surgery is the immediate implant placement and immediate provisionalization (IIPIP). In the IIPIP technique, an implant was placed immediately after tooth extraction, socket gap filling with bone graft, and nonfunctional provisional restoration to seal the extraction socket. One advantage of IIPIP is its efficacy in optimizing esthetic success by preserving the existing tissue architecture and maintaining the natural emergence profile.^[2],[3] The other, and most desirable, advantage of the immediate tooth replacement therapy is that it reduces subsequent treatment procedures, with fewer patient appointments compared to early or delayed implant placement, thereby reducing the overall treatment time while increasing the patient comfort and preserving the natural shape of the surrounding hard and soft tissues.^[1] According to Cochran, the survival rates for immediate implant placement are equal to, if not slightly higher than, those for delayed implant placement.^[1],[4] Despite its advantages, this treatment approach also has disadvantages, such as difficulty in achieving primary stability during insertion, less predictable soft- and hard-tissue dimensions, and the need for bone graft materials.^[5]

The nonfunctional immediate provisionalization in IIPIP is defined as a load where the provisional restoration is adjusted to clear all occlusal contacts in centric and eccentric movements. The success of the provisionalization protocol depends on optimal primary stability, adequate bone quality and/or quantity, and the alveolar anatomy after the tooth extraction.^[3]

Case Report

A 55-year-old female patient without relevant systemic conditions attended a private practice with a fractured right maxillary central incisor [Figure 1]A. Clinical and radiographic evaluations confirmed the diagnosis of horizontal tooth fracture to the level of alveolar bone. Cone-beam computed tomography (CBCT) showed a 10-mm root length, intact buccal wall, and bone availability in the palatal apical of the socket, similar to Kan’s class I sagittal root position (SRP) classification [Figure 1]B. After discussion, the patient chose the immediate implant placement, with the possibility of immediate restoration. The patient signed an informed consent form prior to surgery.

Figure 1: A, Fractured central incisor; B, bone as viewed using CBCT; C, minimal trauma extraction

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Minimal traumatic tooth extraction was performed. No focal infection was found in the periapical area. Following curettage and rinsing of the extraction socket with chlorhexidine (CHX) 0.2%, the integrity of the extraction socket was evaluated [Figure 1C]. A pristine socket wall with a type 1 extraction socket according to Elian’s classification was confirmed.^[6] The osteotomy drill was directed toward the palatal apical position of the socket [Figure 2]A. This position enabled an access hole for implant restoration in the cingulum and screw-retained implant restoration. Osteotomy was performed to enable the placement of a 3.3 × 12 mm implant fixture (Bone Level Tapered, Straumann, Switzerland). The implant was placed in a correct prosthetic-driven position, with the implant shoulder located 4 mm from the gingival margin [Figure 2]B in the cingulum area [Figure 2]C. The insertion torque was 35 Ncm during full insertion, thus enabling the clinician to attach the provisional restoration. A temporary plastic abutment with a metal connection was connected to the implant [Figure 3]A, and the provisional restoration was fabricated chairside. Deproteinized bovine bone mineral (DBBM) particles (Bio-Oss, Geistlich, Switzerland) were used to fill the socket gap, and the provisional restoration was torqued to 15 Ncm [Figure 3]B. The provisional restoration was then evaluated intraorally to ensure that there was no evidence of contact upon the occlusion or functional movement. The patient was instructed to take 60 mg of etoricoxib twice a day for 3 days, if necessary, and to rinse with CHX 0.2% twice a day for 1 week.

Figure 2: A, Implant placement in the cingulum area; B, adequate placement depth; C, optimum three-dimensional position of the implant

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Figure 3: A, Temporary abutment attached; B, provisional in situ

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No complications were observed during the healing period. At follow-up 6 months later, osseointegration was confirmed clinically, and the soft- and hard-tissue volume around the provisional restoration was preserved [Figure 4]A and B. Because of the immediate provisionalization, the tissue emergence profile was similar to that of the adjacent tooth. The final polyvinyl siloxane impression was taken using a customized impression abutment specially made to copy the soft-tissue emergence profile and support the soft tissue during the impression process [Figure 5]. A screw-retained restorative design was used, and the final restoration was torqued to 35 Ncm, followed by covering the access hole with light-cured composite [Figure 6]. Unfortunately, no follow-up radiograph is available in the present case.

Figure 4: A, Preserved tissue profile 6 months postoperatively; B, buccal view of the cervical contour 6 months postoperatively

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Figure 5: A, Shaping the subgingival part of the impression abutment; B, customized impression abutment to support soft tissue

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Figure 6: A, Buccal view of the final restoration; B, palatal view with the access hole in the cingulum area

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Discussion

The immediate replacement of a single tooth with an implant is no longer considered an experimental technique.^[1],[4] As the preservation of existing anatomical structures is easier than their re-creation, provisionalization with a nonfunctional prosthesis immediately after stage I (implant placement) surgery has been suggested.^[7] Nonfunctional restoration is defined as the provisional restoration that adjusted to eliminate occlusal contacts in centric and eccentric movements.^[3] This provisional restoration is intended to support the free gingival margin and is fabricated to seal the socket and maintain the graft particles in place.^[8]

An interest in the IIPIP technique can be attributed to the following benefits: (1) the preservation of tissue and optimization of the soft-tissue contour,^[2] (2) simplification of the treatment and reduction in the number of treatment (follow-up) visits,^[7] (3) improved psychological advantage (patient confidence), and (4) enhanced patient comfort and esthetics.^[3] Although the IIPIP technique requires a much lower number of treatment visits (n = 3) than the delayed technique (n = 7),^[1] the clinician should be aware that this predictability is applied where case indications are properly assessed and its execution is perfectly accomplished.^[7] Bhekare et al. described a five-factor decision tree during the diagnostic and surgical phases of treatment to predictably and successfully apply the IIPIP technique.^[8] These factors are: (1) the absence of the active infection, (2) a harmonious gingival contour, (3) a stable buccal plate, (4) sufficient bone for primary stability, and (5) achievement of the primary stability.^[8]

Compared to the immediate insertion of a dental implant into a noninfected site, the insertion of an implant into an active purulent infection site was associated with a 116% increase in the risk of implant failure.^[8],[9] On the other hand, the high implant survival rates reported in several studies point to the successful osseointegration of implants when placed immediately after the extraction of teeth presenting with chronic endodontic and periodontal lesions, provided that appropriate clinical procedures are performed before implant surgery.^[8],[10] These clinical procedures include antibiotic administration, meticulous cleaning, socket curettage/debridement, and a CHX 0.12% rinse.^[8],[10] In the present case, a preoperative radiograph revealed no periapical infection, and socket curettage confirmed the absence of infection.

After performing the IIPIP, tissue contour stability is always a major concern. The previous research reported that residual bone socket morphology after the tooth removal prior to the immediate implant placement was a critical factor when performing IIPIP.^[8] Elian et al. proposed a classification system for extraction socket defect based on the horizontal and vertical hard- and soft-tissue loss.^[6] Chu et al. later added a modification to the Elian type 2 classification.^[11] Chu’s modification delineated the midfacial horizontal component and the potential risk of midfacial recession associated with labial bone plate loss after the tooth extraction.^[6],[11] According to Elian’s system, defects are classified as types 1, 2, and 3: type 1: labial bone plate and associated soft tissues are completely intact; type 2: soft tissue is present but with indicative of the partial absence of the labial bone plate, 2a—coronal one-third, 2b—middle one-third, and 2c—apical one-third; and type 3: a midfacial recession defect is present, with labial bone plate and soft-tissue loss.

Some authors have suggested that hard- and soft-tissue augmentation preserves tissue volume and improves esthetic outcomes in the long term.^[12],[13] A study on various hard-tissue augmentation techniques with immediate placement showed that the defect fill was similar among the various techniques.^[12] However, extraction socket with dehiscence defects showed significantly greater horizontal resorption than sites with intact bone walls, and significantly less horizontal resorption of the facial bone occurred when peri-implant defects were grafted with DBBMs (13.9%–23.8%) compared to a nonaugmented control group (48.3%).^[12] A systematic review found that a combination of the immediate implant placement and a connective tissue graft resulted in a better stability of the gingival margin.^[2] This stability was related to a significant increase in keratinized tissue width and tissue thickness after performing soft-tissue grafting using the IIPIP.^[13] However, this study did not consider extraction socket defect classification as a variable.

In a multicenter randomized controlled study, Ferrantino et al. evaluated the Implant Crown Aesthetic Index between a soft-tissue graft group and no soft-tissue graft group.^[14] Their results showed no statistically significant difference between the two groups in terms of the condition, no gingival recession, and no buccal bone dehiscence (type 1 Elian classification) in the extraction socket. Their findings suggest that an adjunct use of a connective tissue graft is not mandatory to achieve successful esthetic outcomes in well-planned (indication and execution) IIPIP in a fresh extraction socket.^[14] In the present case, the pristine socket wall and the level of the gingival margin allowed the clinician to perform IIPIP without a soft-tissue graft and still achieve a stable and esthetic implant restoration. The gap between the implant and buccal wall was filled with DBBMs to further reduce the possibility of horizontal bone resorption and the possibility of tissue recession.

To ensure implant integration during the IIPIP, the presence of an intact socket wall following the tooth extraction and the absence of active infection are not enough. Primary implant stability must also be achieved. Primary implant stability can be achieved by engaging 3–5 mm of the implant with the palatal–apical wall of the socket.^[2],[8],[15] A preoperative CBCT evaluation is conducted to assess predicted primary stability in IIPIP, including the morphology of the osseous housing, root length, and SRP classification.^[15]

Kan classified SRP into class I, II, III, and IV.^[15] In class I, the root is positioned against the labial cortical plate. In class II, the root is centered in the middle of the alveolar housing, without engaging either the labial or palatal cortical plates at the apical third of the root. In class III, the root is positioned against the palatal cortical plate. In class IV, at least two-thirds of the root engage both the labial and palatal cortical plate.^[15] The palatal wall of an extraction socket in the anterior maxilla is thicker and more cortical in nature than its labial counterpart.^[8] In a class I SRP, in which the entire length of the root is in contact with the labial cortical plate, a considerable amount of bone is present on the palatal aspect for implant engagement to attain adequate primary stability during the IIPIP.^[2],[8],[15] In the study by Kan about SRP, Kan found that 81.1% (range: 76%–86.5%) of 600 samples were class 1 SRP.^[15] In the present case, the SRP was class 1 with root length of 10 mm. A 12-mm implant was chosen to increase the engagement of the implant into the palatal socket wall and to increase the primary stability.

Conclusions

In conclusion, the treatment outcome using the IIPIP technique is predictable if indications are accurately assessed, and the procedure is performed with care. The main advantages of this technique include fewer appointments/surgeries and the ability to preserve the tissue volume/contour around the implant restoration.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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