CONTINUING EDUCATIONvipimplanteperio.com/wp-content/uploads/2018/10/2015... · 2018-10-24 ·...

110 Summer 2015 • Volume 31 • Number 2

CONTINUING EDUCATION

111 Journal of Cosmetic Dentistry

AbstractFresh socket management requires a critical evaluation of biological and esthetic risk factors (residual bone, gingival margin position, buccal bone characteristics, tissue biotype, infection) to pave the more appropriate decision making process. This article offers guidelines to help the clinician se-lect either socket preservation or immediate implant place-ment after minimally invasive flapless tooth extraction. The hypothesis is that the timing of implant placement should not interfere with the final clinical outcome as long as the “three pillars of success” are observed: adequate three-di-mensional implant positioning, esthetic tissue reconstruc-tion, and prosthetic management.

Key Words: fresh socket, immediate implant, preserva-tion, graft, connective tissue

Socket Management in the Esthetic Zone A Step-by-Step Approach for Selecting Immediate Implant Placement or Socket Preservation

Robert Carvalho Da Silva, DDS, MS, PhDJúlio César Joly, DDS, MSPaulo Fernando Mesquita de Carvalho, DDS, MS

Da Silva/Joly/Carvalho

CECREDIT

After reading this article, the participant should be able to:

1. Understand when to select socket preservation followed by late implant placement or immediate implant placement.

2. Understand the timing of implant placements and final clinical outcomes.

3. Appreciate and understand the "three pillars of success" in implant placement.

Learning Objectives

…the clinician has to determine the course of the therapy and decide the timing of implant placement: immediate, early, or late.


IntroductionDental implants have become the standard of care to replace missing teeth in the anterior region. Following flapless minimally invasive tooth extraction, as part of the treatment plan, the clinician has to determine the course of the therapy and decide the timing of im-plant placement: immediate, early, or late.1 Each of these has its advantages and disadvantages, and they are equally effective in terms of achieving high rates of implant survival.2 However, it is the authors’ opinion that the best option for the patient is either immedi-ate implant placement or socket preservation, after an analysis of clinical and tomographic parameters.

Is has been demonstrated that after tooth extrac-tion, the socket will quickly undergo marked width and height reduction because the volume and shape of the socket is determined and maintained by the stimulus of the periodontal fibers.3,4 As soon as the tooth is removed, that stimulus is discontinued and the socket will gradually be filled with new bone. However, there also will be volume reduction, partic-ularly at the buccal aspect, which is thinner than the palatal aspect and is composed mostly of the bundle bone closer to the cervical area.5,6 The pattern and ex-tension of the resorption can be further affected by the reason for tooth extraction (e.g., periodontal disease, endodontic failure, root fracture); how the tooth ex-traction was performed (traumatic or not); how long ago the tooth was removed; and how the area was re-stored (removable or fixed prosthesis).7 Clinically that means that after tooth extraction, if the socket is left to heal naturally, more resorption will occur and greater, surgical efforts will be required to rebuild the bone and soft tissues in association with implant therapy. This can lead to higher morbidity due to the greater number and magnitude of the interventions and is more time-consuming.

Clinical ParametersWith the above factors in mind, a straightforward step-by-step approach is presented to help the clini-cian treatment plan the case and decide whether to choose immediate implant placement or socket pres-ervation. This approach was developed to prevent es-thetic problems, specifically mucosal recession and/or lack of soft tissue volume and discoloration. The following parameters are considered:

• residual bone (apical/palatal)• gingival margin position• buccal bone characteristics • tissue biotype• infection.

Residual BoneCone-beam computed tomography (CBCT) should be used to evaluate the anatomy of the residual socket and predetermine whether three-di-mensional (3D) implant positioning is possible. Navigation software is available and is a helpful tool in analyzing the residual bone anatomy and to virtually place the implant and check its 3D positioning.8 In a to-mographic evaluation study, Kan and colleagues9 observed different pat-terns of the relation of the sagittal root inclination and the socket. In most of the cases (approximately 80%), the root was observed to be more buc-cally inclined, leaving a favorable palatal and apical bone to engage the implant and sufficient space to fill the gap. The clinician can handle these situations more easily, and extremely long implants are not required since the availability of the residual bone is favorable. In approximately 10% of the cases, the volume of the socket is similar to the shape of the root, but apical bone can still be used for implant stabilization. These cases are technically sensitive; longer and narrower implants are generally used to improve the chances of achieving good primary stability and space to graft the gap, and greater skill and clinical experience is required. The other tomographic situations are associated with thin sockets and severe buccal-apical concavities, which leave no chance of immediate implant placement, and socket preservation and sometimes ridge augmentation are indicated.

When the apical/lingual bones are intact (the so-called bone triangle) and deemed sufficient an immediate implant can be considered, but the decision still has to be validated through observation of the other param-eters. If, however, it is determined that there is not sufficient apical/lin-gual bone to stabilize the implant or the 3D positioning is not attainable, then socket preservation must be performed.

Gingival Margin PositionThe gingival margin of the tooth to be extracted can be in three different positions compared to the adjacent matching tooth or desired margin of the future implant-supported restoration. The best scenario is when the margin is coronally positioned, with vertical excess of the soft tissues and less chance of gingival recession; this also creates the opportunity for prosthetic management and gingival conditioning for leveling the soft tissue margins.

Another situation is when the gingival margin is already leveled. This leaves no room for mistakes, especially if immediate implant placement followed by immediate temporization is intended. The shape of the sub-merged area of the provisional restoration should be carefully prepared (both critical and subcritical areas) to avoid any unwanted pressure on the soft tissues that could lead to mucosal recession and esthetic prob-lems. The gingival margin can also be apically positioned (i.e., gingival recession, the most complicated situation). However the protocol takes into consideration the depth of the recession. When the recession is up to 4 mm and the apical/palatal bone is adequate, the choice of immediate implant placement—but in association with the subepithelial connective tissue graft—still is a valid option. On the other hand, if the recession is greater than 4 mm, a staged approach, in which some type of socket preservation is utilized combined with a soft tissue graft to improve the site, is indicated


Buccal Bone CharacteristicsThe presence (or not) of the buccal bone can be to-mographically observed and clinically perceived us-ing a periodontal probe before extraction. It is con-firmed during socket inspection and curettage after extraction. Several authors believe that compromised sockets (buccal bone loss) are contraindicated for immediate implant placement due to the risk of de-veloping mucosal recession.10,11 In fact, Kan and col-leagues12 observed that the bigger the buccal defect, the greater the likelihood and magnitude of mucosal recession associated with immediate implant place-ment followed by immediate temporization, despite the reconstructive protocol.

Sclar 13 further characterized socket buccal defects by their width and depth. A narrow defect is defined as being narrower than one-third of the mesiodistal di-mension of the socket, whereas a wide defect is wider than one-third of the socket’s mesiodistal dimension. Defects are also classified as shallow (vertical loss of 5 mm) or deep (vertical loss greater than 5 mm). The relation of the defect’s width/depth was then used to classify the buccal deficiencies as favorable (narrow, irrespective of the depth) or unfavorable (wide and deep), in terms of the prognosis of the gingival mar-gin stability.

In the protocol discussed here, the deficient socket does not interfere with the treatment approach selec-tion (immediate implant placement or socket preser-vation), but will be considered at the reconstructive phase. In our suggested clinical protocol, when an un-favorable defect is detected, an envelope-like muco-periosteal flap is elevated using tunneling instrumen-tation, without touching the adjacent papillae, for the placement of a collagen membrane as part of the regenerative procedures. On the other hand, if a favor-able defect is observed the membrane is not necessary.

Tissue BiotypeTwo 2009 studies of tissue biotype indicate two dif-ferent scenarios: thick tissue biotype, with better tis-sue stability related to its soft tissue thickness; and not thick tissue biotype (including thin and intermediate

clinical conditions), which is far more prone to develop soft tissue prob-lems.14,15 We therefore assume that a thinner tissue situation is a risk fac-tor for development of those problems.14,16

It may not be as easy to characterize patients’ tissue biotype, although thickness and thinness can be subjectively evaluated visually with the use of a periodontal probe through the gingival sulcus.15,17 A more objective method of evaluation is with soft tissue tomography, in which the lips and tongue are prevented from touching the soft tissues during image acquisition; this allows the radiologist to measure the thickness and rela-tionship of the soft and hard tissues.18

The suggestion is that all cases considered not thick should be treated with a subepithelial connective tissue graft as part of the therapy (regard-less of whether the treatment is an immediate implant or socket preserva-tion), also known as biotype conversion, to prevent soft tissue issues.14,19

InfectionRecent literature reviews20,21 have shown that the survival rates of implants placed at chronic infected sites are similar to those of implants inserted in pristine or non-contaminated conditions, as long as thorough mechani-cal decontamination is performed during site preparation by means of proper curettage and intense irrigation with saline solution; previous periodontal control has been rendered; and pre- and postoperative micro-biological control is achieved, systemically via antibiotics and locally via mouth rinses with clorhexidine.21,22 On the other hand, acute infections are considered an absolute contraindication for immediate implants or grafting procedures.7,20 When acute contamination is detected, the indica-tion is to first use systemically delivered antibiotics and local drainage/curettage, thus postponing the treatment.

After careful evaluation of the five parameters, the selection of im-mediate implant placement or socket preservation is determined by the relation of the residual bone and gingival margin position (i.e., if both of these are adequate, then immediate implant placement is indicated; but if one of them is not adequate, socket preservation is the clinical choice). The characteristics of the buccal bone indicate whether collagen membrane should be added as part of the reconstructive procedure, the tissue biotype determines whether connective tissue grafting should be performed, and the infection status determines the timing of treatment.

Socket PreservationSeveral socket preservation techniques have been described, but the most effective are the trephine tube technique and the bio-col technique.14 The former approach has been suggested by Misch and colleagues23 and is based upon obtainment of a composite structured bone and soft tissue graft taken from the tuberous area using a trephine bur with a matching diameter of the socket to be treated. Tissue availability and the degree of the mouth opening have to be considered, as well as the morbidity of the harvesting method. We believe that the use of biomaterials (the bio-col technique) is equally effective, less time-consuming, and clinically easier.13

This approach was developed to prevent esthetic problems, specifically mucosal recession and/or lack of soft tissue volume and discoloration.



Several studies have demonstrated, in animals as well as in humans, that particulate bovine anorganic bone mineral alone or with 10% collagen is effective in reduc-ing the contraction of the socket following tooth extrac-tion.24-29 In this protocol, the biomaterial is used alone where intact sockets or favorable defects are observed. When unfavorable defects are identified, collagen mem-branes should be utilized inside the socket, as suggested by Sclar13 and Elian and colleagues.10

The bio-col technique can be further complemented with a soft tissue grafting procedure including a free epi-thelialized gingival graft,30 a subepithelial connective tis-sue graft,31 or a rotated pedicle connective tissue flap.32 The aforementioned techniques are associated with graft protection, prevention of infection, and soft tissue lo-cal augmentation.14 After socket preservation, the tissue should be allowed to heal for six months before implant placement is performed. Figures 1 through 9c illustrate a socket preservation clinical case.

Figure 1: Socket reconstruction using bovine anorganic bone mineral, collagen membrane, and rotated pedicle connective tissue graft. Clinical aspect of the upper left canine, with deep gingival recession, lateral frenulum, and loss of the mesial papilla.

Figure 3: Flapless tooth extraction.

Figure 4: The collagen membrane in position, after an envelope-like mucoperisoteal flap was raised.

Figure 2: CBCT of the affected tooth, showing ankylosis and root resorption.

Figure 5: The socket was filled and packed with biomaterial.


Figures 6a & 6b: The pedicle connective tissue graft was rotated from the palatal area to seal the socket and secured with sutures.

Figure 7: Clinical image after six months, showing satisfactory tissue volume and that the frenulum had been removed.

Figure 8: Flapless implant placement after a circular punch incision.

Figures 9a & 9b: Occlusal and buccal views one year after final prosthesis delivery. Note the nice leveling of the gingival margins at the anterior region and interproximal papillary.

Figure 9c: CBCT one year after final prosthesis delivery.



Immediate Implant PlacementImmediate implant placement is indicated according to the presented approach when apical/lingual bone is considered adequate to engage the implant with good primary stability at the ideal 3D position, and the gingival margin position is adequate. A surgical guide is helpful in ensuring proper implant place-ment. The implant choice (macro and micro geom-etry) is an important factor in attaining good primary stability, which is fundamental for immediate tempo-rization; in providing space for gap grafting, which is important to maintain the volume for esthetics; and in accelerating osseointegration. The macro geometry is related to the implant characteristics (length, shape, thread features, and diameter) and the micro geom-etry is related to surface (machined versus rough). We generally choose an implant with a tapered body with aggressive threads that is long enough to facilitate the primary stability, a narrow diameter to ensure at least 2 mm of space for grafting between the implant body and buccal bone, and a rough surface for faster osseo-integration.33-35 The concept of platform-switching is also important to prevent cervical bone loss.36

Esthetic tissue reconstruction is key for long-term esthetic clinical outcomes.14 In all cases, the buccal gap is filled with blades of anorganic bovine bone-de-rived mineral alone or, preferably, embedded in 10% collagen (Bio Oss, Geistlich Pharma North America; Princeton, NJ) to prevent further bone resorption and loss of volume.20,34,37 In cases with unfavorable buc-cal deficiencies (wide and deep bone defect), one mucoperiosteal envelope-like flap is elevated without touching the papillae, using blunt instruments; and a collagen membrane is inserted between the flap and bone housing to protect the bone graft from soft tissue interference (guided bone regeneration).3,14 A connec-tive tissue graft is also part of the reconstructive proto-col when thin or intermediate tissue biotype is iden-tified or when some gingival recession is present, to increase the gingival thickness (biotype conversion), improve the esthetics, and provide stable soft tissues at the cervical region of the implant-supported resto-ration.19,38

Whenever possible, immediate temporization should be performed. The advantages of the procedure are esthetics, comfort, ease of clean-ing and, most importantly, good support for the soft tissues (proximal and buccal).14 In order to do that, it is essential to achieve good primary stability (at least 35 Ncm), adequate 3D position, and proper occlusal conditions.39 The shape and contours of the subgingival portion of the provisional restoration should be carefully prepared in respect to the criti-cal and subcritical areas to prevent unwanted pressure of the soft tissues, which would lead to recession.40,41 When excellent primary stability is not achieved, the custom healing abutment (the same provisional restoration, but cut at the gingival margin level) will also provide the aforementioned benefits without endangering the initial stability of the implant. Figures 10 through 25 show a case in which immediate implant placement was performed despite the socket being compromised.

Figures 10a & 10b: Immediate implant placement in a compromised socket (no buccal wall). Buccal and occlusal views of the right upper central incisor showing an apical lesion, but with thick tissue biotype and leveled gingival margin position.


Figure 11: CBCT of the affected tooth depicting no buccal wall.

Figure 12: Removed tooth with deep root resorption and apical lesion.

Figure 13: After minimally traumatic tooth extraction, the probe confirmed the complete absence of the buccal bone wall.

Figure 14: Envelope-like mucoperiosteal flap prepared using tunneling instrumentation.

Figure 16: Occlusal view of the implant in position, highlighting the importance of using narrow-platform implants, and positioned according to prosthetic requirements.

Figure 15: Immediate implant placement.



Figure 17: Customized provisional titanium abutment screw retained to implant.

Figure 18: The implant-supported provisional restoration is prepared and finished before the esthetic tissue reconstruction phase.

Figure 19: Occlusal view of the collagen membrane below the flap to protect the bone graft that will be used to fill the gap.

Figures 20a & 20b: Blades of anorganic bovine bone-derived mineral embedded in 10% of collagen were used to fill the gap.

Cone-beam computed tomography should be used to evaluate the anatomy of the residual socket and predetermine whether three-dimensional implant positioning is possible.


Figures 21a & 21b: Buccal and occlusal views of the screw-retained provisional restoration in position.

Figure 22: Occlusal view six months later, immediately after the provisional restoration was removed, showing the excellent volume and architecture of the soft tissue.

Figure 23: Custom esthetic abutment positioned adjacent to the prepared right central incisor.

Figures 24a & 24b: Buccal and lateral views of the metal-free crowns in position one year after cementation, showing natural-looking appearance and perfect symmetry.

Figure 25: Final CBCT obtained at one-year follow-up, showing complete reconstitution of the buccal bone supporting the soft tissue.



SummaryBoth socket preservation followed by late im-

plant placement, and immediate implant placement are effective methods for restoring anterior hopeless teeth. Proper diagnosis is essential in achieving pre-dictable long-term esthetic outcomes. The step-by-step approach discussed here is helpful in treatment planning; and as long as the three pillars of esthet-ics—adequate 3D implant positioning, esthetic tis-sue reconstruction, and prosthetic management—are followed, the two approaches should lead to similar outcomes.

Acknowledgments

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Dr. Da Silva practices and is a clinical director at ImplantePerio Institute in São Paulo, Brazil.

Dr. Joly practices and is a clinical director at ImplantePerio Institute in São Paulo.

Dr. Carvalho practices and is a clinical director at ImplantePerio Institute in São Paulo.

Disclosures: The authors did not report any disclosures


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