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by facial placement of the implant in the socket. The overall result can then be compromised with respect to the mid-facial soft tissue height due to bone resorption at the coronal aspect of the thin facial plate. But, even when the implant is
placed in a palatal position, it is now apparent that maintaining the tissue volume is unpredictable especially with highly scalloped, thin gingival biotypes (Figures ı and 2). More recently it has become established practice to place the implant palatally in the socket and place a bone substitute into the gap between the implant and the facial plate. But this approach does not always prevent mid-facial recession (Chen et al 2007). Another aspect to this loss of
tissue contour is the dimensional changes of the connective tissue and epithelium at the facial aspect of the implant site after tooth extraction. A number of clinicians are also using connective tissue grafts to augment the facial soft tissues (Kan et al 2009, Grunder et al 20ıı, Cornelini et al 2008). This first paper, will describe the step-by-step clinical procedures used to minimise tissue loss in immediate implant cases by combining the use of both a bone substitute and a connective tissue graft protocol. The second paper will discuss
impression making, abutment selec- tion and placement of the final properly contoured restoration in the anterior aesthetic zone.
Procedure for immediate implant placement This protocol calls for a number of basic principles to be adhered to so that the most ideal treatment outcome can be achieved each and every time it is performed.
Table 1 – Treatment sequence for immediate implant placement and provisional restoration
Treatment
1. Atraumatic extraction
2. Debride the socket
3. Correct 3D implant placement
4. Placement of bone graft
5. Placement connective tissue graft
6. Fit of
well-contoured provisional restoration
Surgical details
Severe supracrestal fibres and periodontal ligament using scalpel and periotomes. Using forceps, remove the tooth with minimal trauma to the gingival tissues or facial plate of bone.
Use a curette or spoon excavator to remove any debris or granulation tissue from bony walls and inspect socket for dehiscence/ fenestration defects.
Aim to engage the palatal and apical bone to ensure primary stability, and place the neck of the implant 2mm lingual to the facial plate and 3mm apical to the free gingival margin.
Use a slow resorbing bovine hydroxyapatite and pack between the implant and facial plate of bone.
Harvest tissue from palate or tuberosity and place in the partial thickness pouch created on the facial aspect.
Use an immediate implant crown, a resin bonded fixed restoration or a removable ‘essix’ type retainer used to support the interproximal and facial tissues.
The initial principle involved is the case selection. It is important to closely examine the patient, smile line, gingival biotype and the extent of any socket defect after tooth removal as these parameters all have a significant bearing on the aesthetic success of any immediate implant. As a general rule, if there is a bony
dehiscence with vertical compo- nent greater than 4mm or any pre-existing soft tissue recession that needs to be corrected, then extraction and site preservation is indicated rather than immediate implant placement. The surgical protocol will be outlined using the following three cases as examples.
Case one A 27-year-old female patient presented with trauma to the UL2 (Fig 3). On examination, a 4mm subgingival oblique lingual fracture was noted and the deci- sion was made to extract and place an immediate dental implant. This patient presents quite
“This approach does not always prevent mid-facial recession”
a challenge, surgically, due to the thin gingival biotype and relatively high smile line. Following the protocol as
outlined in Table ı, a ı5C scalpel blade was used to excise supra- crestal fibres, then a periotome is introduced along the length of the root to separate the peri- odontal ligament fibres (Fig 5) before extraction with a forceps (Fig 6). The tooth can be sectioned buccolingally and the fragments elevated out if the tooth has frac- tured apical to the osseous crest. After debridement with surgical
curette (Fig 7) the osteotomy is initi- ated with the use of a Lindemann side-cutting bur (Brasseler USA) (Fig 8) which creates a groove on the palatal wall helping to guide the remaining twist drills to the correct palatal position of the implant – ideally 2mm from the facial plate of the extraction socket at its most coronal aspect. Once the desired osteotomy size
has been created in the socket, a 4.3 x ı3mm tapered moderately rough surface implant (Nobel Replace Tapered, Nobel Biocare) (Fig 9) is placed in the socket, 2mm from the facial plate and 3mm apical to the free gingival margin. A primary stability of greater than 35Ncm and a resonance frequency analysis reading over 65 (Ostell ISQ) is used to dictate whether an immediate restoration is feasible. Placement of the 0.25-ı.0mm
bovine cancellous bone particles (Nuoss, Ace) should be preformed using small increments of material and using a small instrument (perio- dontal probe and amalgam plugger) so as not to block initial 2-3mm of the facial socket, preventing further placement of graft particles (Fig ı0). Do not overfill the gap vertically as this will prevent introduction
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Fig 4
Fig 5
Fig 6
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