Written by David A. Gelb, DDS, FACD Monday, 31 January 2005 19:00
Dentistry has been significantly enhanced by the availability of implant-supported tooth replacement. The surgical and prosthetic procedures for implant placement and restoration, the predictability, the aesthetic outcome, and the long-term success and stability have been well documented1-3 and greatly support implant solutions for tooth replacement. This discipline continues to evolve, yielding ever-improving aesthetic and functional results and ever-expanding clinical indications.
New technologies and techniques have made implant dentistry a mainstream component of lifelong dental healthcare. Implant geometries, textures, abutment selections, and restorative materials continue to evolve, making the clinician’s job easier while providing improved aesthetic outcome for patients. The use of adjacent tooth support, no longer necessary with the implant solution, allows for preservation of natural and previously restored adjacent teeth. The staged implant approach has given way to accelerated implant sequences involving immediate implants and immediate loading. Clinicians and particularly patients prefer these less invasive and more immediate approaches to tooth replacement.
For the fully or partially edentulous patient, the benefits of implants are life-altering. One need only speak with a fully edentulous patient whose teeth have been restored from full-denture prosthesis to a full-arch, implant-supported prosthesis to get a sense of the impact implants have made in changing life quality. The fully edentulous patient restored with implants can function like the dentate patient. No more nights of putting teeth away in glass jars. What starts off as a functional improvement brings about profound life changes. Implant patients claim that meals without dentures now taste better; they can smile unabashedly. Aesthetically pleasing implant prostheses boost a patient’s self-confidence and emotional well-being in ways unobtainable with less permanent dental treatment for the same clinical dilemma.
With implants, both bone and aesthetic soft-tissue dimensions can be preserved. The adverse alveolar remodeling4,5 that occurs with the use of a complete denture or partial denture prosthesis (pathonomonic of these types of prostheses) does not occur with an implant-supported restoration. The successful implant has been documented to preserve bone dimensions and maintain steady-state bone dimension relative to the implant. This observation has been noted even in the partially edentulous dentition, where progressive periodontal disease may affect the natural dentition while having no similar effect on implants in the same arch.
Improved implant surgical protocols have replaced protracted implant protocols with accelerated ones.6-12 Today it is routine to replace hopeless teeth with implants simultaneous with extraction, preserve or en-hance aesthetic alveolar and soft-tissue dimensions, augment diminished sinus height, and simultaneously place implants for both intact and tooth-contained sites. Furthermore, today clinical documentation supports immediate loading13,14 or the ability to place an implant and restoration all in the same day. The current accelerated implant sequence outcome compares favorably with tooth replacement sequences that rely on existing teeth for support or involve a removable prosthesis. The latest extension of this discipline has been “Teeth In An Hour” (Nobel Biocare),15 where CAT scan analysis generates a stent used for precise implant placement and placement of a corresponding custom-milled fixed prosthesis, both of which are placed within an hour-long clinical procedure.
The clinical research that supports immediate load16 protocols relies on new and improved implant textures17 and geometries.18,19 While original implant textures were most commonly machined or polished, present-day implants have textured surfaces such as TiUnite, Osseotite, SLA, TiOblast, etc, all capable of more rapid and profound integration at an earlier stage in healing. These enhanced surfaces have not only contributed to higher success rates for all implant applications, but also provide a better platform for immediate loading. In this way, they satisfy the patient’s tooth replacement needs the day of surgery for the edentulous patient and the day of tooth extraction for the dentate patient. The improved implant surfaces and larger assortment of implant geometries have given the clinician a more favorable selection for implant placement in the multitude of socket morphologies and edentulous sites in need of implant replacement.
The purpose of this paper is to discuss and illustrate through case reports the distinct benefits sustained with implant tooth replacement. The following case reports are but a few examples of the many clinical situations where implant solutions optimize treatment and provide results superior to tooth-supported restorative protocols.
The patient, a 46-year-old fe-male, presented with both maxillary and mandibular dentures that had been in place for more than 10 years. The patient, although able to function, was emotionally handicapped by having to wear dentures and was seeking an implant solution. The final panoramic radiograph and clinical photograph illustrate a full-arch maxillary and mandibular fixed implant prosthesis, which has been in place for more than 8 years (Figures 1 to 3). The patient was pleased and satisfied to be restored to function similar to her dentate state. The steady state of bone around her implants is comparable to bone dimensions at original prosthesis insertion and loading.
|Figure 1. Panoramic radiograph prior to implant surgery.||Figure 2. Eight-year post-op maxillary and mandibular full-arch screw-retained implant prosthesis.||Figure 3. Clinical view: 8-year post-op, maxillary anterior ovate pontics.|
This 16-year-old female patient presented postorthodontics in need of tooth replacement for permanent maxillary lateral incisors, which were congenitally missing. The implant solution as documented at 3 years provides a functional and aesthetic result that is very pleasing and stable. This minimally invasive approach to tooth replacement was much appreciated by both the patient and her parents (Figures 4 to 5).
|Figure 4. Radiographs of congenitally missing laterals and 3-year implant post-op.||Figure 5. Clinical view of implant Nos. 7 and 10 at 3 years.|
This 52-year-old female patient presented with a fracture of an endodontically treated tooth No. 31. The tooth was painful upon biting and exhibited probing depth along one narrow corridor on the mesio-lingual surface of the tooth. The tooth was extracted, and an implant immediately inserted with a bone graft (University of Miami Bone Bank) to re-establish bone proximity with the implant.
After 4 months, the implant was uncovered, a final abutment placed, an impression taken, and a final crown cemented. A year after loading, the postoperative radiograph demonstrates congruity of the regenerated bone with the intact bone and a steady state of the regenerated bone around the implant (Fig-ures 6 and 7).
|Figure 6. Radiograph of tooth No. 31 with vertical fracture identified clinically.||Figure 7. Immediate implant No. 31, 1-year radiographic and clinical post-op.|
This 52-year-old male patient presented with caries and periodontal infection of the mandibular left first molar. The tooth was extracted, the extraction socket thoroughly debrided, the site evaluated with depth gauges20 (3I, Nobel Biocare), and 2 implants placed, which acted as reconstructive scaffolds for a bone and membrane (W.L. Gore) regenerative procedure. At 4 months, stage 2 surgery was performed and final abutments placed. The case was completed with a final restoration. Note the coronal regrowth of bone displayed clinically and radiographically and resolution of the prior intraosseous defect secondary to prior periodontal pathology. At 9 years, a steady state of bone has been sustained around the implants where the bone had been previously diminishing around the natural tooth (Figures 8 and 9).
|Figure 8. Top left—failing tooth No. 19; top right—Gelb Depth Gauge Evaluation No. 19; bottom left—immediate implants No. 19; bottom right—4-month uncovering No. 19.||Figure 9. Post loading No. 19 radiographically and clinically at 9 years.|
This 56-year-old male patient presented with periodontal and endodontic pathology involving tooth No. 31. Rather than proceed with a combination treatment involving periodontics, endodontics, and post and crown, the treatment selected involved immediate im-plant surgery with simultaneous bone-grafting. The tooth was extracted atraumatically, and the site thoroughly debrided of granulation tissue. An implant was placed and acted as a reconstructive scaffold around which deficient bone dimensions were regenerated with bone graft and membrane (University of Miami Bone Bank, W.L. Gore). After 4 months of uneventful healing, the implant was uncovered, an abutment placed, and crown constructed. Note the congruity of the regenerated bone with the native bone and the steady state of bone after 1.5 years of loading (Figures 10 to 12).
|Figure 10. Radiograph of failing tooth No. 31.||Figure 11. Immediate implant placement No. 31.||Figure 12. Implant No. 31; one and half year post loading radiograph.|
This 42-year-old female patient presented with a fractured central incisor treatment-planned for immediate implant placement with immediate loading. After atraumatic extraction and implant and abutment placement, the prescribed torque could not be reached without further rotation of the implant. Hence, the final abutment, although not loaded during the healing period, did provide an optimum scaffold for soft-tissue maturation. At 6 months, the abutment was retorqued (confirming osseointegration) and impressed, and a final crown was cemented (Figures 13 to 17).
|Figure 13. Radiograph of No. 9; fracture identified clinically.||Figure 14. Radiograph of immediate implant and abutment placement No. 9.|
|Figure 15. Implant No. 9 at 6-month final impression.|
|Figure 16. Radiograph of implant No. 9 at one-year post loading.||Figure 17. Implant restoration No. 9 at one-year post loading.|
A 41-year-old male presented for an immediate implant and immediate loading of implant No. 8. The tooth was extracted due to a vertical fracture, and the extraction site was thoroughly degranulated. The implant was placed and stabilized firmly in its prosthetically correct position. A final abutment was torqued down to 45 Ncm, and a temporary crown was fabricated and cemented chairside.
The crown was relieved of occlusion in centric and lateral excursions, and the contacts with teeth Nos. 7 and 9 were minimized. After 6 months of healing, the abutment stability was reconfirmed with 45 Ncm of rotational torque. A final impression was taken, and a permanent crown was fabricated and cemented in place (Figures 18 to 20).
|Figure 18. Vertical fracture No. 8, immediate implant and immediate loading No. 8.||Figure 19. Top left—tooth No. 8 vertical fracture; top right—immediate implant No. 8; bottom left—immediate loading No. 8; bottom right—6-month post-op No. 8.||Figure 20. Radiograph and final crown No. 8 at one-year post-op.|
Implant dentistry provides treatment solutions that are superior to conventional tooth-supported solutions. Prior to the advent of a biologically sound implant system, treatment of the fully edentulous patient (as illustrated in case I) was relegated to dentures, which re-quired periodic relining, had adverse alveolar remodeling, and never provided the patient the function and emotional well-being associated with the dentate state. For the fully and partially edentulous patient, the fixed implant prosthesis is superior to any other treatment alternative.
For the adolescent patient missing secondary teeth (as illustrated in case II) or in need of tooth replacement due to trauma of existing teeth, the implant solution provides a platform for tooth replacement that precludes the need to prepare adjacent teeth. This approach is less invasive and preserves natural teeth.
In addition, these patients benefit from the steady state provided to the bone by implants, which prevents the adverse site dimensions that are secondary to tooth loss. Wherever adjacent teeth are not in need of restoration, the implant solution must be considered the treatment of choice. Long-term observations of the steady state and lack of periodontal pathology associated with implants further underscores the possibility that the implant solution is the best solution, particularly for the adolescent partially edentulous patient in need of a long-term solution to the absence of succedaneous teeth.
Immediate implants (as demonstrated in cases III to VII) not only accelerate the treatment sequence but also provide a scaffold for simultaneous regeneration of both hard and soft tissue. Tooth replacement of the terminal tooth in a dentition (as illustrated in case III) previously required preparation of adjacent teeth and a cantilever restoration or a removable prosthesis. The implant solution allows for a free-standing replacement and resolution of a stable occlusion, thereby avoiding the prior, more invasive restorative alternative.
Bone regeneration around implants may be more conclusive, stable, and predictable than around natural teeth. This has been the author’s observation for the last 29 years of studying bone regeneration around teeth and the last 15 years of studying bone regeneration around implants. The implant acts as a reconstructive regenerative scaffold, and unlike the pathologically involved tooth that cannot al-ways be predictably detoxified (a prerequisite to bone regeneration), the sterile implant surface is predictable in its bone regeneration. Cases IV and V clearly demonstrate the predictability and expeditiousness of immediate implant surgery and bone regeneration even in a site containing an infected tooth. Once the pathology that perpetuated the defect is removed and the granulation tissue thoroughly debrided to a sound bone base, these sites regenerate predictably, as do extraction sockets. The exuberant blood supply associated with these sites particularly enhances the regenerative response.
As demonstrated in cases VI and VII, immediate implants improve the ability to restore aesthetics even in the challenging aesthetic zone. Once the implant is prosthetically correct in its placement and stable in its position, the immediate load protocol allows the patient to leave the office with a replacement tooth the day of tooth extraction. No other treatment regimen provides the biologic and aesthetic benefits associated with the simultaneous im-mediate implant and immediate load protocol. The atraumatic extraction and implant placement, followed by bone regeneration, osseointegration, and soft-tissue development, are predictable and optimized. This protocol provides the most predictable sequence for aesthetic tooth replacement. The author’s exclusion criteria here include those cases where it is not possible to stabilize the implant in the residual available bone (ie, defect size precludes adequate bone base for implant stabilization). New implant designs have provided higher insertion torques, which result in more stable bone-to-implant initial contact and stability. Further-more, increased diameter im-plants now better fill large-volume extraction sockets, minimizing the regenerative needs. Finally, new implant surfaces have enhanced the osseointegration process. All of these improvements have contributed to the success associated with implants, and particularly to the success associated with the immediate load protocols.
Implant tooth replacement protocols exceed tooth-supported tooth replacement protocols. Implant dentistry will grow in its clinical applications as clinicians integrate these new protocols (ie, immediate implant placement, immediate loading, “Teeth In An Hour” [Nobel Biocare]) into their everyday tooth replacement treatment planning. Improved implant geometries and textures have added to the surgical and prosthetic ease, predictability, and applicability of implant solutions to the multitude of clinical problems that dentists are called upon to resolve on behalf of their patients each day. Ulti-mately, patients and clinicians alike are looking for straightforward, minimally invasive, predictable, and permanent solutions that in many cases only implant dentistry can provide.
This paper has demonstrated a small assortment of clinical dilemmas where function, aesthetics, and bone and soft-tissue dimensions have been restored most favorably to prepathology status with implant solutions.
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The author would like to give many thanks to Jonathan J. Gelb, Genevieve Palma, Dr. Adena M. Goldman, and Dr. Barry D. Wagenberg in the preparation of this manuscript. The author wishes to thank and give credit to his restorative colleagues, whose commitment to excellence has resulted in the exemplary prosthetic conclusion for these patients: Dr. Gerard Graham (case I), Dr. Peter Knowles (case II), Dr. Stephen Lupini (case III), Dr. David Purviance (case IV), Dr. Francis P. Camp (case V), Dr. Frederic Landy (case VI), and Dr. David Schwaber (case VII).
Dr. Gelb is a diplomat of the American Academy of Periodontology, a fellow of the Academy of Osseointegration, and a fellow of the American College of Dentists. He received his DDS degree and certificate in periodontology from Columbia University School of Dental and Oral Surgery. He has lectured nationally and internationally for the past 29 years, providing programs for many major meetings, and has published numerous articles in refereed journals. He is in private practice limited to periodontics, implant surgery, and aesthetics in West Hartford, Conn. He can be reached at (860) 236-8550.
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