The 10 Key Steps to Flawless Immediate Implants

The purpose of the 10 keys, a treatment algorithm for successful placement of immediate implants in the esthetic zone, is to provide a structured and evidence-based approach to immediate implant treatment, maximizing the long-term esthetic outcome.^1-3 It is important to realize that all 10 keys should be sequentially followed; otherwise, a compromised outcome may occur. The following discussion outlines where improvements could be made based on current publications that our group is completing.

Use of the esthetic risk assessment tool is important in categorizing and assessing possible preoperative factors affecting long-term outcomes that may need to be addressed in the treatment planning phase. This assessment is also a valuable tool in educating the patient about the complexity of his or her personal anatomical situation, while helping to align the patient and practitioner’s final esthetic expectations prior to initiating treatment.

In this patient, it was important to identify the moderately thin and scalloped gingival phenotype. A thinner gingival phenotype is correlated with a thin buccal plate (< 1 mm),⁴ which was subsequently confirmed with cone-beam computed tomography (CBCT) analysis. This thin buccal plate can be problematic, as following tooth extraction, pronounced buccal bone and soft tissue loss occurs,^5,6 amounting to bone loss of up to 7 mm in the vertical dimension at the mid buccal aspect,⁶ along with up to 50% of the ridge width.⁷ Placing an immediate implant, per se, does not prevent this bone loss from occurring.^8,9 Ridge preservation by means of socket grafting, in conjunction with immediate implant placement, can counteract some of the effects.¹⁰ If not identified prior to surgery and adjusting the surgical plan accordingly (Key nos. 6 and 7), this could lead to major esthetic and long-term maintenance problems.

Assessment via CBCT scans and preoperative virtual planning allows for an appropriately sized and positioned implant to be chosen (Key No. 2), thus ensuring a > 2 mm buccal gap, adequate primary stability, and placement in the ideal position for a screw-retained restoration. It can also allow the practitioner to visualize the thickness of the buccal plate, and the need for any adjunctive soft and hard tissue grafting procedures to counteract the anticipated bone and soft tissue loss.

Key No. 5 states that a narrower-diameter implant should be used to allow for a > 2 mm gap between the implant and internal surface of the buccal plate. However, as shown on the preoperative CBCT scan (Figure 1), the implant size chosen (4.1 × 12 mm) was not ideal, allowing for only a 1.8 mm buccal gap at the implant shoulder. Ideally, a 3.3 × 12 mm implant should have been planned and placed instead (Figure 2). Selecting an implant size that allows for a > 2 mm grafted gap promotes buccal plate stability and counteracts the ridge reduction following extraction.^9,11-13

A larger-diameter implant can obturate the socket, restricting the space to place the bone substitute and compromising the long-term viability of the buccal bone.^11,12 Following resorption of the buccal plate, exposure of the implant may occur, leading to esthetic and possible long-term biologic challenges.

Levine et al¹⁴ (in preparation) evaluated the effect of the buccal gap dimension on the newly formed buccal bone following immediate implant placement in maxillary central incisors. All sites were treated with immediate implant placement and ridge preservation by means of socket grafting, using a xenograft. Assessment via CBCT 5±4 years following implant placement indicated that when the grafting gap dimension was > 2 mm, the thickness of the buccal bone was 1.9 mm; however, when it was ≤ 2 mm, it was significantly reduced to 0.5 mm. This could predispose to esthetic and biological complications in the future. Thus, this study concluded that, ideally, a > 2 mm wide buccal gap should be virtually planned and grafted to allow adequate buccal bone formation, promoting stability for the future.

While use of a CTG may compensate for soft tissue collapse in the most coronal portion of the gingival complex, it does not prevent loss of the buccal bone; consequently, combining a CTG with a bone graft is suggested.¹⁵ A recent systematic review by Seyssens et al¹⁶ indicated that although evidence in the literature was moderate, simultaneous placement of a CTG at the time of immediate implant placement contributes to the stability of the midfacial mucosa and should be considered in sites with a thin gingival biotype and a buccal bone thickness < 0.5 mm. Additionally, thickening of the mucosal tissue to 3 mm or greater is advantageous in masking the color of restorative materials utilized in the implant restoration, preventing graying of the tissue and improving esthetics.¹⁷

Levine et al¹⁸ (2021, accepted) evaluated the effect of a connective tissue graft (CTG) following immediate implant placement and ridge preservation at maxillary central incisor sites. They found that although changes in mid buccal mucosal tissue height and buccal bone thickness over the implants did not vary if a CTG was completed or not, sites treated with a CTG exhibited significantly higher esthetic outcomes. In the current case, a CTG was performed in the coronal aspect, and although some graying of the mucosa was present, the graft positively impacted postoperative healing and esthetics. If the slight graying of the tissue was an esthetic concern for the patient, a second CTG could be placed to further thicken the tissue in the region of the thinner apical bone.

The buccal bone graft material aims to provide space maintenance and wound stability, allowing for bone growth rather than soft tissue. Using a low-substitution-rate graft material reduces the possibility of graft remodeling and resorption, increasing the probability of retaining the original ridge volume, and promoting greater bone stability.¹² When used in combination with a CTG, the patient’s phenotype is shifted from thin to thick,^2,19 promoting a more esthetic outcome. In this case, a 50/50 mix of calcium sulphate and a mineralized allograft was used. Calcium sulphate is considered to be a fast-resorbing material and can resorb in one to three months.²⁰ This combination of graft materials, together with the small buccal grafting gap, could have led to less retention of buccal bone and graying of the mucosa. Today, a low substitution graft material (such as a xenograft) would be used to aid in reducing bone loss on the buccal aspect.¹⁰

Meticulous and systematic planning and clinical execution through use of the updated 10 keys can lead to favorable functional and esthetic results. While this case achieved acceptable esthetics for the patient, as outlined, it is important to closely follow all keys to ensure an optimal esthetic outcome.

References

1. Levine RA, Ganeles J, Gonzaga L, et al. 10 Keys for successful esthetic-zone single immediate implants. Compend Contin Educ Dent. 2017;38:248–260.
2. Levine RA, Ganeles J, Kan J, Fava PL. 10 keys for successful esthetic-zone single implants: importance of biotype conversion for lasting success. Compend Contin Educ Dent. 2018;39:522–530.
3. Levine RA, Ganeles J, Wang P, et al. Application of the 10 keys for replacement of multiple teeth in the esthetic zone. Compend Contin Educ Dent. 2021;42:F1–F11.

4. Cook D, Mealey B, Verrett R, et al. Relationship between clinical periodontal biotype and labial plate thickness: an in vivo study. Int J Periodontics Restorative Dent. 2011;31:345–354.
5. Chen ST, Darby IB, Reynolds EC, Clement JG. Immediate implant placement postextraction without flap elevation. J Periodontol. 2009;80:163–172.
6. Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, Buser D. Ridge alterations post-extraction in the esthetic zone: a 3D analysis with CBCT. J Dent Res. 2013;92(Suppl 12):195S–201S.
7. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003;23:313–323.
8. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol. 2005;32:645–652.
9. Covani U, Cornelini R, Calvo-Guirado JL, Tonelli P, Barone A. Bone remodeling around implants placed in fresh extraction sockets. Int J Periodontics Restorative Dent. 2010;30:601–607.
10. Zaki J, Yusuf N, El-Khadem A, Scholten R, Jenniskens K. Efficacy of bone-substitute materials use in immediate dental implant placement: A systematic review and meta-analysis. Clin Implant Dent Relat Res. 2021;23:506–519.
11. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Tissue modeling following implant placement in fresh extraction sockets. Clin Oral Implants Res. 2006;17:615–624.
12. Rosa AC, da Rosa JC, Dias Pereira LA, Francischone CE, Sotto-Maior BS. Guidelines for selecting the implant diameter during immediate implant placement of a fresh extraction socket: a case series. Int J Periodontics Restorative Dent. 2016;36:401–407.
13. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2 uncovering. Ann Periodontol. 2000;5:119–128.
14. Levine RA, Dias DR, Wang P, Araujo MG. Effect of buccal gap dimension following immediate implant placement on the buccal bone wall: a retrospective CBCT analysis. In preparation. 2021.
15. Jiang X, Di P, Ren S, Zhang Y, Lin Y. Hard and soft tissue alterations during the healing stage of immediate implant placement and provisionalization with or without connective tissue graft: A randomized clinical trial. J Clin Periodontol. 2020;47:1006–1015.
16. Seyssens L, De Lat L, Cosyn J. Immediate implant placement with or without connective tissue graft: A systematic review and meta-analysis. J Clin Periodontol. 2021;48:284–301.
17. Jung RE, Sailer I, Hammerle CH, Attin T, Schmidlin P. In vitro color changes of soft tissues caused by restorative materials. Int J Periodontics Restorative Dent. 2007;27:251–257.
18. Levine RA, Dias DR, Wang P, Araujo MG. Effect of connective tissue graft following immediate implant placement on esthetic outcomes at maxillary central incisor sites: a long-term cohort study. Int J Periodontics Restorative Dent. Accepted for publication. 2021.
19. Cabello G, Rioboo M, Fabrega JG. Immediate placement and restoration of implants in the aesthetic zone with a trimodal approach: soft tissue alterations and its relation to gingival biotype. Clin Oral Implants Res. 2013;24:1094–1100.
20. Fernandez de Grado G, Keller L, Idoux-Gillet Y, et al. Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management. J Tissue Eng. 2018;9:2041731418776819.

This information originally appeared in Robert A Levine, DDS, Jeffrey Ganeles, DMD, David P. Semeniuk, BDSc, MS, Debora R. Dias, DDS, MSc, Ping Wang, BDS, PhD, DMD, Harry Randel, DMD and Maurício G. Araújo, DDS, MSc, PhD. Immediate Implant Placement With Virtual Planning in the Esthetic Zone. Decisions in Dentistry. January 2022;8(1):9-12.