Immediate placement and immediate provisionalisation in the anterior maxilla: What is your experience?
It seems that there is a very mixed bag of opinions of the subject of immediate placement and immediate provisionalisation;some will do and some will not.
Does anyone with alot of experience have a "golden rule" with respect to ideal criteria when they can guarantee success with immediate implant placement and immediate provisionalisation?
Examples: Like thick biotype; class 1 implant site only;complete absence of occlusal contact (although there will always be contact on the provisional from a food bolus and the lips and the tongue);non-buxer.
Also if you are dealing with a class 2,3 and 4 implant site which needs soft/hard tissue grafting what is the best way to temporize the missing tooth if you are not preparing the teeth on either side for crowns which could support a fixed provisonal FPD?
I have heard some clinicians use an Essex type retainer with a tooth placed in the gap but I would think these would be poorly tolerated by patients. Adhesive resin bonded bridges can debond readily especially if there is not a shallow incisal relationship and an acrylic flipper will apply pressure to the grafted site...What has experience led you to chose an ideal esthetic temporisation method??
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Comments
Immediate placement....Doing it less and less
I pretty much eliminated immediates in my office. I tend to extract and graft. No reason to risk failure. I be burned to many times.
Tom
Immediate Placement and Immediate Loading
This is nothing new to implant dentistry! Early root forms and blades were placed with immediate loading. There are many points to consider, such as: implant threads, don't use press fits, age of pt., size of pt., pt. compliance, use of BPs, quality and quantity of bone, do not use grafted sites, occlusion, crossed arch fixation, bruxing etc, using bone compression techniques, and more. I suggest you start with the Journal of Oral Implantology XXX No. 4 2004. You may want to read the work by Linkow, Roberts and Misch to obtain an baseline understanding. I believe this is a viable method but one has to understand the basics. I also believe that patient compliance is greatly underestimated. We have many unexplained or poorly understood failures due to patients doing stupid stuff.
My protocol for immediate placement of implants
In a nutshell, here is my immediate implant placement protocol:
No immediates in the maxilla
Immediates in the anterior mandible
Immediates in the posterior mandible
Here is my rationale. First, the immediate implants will work. That is not the issue. The issue is how things will look 5 years from now. In the maxilla, the buccal bone is thin. Even with grafting, the buccal plate remodelling can be somewhat unpredictable. I have hundreds of cases, all done the same way, and the remodelling varies from person to person. At first, all look great. Over time, as the bone remodels, some look perfect, some look ok., and some look poor. Even Tarnow now states that he does not do any immediates in his program anymore.
In the posterior maxilla, the bone quality is often poor and the remodelling can vary, even with grafting during immediate placement.
In the anterior mandible, the buccal plate is often thin and remodelling can vary after implant/grafting.
That leaves us with the posterior mandible, which is the only place I routinely place immediate implants. The buccal plate in this area is much thicker and remodelling is very predictable with grafting. So long as I have enough distance to the IAN, I will place an immediate in the posterior mandible. In all other areas, I am grafting, placing an ovate pontic to preserve gingival contours, and coming back in a few months to place the implants.
Tarnow doesn't say that anymore...
In response to your comment, it appears that Dr. Tarnow has changed his tune. He now places implants immediately whenever he can unless the buccal plate is missing completely. He stresses no flap for extraction of teeth and does NOT graft the gap between the implant body and the surrounding socket walls preferring to allow a blood clot to form only.
Just thought you may want to know since you use him as a source to substantiate your position.
Sam
When did Tarnow change? Must've been within past year
When did he change his stance on this? I just saw him within the past year and he was preaching no immediates. If he has changed back, he is flip flopping more than a politician! Ha ha! Is that really what he is saying now? He is supposed to lecture in my hometown in a few months. I will be sure to ask him about it when he is down here.
Thanks
True, Tarnow Changed. Immediate vs Staged. It depends??
It depends on the situation....why can't we sometimes do both? Place the implant and graft simultaneously?
I refer you to an article I published on this subject with Funato, A & Salama, M IJPRD Volume 27, No. 4 2007
See a below excerpt from their article, it can be found on www.dentalxp.com for Free download once you register to the site;
Classification of Immediate Implant Placement
Table 2: Categorizing the Potential Implant Site . This classification is based on both the osseous and soft tissue levels of the potential site at the time of extraction.
Class 1: The buccal bone is intact with a thick flap gingival biotype.
“Incisionless” implant placement without flat reflection is viable (Figure 2).
Class 2: The buccal bone is intact with a thin, more scalloped gingival biotype.
Incisionless implant placement is viable but in combination with a connective tissue graft or a subsequent secondary connective tissue graft (staged) (Figure 1).
Class 3: The buccal bone is lost, but the implant can still be placed immediately within the remaining alveolar housing of the extraction socket, providing the necessary osseous support through regeneration utilizing a membrane with guided bone regeneration (GBR) and incorporating a simultaneous connective tissue graft (CTG). Depending on the degree of compromise to the buccal plate, the case may alternatively be handled in a staged approach utilizing a socket augmentation procedure with subsequent implant placement. In many instances, especially in thin biotypes, this method provides a more predictable and safer outcome.
Class 4: The buccal bone is severely compromised, and implant placement within the remaining palatal bone results in a significantly off axis implant position. In these cases, following extraction, implant placement should be delayed. If performed immediately, the long axis of the fixture inclines toward the buccal and will result in a significant esthetic compromise of the final restoration. In these situations, the delayed approach should be utilized with subsequent three dimensional (3-D) bone & soft tissue augmentation of the deficient ridge followed by optimal implant positioning.
Anyone providing abutments to their restoring dentists?
I have noticed a trend where many surgeons are providing the restoring dentists with all of the abutments, impressions copings, etc. needed to restore implants. This is more costly for the surgeon, but helps drive more referrals their way.
I have started doing this and the referring docs obviously like it. Anyone else doing this? How has it affected your bottom line? Have you changed your pricing?
Yes, I provide components to my referrals
I started providing implant components to my referrals because my competitors were doing this. It makes things quite a bit more expensive. I can't charge more for implants, so I have started using more lower cost implants. The customer service is not quite as good with the lower cost implant company, but at this point, I really don't need anything from my rep. I just need them to ship my orders on time and I am happy.
Abutments by specialists for generalists
The idea is good if the case is simple and the two doctors communicate well. If, on the other hand, the surgeon tried to do a favor to gain a favor (referral) without understanding the needs and wants of the restoring dentist, then it could work out quite negatively: cost, perceived imposition by the surgeon on the restoring dentist's protocols, etc. I work in and out of plans. When the case in with a plan that I participate in and, thus, for which my fee is restricted, then I love to have him provide the parts and save me lab and part expenses. This is especially true of the Atlantis system. I get a finished model with the implant analogs already in place. I happen to know that the periodontist I am working with is as fussy as I am so I can trust the impression. Otherwise I insist I do the impression.
Relative to the immediate load issue, I appreciate the convenience of being able to give the patient something to smile with asap, but due diligence is a must. As said above, full CT Scan evaluation and proper patient selection are critical. I also tend to do immediate temporization with cases that will not be C&B cases but a framework with denture set ups. Any recession can be forgiven. So far total successes but that can change in a flash.
Implant parts
Why can't you charge for the abutments as separate items from the implant. Just explain the cost is transferred from your restoring dentist to yourself. That is how my specialist and I handle it.
Immediate placement....Immediate temp...maxillary incisor
Immediate placement with a temp on an anterior maxillary tooth can only occur if you get excellent primary stability >35ncm. You must
1.have at least 5mm of native bone beyond the apex of the tooth to be extracted.
2.use a system that can help generate primary stability
3. be able to place the implant 1mm palatally to a line drawn drawn mid crestally between neighbouring teeth
4.thick gingival biotype
5.Gingival zenith is in a favourable position and will be able to receed 1mm without causing an aesthetic problem
6.be able to place the implant interface 3mm apical to the gingival zenith
7.be able to extract the tooth traumatically
8,do the procedure flapless
9.have a patient who will not place any maticatory forces on the tooth
10.Medically able to heal normally
11.Have periodontically healthy neighbouring teeth on both sides.
12.Have a buccal plate available
The big factor is palatal placement!!!
My concern with immediates in the anterior
My concern with immediates in the anterior is based on my experience. I have pics of about 100 cases all done the exact same way. Flapless extraction. Implant placed with torque > 35 Ncm. Immediate temps. The interesting thing is that I tend to see 3 remodelling patterns: 1) perfect maintenance of facial contours, 2) some resorption of factial plate contours, but outcome is still pretty good, 3)Significant resorption of facial plate and outcome is acceptable, but not great.
The thing is, some of these cases with resorption had thick biotypes. I always have my temps out of occlusion and the patients know to stay away from the implants during healing. To me, I still think immediates in the maxillary anterior can be unpredictable.
I am flaplessly extracting my max anteriors, performing site preservation, and placing resing bonded bridges to preserve contours. I allow to heal for 2 months and then place the implant. This has proven to be very predictable and I am not seeing the variability of facial plate remodelling that I was seeing with the immediate implants.
Just my 2 cents.
THanks
Immediates are not an issue in my practice
I do them when ever I can. As long as I can get stability an immediate will work and save the patient time and additional surgery.