JIACD
The Journal of Implant & Advanced Clinical Dentistry
What is the current thought on anterior immediate implants?
Wed, 11/19/2008 - 13:41 — implantdoc
I see new implants such as the Nobel-Biocare Nobel Active implants that are touting themselves as being specifically designed for immediate placement. On the other hand, world renowned educators such as Tarnow and the NYU group have mentioned in recent lectures that they have gotten away from anterior immediates due to esthetic complications down the road. What are your current thoughts about anterior immediate implants?
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Comments
I am doing immediates...minimal problems to date
I have been doing immediate implants in the anterior for years. I have not had any major problems to date. I always graft the HDD with bone and usually do not attach a temporary to the implant. Lately, I have been giving this a try, however. I have been temporizing my immediate sites with resin bonded bridges that I prepare with the patient's anatomical crown (if available) or a premade acryllic pontic that I fabricate from a diagnostic waxup (if the tooth is missing). This allows the implant to heal unloaded and provides papilla support to the pontic site.
Recession
I have also steered away from doing as many immediate placement, in the anterior, due to about 1.5mm of recession in thin biotype cases. I have not had this problem in cases with thick biotype.
immediate implants
This is a controversial subject. I place a LOT of implants and I have to say Dennis Tarnow is considered an expert for good reason. Yes, I have had many success with immediates, however, I place them less frequently than I did a year ago.
For example, if the patient has a thin biotype and/or a high smile line....I tend to preserve the socket and wait 3 months. I value the decreased chances of difficult esthetic complications. I also sleep better at night. If you have placed many immediates you also have to ask yourself are you considering a success at 1 year or 5 years??? Esthetic problems do not necessarily surface early on. Personally, I want to know that my implants look natural still at 5 years minimum.
When in doubt, I suggest waiting for a 2 stage plan....it is much more predictable. Let us not forget we are talking about someone's smile. These patients put a lot of trust and faith in us to make the right decision...is it worth the risk?
How do you make the resin bonded FPD?
Hi there-I was just wondering how you make the resin bonded temporary FPD say with an acrylic tooth? Do you attch the tooth to the neighbouring tooth with the mesh like arylic resin fibered material-I cannot remember what the name is;Ribbond I think-Can you only do this if the occlusion allows? ie a shallow vertical overjet relation ship? Thank you,Sharon
RBB Technique
Occlusion is critical when making an RBB. If you are placing an implant in the edentulous spot between two teeth, you obviously don't want to take any tooth structure away from the adjacent teeth to accomplish the RBB. Otherwise, you would have just done an FPD in the first place.
When making an RBB for an implant site, I first check to make sure there is enough occlusal clearance. If the bite is not right, there is no point in making an RBB. It is not going to work.
If the occlusion permits, I will make an RBB. If possible, I retain the natural clinical crown to use as the RBB pontic. I use composite to turn the clinical crown into an ovate pontic and bond the pontic to the adjacent teeth with composite. I used to use Ribbond, but I don't really think that it is necessary. Most of my composite is on the lingual. Occasionally, I may flow a tiny amount of composite in the embrasures between the teeth, but I try to keep that to a minimum. Occlusal clearance must be verified in all directions. If the occlusion is high in any spot, the RBB is going to fail down the road and you will waste valuable office time re-bonding the RBB into place.
If the original clinical crown will not work, I will either use a diagnostic wax-up to create a stent for pontic creation or I will use a pre-formed composite crown. I like the custom wax-ups better than the premade stuff. I will do it myself rather than send out to a lab. Only takes a few minutes.
Hope this helps.
err on the side of caution, I say
I think that the stakes are high in anterior cases. These days, success moves way beyond osseointegration and gets critical into soft tissue contour. You must maintain bone on the facial plate. If you do not then you will have a dehiscense of soft tissue and a failure of a case.
When deciding on wether to load immediately consider the following, patient selection/compliance, facial plate intact, primary stability of fixture, biotype of tissue, lip line, patient expectations, and condition of adjacent teeth.
Primarily you need to ask yourself, am I placing the crown on this patient for the patient's benefit and expectations or is it because other doctors say I should be doing this. If the patient didn't request it nor want it, then why take the risk? If they want a crown on immediately, then is it a good idea in your professional opinion to do it for them? Remember, although they will make the decision, they will also hold you accountable for the result. Even if you boast a large percentage of successful cases, you know that one bad case can be expensive and difficult to fix. When making that decision, I err on the side of caution.
Misch gave nice immediate implant lecture at AO
Immediates in the anterior. Very technique and situation dependent according to the Misch lecture. I have had good results with the immediates that I have done, but I am sure that Misch has done many many more. Biotype, gingival scallop, smile line height, tooth morphology are all things to consider in addition to bone thickness, occlusion, etc.
Temporization
When temporizing in the anterior without immediate load, are most of you using a stayplate or are you placing a custom temorary to form papilla? If you use a stayplate, how are you developing your papilla form at a later date? Are you using the actual implant crown or custom temporization prior to placing the crown?