Civitali Dental and Prosthetic Center srl

Immediate loading post-extractive implant.

 

A post-extractive immediate loading implant rehabilitation is, today, still an elective treatment. This is because this kind of surgery is quite more difficult than the traditional protocol applied to rehabilitate post-extractive sites that have already healed. In particular, the flapless approach (implying no gingival incision is performed) impairs visibility and the presence of a post-extractive socket reduces the probability of achieving a proper implant primary stability.


Such technique, therefore, is confined to cases where preparing a provisional prosthesis aesthetically valid and acceptable for the patient during the period preceding the final prosthesis delivery would be very difficult, if not impossible,. Though, this technique may be applied with no concern since it has been known – already for some years – that this treatment is predictable and provides a high success rate.


Advantages claimed are: the preservation from the resorption of the alveolar bone, the maintenance of the morphology of the papillae and the time spared, since less surgical and prosthetic steps are needed with respect to the traditional approach.

This procedure is indicated for all cases in which the dental element has to be extracted because of an untreatable root fracture, or when an endodontic lesion cannot be re-treated. Also, when radicular absorption is observed or in case of periodontal disease, when bone quality and quantity are such that regenerative procedures are not feasible.


Contraindications are: residual alveolar cavities calling for bone regeneration where primary stability is lower than 25 Ncm, above all if resting on a single implant; in situ acute inflammatory processes; smoking, significant systemic disorders; bruxism.

There’s no need to stress that this kind of surgery is reserved to high-compliant patients, capable of maintaining an appropriate oral hygiene over time.

Surgical technique

Clinical assessment


The clinical assessment shows a coronal fracture due to trauma, not involving soft tissue and not affecting hard ones. Beyond a traditional panoramic radiograph, an intraoral pre-surgical radiograph is performed in order to collect more details and plan both the extraction and the following implant placement.

In the case under consideration, a flute-like fracture was observed. It was not easily diagnosed by the radiograph, given the juxtaposition of the radicular third medium.


Tooth extraction

Extraction is performed respecting at a maximum extent both hard and soft tissues, without opening any flap. After accurate cleaning of the cavity, all four walls are carefully probed in order to detect any breaking or dehiscences. Avulsion must be totally atraumatic and spare, above all, the vestibular wall that especially in the frontal areas – at higher aesthetic impact – is particularly thin. If such wall underwent trauma, a defective healing would be observed – leading to aesthetic impairment. As the root is extracted, the diagnosis of fracture is confirmed and length of the implant may be chosen accordingly.


Implant placement

Implant placement has to be performed very carefully and the implant must receive most of its stabilization from the apex. Therefore, it must screw into the bone for at least 3 mm more than the length of the root of the extracted tooth: producing the necessary grip to give the implant the desired primary stability. Under-preparation or hand-preparation may be advised in order to compact bone at the placement site, if necessary. The importance of choosing a conic, threaded implant is evident. This will allow to get the insertion torque needed for immediate prosthesis delivery. In the case under examination, the root was 11.5 mm long and the length of the implant chosen was 15 mm (and diameter was 3.8 mm – XiVE, Dentsply).


Provisional prosthesis

After placing the implant, a pre-shaped provisional prosthesis was re-based over a mount or a provisional abutment, according to the implant system. The emergency profile was shaped in order to support the vestibular soft tissues properly, without applying – though – excessive compression, avoiding the risk of a recession during the following months. In order to avoid any irritation, a screwed provisional prosthesis was preferred. The papilla was left enough space, with a contact point planned according to the gingival and bone morphology.


Patient discharge and recommendations

The patient was discharged after initiating a proper antibiotic therapy, to be carried out for one week, and prescribing analgesics for three days and cryotherapy for the following three hours. She was recommended to avoid any mechanical trauma to the surgical zone, especially before suture removal (7 days), and to not brush the area. She was instructed about performing 0.20% chlorhexidin rinses three times a day, and to apply a chlorhexidin spray or a topic gel after terminating each set of rinses. She was forbidden to chew with the operated zone, and instructed for a soft diet during the first month, returning gradually to a normal one later. The patient was controlled weekly during the first four weeks and then monthly up to the fifth month, when the definitive prosthesis was delivered.


Definitive prosthesis

After six months, definite prosthesis was delivered. First, a radiograph was performed to assess bone remodeling. Then, components were unscrewed and good soft tissue healing and remodeling was observed, thanks to the provisional prosthesis effect and to the careful polishing of the resin over the mucosa.


Follow up

Control visits were planned at one week, one month, six months and then yearly. Careful oral hygiene was advised, through the use of both tooth brush and dental floss. When rehabilitation was complete, both “pink” and “grey” aesthetic zone looked good. The zircon crown, placed on an aesthetic abutment, was perfectly integrated in the morphological and occlusal context of the oral cavity. This procedure, when managed properly, provides the planned prosthetic-implant result guaranteeing both comfort and satisfaction to the patient.


Clinical appearance after trauma