Extraction with immediate placement and immediate temporization: the ultimate in patient satisfaction

Dr. Charles Schlesinger discusses an immediately placed implant with a temporary restoration

Introduction
When faced with an impending extraction, the first thought in the patient’s mind is, “What are you going to put there?” An immediately placed implant with a temporary restoration can be the solution the patient is looking for. But in order to provide an immediate implant-supported restoration, a few factors must be achievable:

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• Minimally traumatic extraction
• Immediate primary stability of the implant in the socket
• Ongoing stabilization of the implant and restoration after placement
• A temporary restoration with optimal occlusion

In today’s modern world of implantology, we try to provide the best short- and long-term treatment for the patient. The hard part is juggling the two, sometime diametrically opposed, demands. One should never sacrifice the long-term success of a case for short-term immediate gratification. Essentially, if you cannot load it — don’t.

The principles of immediate placement, primary stability, and sound occlusion are the necessary predictors for the success of a case that all conscientious practitioners shoot for, and every patient desires.

Clinical case
A 53-year-old female presented to the clinic with a symptomatic lower left cuspid (Figures 1 and 2). She had chosen to forgo endodontic treatment, buildup, and crown, for an extraction and immediately placed dental implant.

The patient’s medical history was unremarkable except for a recent 1-year history of bisphosphonate usage. The patient was apprised of the situation, and we discussed any potential negative issues that could arise as a result of her bisphosphonate usage.

A preoperative alginate was taken in order to later fabricate the temporary restoration (Figure 3). Since an extraction was required, and the site was sufficiently anterior to the mental foramen, an inferior alveolar block was administered with 2% lidocaine with 1:100k epinephrine (Henry Schein®, USA). After profound anesthesia was achieved, the cuspid was extracted using a spade proximator (Figure 4) and a No. 33 lower forceps using only a rotational movement. The use of these two instruments facilitated an atraumatic extraction that was able to preserve the very thin facial wall observed in the CT scan (Figure 5). Once the tooth was extracted and the integrity of the facial wall was verified, the socket was debrided with a small paddled serrated curette (Zoll Instruments, Chicago, Illinois). The extracted root was measured using a measuring pin (OCO Biomedical, Albuquerque, New Mexico). The facial CEJ was at 12 mm and the lingual at approximately 14.5 mm (Figure 6). From these measurements, a 14 mm long implant was treatment planned for the case.

One of the most difficult aspects of immediate placement in an extraction site is re-directing the pilot to create the intended three-dimensional position for the implant. The pilot drill will naturally want to follow the path of least resistance; and in this case, it is the existing socket walls. In order to re-direct away from the socket left after extraction, you must first create a purchase point through the lamina dura of the socket (Figure 7). Once this purchase point is established, it is easy to create the correct path in the softer medullary bone with the pilot drill.

A crucial requirement for successful immediate placement is the establishment of primary stability.¹ On top of that, this primary stability is required in order to successfully place a temporary at the time of surgery.

In an extraction/immediate placement protocol, this primary stability can come from a few sources. It can come from placing the implant beyond the apex of the existing socket and engaging apical bone for stability, or it can come from the lateral walls of the socket. The mesial, distal, or lingual walls are all good options. The potentially fragile facial wall should not be engaged in order to preserve this crucial bone. This is especially important in clinical situations where the facial wall is thin. The engagement of this wall by the implant threads would likely result in a facial dehiscence occurring as a remodeling took place.

A 1.8 mm pilot is taken to full depth of the intended implant (Figure 8). Following the establishment of the trajectory with the pilot, a 4.0 mm final osteotomy former was used to prepare the site for implant placement (Figure 9). Initially, a bone level ENGAGE^™ implant (OCO Biomedical) was chosen (Figure 10), but due to the apical position (Figure 11) of the facial crest mid-root, it was determined that a TSI implant (OCO Biomedical) would better handle the case by not only moving the restorative platform occlusally (Figure 12), but also negating the low mid-facial position of the crestal bone. A final benefit was the sealing of the socket at the crest by the flair of the imbedded tapered platform. By engaging the mesial and distal walls at the crest with a platform, which flairs from 4.0 mm to 4.7 mm, it provides dual stabilization along with the bull nose auger tip at the apex. The imbedded tapered platform is machined rather than polished; therefore, it is possible to place the 2 mm of titanium nitride surface either in the bone or in the soft tissue zone without the normal dieback associated with polished collars.

Prior to placing the 4.0 mm x 14 mm TSI implant, an OsteoGen^® Plug (Impladent, LTD.) was cut and inserted to fill the gap between the implant and the facial wall (Figures 13 and 14). The OsteoGen plug is comprised of OsteoGen (Bioactive Resorbable Calcium Apatite) and Type 1 collagen (bovine Achilles tendon collagen matrix). The plug is easily cut and formed; this material makes for an easy-to-use and economical graft material in cases like this. Studies have shown that it is possible for a 4 mm gap to resolve on its own, but in order to assure predictability and increase the chances for an esthetic outcome, the decision to graft was taken.²

The implant had a seating torque of 50N/cm (Figure 15). An Osstell meter (Osstell, Gothenburg, Sweden) was used to determine the stability in the surrounding bone. Measurements were taken in the M-D and BL directions. The resultant ISQ values were 67 and 58, respectively. It was expected that the B-L measurement was to be lower since the OsteoGen plug cannot give the same degree of stability as native bone. The higher M-D measurement is due to the engagement of the crestal bone by the platform of the implant (Figure 16).

The patented dual stabilization design of the TSI implant allows the implant to be mechanically locked into the site at initial placement. The ability to then load this implant changes this from a passive placement (if it was just buried) to a biomechanically active one. The micro-stimulation of the peri-implant bone by masticatory forces, as long as kept within acceptable limits, will allow for the potential for faster healing of the site as was initially postulated by Linkow.³

A 7-mm tall solid crown and bridge abutment was placed and torqued to 30N/cm. After re-torquing the abutment again, an acrylic coping (Figure 17) was used along with bis-acryl temporary material to fabricate a temporary using a pre-op alginate impression as a matrix (Figure 18). The occlusion was checked and the restoration cemented with Improv^® temporary cement (Alvelogro, Washington). All excess cement was carefully removed and the patient dismissed with a prescription for post-op antibiotics and an analgesic medication. The final radiograph shows the position of the platform (Figure 19 and 20). Some remodeling of the interproximal crestal bone is expected, but due to the thickness of the keratinized tissue present and the emergence profile created by the temporary, complete papillary fill is expected once complete healing has taken place.

This implant will be allowed to integrate 3 months with the temporary in place in order to allow for full turnover of grafting material and integration to occur. If a higher ISQ reading had been achieved in the B-L direction at the time of placement, then transition to the final restoration would have taken place in about 6 weeks. Also, since this is a cuspid, and it will be restored as a guiding cusp in lateral excursive movements, thereby taking a significant amount of lateral load, erring on the side of conservative treatment protocol was a prudent decision in this case.

At 2.5 months, the temporary restoration was removed, and a VPS impression was taken using a snap on impression coping. A metallic analog was placed in the impression; an opposing alginate was taken along with a bite registration. This was sent to the lab for the fabrication of an IPS e-max® (Ivoclar Vivadent®) final restoration.

Two weeks later, the final restoration was cemented (Figure 21) with resin cement after the occlusion was adjusted. The patient was dismissed after any remaining cement was cleaned up and a final radiograph taken (Figure 22).

Conclusion
With all the advances modern dentistry affords us as practitioners, many times the best option either clinically or for the patient’s needs is to extract a tooth. Whichever is the case, the loss of a tooth can be traumatic for the patient not only physically but mentally. If patients can leave with a temporary crown on an implant, they will not only feel better about themselves, but the clinical outcome esthetically will be better too. Implant dentistry can be one of the most rewarding aspects of one’s practice, and performing implant dentistry in this manner can magnify those good feelings to a higher level.
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