Benchmark for Tooth Replacement: Immediate Implant With Immediate Provisional Restoration. Outcome Analytics From 29 Years of Documentation

Implant dentistry has provided predictable and reliable restoration of function and esthetics for patients with tooth loss or regressing dental health requiring tooth extraction. Brånemark's research^1,2 introduced to the dental profession the biologic foundation for evidence-based implant dentistry and revolutionized tooth replacement as dentistry achieved the ability to optimize function and esthetics with fixed implant-supported prostheses.

Immediate implant sites^3-8 have been studied extensively in the literature, though immediate implant sites with simultaneous provisional restoration^9-20 have been studied less extensively. Nevertheless, clinicians are still divergent as to the best protocol to accomplish the transition from teeth to implants. Existing controversies include the applicability of immediate implants and/or immediate restorations in infected sites, compromised bone or soft-tissue sites, the esthetic zone with or without adjacent implants, flap versus flapless surgery, and bone and soft-tissue grafting to augment immediate implant sites. These issues have deterred the universal applicability of immediate implant surgery with or without immediate provisionalization.

The purpose of this article is to report on outcome analytics comparing 29 years of documentation of immediate implant surgery and 16 years of documentation of immediate implant surgery with immediate provisional restoration.^15-20 The article is meant to be a summary of a subset of immediate implants-immediate implant/immediate provisional restorations (IIIPR)-to offer direction and present conclusions. It will include a discussion of reliable IIIPR protocols that are evidence-based and that provide expeditious transition from failing teeth to stable implant solutions that are functionally predictable and esthetically optimal.

Since February 1988 all implant procedures performed by the author were documented in a software module particular to implant dentistry (The Implant Tracker^™, Implant Tracking Systems, LLC, implanttracker.com). This software became the repository of all the data for each implant site (N = 14,946), and it provided outcome analytics to compare success rates of varying protocols, including IIIPR (n = 2,493) and immediate implant/no restoration (IINR) (n = 5,826). The remaining implant sites were intact and were not included in this report.

The data files contain: date of surgery; pertinent medical and dental history; site of surgery; presence of infection; extraction information; size and type of implant placed; bone and soft-tissue regenerative protocol and materials; site as a staged, immediate, and/or immediate load; date of integration confirmation; incidence of implant failure; prosthetic completion; and follow-up.

Intraoral photographs of the procedure showing early healing and follow-up to completion and recall were also documented. This was intended to confirm esthetic harmony of the final prosthesis to the dentition and the congruence of the soft-tissue result. Initial and periodic radiographs and photographs were taken to compare the bone and soft-tissue landmarks years later under loading and long-term function.

The implants used varied in design and prosthetic connection. The IIIPR implants included rough-surface tapered implants with varying thread pitch and design; varying internal connections, including trilobe, conical, and platform shift; and multiple prosthetic connections, including both screw and cement retention. Bone graft material used universally was demineralized freeze-dried bone allograft (DFDBA) of 300 µm to 500 µm. Temporary prostheses for immediate load and final prostheses were either cement- or screw-retained, with a single tooth or multiple teeth. In cases of cementation, a universal protocol was used to extrude cement extraorally on an analog of the final abutment before seating clinically to remove excess cement and minimize the introduction of subgingival cement. The majority of temporary restorations for immediate load were cement-retained and adjusted to be out of occlusion.

The implant software prompted the clinician to complete all the steps for each site for each patient, from initial surgery and integration confirmation to prosthetic completion and patient recall evaluations.

Immediate implant exclusion criteria included the inability to stabilize the implant in the residual bone after ex-traction and debridement, and exclusion criteria for immediate provisional restoration included the inability to attain implant stability greater than 30 Ncm. Insertion torque forces were visible on the electric drilling unit used and were titrated at implant placement so final seating could be accomplished to an insertion torque greater than 30 Ncm irrespective of the quality of the bone.

One clinician completed all surgical procedures in a private practice setting, and different private practice dentists provided the final prosthesis in each case. Surgical protocol included primarily flapless surgery with atraumatic extraction with elevation from the mesio-lingual, direct lingual, or disto-lingual to avoid altering labial soft tissue or papillae, with full debridement of the sites down to sound bone. Root separation was performed prior to extraction of multi-rooted teeth, and in the presence of ankylosed roots a radiograph was taken to confirm the absence of residual root. In the presence of diminished labial or lingual plate, a bone graft was inserted to reestablish socket contour with no flap elevation. If labial fenestration was present, a bone graft was placed from the socket side of the fenestration with no flap elevation and compression of the bone graft with the last drill used to establish the corridor for implant insertion.

Implants were placed precisely at restoration level to conform to the esthetic and prosthetic needs of the site and at apical level for stabilization in the optimal available bone corridor. A high initial insertion torque was attained, and the socket was sealed with the temporary crown or healing abutments to contain the clot and/or bone graft and support the soft tissue. As previously mentioned, for cement restorations cement was extruded extraorally on an analog to avoid the introduction of subgingival cement.

Postoperatively, patients were prescribed antibiotics and analgesics. Time was dedicated postsurgically to provide patients detailed verbal and written postoperative instructions specific to immediate implants and immediate provisional restorations with particular attention given to eating instructions for immediately provisionally restored implant sites to avoid premature loading. At 2 weeks patients were seen for review of home care and reinforcement of instructions to avoid premature loading of the implants, and for postoperative suture removal if needed. Integration confirmation was scheduled between 3 to 4 months for mandibular implants and 5 to 6 months for maxillary implants.

From February 1988 through May 31, 2018, 14,946 implants were placed in 6,037 patients (3,435 women and 2,602 men). A total of 8,319 of these implants were immediate implants in 4,758 patients (2,680 women and 2,078 men). A total of 2,493 implants were IIIPR in 1,782 patients (1,063 women and 719 men), and 5,826 implants were IINR in 3,498 patients (1,937 women and 1,561 men). For the 2,493 IIIPR sites, regenerative protocols included: bone graft and membrane in two sites; bone graft alone in 130 sites; membrane alone in 0 sites; and no bone graft, no membrane in 2,361 sites.

Success was defined as successful osseointegration, successful bone regeneration, a steady state of bone and soft tissue under loading, and good esthetics. The overall success rate of immediate implants was 94.8%: the success rate of IIIPR was 95.1%, and the success rate of IINR was 94.5%. Average follow-up time to determine success was 5 years with a range up to 16 years for IIIPR and 29 years for IINR.

A 53-year-old male patient presented on emergency with severe pain on biting and mobility of tooth-supported bridge No. 6-P-8 (Figure 1 and Figure 2). Clinically, Class II mobility was present with significant periodontal probing along the labial of tooth No. 6 with a suppurative exudate on palpation of the labial tissue.

The patient was anesthetized with infiltration anesthesia, the bridge was removed, and the roots of Nos. 6 and 8 extracted (Figure 3). The sockets were fully debrided of granulation tissue down to sound bone and explored with a ball probe identifying intact labial plate. Preparation of the sites was initiated with a precision drill to identify ideal prosthetic location, and two prosthetically correct 5-mm x 13-mm implants were inserted and stabilized in excess of 45 Ncm (Figure 4). The bone was milled to allow for unimpeded placement of a temporization abutment.

The presenting bridge was revised to be the temporary bridge in infra-occlusion (Figure 5 and Figure 6). Cement was extruded extraorally prior to seating of the temporary restoration. The sockets were sealed with the temporary restoration and no sutures or bone graft was placed. The patient was instructed in postoperative care specific to an immediate-load implant, and an antibiotic and analgesic were prescribed.

At 6 months, integration was confirmed (Figure 7 and Figure 8). The patient was impressed for a final restoration, which was cemented within 4 weeks. A 1-year postoperative clinical photograph (Figure 9) demonstrated good esthetics, and a final x-ray at 6 years postoperative (Figure 10) demonstrated a steady state of bone-to-implant under loading.

A 22-year-old female patient had trauma to teeth Nos. 7 through 9 and Nos. 11 through 14 from an automobile accident. The anterior segment was treated immediately with IIIPRs. Teeth Nos. 11 through 14 persisted in pain on occlusion, and at 2 months post trauma the endodontist determined that Nos. 11 through 14 had vertical root fractures and prescribed extraction (Figure 11 and Figure 12).

An impression of the sextant was taken prior to the extraction to provide a template for fabrication of a temporary bridge for implant Nos. 11 through 14. The patient was anesthetized, teeth Nos. 11 through 14 were extracted, and 4.3-mm x 13-mm implants were placed in site Nos. 11 through 13 and a 6-mm x 13-mm implant was placed in site No. 14 (Figure 13). The implants were prosthetically correct and stabilized in excess of 45 Ncm. They were milled to remove any excess bone that might interfere with full seating of temporary abutments. Temporary abutments were stabilized and a temporary bridge was fabricated for Nos. 11 through 14 (Figure 14).

Excess cement was extruded extraorally prior to seating of the bridge, and occlusion was adjusted so the bridge would be out of occlusion. No bone graft or sutures were placed because the temporary crowns sealed the sockets. The patient was prescribed antibiotics and analgesics and instructed in postoperative care particular to immediate-load implants.

At 6 months, integration was confirmed and the patient returned to her dentist for restoration (Figure 15 and Figure 16). The implants were restored with individual cement-retained crowns and the patient was last recalled at 3 years (Figure 17 and Figure 18).

A 58-year-old female patient presented with a very loose upper left "H" and a horizontally impacted upper left canine (Figure 19). After evaluation of the site with cone-beam computed tomography (CBCT) images (Figure 20) the area was anesthetized, the impacted canine was extracted (Figure 21), the upper left "H" was extracted, and an implant was secured crestally and apically in excess of 45 Ncm, which was prosthetically correct (Figure 22). The lingual void was bone-grafted with DFDBA 300 µm to 500 µm; the area was sutured with sling sutures from the lingual, resulting in primary closure; and the implant was milled to remove any excess bone that might interfere with seating of a temporary abutment. The temporary crown was then fabricated chairside (Figure 23), and after extrusion of excess cement, it was positioned in place and adjusted to be out of occlusion (Figure 24). The patient was prescribed antibiotics and analgesics and instructed in postoperative care particular to immediate-load implants.

At 6 months, integration was confirmed and the patient returned to her dentist for restoration. The implant was restored with an individual cement-retained crown and the patient was last recalled at 4 years (Figure 25 and Figure 26).

Today teeth can be replaced with implants with one minimally invasive surgical procedure. This study evaluated the efficacy of IIIPR as a predictable protocol. In 2,493 implant sites, the treatment objective was accomplished as planned with the completion of an immediate implant with 99% flapless surgery and chairside fabrication of a temporary restoration. Highly focused postoperative instructions were verbally reviewed so patients could understand oral hygiene requirements and the need to avoid premature loading of the implant restorations. In two cases, the patients avulsed the implant and restoration with a very strong daily tongue manipulation; subsequently, postoperative instructions included the need to avoid repetitive tongue pressure on the restoration.

Patients exhibited very little postoperative discomfort and were pleased to leave the office with an implant and restoration in place; in most cases, no sutures were used. In those cases in which the dimension of the restoration did not seal to the soft tissues, viacryl resorbable sutures were used to seal the soft tissue around the restoration and contain the clot. Patients were routinely seen at 2 weeks for reinforcement of home care and review of postoperative instructions. In the presence of poor oral hygiene, patients were seen until home care was acceptable.

Across IIIPR cases, regenerative objectives were accomplished with good bone-to-implant volume and soft-tissue maturation; two sites required regenerative protocol of bone graft and membrane, 130 sites required bone graft alone, and the remaining 2,361 sites relied on normal socket regeneration with no membrane or bone graft. The two sites requiring membrane and bone graft were side-by-side implants in Nos. 8 and 9 where there was extensive infection, periapical granulomas, and lack of labial plate, and these required flap elevation with subsequent primary closure around the temporary restorations. The remaining 130 sites requiring bone grafts represented partial loss of labial or lingual plate and fenestration defects and were grafted from the osteotomy side of the defect with no flap elevation.

Outcome analytics provided data supporting the efficacy of IIIPR with a 95.1% success rate in 2,493 sites. IINR had comparable success rates. This data showed that immediate restoration of an immediate implant does not contribute to a less favorable treatment outcome than immediate implant alone. In this population group, implant failure was primarily the consequence of compromised patient compliance where patients prematurely loaded the implant restoration.

It is important to remember that implant placement is a prosthetic event and immediate implant surgery should be used only if it satisfies the optimal prosthetic objectives of the case. In this implant population, the procedure was highly efficacious with less than 1% of sites found to be unfavorable for an immediate implant.

It should be noted that collaboration between the general dentist and surgeon is essential to provide optimal treatment for the patient. Both parties should be knowledgeable of state-of-the-art implant treatment protocols, and clear communication is needed between the offices to optimize treatment sequence and restorative conclusion. When there is an understanding between the surgeon and general dentist that each is capable of carrying out these protocols, an optimal treatment plan can be confidently initiated. The transition from pathology, ie, root fracture, caries nonrestorable, periodontally hopeless, endodontic failure, etc, to final restoration will, thus, result in a treatment outcome that is most efficient requiring minimal surgical visits and time and is functionally and esthetically optimal for the patient.

The outcome analytics from this study on IIIPR procedures suggest this protocol is highly successful and predictable. Immediate implant regenerative procedures are reproducible in diverse clinical situations. The time of extraction is ideal for implant placement, as with atraumatic extraction the integrity of the bone and soft tissue is maintained and its vascularity and cellularity are sustained, which promotes bone and soft-tissue regeneration simultaneous with osseointegration around the osteophilic implant surface. The immediate implant provides an ideal platform for esthetic tooth replacement. A temporary crown or healing abutment is a good scaffold for soft-tissue development and maturation and serves as a socket seal to contain the bone graft or clot. The immediate implant accomplishes site retention and development in one procedure, minimizing the number of surgical procedures.

This protocol helps facilitate a patient's transition from natural teeth to restored implants. The treatment reduces multiple surgeries to one surgery, provides patients an esthetic restoration the day of implant placement, utilizes flapless surgery, retains esthetic soft-tissue dimensions that mature around an ideal temporary crown scaffold, and offers a normal sequence to prosthetic completion.

The author is the co-developer of the Implant Tracker, which is sold by Implant Tracking Systems, LLC. He is also the developer of the Gelb Depth Gauge and has lectured on behalf of Nobel Biocare.

The author wishes to acknowledge the following colleagues for their prosthetic work: Drs. Jeffrey Burns (case 1), Donald Annicelle (case 2), and Susanne M. Gelb (case 3).

David A. Gelb, DDS

Diplomate, American Board of Periodontology; Fellow, Academy of Osseointegration; Fellow, American College of Dentists; Fellow, International College of Dentists; Fellow, Pierre Fauchard Academy; Private Practice, West Hartford, Connecticut