Immediate Implant Placement and Provisionalization in the Esthetic Zone Using Flapless Technique

Chiapasco et al compared the effect of immediate versus delayed loading of implants and concluded that no significant difference was found between the two methods, suggesting that immediate loading is not detrimental to the osseointegration process.³ Covani et alanalyzed bone healing and coronal bone remodeling around 15 dental implants placed immediately into fresh extraction sockets and noticed a healing pattern with new bone apposition around the neck of the implants. Reported bone resorption was minimal, with only a slight horizontal width reduction of the alveolar ridge.⁴

During immediate implant placement, the question arises whether to conventionally lay a flap or utilize a flapless technique. Use of a flapless technique with bone grafting and immediate provisional restoration has shown great success, particularly in the maxillary anterior region or esthetic zone. This technique eliminates the drawbacks of the conventional open-flap technique by reducing postoperative discomfort, shortening the overall treatment time, and allowing minimal disruption of the peri-implant soft tissue. Collectively, this helps maintain soft-tissue contour, crestal bone levels, and probing depths and minimize overall inflammation.⁵

Predictability and reproducibility are especially important in the high esthetic zone. The flapless technique minimizes the volumetric changes that occur with the labial plate of the post-extraction socket in both the buccolingual and apicocoronal aspects.⁶ This minimizes labial gingival recession and reduces negative optical manifestations of the soft tissue due to concavities. Valavanis et al showed successful results for immediate implant placement in intact type 1 sockets with ideal hard- and soft-tissue profiles and using a combination of bone graft and an immediate provisional at the time of extraction and implant placement.⁶ Tarnow et al showed that placing a bone graft and provisional restoration at the time of anterior tooth extraction will increase both the apicocoronal and labial-palatal dimensions by 0.5 mm to 1 mm, as compared to placing neither a bone graft nor a provisional restoration at time of surgery. Increases were most frequently noted in the gingival and middle zones, where thickness gains were above the critical soft-tissue threshold of 2 mm.^7,8

This case report highlights immediate implant placement using a flapless technique with immediate provisionalization and a screw-retained temporary restoration in the maxillary anterior area (tooth No. 9). Successful results maintained at 1-year follow-up are demonstrated.

A 37-year-old African American man presented to the authors' private practice with the chief complaint that his "front tooth got hit" while he was playing basketball and "now it's loose." The patient had no significant medical history and was not taking any medications. His SpO₂ was 99%, and blood pressure was within normal limits.

Extraoral examination revealed no abnormal findings, and oral cancer screening was negative. Upon examination of the full-mouth radiographs, a periapical radiolucency associated with tooth No. 9 was found (Figure 1). The tooth was supraerupted with grade III mobility based on the Miller classification and was sensitive to percussion. Discoloration of the tooth was noticeable compared to the adjacent teeth, and a fistula was present near the approximate location of the apex of tooth No. 9 (Figure 2 and Figure 3). The soft tissue around the tooth was sensitive to palpation as well. A cone-beam computed tomography (CBCT) scan showed sufficient bone around tooth No. 9 and an intact buccal plate (Figure 4). Taking into account these findings, tooth No. 9 was deemed nonrestorable.

After presenting possible treatment options to the patient, it was decided that tooth No. 9 would be extracted and restored with a dental implant and screw-retained implant crown.

The procedure was carried out under intravenous moderate sedation and local anesthesia. Because the tooth had an intact buccal plate and sufficient soft tissue facially, categorized as a type 1 extraction socket, a flapless surgery technique was used to maximize the esthetic outcome.^7-9 Tooth No. 9 was extracted with minimum trauma to maintain the buccal plate. The periapical lesion and granulation tissue were curetted, and with the use of an explorer the socket was deemed to be intact. Chlorhexidine gluconate 0.12% oral rinse (Peridex^™, 3M Oral Care, 3m.com) was used to rinse the socket.

The surgical guide was fabricated out of a thermoplastic, vacuum-formed clear sheet after an ideal wax-up was done on the cast for tooth No. 9. The surgical guide was placed for initial osteotomy, and x-rays were taken to verify the direction of the osteotomy. The implant system used to restore the patient's tooth was Neodent^® Helix Grand Morse^™ (Neodent, straumann.com). The implant (Neodent GM Helix, 4.3 mm x 18 mm) was placed following the osteotomy favoring the palate with a 2 mm gap between the implant and buccal plate to create enough room for bone graft material. A torque value of 50 Ncm was achieved (Figure 5 and Figure 6).

A GM Implant Exact closed-tray impression coping (Neodent) was hand-tightened on top of the implant, bone graft was placed, soft tissue was sutured, and an impression was made for fabrication of a same-day provisional crown for the No. 9 implant. Instradent^® XenoGraft (0.25 g, small granules, Neodent) was used to graft the site, and Surgifoam^® oral sponge (Ferrosan Medical Devices, Ethicon, ferrosanmedicaldevices.com) was placed on top to hold the graft material in place. Interrupted chromic gut (3-0) sutures (Surgical Specialties Corp, surgicalspecialties.com) were used on each side of the implant.

After primary closure of the soft tissue and hemostasis were achieved, the patient's vitals were monitored until they were within normal limits. An implant-level impression was made using polyvinyl siloxane (PVS, medium and light body) (Identium^®, Kettenbach, kettenbach-dental.us) impression material. An opposing model was made at a prior appointment and the occlusal relationship was transferred to the lab using occlusal bite registration material (Blu-Bite HP^®, Henry Schein Dental, henryschein.com).

Next, the fabrication of the acrylic provisional crown was completed in the lab and inserted in the patient's mouth. Proximal contacts were adjusted as needed. Occlusion was checked in maximum intercuspation, and protrusive and laterotrusive movements were adjusted to have no contact with the opposing teeth (Figure 7 through Figure 9). The screw-access holes were sealed with teflon tape and temporary filling material (Tempit^®, Centrix, centrixdental.com).

Postoperative medications included amoxicillin 500 mg, Medrol Dosepak, Norco 5/325 mg, ibuprofen 800 mg, and chlorhexidine 0.12% mouthrinse. Before the patient was discharged, both he and his caregiver were given postoperative instructions in both verbal and written form.

The patient was seen at 1-week and 3-week postoperative appointments to evaluate the healing of the surgical sites and assess the occlusion. Four months after the surgery, the patient returned for evaluation of healing and osseointegration of the dental implant as well as soft-tissue healing. Radiographic x-ray was taken of the implant. The provisional crown was removed, and soft tissue was evaluated for proper contour and gingival zenith compared to the adjacent teeth. Subsequently, the decision was made to proceed with final impression to fabricate the final prosthesis.

The final implant soft-tissue contour was captured using a closed-tray impression coping and flowable composite. Final impression was made with PVS (medium and light body) impression material to make a screw-retained porcelain-fused-to-zirconia (PFZ) crown (Prettau^® Zirconia-Enamel S1, ICE Zirkon KEramic, Zirkonzahn, zirkonzahn.com) using a custom abutment (CARES^® Abutment, Straumann) with the proper shade. The lab prescription was written detailing the instructions for the in-house lab.

At the delivery appointment, the final PFZ crown was inserted using a new prosthetic screw (Figure 10 and Figure 11). The prosthetic screw was torqued to 30 Ncm following the manufacturer's recommendation, minor occlusal adjustments were made, and the screw-access hole was restored using teflon tape and light-cure material (Tempit). Recommended recall for the patient was initially determined to be every 6 months for the first year. If the bone level and soft-tissue contour was stable and the patient had good oral hygiene with no issues with the implant crown, then annual recall would be scheduled thereafter.

Over the decades, implant protocols have rapidly evolved leading to shortened prosthetic load time, culminating in today's immediate implant loading concept. This has afforded patients the option to satisfy various esthetic demands before the completion of osseointegration.¹⁰ A systematic review from Esposito et al revealed no evidence of clinical difference in prosthesis failure, implant failure, or bone loss between various loading times of implants (immediate, early, and conventional).¹¹

The flapless technique was successfully utilized in this particular case. While elevating a flap aids in visualization of the topography of underlying bone to avoid dehiscence or fenestration, it is not always necessary or beneficial.¹² A consideration in this case was the maxillary anterior situation and the fact that the facial bone only has three sources of blood: the periodontal ligament (PDL) of the tooth, the alveolar bone marrow space, and the periosteum. Additionally, the maxillary facial plate is 1 mm or less in most patients and is mostly cortical bone with very little to no marrow space. Thus, with the PDL blood source absent after extraction, and the periosteum blood supply being interrupted with any sort of flap elevation, postoperative peri-implant tissue loss during healing can be difficult to predict and manage.^7,8 With this in mind, the flapless technique most importantly preserves the periosteum blood supply to minimize peri-implant tissue loss and provides a less traumatic surgery while decreasing both surgical and healing time for the patient.¹²

When considering the flapless technique used in this case, it is important to classify the extraction socket to correctly assess and modify the surgical protocol to achieve the optimum esthetic result. A simplified socket classification is used to grade the extraction socket based on the amount of facial hard and soft tissues remaining after extraction.⁹ The patient presented with a type 1 extraction socket due to the sufficient presence and preservation of both hard and soft tissues, which was a most favorable scenario. In addition to the patient's thick and flat soft-tissue profile, these factors allowed for a predictable treatment.

A significant risk to the success of an immediately loaded implant is the presence of micromovements above 150 µm, with a tolerated range of 50 µm to 150 µm.¹³ Thus, achieving good primary stability is key to the long-term success of an immediately loaded implant.¹⁰ The implant used in this case has a hybrid design with both a cylindrical coronal area and conical apical area that helps to both compress bone during insertion and avoid anatomical structures such as adjacent tooth roots and labial concavities to preserve as much peri-implant bone structure as possible.¹⁰ The implant also has a dynamic thread design with a trapezoidal form in the coronal area and V-shape thread form in the apical area to help achieve high primary stability needed to negate harmful micromovements. The implant was successfully torqued to 50 Ncm the day of surgery.

Following implant placement, the "facial gap" or area between the implant and the facial plate was grafted. Tarnow et alshowed the greatest preservation of facial-palatal contour when using both bone grafting for the facial gap and stabilizing the graft material with an immediate same-day provisional, both of which were done for the current patient.^7,8 However, a superior type of graft had not been determined at the time of that study. A subsequent systematic review by Jambhekar et al aimed to analyze the outcomes of various types of graft materials following flapless extraction and showed that over the course of 12 weeks, the least postoperative socket dimension change was found with xenograft bone graft material.¹⁴ This was taken into account when selecting the bone graft material used for this case (Instradent XenoGraft). This graft material also offers excellent biocompatibility due to its similar balance of calcium and phosphate to human bone, low crystallinity and high porosity for optimal bone regeneration, and slow resorption rate for long-term volume, and it affords the option of being mixed with autogenous or allograft bone materials to enhance overall characteristics.¹⁵

This case report illustrates a successful approach for restoring a single tooth in the high esthetic zone in 1 day. Initially, a detailed examination of existing conditions prior to presenting treatment options is critical and should include patient history, medical history, clinical examination, and radiographic analysis. Analyzing the CBCT for bone thickness and bone levels, as well as classifying the predicted extraction socket type is important in choosing the correct surgical technique, graft materials and membranes if needed, and type and size of dental implant and making the decision to immediately load a provisional prosthesis.

This article was commercially supported by Neodent.

Chris Yang, DMD, MS
Private Practice in Surgical Prosthodontics, Dallas and Fort Worth, Texas

Khalid Azzouz, DDS, MS
Private Practice in Surgical Prosthodontics, Dallas and Fort Worth, Texas

Riad Almasri, DDS
Adjunct Faculty, Post-Graduate Prosthodontics, Nova Southeastern University College of Dental Medicine, Fort Lauderdale, Florida; Fellow, Academy of Osseointegration; Fellow, International Congress of Oral Implantologists; Private Practice in Surgical Prosthodontics, Dallas and Fort Worth, Texas

Tirakhsh Emadi, DDS, MS
Private Practice in Surgical Prosthodontics, Dallas and Fort Worth, Texas