Various studies of implant

2001/2/4 perio-prostho seminars

Topic
Immediate implant vs delayed
immediate implant ()
Wide-diameter implant vs standard-
diameter implant ()
Single-stage vs Two-stage ()
Immediate loading vs progressive
loading ()
Brnemark group traditional protocol
recommends a 12-month healing period
between tooth extraction and placement of
implants.(Adell R et al 1981 Int J Oral Surg)

Preserve alveolar bone concept
immediate implant concept

Schulte(1984)

Tuebinger implant

Frialit-2 implant

Stepped-tapered root
analog
Immediate implant
Advantage
Preservation of the alveolar bone
Esthetic (extracted tooth has a desirable alignment)
ideal implant position
natural scalloping and distinct papillae are easier
to achieve
maximal soft tissue support
Fewer surgical interventions
Reduction in treatment time & cost

Immediate implant
Disadvantages
Misalignment of the extracted tooth may lead to
unfavorable angulation of the fixture
Stabilization may require more bone than is
available beyond the apex
Localized peri-implant bone defect
Primary soft tissue closure
( submerged vs transmucosal implant)
Indication for Immediate implant
Root fracture
Trauma not affecting the alveolar he
alveolar bone
Decay without purulence
Endodontic failure
Severe periodontal bone loss
Residual root
Contraindication for Immediate
implant
Presence of pus
Lack of bone beyond the apex or close
relationship to the anatomical vital
structures
Extraction site defects
Residual defect
morphology and the
regenerative potential at
the extraction sites

Salama H & Salama M
1993 IJPRD
Extraction site defects
Type I ideal site for immediate implant
4-/3-wall socket with minimal bone
resorption (<5mm apico-coronal defect)
Sufficient bone available beyond the apex
Acceptable discrepancy between the
fixture head & neck of the adjacent teeth
Manageable gingival recession or
esthetics is not essential.
Extraction site defects
Type II need orthodontic extrusion
Dehiscence > 5mm
Substantial discrepancy between the
fixture head & neck of the adjacent teeth
Significant gingival recession or esthetics .

Extraction site defects
Type III not suitable for immediate
implant
inadequate vertical &B-L bone dimension
Recession and severe loss of labial bone
Severe circumferential and angular defect


The decision to submerge should base on
the following factors
Plaque control
Smoking
Periodontal conditions
The degree of stability
The presence of provisional removable
denture
Submerged implant
Primary closure
Bowers & Donahue(1988)
Edel (1995) ,Chen & Dahlin(1996)
Rosenquist(1997)
Rotated palatal flap for
immediate implant
Nemcovsky CE
2000 COIR
Transmucosal immediate implant
Cochran & Douglas(1993);Brgger et al (1993)
Schultz(1993) ;Lang(1994)
Brgger et al (1996);Hmmerle et al (1998)
Evidences emphasize the importance of
infection control for a successful tx. of
outcome following immediate implant of
transmucosal implants
Transmucosal immediate implant
Original peri-implant defect was the
most critical factor relating to the final
amount of bone-to-implant contact
Horizontal defect dimensions of >4mm
resulted in a lower bone-to implant
contact than dimension of 1.5mm or less
Wilson et al 1998 J OMI
Conclusion about immediate
implants
High survival rate : 93.9%-100%
Implants must placed 3-5mm beyond the
apex in order to gain a maximal degree of
stability
Implant should be as close as possible to
the alveolar crest(0-3mm)

Schwartz-Arad D et al 1997
Conclusion about immediate
implants
There is no consensus regarding about
the need for gap filling and the best graft
materials
The use of membrane does not imply
better results on the contray ,membrane
exposure may carry complications
The absolute need for primary closure
Schwartz-Arad D et al 1997



Immediate vs non-immediate
implantation for full-arch fixed
reconstruction following extraction of all
residual teeth : A retrospective comparative
study

Schwartz-Arad D et al 2000 J P



Results
5-year cumulative survival rate(CSR)
Immediate implant (96%) non-immediate(89.4%)
Mean potential contact area(PCSA) 230mm
2

Significant differences in CSR in maxilla(96.6%
vs 82.9%)
Posterior Max.
Immediate implant (100%) non-immediate(72%)

Conclusions
Survival rates of implants placed to support full-arch
ceramo-metal prosthesis can be ranked as follows :
bone quality , immediate implant,PCSA
Immediate implantation exerts its effect through
higher PCSA values by a compensatory effect for
bone quality
Immediate implant does not carry additional
morbidity

Delayed Immediate implant
To allow primary soft tissue healing following
tooth extraction for a period of 6-10 weeks ,prior
to implant placement
Advantages
1) adequate soft tissue
2) minimized the effect of microorganism
associated with the failed tooth or wound
healing (Gher 1994)
3) highly osteogentic activity
Spontaneous in situ
gingival augmentation
Burton Langer
IJ PRD 1994;14:525-535
Delayed immediate implant
Alveolar bone changes during the healing
period
Strong tendency for the defects to fill-in in the
horizontal plan and bone growth to occur in the
vertical plane of the height of the cover screw .
Good short-term prognosis with bone
regeneration occurring around the defect
without the use of barrier membranes or bone
substitutes
Nir-Hadar O et al (1998)


After an average follow-up of 12.4 months, peri-
implant pocket depth, the gingival index, the
hygienic index, and the degree of bone
resorption were examined. A life-table
approach (Kaplan-Meier) was applied for
statistical analysis, and showed no difference
between primary and secondary immediate
implants. Also, none of the parameters
examined demonstrated a statistically
significant difference between the two
groups.
Mensdorff-Pouilly et al 1994 J OMI
However, compared with the groups of
secondary immediate implants, the group of
primary immediate implants showed a
tendency towards deeper pocket formation
and an increased frequency of membrane
dehiscences that may be due to the poorer
quality of the soft tissue covering.
Mensdorff-Pouilly et al 1994 J OMI



3-year Prospective Multicenter
Follow-up
No clinical difference with respect to socket
depth or when comparing the different
placement methods.
Higher failure rate was found for short implants
in the posterior region of maxilla .(extracted for
periodontitis)
Mean marginal bone resorption : (from loading
to 1yr F/U) Max.(0.8mm),mand(0.5mm)
Implant survival : Max(92.4%);Mand(94.7%)
Grunder U et al 1999 J OMI

Generally,
primary immediate implant
max. anterior
secondary immediate implant
mandible,posterior maxilla

Mensdorff-Pouilly et al 1994 J OMI

Thanks for your attention!!
Evidence for osseointegration of
immediate implant
Experimental animal studies (Kohal et al
1997)
Controlled human studies(Palmer et al
1994)

Evidence for osseointegration of
immediate implant
Root-analogue titanium implants
Lundgren et al (1992) beagles dog study
Kohal et al(1997) monkeys
Evidence for osseointegration of
immediate implant
Conventional screw- or cylinder-type
implant
Experimental animal studies
Parr et al (1993) dog study
Barzilay et al (1996) controlled monkey
Similar result for immediate and late
implant ( Clinical,radiography,histology)

Evidence for osseointegration of
immediate implant
Clinical studies
Becker et al(1998) prospective clinical
human trials of 47 immediate implants
without bone augmentation
cumulative success rate of 93% followed
between 4 to 5 years
Bone augmentation in combination
with immediate implant
GBR-barrier membranes
Experimental animal studies
Dahlin(1989) rabbits
Becker et al (1991) barriers enhance
predictability of bone fill in immediate
extraction sockets when compared with
a mucoperiosteal flap
Bone augmentation in combination
with immediate implant
GBR-barrier membranes
e-PTFE membrane
Lazarra(1989)
Becker &Becker(1990)
Nyman(1991)
Hammerle(1998)

Bone augmentation in combination
with immediate implant
GBR-barrier membranes
e-PTFE membrane
Becker (1994) 49 immediate implant
with e-PTFE alone
--- 93.6% bone fill ,1-year functional
loading success rate 93.9%

Bone augmentation in combination
with immediate implant
GBR-barrier membranes
e-PTFE membrane
Gher et al (1994 )
influence of original defect morphology on bone
fill with e-PTFE at immediate implant sites
Dahlin et al (1995) prospective multicenter study
2-year cumulative survival rate
Max.(84.7%) mand(95%)

Bone augmentation in combination
with immediate implant
GBR-barrier membranes
Collagen membrane( Cosci&Cosci 1997)
polyglactin (balshi 1991)
Polylactic acid (Lundgren 1994)
Fascia lata (Callen & Rohrer 1993)
Autogenous gingival grafts(Evian & Cutler
1994)
Bone augmentation in combination
with immediate implant
GBR-barrier membranes
Zitzmann et al (1997)
e-PTFE vs collagen ( deproteinized bovine bone )
no significant difference in average percentage bone
fill for collagen (92%) and e-PTFE(78%) But, 44%
wound dehiscence and premature membrane
removal in the e-PTFE group was reported.
Barrier membrane exposure
Compromised results
Simion (1994) bone fill (97% vs 42%)
Augthun(1995)
Successful bone regeneration & complete bone
filling ,but strict infection control is followed
Mellonig (1993)
Shanaman(1994)
Rominger & Triplett (1994) 96.8%
GBR and bone grafts
DFDBA ( negative )
animal study
Becker (1992) dogs study
Becker (1995) dogs study
Kohal(1998) dogs study
Clinical study
Gelb(1993)
GBR and bone grafts
DFDBA ( positive )
Callan (1990)
Mellonig (1993)
Landsberg (1994) combined with Tc
Gher (1994)

GBR and bone grafts
Hydroxyapatite
Wachtel et al (1991) biopsies taken on
3M showed enhanced bone regeneration
than non-grafted sites.
Knox (1993)
Novaes & Novaes (1993)

GBR and bone grafts
Simion(1994)
Cosci & Cosci(1997)
Fugazzotto (1997)
Schwartz-Arad & Chaushu(1997)
Compromised sites infection
Pecora(1996)
32 teeth due to root fx.,perforation,endo-
perio complication ,F/u 16M
Rosenquist & Grenthe(1996)
periodontal disease (92%)
trauma,root fx.,endodontic failure (95%)
Novaes(1995,1998)

Compromised sites infection
Immediate implantation at chronically
infected sites may be successful,the
extent of the defect ,the implant primary
stability,and esthetic consideration of
future restoration must be considered.
Biologically active bone-
differentiating substances
Cook (1995) recombinant human
osteogenic protein-1(rhOP-1)
Cochran et al(1997) recombinant human
bone morphogenetic protein-2(rhBMP-2)
Hedner & Linde(1995) membrane + BMP
compromised blood supply

Future about biologically active
bone-differentiating substances
Identification of the ideal carrier substrate
Dose application
The effect of combination
Late implants
A period of >6 months for healing of the
extraction site is recommendation prior to
implant placement