Timing of implant placement

Treatment plan

• Treatment planning, a decision must be made whether the implant(s) should be placed immediately after the tooth extraction(s) or if a certain number of weeks (or months) of healing of the soft and hard tissues of the alveolar process should be allowed prior to implant installation.

• There is no ideal time point following the removal of a tooth, at which the extraction site has:

• (1) maximum bone fill in the socket

• (2) voluminous mature covering mucosa

The changes in the soft and hard tissue following tooth extraction over time

• Type 1:the implant is placed immediately following the extraction of a tooth

• Type 2:the implant is placed in a site where the soft tissue have healed and a mucosa is covering the socket entrance

• Type 3:the implant is placed in an extraction site at which substantial amount of new bone have formed in the socket

• Type 4:the implant is placed in a fully healed ridge

Type 1

• Easier definition of the implant position

• Reduced number of dental visits in the dental office

• Reduced overall treatment time and costs

• Preservation of bone in the site of implantation

• Optimal soft tissue esthetics

• Enhanced patient acceptance

• Implant placement in a fresh extraction socket may in fact not prevent the physiologic modeling/remodeling that occur in the ridge following tooth removal

• Clinical problem of type 1:

esthetic concern

Bone loss will frequently cause the buccal bone portion of the implant to gradually lose its hard tissue coverage, so the metal surface may become visible through thin preimplant mucosa

Stability of implant

• The anchorage of the implant to obtain primary stability

in native bone apical to the alveols

alveolar walls

inter radicular septa

Contraindication of immediate implant placement:

• Presence of prulent exudate at the time of extraction

• Lack of an adequate bone apical to the socket

• Adjacent soft tissue cellulite and granulation tissue

Contraindication of immediate implant placement:

• Adverse location of the mandibular neurovascular bundle, maxillary sinus and nasal cavity

• Poor anatomical configuration of remaining bone

Type 2

• Complete soft tissue coverage of the tooth socket

• Typically 4-8 weeks after extraction

• Resolution of preapical lesion

Soft tissue in type 2:

• Comparatively mature

• Proper volume

• Can be easily managed during flap elevation and replacement procedure

•

• not achieving primary implant stability is similar in type 1 and type 2 approaches.

Type 3

• Substantial bone fill has occurred in the extraction socket

• 10-16 weeks after tooth extraction

• The mocusa of the extraction site:

residing on a mineralized ridge

mature and more easy to manage during surgical

Type 3 approach

• Allow the clinician to place the implant in a position that faciliate the prosthetic phase of the treatment

The disadvantages with the type 3 approach:

• A prolong treatment time

• Additional resorption and diminution of the ridge

• Concomitant loss of soft tissue volume

Type 4

• The alveolar ridge is healed following tooth loss

• After 6-12 months of tooth extraction

The disadvantages with the type 4 approach:

• Increased treatment time

• Further reduction of the overall volume of the ridge and changes of its external contour

Evaluation of clinical concepts in treatment planning phase:

• The overall objective of the treatment

• The location of the tooth within the oral cavity (in the esthetic and non esthetic zone)

• The anatomy of the bone and the soft tissue

Esthetic importance and tissue biotype

• when an implant is to be placed in the esthetic zone, not only the anatomy of the hard tissues but also the texture and the appearance of the soft tissues must be considered

• Type 2 installation is often preferred when implants are placed in the esthetic zone

• The key advantage of type 2 (as opposed to type 1) installation is the increased amount of soft tissue that will have formed during the first weeks of healing following tooth extraction.

• The biotype of the soft and hard tissues may play a role in the esthetic outcome of implant therapy

• Two biotye:

• the flat thick

• the pronounced scalloped (thin biotype)

• Buccal tissue recession at single‐tooth implants was more pronounced in patients exhibiting a thin biotype compared to patients with a thick biotype

• patients exhibiting a pronounced scalloped biotype should be treated with a type 2, 3, or 4 rather than a type 1 implant installation approach

• Type 1 Implant placement as part of the same surgical procedure

• as immediately following tooth extraction reduced number of surgical procedures

• Reduced overall treatment time • Optimal availability of existing bone • Site morphology may complicate optimal placement and

anchorage • Thin tissue biotype may compromise optimal outcome • Potential lack of keratinized mucosa for flap adaptation • Adjunctive surgical procedures may be required • Technique‐sensitive procedure

Type2 implant placement

• Complete soft tissue coverage of the socket (typically 4–8weeks) • Increased soft tissue area and • volume facilitates soft tissue flap • management • Allows resolution of local pathology • to be assessed

• Site morphology may complicate optimal placement • and anchorage • Increased treatment time • Varying amounts of resorption of the socket walls • Adjunctive surgical procedures may be required • Technique‐sensitive procedure

Type3 implant placement

• Substantial clinical and/or radiographic bone fill of the socket (typically 12–16 weeks

• Substantial bone fill of the socket facilitates implant placement Mature soft tissues facilitate flap management

• Increased treatment time

• Adjunctive surgical procedures may be required

• Varying amounts of resorption of the socket walls

Type4 implant placement

• Healed site (typically >16 weeks)

• Clinically healed ridge

• Mature soft tissues facilitate flap management

• Increased treatment time

• Adjunctive surgical procedures may b required

• Large variation in available bone volume

Conclusion:

• overall objective of the treatment,

• the location of the tooth within the oral cavity

• the anatomy of the bone

• the soft tissue at the site

• the adaptive changes of the alveolar process following tooth extraction.