INTRODUCTION
Dental implant complications often lead to implant failure. These failures may arise from a number of patient-related and dental implant complications, including biological, mechanical, or iatrogenic variables.1 In particular, late implant failures often stem from infections, the most prevalent of which is peri-implantitis, affecting approximately 34% of dental implant patients.2 In the end, bacteria is the culprit for many implant complications and should be anticipated and addressed proactively, especially in cases involving immediate implant placement.
At Ueno Center Dental Specialists, a surgical specialists and implant practice in Campbell, Calif, the adoption of free-running pulsed Nd:YAG laser technology (PerioLase MVP-7 [Millennium Dental Technologies]) helps ensure reliable disinfection of extraction sites. In contrast, new techniques and implant designs facilitate immediate implant placement in areas previously deemed impossible or risky. Prior to the adoption of laser-assisted protocols, Ueno Center clinicians only placed implants immediately post-extraction in approximately 50% of its cases. Today, of the more than 1,000 implants placed annually, more than 80% of extraction cases now involve immediate implant placement.
In addition to preventing implant failures due to infection, protecting bone is essential. The Zero Bone Loss Concepts approach to implant dentistry, introduced by Prof. Tomas Linkevičius,3 emphasizes an understanding of the interactions between biology, biomechanics, and surgical and prosthetic factors that affect crestal bone stability. This includes acknowledging that bone loss is a major complication that dentists often encounter, but one that can be prevented. Consequently, the adoption of different strategies to achieve zero bone loss years after treatment includes surgical concepts ranging from implant design and placement to prosthetic factors for maintaining crestal bone stability.4 Such concepts have been found to be particularly valuable for immediate implant placement cases at Ueno Center.
At its core, immediate placement has several advantages for both the patient and clinician. These include accelerating healing and transforming woven bone into lamellar bone.5 Additional benefits include maintaining the size and shape of the bone and soft-tissue architecture, shortening treatment time, increasing patient comfort, and improving aesthetics.
Immediate implant placement also helps reduce treatment appointments and eliminates the chance of buyer’s remorse in implant dentistry. Indeed, immediate implant placement ensures patients complete their treatments in fewer visits with a positive long-term outcome—a win for everybody involved.
The following case was selected to demonstrate the successful outcome of immediate implant placement post-extraction using laser-assisted treatment and applying Zero Bone Loss Concepts.
CASE REPORT
A 51-year-old male patient presented complaining of pain on the lower right side of his dentition. He had been referred by an endodontist for an implant evaluation. Upon examination, a large endo-perio lesion on the distal aspect of tooth No. 30 was observed (Figure 1). Purulent exudate was present, and the tooth had >12-mm probing depths. It was determined that tooth No. 30 could not be restored due to fracture.
Figure 1. Preoperative radiograph of tooth No. 30 with an endo-perio lesion on the distal aspect.
The patient had a history of mild periodontal disease but no signs of active inflammation. The patient had Class I occlusion, and no additional areas of concern were observed radiographically. Moreover, about 15 mm of bone was present from the osseous crest to the inferior alveolar nerve (IAN). From a medical history standpoint, the patient had no systemic conditions that would contradict implant placement, nor was he a smoker.
A typical case like this might require delayed implant placement, with extraction and bone grafting in phase I and a delayed implant in phase II. Traditionally, such procedures would involve several appointments and at least 6 months before the final impression. However, by employing laser-assisted socket disinfection and placing an implant with aggressive threading (Straumann Bone Level Implants [BLX]), immediate implant placement was performed with high primary stability.
No scalpels or flaps were required. Sectioning and extraction of tooth No. 30 was conducted using elevators and proximators to preserve the existing alveolar housing. This aided in keeping as much native bone intact as possible to help with guided bone regeneration, which was performed at the end of the procedure.
For laser disinfection and hemostasis of the site, the preset hemostatic setting on the PerioLase MVP-7 was selected. This disinfection setting avoids overheating the bone while facilitating hemostasis and wound healing. For the procedure, a small optical fiber was inserted into the extraction site of No. 30 and swept around the sulcus and bone to administer energy, targeting diseased tissue. When administering laser treatment within the socket, high-volume evacuation was performed in case of unexpected blood splatter.
Next, a diluted povidone-iodine disinfection solution was administered for approximately 3 minutes to further ensure appropriate socket disinfection.
After administration of the disinfection protocol, the osteotomy was prepped slightly past the apex of the tooth since the IAN was situated lower in the mandible due to the shape of the bone (Figure 2). In a case where the IAN was located higher, an attempt would have been made to engage the existing bony housing of the socket to get primary stability in order to stay away from the nerve.
Figure 2. Postoperative CBCT image of site No. 30, showing 15 mm of native bone and sufficient distance from the inferior alveolar nerve.
A Straumann BLX WB 6.5- × 12-mm implant was placed approximately 4 mm from the gingival margin to provide adequate apico-coronal distance from the implant platform to the free gingival margin—or “running room”—for the prosthetic. With the implant in the ideal location, the dead space was filled with bone graft (Puros Allograft [ZimVie]), although almost any cortical-cancellous allograft would have been acceptable. One benefit of Zero Bone Loss Concepts is that they do not advocate for the use of a membrane. Instead, they advocate for a custom healing abutment, which acts as the membrane and achieves excellent results while saving on material costs.
The custom healing abutment was fabricated chairside utilizing a metal temporary abutment and composite (Figure 3). Custom healing abutments aid in the support of soft-tissue contours and tend to be more aesthetic with better contours and improved contact (Figure 4). Plus, areas experience less food impaction when restored. The soft-tissue anatomy was supported with 2 to 3 mm of composite, ensuring the material would not impinge on the socket’s bone. A radiograph was taken as part of the standard procedure (Figure 5).
Figure 3. Custom healing abutment fabricated chairside at the time of surgery.
Figure 4. Placement of the custom abutment to support soft-tissue contours.
Figure 5. Periapical radiograph taken immediately after implant placement surgery.
The implant was allowed to integrate for 2 to 3 months before the patient returned for examination. A Periotest was conducted to assess implant osseointegration. The Periotest’s scale ranges from -8 to +50, with lower values indicating greater stability. The Periotest value corresponds to the damping effect of the implant and the mobility of the teeth, with -8 being the highest stability number we can achieve. A test reading of -5.0 was observed, indicating stability.
The custom healing abutment was removed and disinfected. At the same appointment, the sulcus was debrided, and loose allograft particles in the soft tissue were removed. This is fairly common with immediate placement.
For clinicians who have digital workflow connectivity with partner laboratories, a digital impression may be shared using an advanced intraoral scanner such as a TRIOS 5 (3Shape) or Primescan (Dentsply Sirona). For this specific case, an authentic Straumann Scanbody was used to accurately capture implant position and angulation for the digital impression (Figures 6 and 7). The digital impression was then transmitted to the dental laboratory (Unident Laboratories), which commenced the design and fabrication of the final restoration on a titanium base abutment (Figure 8).
Figure 6. Occlusal view of the digital impression using Straumann Scanbody.
Figure 8. Lab design of the restoration using a titanium base abutment.
A 1% metronidazole gel antibiotic was applied in the sulcus and around the custom healing abutment before reattaching it to the implant. The access hole was packed with polytetrafluoroethylene tape, to create a hydrophobic, tight-fitting seal, and covered with a temporary filling material. Taking the proper steps for an atraumatic extraction, such as not raising flaps and spending the extra time to make a custom healing abutment, contributes to the success of these cases.
Figure 9. Final restoration composed of ultra-polished zirconia.
The final ultra-polished zirconia crown included an aesthetic shade value to closely match the patient’s surrounding dentition (Figure 9). Because of the use of a custom healing abutment, the emergence profile was improved considerably compared to the use of a typical stock abutment (Figure 10). Ultimately, the desired outcome is greater epithelial attachment to the restoration for better aesthetics and to protect the implant from bacteria, facilitate hygiene, and decrease food impaction.
DISCUSSION
Clinicians may experience an increase in implant complications and failures if improper or incomplete socket disinfection protocols are not administered at the time of immediate implant placement for extraction cases. Maintaining a proper disinfection protocol will eliminate many issues for immediate placement cases and subsequent implant failures. Laser treatment is well-suited as a protocol since it is selective in targeting specific tissue and has been shown to deliver profound hemostasis.
In clinical practice, the PerioLase MVP-7 employs 7 pulse durations—100, 150, 250, 350, 450, 550, and 650 µsec—with energy per pulse between 20 and 300 mJ. It is highly effective at treating periodontitis and peri-implantitis because the light scatters and treats adjacent tissue where bacteria can linger. Additionally, it is excellent for biostimulation. When patients have postoperative paresthesia, the laser works well to help the nerve recover faster and promote healing. Patients also report less discomfort after treatment compared to conventional surgery.
Meanwhile, the application of Zero Bone Loss Concepts takes into account various crestal bone reactions to implants, including the possibility of resorption. At least 3 mm of vertical soft-tissue thickness is recommended for biological considerations. Other considerations include the influence of implant position and bone level on bone stability, depending on implant design. Recommendations include more than 3 mm of bone on the buccal of aesthetic implants and a minimum of 4 mm of running room, as well as more than 3 mm distance between implants and a 2-mm “zone of safety” between vital structures and the implant.
Over the last 2 years, clinicians at Ueno Center Dental Specialists have focused on placing implants on the day of extraction in as many cases as possible with either a custom healing abutment or a screw-retained temporary tooth. Except for emergency or trauma cases, the immediate temporaries are produced digitally and 3D printed before the patient’s surgery. This allows for an improved emergence profile for the final restoration.
The ultimate goal for specialists with referral-based practices is to eliminate friction and foster collaboration among the referring dentist, specialist, office staff, dental laboratory, and patient. At Ueno Center, sites are restored as quickly as possible, with most final impressions taken within 2 to 3 months. When the implant integrates, a digital impression is performed and sent to the dental laboratory requested by the referring clinician. The abutment and crown are then sent directly to the restorative dentist 2 weeks later. This predictable delivery and installation will likely be the highest-producing 15 minutes of the restorative dentist’s day with the least amount of stress.
The patient experience also is much better because immediate implant placement is performed in one procedure vs multiple appointments. Second, wound healing occurs faster with flapless and atraumatic surgery. While it is still 2 to 3 months before delivery of the final restoration, the treatment time has been cut in half compared with traditional delayed implants. Overall, the number of visits at the Ueno Center has been reduced from 6 to 8 appointments to just 3 (surgery, post-op, and implant check/digital impression). This is a win not only for clinicians but for patients, too.
In addition to efficiency gains, the adoption of laser-assisted treatment also contributes to production increases since clinicians may now capture more revenue from immediate implant placement cases via patients who otherwise may not return for a delayed placement protocol. Laser therapy also boosts revenue outside of implant placement workflows, with many associates at Ueno Center utilizing up to 4 lasers all day, performing LANAP and LAPIP protocols for the treatment of periodontal disease and peri-implantitis, respectively.
CONCLUSION
This case shows what is possible with immediate implant placement facilitated by a disinfected extraction socket. Since treatment, the patient has exhibited a stable and healthy implant with no signs of infection or bone loss in the implant area. Disinfection of the extraction socket before implant placement with laser therapy is an excellent method to protect the bone and improve the outcomes of implant cases. In addition, protecting crestal bone is essential to successful implant therapy, and immediate implant placement using Zero Bone Loss Concepts is critical to this protection. Combined, these strategies facilitate immediate implant placement post-extraction and help ensure long-term clinical success.
REFERENCES
- Singh R, Parihar AS, Vaibhav V, et al. A 10 years retrospective study of assessment of prevalence and risk factors of dental implants failures. J Family Med Prim Care. 2020;9(3):1617-19. doi:10.4103/jfmpc.jfmpc_1171_19
- Thiebot N, Hamdani A, Blanchet F, et al. Implant failure rate and the prevalence of associated risk factors: A 6-year retrospective observational survey. J Oral Med Oral Surg. 2022;28(2):19. doi:10.1051/mbcb/2021045
- Linkevičius T. Zero Bone Loss Concepts. Quintessence Publishing; 2019.
- Elian N. Zero Bone Loss Concepts [book review]. Implant Dent. 2019;28(6):523–5. doi:10.1097/ID.0000000000000940
- Ebenezer V, Balakrishnan K, Asir RV, et al Immediate placement of endosseous implants into the extraction sockets. J Pharm Bioallied Sci. 2015 Apr;7(Suppl 1):S234–7. doi:10.4103/0975-7406.155926