The Single-Tooth Implant:

A Minimally Invasive Approach for Anterior and Posterior Extraction Sockets

Dennis P. Tarnow, Stephen J. Chu

• Publisher: Quintessence Publishing Co, Inc
• Year: 2019
• ISBN:
  9780867159738
• Topic: Medicine
• Subtopic: Dentistry

The replacement of the single tooth with a dental implant is one of the most common clinical situations practitioners face on a daily basis. While in the past sockets were left untouched for months after tooth extraction before attending to the residual ridge, today it is possible to perform "one surgery, one time, " which is a huge benefit to both the patient and clinician alike. Written by two world-class masters, this book begins with a discussion of the history and rationale for anterior and posterior single-tooth implants, and then it walks the reader through the three types of sockets—type 1, type 2, and type 3—and their various indications and limitations. An entire chapter is devoted to clinical management of posterior teeth, followed by a chapter on cementation and impression-making techniques and complications. The final chapter is a clinical case appendix detailing 11 cases of single-tooth replacement in all types of sockets previously described. The protocols showcased in this book will make patient care faster, easier, simpler, more predictable, and, in many cases, less costly.

IN THIS CHAPTER:

• Immediate Versus Delayed Tooth Replacement Therapy

• Clinical Example

• Challenges with Immediate Implant Placement

• Classification of Extraction Sockets

• Diagnostic Aids for Socket Management: Radiographic and Clinical Examination

Chapter 1

History and Rationale for Anterior and Posterior Single-Tooth Implants

The single-tooth implant restoration comprises roughly one-half of all the implant case types that present daily in a clinical practice, and in the authors’ experience, many are in the esthetic zone. This section discusses some of the current concepts, science, and knowledge associated with immediate implant placement and provisional restoration in anterior postextraction sockets, better known as immediate tooth replacement therapy because both the root of the tooth and the clinical crown are being replaced simultaneously.

Some common questions that arise when a tooth is removed and an implant is placed into a fresh extraction socket include the following:

• What happens when a tooth is extracted?

• What kind of hard and soft tissue dimensional changes take place as a result?

• Are there differences in wound healing of anterior versus posterior extraction sockets?

• Should flap elevation be employed to remove the root remnant?

• Should primary flap closure be used, or should the socket be allowed to heal by secondary wound intention?

• What graft, if any, should be used?

• Should a connective tissue graft be placed in conjunction with the implant?

• What is the proper 3D spatial position of the implant within the extraction socket?

• Does the graft alter the wound healing process of the extraction socket?

• Does it make a difference if there is a residual gap after implant placement?

• Should a provisional restoration or custom healing abutment be fabricated in conjunction with the implant, or is it better just to place a stock healing abutment? Which would be better in regard to implant survival, osseointegration, and esthetic success?

These are just some of the questions that arise when immediate placement of implants into postextraction sockets is discussed. All of these topics remain controversial, and every practitioner has his or her own solutions, but how reliable are the results? This book seeks to answer these questions and to provide objective and concrete information to help clinicians, both specialists and general practitioners alike, place single-tooth implants and restore them with consistent periodontal, restorative, and esthetic outcomes in various clinical situations.

Immediate Versus Delayed Tooth Replacement Therapy

The survival rates for immediate implant placement are equal to, if not slightly higher than, those for delayed implant placement.1 The literature seems to support this.2–9 While the delayed protocol has survival rates higher than 90%, the immediate protocol boasts survival rates of 95%.5 Among anterior teeth alone, the survival rate increases to 97%.4,5 So it stands to reason: If the placement of an implant directly into the extraction socket has no bearing on that socket’s ability to heal, why not do it? After all, the socket is genetically engineered to heal whether or not a sterile titanium screw, which is biologically acceptable and compatible, is placed.

The main advantage of immediate tooth replacement therapy is that it condenses treatment procedures into fewer patient appointments, thereby reducing overall treatment time and increasing patient comfort while preserving the natural shape of the surrounding hard and soft tissues (Table 1). Most of the procedures such as tooth extraction, implant placement, socket grafting, and provisional restoration are delivered at the first treatment appointment, so more time should be appropriately allotted. With this approach, the clinician has the ability and opportunity to preserve hard and soft tissues at the time of tooth extraction, especially for a single tooth and maybe even multiple adjacent implants. This preservation concept is critical for esthetics, which is a major advantage with today’s esthetically demanding and knowledgeable patients.10

TABLE 1 Immediate implant protocol

Appointment #	Surgical intervention	Healing time (weeks)
1	Tooth extraction, implant placement, socket grafting, provisional restoration or custom healing abutment	12-24
2	Impression making	None required
3	Delivery of definitive restoration	None required

Conversely, delayed implant placement affords the clinician the opportunity to perform all site development prior to implant placement, provided that the clinical situation is amenable to augmentation and correction.11–13 However, this protocol requires more treatment time: First the tooth is extracted, then the socket must heal for several months before implant placement with contour grafting is performed either as a single- or two-stage procedure. Once the implant has integrated, the implant is surgically exposed (two-stage procedure), and a flat profile healing abutment can be placed. The patient must return fo...