02 Timing of Implant Placement

Question 1

When would be the optimal time to plan the restorative treatment of a patient?

Answer 1

• Prior to tooth/teeth extraction
• Whether the implant should be placed immediately after the tooth extraction or if a certain number of weeks/months of healing of tissues of alveolar process should be allowed prior to implant installation

Question 2

Briefly describe the stages of post extraction healing.

Answer 2

1. socket fills up with cancellous bone
2. buccal wall of edentulous site is diminished
3. lack of mucosa and socket entrance opens
4. cell proliferation within the mucosa results in an increase of its CT volume
5. soft tissue wound becomes epithelialized
6. keratinized mucosa covers the extraction site
7. contraction of ridge is the net result of bone loss as well as loss of CT

Question 3

Describe the classification of types 1-4 placements, advantages, disadvantages using the pdf provided with the refined classification (Chen et al. 2009)

Answer 3

Question 4

What would be the two methods for flap closure?

Answer 4

1st approach : requires primary wound closure which leads to submerged healing
2nd approach : allows for a transmucosal position of implant/healing cap which leads to transmucosal healing

• No differences regarding survival rates and interproximal bone levels were found when these two methods were compared in a split-mouth design

Question 5

Describe the conclusion of a review analyzing the clinical outcomes of implants placed according to the above-described timing scheme. Discuss their clinical significance.

Answer 5

Bone regeneration procedures may be required to improve or retain bone volume and the buccal contour at a fresh extraction site. Such bone augmentation is sometimes mandatory in the esthetic area and therefore, a late placement may be preferred over early placement.

Question 6

Mention the claims made in the past concerning the advantages of Type 1 (immediate implant placement). What does current research show?

Answer 6

Advantages:

• reduced number of visits to the dental office
• reduced overall treatment time
• enhanced patient acceptance - maybe

Current research shows that:

• Atrophy of the edentulous ridge will occur following tooth loss in the process of adapting to altered functional demands

The atrophy includes:

• marked reduction of the width and height of both the buccal and lingual bone plates
• buccal bone plate will undergo marked change -> lose its hard tissue coverage
• metal surface may become visible through a thin peri‐implant mucosa and cause esthetic concerns
• bone augmentation procedures are required and in the esthetic area sometimes is mandatory which are more difficult when we have placed the implant already

Question 7

When an implant placement can be considered Type 2? Provide a range (between how many days, weeks, or months?) What are the main advantages and disadvantages of a Type 2 implant placement?

Answer 7

Question 8

When an implant placement can be considered Type 3? Provide a range (between how many days, weeks, or months?). In which areas/ type of teeth this timeframe would be chosen? What are the main advantages and disadvantages?

Answer 8

• When bone fill is required within the extraction socket .
• Newly formed woven bone will occupy the socket area after healing periods extending from 10 to 16 weeks .
• Type 3 is placed in a position that facilitates the prosthetic phase of the treatment.

Advantages :
The mucosa that covers the extraction site is:
1. residing on a mineralized ridge
2. mature and easier to manage during surgical flap elevation and replacement procedures
Disadvantages :
1. prolonged treatment time
2. additional resorption and diminution of the ridge (including a substantial change of its contour)
3. a concomitant loss of soft tissue volume

Question 9

When an implant placement can be considered Type 4? Provide a range (between how many days, weeks, or months?). What are the advantages and disadvantages?

Answer 9

When the implant is placed in a fully healed ridge . Such a ridge can be found after 4 months, but more likely after 6–12 months of healing following tooth extraction (loss)

Advantages :
1. complete healing
2. only minor additional change of the ridge may occur
Disadvantages :
1. increased treatment time
2. further reduction of the overall volume of the ridge and change of its external contour. This pronounced additional
3. loss of ridge volume may at times require complicated bone augmentation procedures

Question 10

During the treatment planning phase changes over time must be considered. What other aspects must be evaluated?

Answer 10

1. The overall objective of the treatment
2. the location of the tooth within the oral cavity (aesthetic zone or not)
3. the anatomy of the bone and the soft tissue at the site
4. the adaptive changes of the alveolar process following tooth extraction