In implant dentistry, the extended healing period traditionally associated with prosthetic restoration remains a concern for both patients and clinicians, causing increased anxiety and inconvenience.1,2 In the aesthetic zone, delayed implant loading causes increased concern due to aesthetic demands in this region. The safety and predictability of immediate loading have been demonstrated in a number clinical trials, both for completely edentulous patients and in cases requiring single-tooth restoration.3-7The harmonic combination between the gingival tissues and the crown determine the aesthetic results in dental prostheses. A series of fundamental criteria are used to evaluate oral aesthetics;8 elements that characterize tissue morphology include: gingival health, interdental closure, gingival zenith, gingival level equilibrium, and interdental contact levels.
With implant-supported prostheses, obtaining extraordinary aesthetic results may be complicated following tooth extraction due to inevitable alterations to the hard and soft tissues with a loss of the preexisting tissue morphology. The re-establishment of this tissue architecture isthe greatest challenge the professional must overcome in order to obtain pleasing aesthetic results. This can be achieved with the immediate function of implants, guided bone regeneration (GBR), or a combination of both.9,10 Under certain circumstances, a nonsurgical approach may be adopted (eg, orthodontic extrusion of nonviable teeth), in order to increase the amount of bone and soft tissue at proposed implant sites. Recently, immediate placement and provisionalization of single implants in the maxillary aesthetic zone have been advocated, with successful results.11 The use of this procedure has demonstrated more favorable aesthetics, as flap elevation can often result in gingival recession and bone resorption around natural teeth.12,13
To minimize the possibility of postoperative peri-implant tissue loss and overcome the challenge of soft tissue management during or following surgery, the concept of flapless implant surgery has been introduced and clinically applied to both delayed and immediate loading cases.14-16 This technique also reduces postoperative complications such as pain and swelling relative to flap elevation. The following clinical presentations depict the use of single-tooth immediate implant restoration in the anterior region with a flapless technique for immediate function.
On initial examination, the patients’ medical histories were reviewed to rule out any local or systemic diseases that might contraindicate surgical procedures. Clinical and radiographic evaluations were performed prior to the surgical procedure. During the assessment phase, the alveolus and mesiodistal bone levels were evaluated to verify that they remained intact, and the position of the vestibular bone crest levels was analyzed. In cases where vestibular bone probing was greater than 5 mm, even with an intact residual bone crest, the no-flap technique is not recommended due to the considerable potential for apical tissue migration. This technique is also contraindicated in patients with less than 2 mm of functional keratinized tissue.
During tooth extraction, care was taken to maintain the vestibular bone crest intact to avoid the need for vestibular flap elevation. Ideal implant placement was critical,17 using the palatal portion of bone; care was taken to ensure slight palatal positioning and to avoid contact with the vestibular bone crest (Figures 1-2-3-4).
Insertion torque was maintained at a minimum of 35Ncm. Care was also taken to maintain proper implant inclination to position the screw-retained abutment on the palatal aspect of the tooth. The gap between the implant and the vestibular bone crest was filled with an osteoconductive bone substitute. The provisional prostheses were then positioned.
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A 33-year-old, nonsmoking, healthy female patient presented with a preexisting single crown restoration (Figure 5). Mobility was evident, and radiographic examination revealed a large carious lesion beneath the crown. The root structures were unusable for prosthetic retention, and the tooth was atraumatically extracted (Figure 6). Because approximately 4.5 mm of vestibular bone probing was evident with 2.5 mm of functional keratinized tissues, an immediate implant placement modality was selected.
Following administration of local anesthesia root extraction was performed without mucoperiosteal elevation. Immediate implant placement was facilitated following sequential osteotomy preparation under copious saline irrigation (Figures 7 and 8). In this case, the preexisting crown was used as a provisional restoration. The temporary abutment was adapted to the patient’s occlusion and then isolated prior to rebasing with an acrylic resin material. The alveolus was then filled with a bone substitute and the prosthetic restoration was refined with a composite resin material (Figure 9). The provisional crown was torqued to the implant with 20 Ncm and the palatal hole was closed with resin to facilitate provisionalization (Figures 10-11-12-13-14).
A 29-year-old male, smoking patient presented for restoration of the maxillary left central incisor. The tooth presented advanced root resorption; restoration was not a viable alternative, so extraction and prosthetic replacement was indicated. The right central incisor had been previously restored with an implant-supported, metal-ceramic crown over 8 years prior to presentation for treatment of the adjacent tooth (Figure 15).
Examination with dental probe revealed a vestibular bone probing of 3.5 mm with only 1 mm of functional keratinized tissue. Immediate implant placement was scheduled, followed by placement of a subepithelial soft tissue graft (Figures 16-17-18). A sequential, atraumatic implant osteotomy was performed under copious saline irrigation and the direction of the preparation was evaluated using a guide pin following each osteotomy drilling. Implant placement was performed with 50 Ncm of torque. The external crown of the tooth was utilized as a provisional restoration for the six month temporization period (Figures 19-20-21-22-23).
The surgical aspect of a flapless implant protocol with immediate loading is intended for bone preservation. Advantages of the flapless technique included reduced trauma, decreased operative time, fewer postoperative complications, and increased patient comfort and satisfaction. In addition, soft tissue profiles were maintained and improved using this approach. This method is primarily recommended for use in patients with high smile lines where recession and scarring would be visible. Moreover, the prosthetic implant treatment time and the number of surgical interventions required were greatly reduced, satisfying the expectations and demands of each patient. This improved convenience can be attributed to the avoidance of flap reflection, which might cause postsurgical bone resorption and soft tissue recession, as reported in literature.12,13,18
Following tooth removal, interproximal bone loss usually occurs, but it is generally isolated to the coronal wall of the extraction socket, creating an angular defect that can be minimized if an implant is immediately placed into the tooth socket. In addition, it has been shown that the lateral aspect of the angular defect usually does not extend beyond 1.5 mm from the implant.19,20 Therefore, a minimum implant-tooth distance of 2 mm is needed to keep the adjacent tooth’s bony attachment intact.21 Under such circumstances, the interproximal papilla can be maintained.
If this distance is, however, less than 2 mm, the integrity of adjacent tooth’s bony attachment may be affected, resulting in horizontal bone loss.21 The subsequent increase in vertical distance bone crest and apical contact point of the tooth will compromise the presence of the papilla.
Evaluation of bone levels is more difficult in flapless surgery, and care should be taken to ensure correct implant placement. Bone probing combined with intraoperatory and postoperative radiographic examinations are critical instruments in the evaluation of bone morphology and the relationship between implant, adjacent teeth, and bone levels. The choice of implant diameter is regulated by mesiodistal and vestibular space. Implants must be placed 3 mm from the vestibular crest, 1.5 mm to 2 mm from adjacent natural teeth, and 3 mm from adjacent implants.17
Coronal positioning of the implant will further influence the successful placement of osteoconducive bone grafting materials in the vestibular gap for development of correct tissue morphology during healing. Postoperatively, it is imperative to note that the vestibular bone crest will be reabsorbed while the bone substitute will maintain a superficial gingival anatomy following implant osseointegration.22 With regard to immediate loading, primary stability should be confirmed by hand-torquing the provisional abutment. If mobility is noted during hand-torquing, a delayed loading protocol should be considered.
While the use of an immediately loaded, flapless technique demonstrates considerable predictability, appropriate case evaluation and selection, meticulous treatment planning, and the use of precise surgical and prosthetic techniques are crucial to treatment success.
Private practice, Cattolica, Italy.
†Private practice, San Giovanni in Marignano (RN), Italy.
- Salama H, Rose LF, Salama M, Betts NJ. Immediate loading of bilaterally splinted titanium root-form implants in fixed prosthodontics. A technique reexamined: Two case reports. Int J Periodont Rest Dent 1995;15(4):344-361.
- Schnitman PA, Wöhrle PS, Rubenstein JE, et al. Ten years results for Brånemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Impl 1997;12(4):495-503.
- Testori T, Meltzer A, Fabbro MD, et al. Immediate occlusal loading of osseotite implants in the lower edentulous jaw. A multicenter prospective study. Clin Oral Impl Res 2004;15(3):278-284.
- Degidi M, Piattelli A, Felice P, Carinci F. Immediate functional loading of edentulous maxilla: A 5-year retrospective study of 388 titanium implants. J Periodont 2005;76(6):1016-1024.
- Andersen E, Haanaes HR, Knusten BM. Immediate loading of single-tooth ITI implants in the anterior maxilla: A prospective 5-year pilot study. Clin Oral Impl Res 2002;13(3):281-287.
- Cooper L, Felton DA, Kugelberg CF, et al. A multicenter 12-mounth evaluation of single-tooth implants restored three weeks after 1-stage surgery. Int J Oral Maxillofac Impl 2001;16(2):182-192.
- Lorenzoni M, Pertl C, Zhang K, et al. Immediate loading of single-tooth implants in the anterior maxilla. Preliminary results after one year. Clin Oral Impl Res 2003;14(2):180-187.
- Belser UC. Esthetics checklist for the fixed prosthesis. Part II: Biscuit-bake try-in. In: Schärer P, Rinn LA, Koop FR (eds). Esthetic Guidelines for Restorative Dentistry. Chicago, IL: Quintessence Inc, 1982:188-192.
- Tsirlis AT. Clinical evaluation of immediate loaded upper anterior single implants. Impl Dent 2005;14(1):94-103.
- Hall JA, Payne AG, Purton DG, et al. Immediate restored, single-tapered implants in the anterior maxilla: Prosthodontic and aesthetic outcomes after one year. Clin Impl Dent Relat Res 2007;9(1):34-45.
- Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior single implants: A surgical and prosthodontic rationale. Pract Periodont Aesthet Dent 2000;12(9):210-218.
- Ramfjord SP, Costich ER. Healing after exposure of periosteum on the alveolar process. J Periodontol 1968;38(4):199-207.
- Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. Alveolar crest reduction following full and partial thickness flaps. J Periodontol 1972;42(3):141-144.
- Hahn J. Single stage, immediate loading, and flapless surgery. J Oral Implantol 2000;26(3):193-198.
- Campelo LD, Camara JR. Flapless implant surgery: A 10-year clinical retrospective analysis. Int J Oral Maxillofac Impl 2002;17(2):271-276.
- Rocci A, Martignoni M, Gottlow J. Immediate loading in the maxilla using flapless surgery, implants placed in predetermined positions, and prefabricated provisional restorations: A retrospective 3-year clinical study. Clin Impl Dent Relat Res 2003;5(Suppl 1):29-36.
- Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodont Rest Dent 2005;25(2):113-119.
- Oh TJ, Shotwell J, Billy E, et al. Flapless implant surgery in the esthetic region: Advantages and precautions. Int J Periodont Rest Dent 2007;27(1):27-33.
- Kan K, Rungcharassaeng K. Interimplant papilla preservation in the esthetic zone: A report of six consecutive cases. Int J Periodont Rest Dent 2003;23(3):249-259.
- Tarnow DR, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol 2000; 71(4):546-549.
- Esposito M, Ekestubbe A, Grondahl K. Radiological evaluation of marginal bone loss at tooth surfaces facing single Brånemark implants. Clin Oral Impl Res 1993; 4(3):151-157.
- Botticelli D, Berglundh T, Linde J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-828.