Surgical Planning and Procedures
Consensus Statement
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At the 3rd ITI Consensus Conference in 2003, it was recognized that descriptive terms for the time points for implant placement after tooth extraction encountered in the dental literature were imprecise, and therefore open to interpretation. A classification system for timing of implant placement after tooth extraction was therefore proposed, based on desired clinical outcomes during healing rather than on descriptive terms or rigid time frames following extraction(1).
In spite of this new classification system, descriptive terms have remained in use since 2003. Therefore, to avoid ambiguity and misinterpretation of the various time points for implant placement after tooth extraction, the descriptive terminology in the ITI Treatment Guide, Volume 3, was adopted for this Consensus Conference(2). The following additional terms were defined:
References:(1) Hämmerle CH, Chen ST,Wilson TG Jr.Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 2004;19(suppl):26–28.
(2) Chen S, Buser D. Implants in post-extraction sites: A literature update. In: Buser D, Belser U, Wismeijer D (eds). ITI Treatment Guide, vol 3: Implants in Extraction Sockets. Berlin: Quintessence, 2008:9–15.
Healing and Regenerative Outcomes
Survival Outcomes
Esthetic Outcomes
Ridge Preservation
Advantages and Disadvantages of Immediate Implant Placement (Type 1)
With immediate implant placement (type 1), combining tooth extraction and implant placement reduces the number of surgical procedures that the patient needs to undergo. The peri-implant defect usually presents as a two- or three-walled defect, which is amenable to simultaneous bone augmentation techniques. In addition, there is an opportunity to attach a provisional restoration to the implant soon after placement so that the patient avoids the need for an interim removable prosthesis. However, these advantages are counteracted by the increased technical difficulty of preparing the osteotomy to allow the implant to be placed with initial stability and in a good prosthetic position. There is also an increased risk of mucosal recession, which may compromise soft tissue esthetic outcomes. Additional hard and soft tissue augmentation procedures are usually required to overcome this risk, further increasing the technical demands of the procedure. Although grafting of the peri-implant defect with particulate bone or bone substitutes is readily achieved, grafting of the external surface of the facial bone is more demanding due to the convexity of the bone wall. If primary soft tissue closure is required, the lack of soft tissue increases the difficulty of attaining tension-free closure. Flap advancement may alter the mucogingival line. Clinicians should be mindful of the fact that bone modeling following tooth extraction is unpredictable. This may potentially lead to suboptimal bone regenerative outcomes and unpredictable dimensional changes.
Advantages
Disadvantages
Advantages and Disadvantages of Early Implant Placement (Type 2)
With early implant placement (type 2), healing of the soft tissues increases the volume of mucosa at the site. This facilitates manipulation of the surgical flaps and allows flap advancement for partial submergence of the implant or primary closure to be more readily achieved. In areas of high esthetic importance, the increased volume of soft tissue may enhance soft tissue esthetic outcomes. In the 4- to 8-week period following tooth extraction, slight flattening of the facial bone wall is commonly observed.This facilitates grafting of the facial surface of the bone with bone substitutes possessing low rates of substitution. These grafts may serve to limit long-term dimensional changes of the ridge. As there is minimal bone regeneration within the socket at this time point, periimplant defects are usually still present. However, the defects usually present with two or three intact walls, which are amenable to simultaneous bone augmentation techniques. The lack of bone regeneration within the socket may increase the difficulty of attaining initial stability of the implant. This approach allows pathology associated with the extracted tooth to resolve prior to implant placement.
Advantages
Disadvantages
Advantages and Disadvantages of Early Implant Placement (Type 3)
For early implant placement (type 3), partial bone healing in the socket usually allows implant stability to be more readily attained compared to type 1 and type 2 placement. The soft tissues are usually fully healed, allowing tension-free closure of the site. The increased volume of soft tissue may enhance soft tissue esthetic outcomes. However, it should be noted that modeling of the bone is more advanced than with type 2 implant placement. The socket walls exhibit varying degrees of resorption that may limit the volume available for implant placement. Peri-implant defects may still be present, but they are usually reduced in orofacial dimension. Two- and three-walled defects are amenable to simultaneous bone augmentation procedures. Flattening of the facial bone facilitates grafting of the facial surface with bone substitutes, a procedure usually necessary for augmentation of ridge contour. With Type 3 placement, the increased time from tooth extraction allows healing of extended pathological defects to take place.
Advantages
Disadvantages
Advantages and Disadvantages of Late Implant Placement (Type 4)
In late implant placement (type 4), the socket walls exhibit the greatest amount of resorption. Although the soft tissues are fully healed and manipulation of the surgical flaps is facilitated, ongoing modeling and horizontal resorption increases the risk of there being insufficient bone volume to place the implant. Additionally, there is a greater risk that peri-implant defects will present as no- or one-wall defects, compared to immediate and early implant placement.
Advantages
Disadvantages
References:(1) Martin WC, Morton D, Buser D. Diagnostic factors for esthetic risk assessment. In: Buser D, Belser U, Wismeijer D (eds). ITI Treatment Guide, vol 1: Implant Therapy in the Esthetic Zone - Single-Tooth Replacements. Berlin: Quintessence, 2007:11–20.
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