In the aesthetic area, there are a number of factors which have to be under control before surgical treatment can commence. Some cases would become nightmares if treatment were performed without the required biological knowledge.
The speaker presented a case involving a vertical fracture in the root and a fistula in an upper central incisor. The other incisor had deep root resorption which was preventing any potential conservative treatment of the tooth. The anatomy was maintained and the buccal bone wall was still suitably thick. The speaker outlined the diagnostic parameters which should be evaluated (Kan et al. 2018):
- gingival level (in relation to adjacent teeth)
- osseous and gingival tissue interface at facial aspect
- bone sounding of adjacent teeth (using a peri-apical radiograph)
- gingival biotype (which can be determined by probing – Colorvue Biotype Probe System® (Hu-Friedy) developed by Giulio Rasperini & Tiziano Testori)
- sagittal root position (by CBCT if required)
- labio-palatal width
- inter-radicular mesiodistal width
- tooth shape (diagnostic wax-up)
Before placing the implant, the fistulous tract should be removed to prevent contamination from the biofilm which used to be inside the fistula. The steps which should be observed during the surgical procedure are (Kan et al. 2018):
- minimally traumatic extraction (cutting the root into pieces with a piezoelectric saw)
- evaluation of the labial bony plate with a periodontal probe
- correct 3D implant position (85% of patients present a class I sagittal relationship (Kan et al. 2011), which is safest for immediate implant placement). Guided implant placement is highly recommended
- primary implant stability (no less than 45Ncm)
- evaluation of the gap (between implant and vestibular bone plate)
Positioning the longitudinal implant axis along the future incisal edge is a new concept recommended for use with a shoulderless abutment. The final profile will then be provided by the restoration (Scutellà et al. 2015).
When faced with a tooth that needs to be extracted, we should ask ourselves if there is enough volume in the alveolar envelope to support the planned restoration. If the answer is yes, then ridge preservation will be enough. If not, then an approach involving ridge augmentation beyond the existing skeletal envelope will be required when extracting the tooth.
Animal histologic studies have shown that grafting with anorganic bovine bone (ABB) can minimise the loss of buccal bone in the socket (Araújo M et al. 2008; Araújo M et al. 2009; Araújo M et al. 2011). These results have also been clinically confirmed (Araújo et al. 2015).
In cases involving buccal bone dehiscence, we can still use a flapless approach by inserting a barrier membrane between the periosteum and the buccal bone wall. The barrier is then folded, covering the socket, and placed under the palatal soft tissue margin.
The speaker went on to say that these two techniques could actually be combined. Grafting the gap between the implant and the buccal wall can help preserve the volume and compensate for reduction in the bone wall (Araújo et al. 2010).
An immediate protocol would not be ideal when there is inadequate bone volume or acute infection at the extraction site, or when the predictability of the aesthetic result is low. An example of this would be in cases involving a thin biotype and a buccal wall < 1mm thick.
How fast can we go?
As fast and predictably as possible. However, proper anatomy and skill is absolutely necessary.
What is the role of late implant placement in implant dentistry?
When immediate placement is not possible, late implant placement is used to compensate for the lack of adequate conditions which meant that an immediate approach was not suitable.