Multiple immediate implants placement with immediate loading.

The replacement of missing teeth with implant-borne restorations has become a treatment modality accepted by the scientific community for fully and partially edentulous patients. Recent reports have demonstrated the successful placement of dental implants into the fresh extraction socket in the anterior as well as in molar regions, which is made possible due to modification in implant surface. The present case report highlights the placement of three bicortical screw (BCS) implants into the fresh extraction sockets and one KOS implant in edentulous area with flapless technique. All the implants were immediately loaded and followed up for a period of 6 months.

INTRODUCTION

The replacement of missing teeth with implant-borne restorations has become a treatment modality accepted by the scientific community for fully and partially edentulous patients.[12] This breakthrough in oral rehabilitation was initiated by the discovery that dental implants, made of commercially pure titanium, can achieve anchorage in the jaw bone with direct bone-to-implant contact. This functional ankylosis is often referred to as osseointegration, and was first described by the two research groups of Branemark and Schroeder.[3] The mechanism of osseointegration has been well described by several authors.[4567] The original Branemark protocol requires the implant to be inserted 4-6 months prior to loading. This long treatment period that involves the wearing of a temporary prosthesis may be of great inconvenience, and is sometimes the reason for not choosing implant-supported restorations at all. Recent reports have demonstrated the successful placement of dental implants into the fresh extraction socket in the anterior as well as in molar regions.[8] The technique was made possible due to developments in implant surface.

Two different approaches for immediate loading of dental implants are currently known. Both have in common the implicational concept that splinting/stabilization of several implants is accomplished through the prosthetic superstructure. The first approach relies on the compression screw principle. Screw implants of this type can result in lateral condensation of spongy areas. Implant stability is greatly increased by a mechanism that could be regarded as “corticalization” of the spongy bone (KOS). The second approach is to establish cortical anchorage of thin screw implants [bicortical screw (BCS)] or basal implants. Excellent primary stability can be obtained along the vertical surfaces of these implants with no need for corticalization. Implants of this type are, therefore, well suited not only for immediate loading but also for immediate placement.

This case report highlights the use of single-piece immediate implants (three BCS and one KOS) in the management of posterior missing teeth.

CASE REPORT

A 62-year-old male reported to the Department of Periodontology and Oral Implantology with the chief complaint of presence of root stumps in the lower left posterior region. On intraoral examination, it was observed that the patient had full mouth oral rehabilitation with porcelain fused to metal bridges and root stumps with 36 and 37 [Figures 1 and 2].

Figure 1

Preoperative photograph showing root stumps with 36 and 37

Figure 2

OPG showing root stumps in 36 and 37 regions

There was no significant medical history, and the patient was advised to undergo full mouth scaling followed by immediate placement of three BCS implants [Figures 3 and 4], one each in the mesial and distal extraction sockets of 36 and one in the mesial extraction socket of 37. An additional KOS implant was placed in the edentulous region of 35 using the flapless technique, so as to achieve a balanced occlusion [Figure 5]. Satisfactory primary stability was achieved with all the four implants and immediate orthopantomogram (OPG) showed good parallelism as well [Figures 6 and 7]. All these implants were immediately loaded at 1 day interval [Figure 8]. The OPG taken 6 months postoperatively showed good healing at the implant–bone interface [Figure 9].

Figure 3

Extraction sockets with 36 and 37 regions

Figure 4

BCS implant for placement in 36 and 37 regions

Figure 5

KOS implant for placement in 35 region

Figure 6

Implants placed

Figure 7

Immediate postoperative OPG

Figure 8

Implants loaded at day 1

Figure 9

OPG after 6 months showing all four implants with good osseointegration

DISCUSSION

The immediate-loading dental implants are more predictable than before,[910] though the chances of crestal bone loss are comparatively higher.[11] It can be speculated that early loading may interfere in the formation of new bone in areas of necrotic bone (created by surgical trauma). In order to achieve primary stability, osteotomy was done 3 mm apical to extraction socket,[12] which is the main factor determining the success of immediate implants. Single-piece implants work well in D1 and D2 bone. So, the extraction site must be evaluated to check weather it is suitable for placement of such an implant. In the present case, the four root stumps were extracted from 36 and 37 regions preserving the sockets, and thereafter, three BCS implants were placed, one each in the mesial and distal sockets of 36 and one in the mesial socket of 37. All the implants were placed approximately 3 mm apically to the base of the extraction sockets along with the bone graft material to attain a good primary stability. The BCS or basal implants provide excellent primary stability along the vertical surface of these implants with no need for corticalization. So, the BCS implants are well suited not only for immediate loading but also for immediate placement.[13]

In the region of 35, one KOS implant was placed. The KOS implant offers the advantages of not requiring flap elevation (no open surgical procedure is necessary), can be carried out in a single sitting, and can be immediately loaded as well.[1415] The KOS implants are single-piece implants with an apical compression thread. The compression screw design facilitates immediate prosthetic loading, provided surgical placement was carried out correctly (restoration can placed within 3 days or less). The KOS implant procedures are less time consuming. Moreover, being a single-piece implant, the strength provided by the implant is excellent as there is no separate root portion and abutment portion.

In the present case, three BCS and one KOS implants were placed and loaded immediately, which showed promising results at a follow-up of 6 months.