Ladera Dental Implant Training - Dental Implant Education - Dr.
Todd B. Engel, DDS - The Emergency Dental Implant
on: October 6, 2009, 6:53 am
The Emergency Implant
Todd B. Engel, DDS
expert diagnostician will advise the very best treatment
for a patient’s needs, regardless if the best course of
treatment is a service that he or she routinely provides or not.
In cases where the best treatment for the circumstances is not
a treatment that is routinely performed in the office, then palliative
treatment along with a referral to a specialist may be in order.
Many more options are now available in the repertoire for restorative
dentists placing dental implants. If the final result can be “blueprinted”
prior to initiating treatment (and the clinician has the knowledge
and ability to produce it), then some of the “afternoon
emergency dilemmas” will appear a bit more straightforward,
if not quite predictable.
this author’s opinion, there is no better feeling than consoling
a distraught patient in an emergency situation, having the expertise
to diagnose the emergency appropriately, and having the knowledge,
confidence, and capability to produce a positive result for the
patient. This article will attempt to illustrate a simplified
method for an immediate implant placement, along with a guided
tissue procedure, into a fresh extraction site. All of the standard
“pre-procedural” diagnostic measures and conditions—with
heavy emphasis on the patient’s health history—need
to be considered and deemed acceptable before beginning treatment.
measures and conditions should include (but are not limited to):1
All pertinent clinical data
• Hard and soft tissue analysis
• Gingival biotype
• Lip lines
• Radiographic interpretation
• Interarch space
• Keratinized tissue
• Esthetic demands
• Applicable informed consent
• Arch relationship
• Emergence profile
• Clinician confidence to control the case
In the following case report, a “prospective” new
patient reported to the Ladera Ranch Implant Institute on a typical
hectic afternoon in need of emergency treatment.
A 42-year-old man presented with the chief complaint of a “loose
filling in his front tooth” along with what he called some
recent “tissue irritation” around the maxillary right
complete dental examination was performed, as well as the review
of his medica history. The medical history was unremarkable, and
his dental condition was excellent with the exception of some
localized, minimal tissue recession. The patient mentioned that
he smoked more than a pack of tobacco per day, had no allergies,
was not taking any prescribed medications, and that he was not
under the care of a physician. During the intraoral evaluation
(Figure 1 View Figure),
the clinical crown was sacrificed after removal of the “loose
filling.” Additional root caries was found extending well
below bone level. The soft tissue surrounding the tooth was within
normal limits. The preliminary x-ray (Figure 2 View
Figure) revealed internal resorption, deep root caries, and
biological width invasion. The culprit tooth had been previously
treated with root canal therapy and a multi-surface composite
filling. Aside from the patient’s complaint of the “filling
feeling loose,” he had no other clinical symptoms.
After an exploratory removal of additional decay, the tooth was
deemed not salvageable (Figure 3 View
Figure). Once presented with all remaining treatment options
based on this scenario, and considering previous time and financial
investments already put into this tooth, the patient elected to
proceed with the extraction of tooth No. 8 and, should it be a
possibility once the site was evaluated and deemed appropriate
after the tooth extraction, have an immediate implant placed.
At this point, the “blueprint,” along with a time
line and financials, were presented to the patient. All treatment
plans, informed consents, and financial arrangements were discussed
is the first step to a successful blueprint. The patient was given
the appropriate informed consent which included (but was not limited
to) the proximity to the nasal floor and nasopalatine foramen,
as well as possible pain, swelling, infection, damage to adjacent
teeth, numbness (temporary or permanent), along with possible
implant failure of unknown cause. Additionally (and, in the author’s
opinion, a must for any implant surgery performed in the esthetic
zone), informed consent was rendered for a potential need for
a second periodontal surgical procedure, based on healing that
may be less than ideal in the esthetic zone. Again, as with all
smokers in need of treatment, a heavy emphasis was placed on the
need for a healthy blood supply to reach the surgical site, and
how the patient’s smoking would be a significant interference
with respect to a successful outcome.2
beginning such a case, all provisional options and modalities
must be considered and available before initiating surgery. This
will help greatly in case of a potential shift in treatment plan
mid-surgery. This is the stabilizer in most, if not all, successful
anterior implant cases.
Protocol: Materials and Methods
Initially, this surgical approach would be performed by way of
a “flapless” technique in an attempt to avoid any
unnecessary invasion or trauma to the periodontal architecture
and support. Upon successful tooth removal, a further evaluation
of the boney walls and socket integrity would be evaluated, thus
indicating if a full-thickness flap reflection would be necessary
to complete the implant placement or to repair any defects.3
patient was given a vestibular infiltration with one cartridge
of lidocaine with epinephrine 1:50,000, along with supplemental
infiltration on the palatal side of tooth No. 8. After complete
loss of sensation was achieved, a periotome (Nobel Biocare, Yorba
Linda, CA) was used to carefully separate the central incisor
and its periodontal ligament (PDL) from the surrounding bony housing.
This protocol is extremely important to ensure that the remaining
boney housing is not jeopardized and/or fractured during the attempted
tooth extraction. In cases such as this, further tooth breakage
should be expected if one attempts to manually elevate or remove
the remaining sacrificed tooth structure with forceps.4,5
circumferential PDL detachment was accomplished, the central incisor
was then atraumatically removed by simple elevation. This natural
intact root would now serve as an ideal indicator of depth, width,
and socket morphology, and would also confirm initial pre-surgical
radiographic calculations. During further debridement and socket
evaluation, a facial defect 3 mm in width and 3 mm in height was
detected, necessitating the need for a full-thickness flap. The
conservative flap extended both one tooth anteriorly and posteriorly,
along with two vertical releasing incisions (Figure 4 View
Figure), while keeping the base of the flap (vestibule) wider
than the apex. This would maintain a healthy blood supply to the
flap, prevent tissue necrosis, and would reduce the possibility
of tearing or laceration when repositioning took place.6,7
on root morphology and size, a regular platform 4.3-mm X 10-mm
NobelReplace™ Tapered Groovy implant (Nobel Biocare) was
selected to complete the case. The surgical bur was then placed
by hand directly into the socket to confirm a snug fit and also
to confirm depth. The appropriate 4.3-mm X 10-mm surgical bur
was then used to further obliterate the socket, gain apical advancement
in virgin bone, and to create fresh bleeding internally.
implant was then placed into the fresh extraction socket, with
emphasis placed on maintaining the desirable restorative angles
and correct emergence profile as well as being respectful to all
zones of safety (minimum of 2 mm) between the implant and adjacent
natural teeth for an adequate and healthy blood supply.8
on the constriction toward the apical portion of the socket, a
torque of 40 Ncm was achieved when the implant was placed in its
final desired position. A cover screw was placed to seal off the
opening of the implant in an effort to prevent any grafting debris
from entering into the implant site (Figure 5 View
Figure, Figure 6 View Figure,
Figure 7 View Figure, Figure
8 View Figure).
before flap closure, the aforementioned facial defect was in need
of repair. A pure-phase, beta tri-calcium phosphate, 150-µm
to 500-µm particulate material, Cerasorb® (RIEMSER,
Raleigh, North Carolina), was mixed with the patient’s own
blood and placed directly onto the facial bone defect and exposed
implant surface. All attempts were made to re-create the topography
of the original bone pattern before any defect had occurred. Additionally,
to protect and support the fresh clot and avoid any in-growth
of unwanted epithelium into the graft itself, a bio-resorbable
membrane, Epi-guide (RIEMSER), a bioresorbable synthetic membrane,
was modified and placed directly over the Cerasorb graft material
and beneath the tissue periosteum (Figure 9 View
Figure and Figure 10 View
Figure). The bio-resorbable membrane should remain a minimum
of 1 mm away from the adjacent sulcus to prevent transmission
of bacteria across the membrane surface from adjacent teeth. Although
suitable torque was achieved to immediately load the implant,
the author chose to delay loading because of the boney defect.9,10
and just before flap repositioning, a release of the underlying
periosteum was indicated to ensure a relaxed flap closure and
to avoid wound opening. The flap was repositioned with two horizontal
mattress and four interrupted PTFE sutures (Osteogenics Biomedical
Inc, Lubbock, TX) (Figure 11 View
this point, the temporization decision is key and quite critical
to assist in healthy tissue healing and natural adaptation. A
composite Maryland bridge provisional was fabricated chairside
to complete this interim phase of treatment, in the effort of
training and maintaining healthy, intact papilla by way of an
ovate pontic design. Several try-ins were attempted before the
final bonding to ensure that no contact was directly on the surgical
site, at which time the temporary was adjusted out of occlusion
and bonded into place (Figure 12 View
patient was prescribed amoxicillin 500 mg four times a day for
1 week, ibuprofen 800 mg three times a day for 4 days, and 0.12
chlorhexidine rinses three times a day for 1 week, and given a
10-day recall appointment. Before dismissal, the use of tobacco
products was reviewed once again, and the patient was advised
to refrain from smoking during the healing period.
the 10-day interval, the patient returned for a follow-up postoperative
appointment. The bonded provisional restoration was removed for
further evaluation of the surgical site and all sutures were removed.
Ultimately, the provisional bridge was bonded back into place
over the surgical site, and would remain in place throughout the
remainder of the healing phase (Figure 13 View
Figure). Based on the site evaluation and a short discussion
with the patient, the first week proved to be successful. The
patient was given a 4-month recall appointment for the restorative
phase of treatment.
4 months, the patient returned for the second phase, or restorative
portion of treatment, which encompassed uncovering the implant
fixture. Based on the author’s evaluation of healing after
the 4-month period, an interproximal full-thickness flap was opted
over a traditional “punch” technique to reveal the
implant fixture for the implant-level impression. The rationale
for this was to displace some of the healthy keratinized tissue
from the palatal side of the implant, toward the facial aspect,
as this would provide a more adequate biological seal and a more
ideal esthetic result.
semi-lunar, full-thickness incision was initiated slightly palatal
to the center of the ridge, while sparing the papilla interproximally
(Figure 14 View Figure
and Figure 15 View Figure).
At this point, a transmucosal healing abutment was used to support,
train, and maintain the repositioned flap for a more ideal result
(Figure 16 View Figure).
During the temporary phase, a well-designed provisional with ideally
positioned proximal contact points is key, and will assist with
overall papilla health (Figure 17 View
weeks later, the patient returned for the definitive prosthesis,
symptom-free. The all-ceramic NobelProcera™ crown (Nobel
Biocare) was placed into position, and an x-ray was taken to confirm
fit before cementation (Figure 18 View
Figure). The NobelProcera crown was then cemented into place,
the occlusal scheme was checked to make certain that the crown
was solely in a light centric contact, and all parafunctional
contacts were removed. The patient was very happy with his choice
of treatment, as well as the final result (Figure 19 View
After surgery, the patient was evaluated at intervals of 1 week,
1 month, 4 months, and 1 year (Figure 20 View
Figure). Radiographs were taken at all appointments to verify
implant support and rule out any possible pathology.
Understanding patients’ needs and using all of the treatment
options available puts dentistry into an expressive class by itself.
As we progress through our dental “practice” journey,
it is of utmost importance to move and grow with the evolution
of treatment modalities, as well as technology, not only for our
patients, but for our professional development as well.
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About the Author
B. Engel, DDS
Director and Founder
Ladera Ranch Implant Institute
Ladera Ranch, California www.laderaimplants.com
Orange County, California
Contact Details: Todd B. Engel, DDS
Director and Founder
Ladera Ranch Implant Institute
Ladera Ranch, California www.laderaimplants.com