Immediate implant placement into fresh extraction socket

Category: Surgery

Instructor(s): Iñaki Gamborena

Course structure: Lessons: 15 lessons | Duration: 14 h 25 min

Course overview

The course introduces a comprehensive approach to optimize the functional and esthetic results of immediate implant placement into fresh extraction sockets by merging surgical, technical and restorative steps into one successful protocol. Immediate surgical and restorative protocols facilitate superior esthetic and functional success.
Masterclass will mainly address the key elements of advanced aesthetics and implant dentistry, critical thinking, and the importance of CTG, and give all participants the chance to interact with one of the world’s leading experts in the field.

Curriculum

Lecture: Treatment philosophy to preserve what there is immediate implants

• The ultimate goal is to replace missing teeth with implant restorations that are indiscernible from the surrounding dentition in terms of shape, morphology, and color, but also to restore and maintain a natural hard and soft-tissue architecture, which is considered the frame for any restoration.
• Soft-tissue aberrations, defects, and deficiencies will make even the most beautiful restoration unsuccessful, not just in the beginning, but also when they happen long after completion of treatment. This is probably the most challenging aspect in implant dentistry.
• This part of the lecture will focus on how much CTG can create to achieve the above-mentioned goal with several implant esthetic failures and how to solve them.

Lecture: Critical thinking, the importance of CTG

• Traditionally, the palate was the preferred connective tissue donor site due to its abundance of tissue and relatively easy access. Limiting anatomical structures on the palate, great variations in thickness, and significant patient discomfort are some of the disadvantages reported.
• Another CTG donor site is the maxillary tuberosity, which is less favored due its more complicated surgical access. However, patient discomfort is more limited compared to palatal donor aeras. In addition, tissue thickness is typically greater and more consistent among patients. Unlike palatal subepithelial connective tissue, it is denser, due its higher collagen fiber content, and contains less fat, making it less prone to postoperative resorption.
• In this section surgical technique will be discussed in order to facilitate the sampling of tissue.

Lecture: Evolution, concept & long-term results

• The fact that even the slightest changes can have devastating consequences in esthetic areas is one of the major challenges. These problems are exacerbated in younger patients, where treatment outcomes should last for many years or even decades.
• Tuberosity CTG has help us successfully achieve our goals at any age, providing a truly stable long-term result. We are going to introduce representative cases of consistent long-term outcome in our professional career.

Lecture(Surgical Video): DTX Studio Implant Plan & execution - Smartfusion

• A clinical video shown in lecture 4 from the all pre-prosthetic and laboratory aspects to surgery.
• Provisional restoration + final impression
• Pour PVS final impression in epoxy
• Full contour wax-up
• 2 silicone matrices indexes before cutting abutment
• Scan epoxy model to perform smart fusion
• DTX implant studio implant placement - export STL file
• Print surgical guide & bond ring
• Transfer implant placement into epoxy master model
• Duplicate tooth diameter & finishing line into custom abutment
• Transfer implant head orientation into surgical guide

Lecture: Contemporary protocol, the 8 steps - Step 1

• This lesson will focus on the first of the 8 steps of this systematic approach:
• 1. Provisional restoration of the tooth to be extracted
• Placing a provisional restoration before tooth extraction, no matter the condition of the tooth to be extracted, and before immediate implant placement has many advantages for implant position planning and simplified treatment execution
• Learning how to copy the result achieved with the provisional crown and transfer it to the implant
• Understanding how to evaluate the ideal emergence profile and reference point for implant position depth with the intracrevicular preparation finish line
• Learning how to communicate to the dental technician the location of the subgingival crown margin, tooth diameter, and the prepared abutment characteristics
• Understanding how to estimate the necessary CTG volume using the abutment as a reference to evaluate the amount of vertical tissue collapse

Lecture: Contemporary protocol, the 8 steps - Steps 2 and 3

• This lesson will focus on the second and third of the 8 steps of this systematic approach:
• 2. Atraumatic extraction
• 3. Ideal implant placement with surgical guide
• In this lecture you will learn:
• The technique to perform the atraumatic tooth extraction without placing any instrument between the crestal bone and the root
• The systems and tools available for an atraumatic tooth extraction
• The ideal 3D implant placement: all immediate implants are inserted with a computer or model-based surgical guide to place the implant precisely with the planned position, angulation, and depth
• Implant recommended placement: the authors’ opinion

Lecture: Contemporary protocol, the 8 steps - Steps 4, 5, 6, 7 and 8

• This lesson will focus on the fourth, fifth, sixth, seventh and eighth of the 8 steps of this systematic approach:
• 4. Initial stability above 35-Ncm torque
• 5. 3D bone packing
• 6. Customized abutment delivery
• 7. Provisional reline
• 8. TCTG
• In this lecture you will learn that:
• Reaching 35Ncm or above is mandatory for a successful treatment alternative
• Insertion torque should be 35 Ncm or above and that this can be achieved only with proper selection of implant type, shape, diameter, and length
• The initial implant osteotomy is critical for reaching the desired insertion torque value when placing an implant into a fresh extraction socket. The cutting, compressing, bone expansion, and, most importantly, the reorientation capabilities, with no major torque loss, make this an ideal implant for immediate placement
• 3D bone packing technique provides support and stabilization of the surrounding bone Customized implant restoration serves to seal the socket and protect the tissue grafts
• There is a customized abutment and cement-retained provisional restoration in the immediate implant protocol
• Sealing the sockets protects and retains the blood clot and the CTG
• You can transfer to the position of the implant abutment precisely as fabricated on the master model
• The advantage of using the same provisional again is that it already features all the necessary anatomical, functional, and esthetic parameters
• CTG placement is the final step of the immediate implant treatment protocol
• The donor site of the CTG is arguably the most important factor for long-term soft tissue stability

Lecture: Video presentation of a clinical case on the 8-step schematic protocol

• 1. Delivering a provisional restoration from day first (on tooth 1st)
• 2. Surgical stent ready for ideal implant placement
• 3. Delivery at day of surgery: the final Zr abutment
• 4. Same provisional restoration relined on the final Zr abutment
• 5. CTG from tuberosity around the implant

Lecture: Case presentation with video surgeries, recorded in Dr. Gamborena’s Clinic

• Presentation of the clinical case using different design with Ti Ultra Nobel Implants
• Presentation of the post-op results
• Discussion of the surgical approaches used
• This surgical lectures focuses on:
• Tooth extraction + immediate implant placement in 22 + CTG and pontic in 23 + provisional abutment and crown
• Provisional restoration on tooth
• The importance of provisional in defining the tooth diameter/locating margin
• Planning the incisal implant placement
• Transfer the provisional interface and customized abutment
• CTG below the finishing line

Lecture: Type 2 socket treatment alternatives

• This lecture combines clinical and surgical clips.
• Elian Type 2 socket represents a higher degree of difficulty as one of the socket is missing. This means that it will have to be reconstructed as in the previously discussed protocol.

Lecture: Type 2 socket treatment alternatives: multilayer technique

• This lecture, which combines clinical and surgical videos, will focus on the different treatment alternatives as well as the treatment sequencing, materials and execution and their relative outcome.

Lecture: Socket type 3 treatment alternatives

• This lecture, which combines clinical and surgical videos, will focus on the treatment approach to adopt when the tissue is also deficient as in type 3 sockets where the implant positioning is uncommonly deeper and where a transmucosal abutment is advisable for bone stability.

Lecture: Adjacent implants long-term results - Part 1

• The above protocol applies to single, multiple, and adjacent implants.
• The protocol has been successfully applied to a wide variety of cases. Periapical radiographs document the initial situation of some cases in 2006 and the follow-up situation up to 2021.
• In this section, the cases discussed prove the satisfying outcome obtained on average in 15-year span.

Lecture: Adjacent implants long term results - Part 2

• The above protocol applies to single, multiple, and adjacent implants.
• The protocol has been successfully applied to a wide variety of cases. Periapical radiographs document the initial situation of some cases in 2006 and the follow-up situation up to 2021.
• In this section, the cases discussed prove the satisfying outcome obtained on average in 15-year span.

Lecture: All-at-once concept

• This series of cases depicts a new “all-at-once concept” described in 2016 for instantly placed single anterior implants that are immediately restored with a definitive Crown on type 1 socket.
• The final crown is fabricated beforehand on the natural tooth to be extracted and then picked up with a polyvinyl siloxane (PVS) impression. In the laboratory, computer-guided or model-based implant surgery is simulated on the master cast. The final zirconia abutment is fabricated on the same model and retrofitted to the definitive crown to construct a screw-/ cement-retained implant restoration.
• Critical aspects are explained in detail in this lecture with detailed videos of some of the cases presented at 5 years.
• Benefits of the all-at-once concept:
• The all-immediate approach of the procedure allows for significantly faster healing and less trauma, which translates to patient satisfaction
• The ASC abutment design provides great versatility and ideal implant placement
• One of the disadvantages is that this concept is technique-sensitive and requires a certain level of expertise as well as excellent communication between the clinician and the dental technician.