Aesthetic Value of Immediately Loaded Immediate Post-extraction Implants

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1 2 EDI A retrospective assessment of the performance of implants in obtaining the essential initial stability Aesthetic Value of Immediately Loaded Immediate Post-extraction Implants Matteo Danza, MD 1, Tania Sinderowsky 2, Francesco Carinci 3 and Professor Stefano Fanali 4 The field of implantology is continually evolving. New indications are established and existing ones updated, new components and systems are constantly being introduced, and on top of all this, patients have rising expectations of ever earlier function. We are increasingly asked to solve aesthetic problems involving the anterior maxilla, where we need to be very careful to balance the possibility of obtaining an excellent result in a shorter time against our responsibility to minimize the risk of unnecessary failure. It is very satisfying to both patient and practitioner to be able to replace an extracted tooth immediately with an implant-supported restoration that reproduces its shape, size and function. The international literature is full of studies which provide the foundations for our everyday clinical practice, and which support us in deciding to load an implant that has just been placed in a fresh extraction socket. This approach disrupts the local anatomical and physical situation by forcing both hard and soft tissues to follow our intentions. 1 Dental School, University of Chieti, Italy 2 Maxillofacial surgeon, free professional in Tel Aviv 3 Maxillofacial Surgery, University of Ferrara, Italy 4 Head of the Department of Odontostoma - tologia II, University of Chieti, Italy For some time now, a team from our institute has been working with implants placed in post-extraction sockets. A team from the G. D Annunzio University Oral Medicine Clinic, Chieti (director: Professor Stefano Fanali), analyzed the clinical and radiological behaviour of implants placed at different times after extraction, i.e. immediate, early delayed and late delayed placement, with bone regeneration where necessary. The most striking conclusion was that the most successful implants were those placed immediately after extraction [1]. The most likely reason is that the surgical procedure probably disturbs the spatial distribution of the forces generated by the dental root that ensure the crucial vascularization of the alveolar ridge, but we do not completely interrupt its function as it is immediately restored, albeit in a different form, when an implant is placed in the extraction site.

2 EDI 3 This article offers a retrospective assessment of the performance of the Spiral and Spiral Flare Bevel (SFB) implants (Alpha-Bio Implant Ltd., Petah Tikva, Israel) in obtaining the essential initial stability that is a minimum and sufficient condition for obtaining osseointegration in immediate post-extraction implants subjected to immediate loading. Post-extraction implants Although the validity, predictability and high success rate of this implant placement method have been recognized in many articles published over the last few years [2], the method has not yet been formally recognized as being equal to other methods used in traditional protocols. Many of our colleagues take a defensive approach, regarding the technique as a dangerous simplification of the traditional method because of the relative difficulty in obtaining initial stability and the large number of cases in which further bone regeneration is required to fill a gap between socket and implant. However, in spite of this the method continues to be used successfully and has been studied in many leading centres all over the world. Recently, the University of Tübingen (Germany) published a very interesting study in the International Journal of Oral and Maxillofacial Implants, the leading journal in the field of osseointegration, presenting six-year follow-up data for 124 Frialit implants inserted in post-extraction sockets. Sixtyeight percent of the implants supported single-tooth restorations. The survival rate was 99% after the first year, dropping to 97% after six years in function [3]. Other studies have compared immediate postextraction implantation with conventional implantation. A team from Tel Aviv University placed 380 implants, 117 (31%) of which were placed using an immediate post-extraction method, while the other 263 were placed in mature bone using a conventional method. Five-year survival rate was 96% for implants in the first group and 89.4% for implants in the second group. The study results showed that in the critical part of the maxilla, the posterior maxilla, the five-year cumulative survival rate (CSR) was 100% for immediate post-extraction implants and 72% for those placed using a traditional protocol [4]. It is now well recognized that immediate postextraction implantation preserves maxillary anatomy and maintains bone morphology; a large number of clinical studies on this subject have reported a high level of success, but none of them has ever included histological analysis of implants placed in post-extraction sockets without filling material or membrane. In November 2001, our university (Chieti) published an interesting study in which 48 patients received at least one post-extraction implant, in symmetrical quadrants, in addition to other implants inserted using a conventional protocol. The study was carried out without the use of filling materials or membranes, just a flap repositioned coronally to obtain primary wound closure. After six months, the implants inserted by the post-extraction method were removed and the sections were examined histologically. In particular, the percentage of boneimplant contact was measured. There were no statistically significant differences in clinical, radiographic or histological parameters between the two groups of implants. It was concluded that although no bone regeneration had been used, there was no difference in the degree of osseointegration between the two groups of implants when the bone-implant gap was less than 2 mm [5]. Immediate loading In edentulous patients, fixed implant-supported restorations can have a very high success rate, if implants are allowed to heal without loading for three to six months. Many published data have shown that this type of restoration can be successful for many years [6, 7]. The disadvantage of the procedure is that the patient has to wear a full provisional denture for several months, as a healing period of three to six months is recommended after the teeth have been extracted and implants placed, before any loading is applied to the implants. The patient cannot wear any kind of denture for at least two weeks after the procedure. A further disadvantage of using a full denture after the extractions is that existing papillae are flattened [8]. In 1977, Schnittman and Tarnow [9, 10] suggested that full dentures could usefully be dispensed with during the implantation process. In patients who have lost all their teeth from periodontal disease and who intend to have an implantsupported fixed restoration, a temporary restoration placed immediately onto post-extraction implants would be an even greater benefit. Many published studies have shown that implants inserted immediately after dental extraction can have a similar success rate to that of implants placed in healed sites [11-19]. For immediate implants, a success rate of more than 95% may be expected. Many studies have now been published confirming that excellent results can be obtained with immediate loading of both edentulous arches [9, 10, 15, 17] and individual teeth [18, 19] although in the latter case the immediate loading was not functional

3 4 EDI loading as the provisional restorations were not functional. True functional immediate loading takes place only in edentulous arches; this concept has been validated over time with bar-retained implantsupported overdentures. Examples of fixed restorations on implants in edentulous mandibles have been widely reported in the literature. In similar cases, Randow and co-workers [20] reported a 100% success rate in 16 patients in whom implants were placed and then immediately subjected to early loading. Five or six implants (minimum length 10 mm) were placed in each of the 16 patients between the mental foramina and then loaded with a fixed superstructure bilaterally extending to include the second premolar. The follow-up for this study lasted 18 months. In Loma Linda University (California), Rungcharassaeng and co-workers [21] confirmed the high success rate of this treatment method and confirmed that it is a valid and predictable option, provided that the prerequisites of careful patient selection and case planning are complied with. Gatti, Helfinger and Chiapasco (2000) assessed immediate loading in mandibular overdentures with ITI implants placed between the mental foramina, obtaining an identical success rate (96%) after three years of follow-up to that for conventional delayed loading [22]. Piattelli and co-workers analyzed bone reaction to early loading (two weeks) around plasma sprayed implants in cynomolgus monkeys. Histological study showed that high percentages of bone-implant contact can be obtained with this implant placement protocol [23]. Testori and co-workers carried out a histological study of two Osseotite (3i) immediately-loaded implants which were sampled four months after loading. Histological and morphometric analysis confirmed a high percentage of bone-implant contact (85%) [24]. Horiuchi and co-workers studied immediate loading with Brånemark implants with a screw-retained provisional metal-reinforced resin prosthesis in 140 implants placed in an 8 to 24 month period [25]. The criterion for loading was a placement torque of 40 Ncm or more; implants with a lower placement torque or implants that required bone grafting were submerged. The success rate was 97.2%. Similar percentages (95%) were obtained by Jaffin, Kumar and Barman with implants that were loaded immediately (within 72 hours) with reinforced resin provisionals. Inclusion criteria were adequate bone volume and density for a minimum of four (10 mm diameter or greater) implants in the mandible, and six in the maxilla. In this study, fewer sandblasted/ acid-etched implants were lost than machined implants [26]. In 2001, Grunder carried out a comprehensive study and reported results for 91 implants, 66 of which were inserted immediately after extraction in the post-extraction sockets and all of which were loaded immediately [8]. No bone grafting or membranes were used in any of the 66 post-extraction sites, despite the fact that in many cases there were gaps between the implant surface and the post-extraction parietal alveolar bone. It is very interesting to review the different treatment strategies used for implants that are not in contact with bone, especially in singlestage surgery. The classic approach is that good bone-implant contact at the height of the first thread is needed for good long-term results. Nir-Hadar and co-workers [27] showed that with the submerged method, when there was a gap between implant and bone, there was a strong tendency for pre-implant defects to fill with bone in both the horizontal and vertical planes, up to the cover screw. These results were based mainly on clinical observations. Akimoto and co-workers [28] showed that when the submerged implant method was used without bone regeneration, the bone-implant gap filled with new bone. As the gap widened, the amount of boneimplant contact decreased. When the initial gap was 1.35 mm, there was a very low amount of boneimplant contact. Brunel and co-workers [29] carried out a careful study of bone regeneration methods combined with post-extraction implant placement in beagle dogs. In the control group, defects between 2.5 and 4.00 mm were left untreated and 50% of the implants failed. In both treatment groups, failure rates were 30% when hydroxyapatite was used to fill the gap and 0% when a collagen membrane was applied, alone or in combination with hydroxyapatite. Implants in the control group that had been successful without any additional treatment had a better level of bone-implant contact. The study concluded that the use of bioabsorbable materials slightly increases osseointegration when used in conjunction with the immediate placement of non-submerged implants. In the Grunder study [8], implant failures did not appear to be related to gaps between the coronal part of the implant and the bone. Gaps were present in all implant sites but all the failures occurred in the posterior region. These failures were therefore related to implant location. Six out of seven implants had been positioned in the posterior maxilla, and five of these were between 8.5 and 10 mm long [30, 31]. In the Grunder study, the main cause of failure was poor bone

4 EDI 5 Fig. 1 Radiographic appearance of the incisor at the first visit. 1 2 Fig. 2 Clinical appearance of 21. Fig. 3 Detail of previous photo. 3 4 Fig. 4 Broken coronal fragment and the extracted root fragment. quality (100% of implant failures were in type IV bone). Other causes of failure were provisional restorations without metal reinforcement in patients with bruxism, and imperfectly seated abutments. In this study, initial stability was achieved in 100% of cases, and for this reason alone, treatment could be considered successful. The global success rate of 92.31% after 24 months may be acceptable. It was not possible to demonstrate that implant surface had any positive effect, as there was no control group. Success rates could certainly have been higher if patients had been selected more carefully, by enrolling patients with good bone quality and volume in the posterior maxilla. The conclusions of the Grunder study were that functional loading with immediate post-extraction implants for fixed restorations of complete arches, without the use of bone substitutes or barrier membrane, could be successful over a two-year period. Immediate loading of post-extraction implants: case histories Case history 1 A 25-year-old patient came to our clinic wanting to solve the aesthetic and functional problems caused by his left upper central incisor. From the history, it emerged that the tooth had suddenly had a traumatic oblique fracture a few years earlier, which was treated endodontically with fracture union obtained using a bonding method (Fig. 1). The patient reported that he had had to reattach the fragment on a number of occasions and now felt it was unstable; the fragment was also slightly extruded and had migrated vestibularly. His major concern was the disfiguring aesthetic result if the tooth was removed. Physical examination showed the crown of tooth 21 with clear discoloration, slight extrusion and slight mobility (Figs. 2 and 3). The treatment plan involved removal of the fragment followed by intraoperative assessment of the treatment options, i.e. fabrication of a post and core for an all-ceramic crown, if the clinical situation would allow this, or alternatively, extraction of the fractured tooth and immediate replacement with an implant-supported crown. The patient signed a standard informed consent form and accepted the treatment plan. At the next visit, the coronal fragment was removed and after examining the fragment and the fracture margins (Fig. 4), we decided on extraction and replacement with an immediate post-extraction implant. The fragment was extracted atraumatically with the usual care required in these situations to preserve the integrity of the alveolar cortex and to encourage predictable bone regeneration around the coronal portion of the implant and long-term survival for the post-extraction implants [32, 33]. The root fragment was therefore carefully luxated; toothextraction forceps were only used after the fragment had been mobilized.

5 6 EDI 5 6 Fig. 5 SFB implant. Fig. 6 Angle of palatal axis. 7a 7b Fig. 7a Prosthetically determined positioning of the implant head... Fig. 7b... with 0 Paraguide system. 7c 7d Fig. 7c... with 15 Paraguide system. Fig. 7d... with 25 Paraguide system. After careful curettage, the socket was washed with saline and the site was prepared for implant placement through the extraction socket, without any incision of the soft tissues. The implant chosen for this type of restoration was a Spiral Flare Bevel (SFB) implant, Alpha-Bio. The implant has special features in the form of a tapered neck and NanoTec surface treatment, which make it possible to obtain a thicker layer of well vascularized, keratinized tissue around the implant neck (Fig. 5). The implant site was prepared using the palatal wall of the socket and native alveolar bone for 3 to 4 mm beyond the apex of the extracted tooth, in order to achieve the crucial initial stability. The osteotomy was started on the palatal wall of the extraction site using a 2-mm round bur, under copious irrigation with saline. Once this initial step had been completed we were able to use the series of rotary instruments specified for the operative procedure, in order, along the palatal preparation axis cut by the first drill (Fig. 6). A 6 x 13 mm SFB implant was inserted in the first part of the prepared socket along the direction set by the rotary instruments, but the first three to four threads were hardly engaged when it had to be redirected vestibularly by a gradual levering action using a manual insertion instrument (surgical screwdriver). Correcting the implant axis during insertion meant that the implant head emerged in a prosthetically ideal position without compromising the vestibular bone wall, resorption of which could have caused dangerous recession of the soft tissues, especially in a thin periodontal biotype (Figs. 7a to d) [34].

6 EDI 7 Figs. 8a and b Straight abutment connected immediately to implant. 8a 8b Fig. 8c Abutment prepared intra orally. 8c Fig. 9 The provisional crown has just been put in place. Note the flapless technique and the absence of sutures Fig. 10 General view in centric occlusion. The implant head was positioned 3 mm apically, at the future gingival margin. The height of the soft tissues determines the dimension available for the emergence profile and for the maintenance of a sufficiently deep peri-implant sulcus to ensure the long-term health of the peri-implant soft tissues. The gap between the implant and the vestibular wall was not filled by bone grafting, as this is not necessary if the width of the gap is less than 2 mm [5]. We used the ParaGuide system which adjusts the parallelism of the implant and is an extremely useful guide when choosing the ideal prosthetic abutment (Figs. 7a to d); we chose a preformed straight abutment which was connected immediately to the implant and modified immediately in position, using special multi-blade diamond burs for titanium (Figs. 8a to c). An acrylic resin temporary crown prepared beforehand was rebased and cemented provisionally to the abutment that had just been placed (Fig. 9). Occlusion was checked very carefully in view of the patient s overbite, and the optimum provisional crown occlusion was obtained, with light centric contact and no contact in the lateral excursions (Fig. 10). The patient was discharged with the usual instructions to continue taking the antibiotic (amoxicillin 1 g twice daily) for a further five days, practice careful oral hygiene, rinse twice a day with 0.12% chlorhexidine mouthwash and avoid biting or tearing at food so as not to overload the new dental implant.

7 8 EDI Fig. 11 Postoperative radiograph a 12b Figs. 12a and b Radiographic and clinical appearance eight days after the procedure. 13a 13b Figs. 13a to d Healing of soft tissues two months after the procedure and follow-up radiograph. 13c 13d Postoperative intraoral radiograph showed that all the factors involved had been addressed and the implant-crown assembly had integrated very well into the patient s actual anatomy (Fig. 11). The postoperative course was uneventful, with no complications. The patient returned for a check-up eight days later and reported that he had not had any problems. At this visit, the appearance of the soft tissues was excellent (Figs. 12a and b). The patient s good oral health continued to improve; at a check-up two months later, the clinical and radiographic appearances were very encouraging, and an alginate impression was taken to make an individual impression tray (Figs. 13a to d). Soft-tissue healing, clinical situation and radio - graphic appearance of the result when the definitive abutment and the all-ceramic crown were tried-in were all excellent, and all the features for which we had chosen the SFB implant were found to be very satisfactory (Figs. 14a to e). They could also be confirmed radiographically (Figs. 15 and 16). The intimate contact between implant and surrounding bone tissue is clearly visible on the radio - graphs. The healthy state of the implant and its osseointegration had a direct effect on the soft tissues overlying the emerging implant structures. The interproximal papillae were perfectly preserved with the colour and stroma resembling those of a natural tooth.

8 EDI 9 Figs. 14a to e Stages in gradual tissue maturation. 14a 14b 14c 14d 14e Fig. 15 Radiograph at time of abutment try-in. Fig. 16 Radiograph at time of try-in of the crown. This vascularization of the peri-implant soft tissues is probably related to the special profile and reverse taper of the SFB implant neck, as these features deliver a larger amount of inter-implant alveolar bone from which the vascular system can support the papillae. The vascularization requirement of the periimplant soft tissues should always be borne in mind when planning implant-supported restorations. To allow adequate organization of the connective tissue and the supracrestal epithelial tissue, the inter-implant space (or the distance between abutments, whether natural or alloplastic) should be at least 3 mm to provide a sufficiently wide base for the shape and the projection of the papilla for harmonious development of the profile and structure [1]. The maintenance of a healthy peri-implant mucosal seal over time depends on both prevention of sepsis and the ability to satisfy the morphological and anatomical requirements for establishing a suitable vascular support for the connective tissue stroma of the inter-implant papillae, to ensure the maximum vitality and reactivity of the tissue itself and the epithelium covering it. Placing implants too close to each other or excessively close to contiguous natural elements reduces the amount of space left for the papilla, leading to the development of narrow and elongated papillae with less vascularization and increased susceptibility

9 10 EDI 17a 17b Figs. 17a and b Laboratory photo: Implant and all-ceramic crown, ready for the try-in. 18a 18b Figs. 18a to e Stages in completion of the procedure. 18c 18d 18e to any microbial insult. This leads to a certain degree of instability in the mucosal seal, with more apical reorganization of all of the tissues that contribute to the biological width (peri-implant bone, supracrestal connective tissue and junctional epithelium). The SFB implant appears to have the characteristics needed to satisfy these requirements. At the next visit a week later we placed the prosthetic abutment obtained by adapting a prefabricated provisional abutment, with the characteristic golden colour of the transmucosal neck obtained by excessive oxidation of titanium (Figs. 17a and b). At the next check-up a few days later, the definitive fabricated crown was placed (Figs. 18a to e).

10 EDI 11 Fig. 1 Initial patient ortho - pantomogram. 1 2 Fig. 2 Baseline clinical situation. Fig. 3 Tissues after root extraction. 3 4 Fig. 4 Small access flap for optimum positioning of the more distal implant. Fig. 5 Post-extraction placement of NT Certain implants inserted immediately at sites 25 and Fig. 6 Healing abutments positioned for suturing. Fig. 7 Repositioning of the flap around the healing abutments using Dr Palacci s interimplant papilla regeneration method. Case history 2 This was a 76-year-old woman who came to our clinic with a fractured bridge in the second quadrant (25-27). The patient s main concern was to avoid having to wear a removable partial denture. Her general dental health was excellent. She was offered a prosthetic implant solution in the form of post-extraction placement of two implants at sites 25 and 26 (Figs. 1 and 2). The patient reviewed the treatment plan and signed a standard informed consent form. On the day scheduled for surgery, the patient took 3 g of amoxicillin one hour before the procedure and rinsed with a 0.2% chlorhexidine solution for two minutes. The two root fragments were extracted in accordance with the protocol for delicate and minimally invasive surgery [32]. First of all, we performed a delicate syndesmotomy, then luxated and elevated the 7 root fragments. Particular care was taken to preserve the vestibular cortical bone, which is thin and delicate and very important for preventing vestibular bone recession (Figs. 3 and 4). At the same visit as the extractions, two Osseotite NT Certain (3i) implants (5 x 13 mm and 5 x 11.5 mm) were inserted after careful modification of the postextraction sockets (Figs. 5 to 7).

11 12 EDI 8 9 Fig. 8 Healing of soft tissues and excellent state of health of the two implants. Fig. 9 Reproduction of the soft tissues in the laboratory Fig. 10 Abutments. Fig. 11 Trying-in the abutments Fig. 12 Lined provisional crown. Fig. 13 Follow-up radiograph. Fig. 14 Radiograph after replacement of the distal implant. After placement, the implants were connected to healing abutments to allow accurate repositioning of the flap and so obtain the aesthetic results that the patient wanted, using Dr Palacci s papilla regeneration technique [35]. The postoperative period was uncomplicated. Healing of the peri-implant soft tissues clearly testified to the excellent state of health of both implants (Fig. 8), and about two months after placement they were fitted with prosthetic abutments and gradually loaded with an acrylic resin provisional crown (Figs. 9 to 12). When we were taking the transfer coping impression, about 40 days after loading, we realized that the most distal implant (26) had lost stability, which was confirmed with radiographs showing transparent haloes around the implant (Fig. 13). The implant was removed and replaced at the same visit with a 6 x 11.5 mm Alfa Bio SFB implant, changing its orientation and recording its position with an intra-operative impression (Fig. 14).

12 EDI 13 Fig. 15 Intraoperative view Fig. 16 Provisional crowns after adjustment. Fig. 17 Follow-up radio graph after crowns have been fitted Fig. 18 Abutments connected to implants. Fig. 19 Definitive ceramic crowns. 19 Figs. 20 to 22 Follow-up radio - graphs taken after fitting of definitive crowns, three months and six months after loading A 25 pre-angled abutment was placed on the implant that had just been inserted, and the provisional resin crown was trimmed to fit (Figs. 15 and 16). A week later, the second definitive abutment was connected and the two ceramic crowns were placed (Figs. 17 to 19). Control radiographs taken after the prosthetic work had been completed and three and six months after loading confirmed the healthy status and excellent osseointegration of the implants (Figs. 20 to 22). Results for the SFB implant inserted using an immediate post-extraction method and subjected to immediate loading were very encouraging at the time of writing. This type of procedure generally needs to be followed-up later.

13 14 EDI 1 2 Fig. 1 Initial clinical appearance. Fig. 2 Initial radiographic appearance. Fig. 3 Implant in position. 3 4 Fig. 4 The preformed abutment has just been adjusted and connected to the implant using gentle torque of 15 Ncm on the fixation screw. 5 6 Fig. 5 The acrylic resin temporary crown manu factured in the laboratory prior to implant insertion, based on a diagnostic wax-up; it has been trimmed and cemented with provisional cement. 7 Case history 3 A 20-year-old woman came to our clinic for extraction of an impacted third molar (48); tooth 46 had been extracted the previous week because of untreatable root caries. The patient, an aspiring actress, said that she had heard that treatment times were very long for implant-supported restoration after a single tooth has been extracted. We suggested surgical extraction of the impacted tooth and immediate placement of a post-extraction implant at position 46 with immediate loading, with a treatment plan giving a much shorter time for solving the problem. The patient accepted our treatment plan and signed a standard informed consent form. Clinical and radiographic examination clearly showed the recent extraction of 46 (Figs. 1 and 2). It was decided to use the distal socket for insertion of a 6 x 13 mm SPI implant (Alpha-Bio), because this was the implant that would give the best emergence profile. We performed an incision distal to site 47 to allow access to the third molar. The incision went around site 47 intracrevicularly and continued along the middle of the crest to the edentulous region in order to open the margins of the residual alveolar wound, which had not yet re-epithelialized, and to expose the post-extraction socket, which was still fresh. Fig. 6 The procedure is concluded by suturing both the third molar extraction region and the implant region. Fig. 7 Follow-up radio - graph shows intimate contact between the implant and the surrounding bone tissue.

14 EDI 15 Fig. 8 Healing of the soft tissues around the immediately placed provisional crown shows the beneficial effect of immediate loading on vascularization. 8 9 Fig. 9 Complete integration of the implant abutment with the tissues has sculpted the gingival contour Figs. 10 and 11 Gingival walls at the emergence site. Fig. 12 Abutment. Fig. 13 Definitive allceramic crown Fig. 14 Enlargement of previous image. The distal socket chosen for implant placement was modified and optimized by the use of increasing diameter drills, as described in the standard Alpha-Bio surgical protocol, so that an SPI implant could be inserted (Fig. 3). The implant was seated in the distal socket, achieving excellent initial stability, which allowed us to continue with immediate provisionalization. The residual lingual and vestibular gaps were small enough not to require grafting with biomaterials. A titanium abutment from the catalogue range was connected at the same visit as the post-extraction implant was inserted, making it possible to load the implant immediately with an acrylic resin provisional crown, to contribute to soft tissue management (Figs. 4 to 7). The rule of light centric occlusion and no contact in the lateral excursions was complied with. About two months later, the soft tissues appeared healthy, and we took an impression of the implant 14 position. Figures 8 to 14 clearly illustrate the excellent results obtained with the SPI implant using the method described (Alpha-Bio). The prosthetic work was completed using a wide platform abutment (see Fig. 12) and an all-ceramic crown (Figs. 15 and 16). All stages from insertion to fitting of the crown were monitored radiographically. The images show the stages described (Figs. 17 to 20).

15 16 EDI Figs. 15 and 16 Laboratory images of the crown Fig. 17 Follow-up radio - graph of inserted implant. Fig. 18 Radiograph after two months of healing Fig. 19 Radiograph to check abutment connection. Fig. 20 Follow-up radio - graph of abutment connection. Conclusions This article discusses a procedure that is becoming increasingly more predictable and that is now routinely performed by a large number of professionals. There are a number of advantages in using this method: single surgical stage; biological tissue sparing; ease of obtaining initial stability; aesthetic solution to edentulousness; good success rate, found to be around 98% in our population; and better integration of both hard and soft tissues. In fact, from our experience it would appear that immediate loading in itself, and even better, immediate loading of a post-extraction implant, has a marked positive effect on the quality of peri-implant soft tissues. In our patients we have consistently found that periimplant tissue was keratinized, stable, fibrous and free of any trace of inflammation. The cases presented here used SFB and SPI implants (Alpha-Bio), which in these specific applications invariably satisfied the demands placed upon them. They can be used electively for immediate implantation after tooth extraction because of their special features of dual taper profile, high performance self-drilling and self-tapping, gradual increase in diameter and variable thread profile in the apicocoronal direction, which deliver excellent primary stability. A list of references can be found on Contact Address Matteo Danza, MD Via Carducci Pescara ITALY Fax:

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