Dimensional changes in the supporting tissues following immediate placement and restoration of dental implants in the aesthetic zone: a retrospective study Nabil Omar Khzam BDSc School of Dentistry and Oral Health Griffith Health Griffith University Submitted in fulfilment of the requirements of the degree of Master of Philosophy March, 2010 ABSTRACT Aim: The objective of this retrospective study was to assess the survival rate and the hard and soft tissue response following immediate placement and provisional restoration of singletooth implants in the aesthetic zone Materials and Methods: Thirty-four patients (13 male and 21 female) with 37 immediately placed and restored implants (Astra-Tech® AB, Mölndal, Sweden) were identified as eligible to participate in this retrospective study Thirteen of these patients returned for the follow-up examination All participating patients underwent the same treatment strategy which was removal of the failed tooth, flapless surgery, immediate implant placement and the connection of a screw-retained temporary restoration Reasons for tooth loss included failed root canal treatment, trauma and tooth resorption Three months following implant placement, the temporary crowns were replaced by the definitive restorations Implant survival rates and hard and soft tissue changes were measured using photographs and periapical x-rays The range of observation period was between 12 to 27 months with a mean period of 16 ± months Results: At 16 ± months, all implants were present at the time of follow-up with no complications, resulting in an implant survival rate of 100% Radiographic evaluation revealed that there was no statistical difference in bone loss mesially and distally between baseline and follow-up Clinical evaluation of the soft tissue revealed no statistically significant changes in mesial papilla, distal papilla and mid-facial tissue stability throughout the observation period Conclusions: Within the limitation of this retrospective study, immediate implant placement and provisional restoration in the aesthetic zone of the maxilla can result in acceptable treatment outcomes as well as stable peri-implant tissues after a follow up period of 16 ± months using the Astra Tech implant system This work has not previously been submitted for a degree or diploma in any university To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made in the thesis itself Table of contents LIST OF ILLUSTRATIONS ………………………………………1 LIST OF TABLES………………………………………………… ACKNOWLEDGEMENTS 1.0 INTRODUCTION……………………………………………5 1.1 OVERVIEW……………………………………………… 1.2 RESEARCH QUESTION……………………………………6 1.3 SIGNIFICANCE OF THE CURRENT STUDY.… ……….6 1.4 OBJECTIVES OF THE CURRENT STUDY……… …… 2.0 LITERATURE REVIEW………………………………… 2.1 TERMINOLOGY…………………….………………………8 2.2 HISTORICAL BACKGROUND OF IMMEDIATE IMPLANT PLACEMENT AND RESTORATION…… 10 2.3 IMMEDIATELY PLACED AND RESTORED IMPLANT COMPARED WITH DELAYED IMPLANT PLACEMENT… 11 2.4 LIMITATION OF THE IMMEDIATE IMPLANT PLACEMENT AND RESTORATION STRATEGY…… 12 2.5 REVIEW OF THE LITERATURE AND SEARCH STRATEGY……………………………………………… 14 2.5-1 SURVIVAL RATE OF IMMEDIATELY PLACED AND RESTORED IMPLANTS IN THE AESTHETIC ZONE…………………………………………………………18 2.5-2 SOFT TISSUE CHANGES FOLLOWING IMMEDIATE IMPLANT PLACEMENT AND RESTORATION 29 2.5-3 HARD TISSUE CHANGES FOLLOWING IMMEDIATE IMPLANT PLACEMENT AND RESTORATION…… 39 3.0 MATERIALS AND METHODS ………………………… 46 3.1 PATIENT SELECTION (THE INCLUSION CRITERIA……………………………………………………46 3.2 SURGICAL PROTOCOL AND TECHNIQUES………… 47 3.3 TEMPORARY CROWN PLACEMENT…………….… 51 3.4 PERMANENT CROWN PLACEMENT …………… .53 3.5 HARD TISSUE MEASUREMENTS…………………….….54 3.6 SOFT TISSUE MEASUREMENTS……………………… 56 3.7 OTHER MEASUREMENTS……………………………… 59 3.7-1 IMPLANT SURVIVAL RATE…………………………… 59 3.7-2 ASSESSMENT OF INTERDENTAL PAPILLA………… 60 3.7-3 PLAQUE LEVELS ……………………………………… 60 3.7-4 GINGIVAL TISSUE BIOTYPE……………………………60 3.8 STATISTICS USED IN THE STUDY…………………… 60 4.0 RESULTS…………………………………………………….62 4.1 PARTICIPANTS ENROLMENT AND DEMOGRPHICS 62 4.2 HARD TISSUE PARAMETERS………………………… 65 4.3 SOFT TISSUE PARAMETERS…………………………….70 4.4 JEMT S’ INDEX…………………………………………… 75 4.5 PRESENCE OF PLAQUE .75 5.0 DISCUSSION…………………………………………………76 5.1 PATIENT ENROLMENT……………………………… …76 5.2 IMPLANT SURVIVAL RATE………………………… ….77 5.3 HARD TISSUE MEASUREMENTS…………………… .79 5.4 SOFT TISSUE MEASUREMENTS…………………… 82 5.5 PLAQUE LEVELS……………………………………… .91 5.6 GINGIVAL TISSUE BIOTYPE…………………………….92 5.7 FUTURE CONSIDERATIONS…………………………… 92 6.0 CONCLUSIONS………………………………………… .94 7.0 LIST OF REFERENCES…………………………………….95 LIST OF ILLUSTRATIONS Figure Surgical techniques- failed tooth before extraction………………………49 Figure Surgical techniques- tooth extraction…………………………………….50 Figure Surgical techniques- implant secured in place………………………… 50 Figure Temporary crown placement………………………………………………51 Figure Temporary crown placement………………………………………………52 Figure Temporary crown adjustment…………………………………………….52 Figure Permanent crown placement- months postoperatively ……53 Figure Permanent crown placement- months postoperatively …….………… 53 Figure Illustration of hard tissue measurements on periapical x-ray…………….55 Figure 10 Illustration of the measurements of the soft tissue on photographs…… 58 Figure 11 Level of mid-buccal gingiva at placement of temporary restoration……85 Figure 12 Level of mid-buccal gingival at the follow-up………………………….86 Figure 13 Level of mesial papilla at the placement of the temporary restoration….89 Figure 14 Level of mesial papilla at the follow-up……………………….……… 89 LIST OF TABLES Table Selected studies reporting on immediately placed and provisionally restored single maxillary implants in the aesthetic zone………………………………………………….17 Table Implant survival rates for immediately placed and restored implants in the aesthetic zone………………………………………………………………………………… .28 Table Reported soft tissue dimensional changes following immediate implant placement and restoration in the aesthetic zone………………………………………….… 38 Table Reported hard tissue dimensional changes following immediate implant placement and restoration in the aesthetic zone…………………………………………… … .45 Table Tooth types and reason for tooth extraction…………………… .64 Table Overview of clinical data……………………… 64 Table Bone level changes (presented as percentage change)…………… 65 Table Frequency analysis of hard tissue changes (mesial measurement in millimetrs) 66 Table Frequency analysis of hard tissue changes (mesial measurement in percentage) 67 Table 10 Frequency analysis of hard tissue changes (distal measurement in millimetrs) 68 Table 11 Frequency analysis of hard tissue changes (distal measurement in percentage…………………………………………………………………………… .69 37 ATTARD, N J & ZARB, G A (2005) Immediate and early implant loading protocols: a literature review of clinical studies J Prosthet Dent, 94, 242-58 38 GLAUSER, R., ZEMBIC, A & HAMMERLE, 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