Immediate Implant Placement and Immediate Loading in the Aesthetic Zone: A Flapless Approach

Replacing missing or failing teeth with implants can be a clinical challenge, especially in the aesthetic area, because patients expect an esthetically ideal prosthesis besides the osseointegration of implants. In this regard, immediate placement of implants with immediate loading is preferred by the patients, for the fewer surgeries involved and the immediate restoration of the potential edentulous sites. This article aims to present a case report of immediate placement of implant and immediate loading of the maxillary right lateral incisor.


INTRODUCTION
Although multi-step traditional implant placement protocols provide long-term stability, especially in imperiled situations with reference to general health, bone support or local inflammation, they require long healing time, provisional phase with an oftentimes inadequate implant prosthesis, and multiple surgeries.Moreover, with the thorough understanding of dimensional ridge alterations following extraction, implant placement into healed sites has completely lost its dominance, particularly in the case of single tooth replacement. 1     preventing the marginal bone loss. 4Vergara and Caffesse suggested that immediate implant placement with a flapless approach in the maxillary anterior teeth maintained the soft tissue architecture and minimized the alveolar bone alterations. 5acing bone grafts into the void between the implant surface and socket walls, after immediate implant placement, has shown to preserve, at least in part, the to the sites that were not grafted. 10mediate loading is determined by the primary stability assessed via the insertion torque values.
Insertion toque > 25 Ncm is proposed if accelerated loading protocols are utilized. 6Tortamano et al. has reported stability of the peri-implant soft tissue over 18-month period with immediate implant and provisional restoration in the aesthetic zone. 7

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In contrary, Considerably reduced treatment time, fewer surgeries, and immediate aesthetic rehabilitation, the key advantages of immediate implant protocols, have rendered immediate implant placement and immediate loading an attractive protocol from a patient perspective. 2,3CASE REPORT A 43-year-old female patient presented to the Dr. Savvy Pokhrel, 1 Dr. Bhageshwar Dhami, 1 Dr. Shristi Poudel 1 Department of Periodontology and Oral Implantology, Kantipur Dental College and Hospital, Basundhara, Kathmandu, Nepal.Department of Periodontology and Oral Implantology with the chief complaint of spacing in the upper front region of the jaw which had progressed over time, along with loosening of the tooth adjacent to the space.No significant medical, dental or habit history was reported.Clinical examination revealed extrusion and Grade II mobility of the maxillary right lateral incisor, along with spacing mesial to it.(Figure 1) Radiographic examination revealed bone loss with respect to 12 and 11, and periapical radiolucency in 12. Cone Beam Computed Tomography (CBCT) was further performed on the patient, which additionally gave out extensive bone loss and periapical radiolucency with respect to 12, in sagittal plane view.(Figure 2) The CBCT analysis showed more than 50% bone loss on both the facial and lingual aspects of 12 as well as significant widening of the periodontal ligament space.Following thorough clinical and radiographic evaluation, as well as in view of aesthetic interest of the patient, extraction of 12 was planned followed by replacement with an implant supported prosthesis.Distance from the socket to nasal floor, faciopalatal bone width, buccal bone thickness, palatal bone thickness, and mesiodistal bone width were 11.1 mm, assessed on the CBCT scan favoured the immediate implant placement protocol.A 3.5×11.5mm implant was planned using the implant planning software (BlueSky plan).(Figure 3C) After evaluation of coagulation profile, blood glucose level and blood pressure of the patient, written consent was taken.The surgical procedure was performed in aseptic conditions under local anaesthesia (Infiltration with 2% Lidocaine with 1:200000 Epinephrine).Tooth was gently extracted without raising a flap, therefore causing minimal trauma to soft tissues.(Figure 4A) Degranulation of the socket was done with copious saline irrigation.(Figure 4B) Following sequential drilling, a 3.5×11.5mm i-Fix ® implant was placed into the osteotomy Pokharel et al: Immediate Implant Placement and Immediate Loading in the Aesthetic Zone: A flapless Approach

Figure 1 :
Figure 1: Pre-operative clinical photographs showing A) Right lateral view, B) Palatal view.

Figure 6 :
Figure 6: A) Fourteen months follow-up.B) Radiograph at 14 months.alveolar ridge dimensions.The advantages of such grafting are more evident in the anterior maxilla, where the majority of patients have a thin buccal bone plate i.e. ≤ 1 mm. 8,9Moreover, a computed tomographic study by Nevins et al. has reported loss of less than 20% of buccal plate in sockets treated with deproteinized bone graft (Bio-Oss) as compared