Introduction

There have been many changes in our therapeutic attitude since the Swedish school published its works concerning osseointegrated implants in 1985 [1]. Some of us, as practitioners, understood the revolution that was brought about by this new implant concept; others preferred to “wait and see” … [2].

I personally was happy to be “at the right time, at the right place, in France”, taking part in the birth of the first Department of Implantology in Paris-France (University Paris VII – 1986), standing behind and supporting our department head, Pr. Patrick MISSIKA. We were proud and very enthusiastic about how we were able to improve our patients’ smiles and chewing function by following Branemark’s procedures… while at the same time, trying to stretch and expand the strict boundaries recommended by the Swedish professor.

 

Part I: Immediate Implant Placement in the Esthetic Zone

As a result, starting in 1987, we began adopting protocols of immediate implant placement following tooth extraction [3-6] – that was sanctioned by some authors [7,8], but not allowed by Branemark and Co.; the reason being that the practitioner should only work “on healed and healthy bone site receivers”. At that time, we were castigated by the orthodox Branemark followers in both France and abroad. But as time went by, the validity of our method was finally recognized [9] because of the satisfactory results [10-12].

During this same time period, other pioneering clinicians tried and sanctioned other protocols:

– One stage surgery [13-16];

– Immediate esthetic provisional crowns on single implants [17,18];

– Immediate fixed full-arch provisional prosthesis just after implant placements [19,20].

These clinical protocols were, and still are, backed by research studies and clinical publications, along with implant shape evolution which enhance primary stability, osseous integration and stress-impact diminution while implants become functional [21-24].

As is evident from this technical feature, one point appears clear: nowadays, most of the implant systems use either conical or cylinder-conical shapes because it is undeniable that they improve implant stability [25,26] which in turn leads to rapid osseointegration [27].

Furthermore, spiral implants have been shown to not only contribute to greater stability in poor quality bone sites, but also to improve implant placement even under precarious circumstances such as when doing immediate implant placement after tooth extraction [28-31].

The AlphaBio-Tec Implant System (SPI/ICE/NICE and recently available NEO) and NOBELBIOCARE Implant System (NOBELACTIVE) are recognized to be the leaders in that area. The purpose of this article, on the one hand, is to highlight the latest clinical as well as technological developments while also taking into consideration the demands of patients and treatment plans of the practitioner.

Immediate implant placement in the esthetic zone

Until today, when confronted with the challenge of replacing an anterior compromised natural tooth, we usually choose from several specific implant designs and protocols [3,18,32-36]. It has become a quasi-routine, 1-hour procedure, often ending in placing an esthetic, temporary implant-supported crown onto the site. Then, after a period of 3 to 4 months, and after successful tissue integration, a permanent ceramic crown replaces the temporary one [36]. But the way of dealing with the clinical procedure can change with regard to:

– Clinical and Radiological (3D) tissue-site evaluation before tooth extraction;

– Anatomic parameters (proximal teeth and nasal or sinus fosses);

– Experience and self-confidence of the practitioner and his/her team;

– Available implant systems;

– Patient motivation and those implications in the treatment.

In cases where the anatomic context is not in optimal condition, but the patient’s demands are still high, the clinician must take full advantage of high tech equipment which allows him/ her to follow a specific treatment plan that was developed and sanctioned after using a precise 3D X-ray analysis as well. Full cooperation from both the patient and the implant team are essential [35,36].

Figures of cases 1 and 2 illustrate these kinds of challenges.

Case 1: December, 2009: young lady, 27 years old, presenting 2 mobile milk canines surmounted by 2 horizontally impacted permanent canines. She is in demand of a quick-efficient solution

(Figures 1a-1x).

Figure 1a
Initial clinical and radiological situation.
Figure 1b
Initial clinical and radiological situation.
Figure 1c
Initial clinical and radiological situation.
Figure 1d
Initial clinical and radiological situation.
Figure 1e
Teeth-extraction surgery.
Figure 1f
 Teeth-extraction surgery.
Figure 1g
Teeth-extraction surgery.
Figure 1h
Implant placements (Nobel Active), despite precarious bone condition.
Figure 1i
Implant placements (Nobel Active), despite precarious bone condition.
Figure 1j
Implant placements (Nobel Active), despite precarious bone condition.
Figure 1k
Bone-defects filling (Bio-Oss Geistlich) and gingival flap closure.
Figure 1l
Bone-defects filling (Bio-Oss Geistlich) and gingival flap closure.
Figure 1m
Bone-defects filling (Bio-Oss Geistlich) and gingival flap closure.
Figure 1n
Immediate placement of 2 temporary crowns on Zirconium abutments.
Figure 1o
Immediate placement of 2 temporary crowns on zirconium abutments.
Figure 1p
Immediate placement of 2 temporary crowns on zirconium abutments.
Figure 1q
Immediate placement of 2 temporary crowns on zirconium abutments.
Figure 1r
Immediate placement of 2 temporary crowns on zirconium abutments.
Figure 1s
Immediate placement of 2 temporary crowns on zirconium abutments.
Figure 1t
Clinical appearance on day-8 postoperative.
Figure 1u
Clinical appearance on day-8 postoperative..
Figure 1v
Clinical appearance on day-8 postoperative.
Figure 1w
Final prosthetic crowns after a period of 4 months-healing (Dr. DELESTI/Lab. CERALOR).
Figure 1x
Final prosthetic crowns after a period of 4 months-healing (Dr. DELESTI/Lab. CERALOR).

Case 2: February, 2014: young woman, 38 years old, presenting an internal resorption on her upper right canine. Her general practitioner cannot treat and save it. The demand consists I an immediate tooth replacement with respect of esthetic clinical appearance (Figures 2a-2g).

Figure 2a
Initial clinical and radiological presentation.
Figure 2b
3D R-Ray analysis and treatment plan: after tooth extraction, we’ll try to insert the implant according to a double lead angle axis in order to get an initial primary fixation of the implant, while also taking care not to touch the sinus cavity and the proximal vital roots as well.
Figure 2c
Tooth extraction and immediate implant (AlphaBio Tec SPI) placement.
Figure 2d
The whole surgical-temporary-prosthetic protocol is achieved so that we can place a screwed-in (palatal access) temporary crown immediately after surgery.
Figure 2f
Clinical and radiological result at 8 days postoperative.
Figure 2e
The whole surgical-temporary-prosthetic protocol is achieved so that we can place a screwed-in (palatal access) temporary crown immediately after surgery.
Figure 2g
Last clinical check, final crown in place (Dr. CHAPELLE) and X-Ray control at 4 months postoperative.

Part II: Immediate Implant Placements for Full-Arch Fixed Reconstructions

As practitioners, we frequently must choose between “treat and conserve” or “pull out and replace” [37]. It is frequently

technically possible to rebuild ad integrum full dental arches in patients who require this (Case 3). The negative side is that these types of treatments are often long and need a lasting cooperation

between the patient and the mouth-care team. I visited Paulo Malo in Portugal a year after he published his work in 2005 [38]. Dr. Malo suggests treating edentulous patients in a simplified

manner, even in the case of atrophic maxillae showing prominent sinus cavities. After returning to France, I began using his method and it has basically changed part of my implant practice.

But the most important change to my treatment practices came about in 2010 when a patient (an architect, 49 years old, sent by his general practitioner) came for another implant treatment

after I had already placed 2 implants in his lower left jaw in 2006. His original demand was new but very clear: “I’ve got lots of problems in my mouth already, including teeth which have been treated with or without crowns and I’m fed-up with wasting so much time and money at the dentist’s office. As an architect, I can understand that it is easier to construct a new building on clean, virgin land than it is to conserve some of the original parts of the old building while building a new one. Is this approach acceptable to you as a dentist?”

Indeed, as a practitioner, I could understand his point of view, although I tried to convince him to conserve and treat his natural teeth to the extent that it was possible. But he insisted on a

“Robocop Treatment”. Besides the questionability of extracting curable and/or healthy natural teeth in order to put in an implant supported restoration, we must say that:

– This personalized approach is easy to understand [39,40];

– Experience confirms that this approach is technically and clinically feasible to do all at one time;

– Such a radical approach could actually lead to fewer postoperative complications and to a better final prognosis than a more traditional, conservative treatments [41].

We finally accepted the terms of the treatment… (Case 4) Today we feel secure in such implant treatments for the following reasons:

– Patient satisfaction can be higher with this method than with more difficult, time-consuming, traditional treatments (Case 5);

– Patients feel better immediately;

– Patients with this type of treatment take better care of their new teeth (Case 6);

– The long term prognosis may be better.

Case 3

August, 2006: man, 49 years old motivated by changing his esthetic aspects (Figures 3a-3e).

Figure 3a
Initial clinical esthetic appearance.
Figure 3b
Radiological investigation shows lack of occlusal stabilization on both posterior areas, forcing the patient to chew on the (mobile) front teeth.
Figure 3c
Final esthetic and stable result after conservative andreplacing treatments (final prosthesis by Dr. DELESTI /Lab. CERALOR).
Fig 3d
Final X-Ray control showing results of conservative (endo-perio-prosthétic) treatments on front teeth (excepted for left lateral incisor) and replacing treatments (bone grafts and implants) on the posterior areas.
Fig 3e
Here, we assumed [42,43] a rigid implant-teeth connection (zirconium-ceramic crowns) allowing a good esthetic and biomechanical result with a good long-term prognosis as well.

Case 4
October, 2010: man, 51 years old demanding a “ROBOCOP” treatment (Figures 4a-4c).

 

Fig 4a
Initial clinical and radiological situation.
Fig 4b
Final result, 4 months after the unique surgical phase (teeth extraction+immediate implant placements+immediate temporary fixed full-arch denture)..
Fig 4c
Final result, 4 months after the unique surgical phase (teeth extraction+immediate implant placements+immediate temporary fixed full-arch denture); Implants = NobelActive / Final prosthesis achieved by Dr Sophie FONTENEAU

Case 5
February, 2014: woman, 51 years old with apertognathia, demanding an efficient-esthetic treatment. The whole treatment

Fig 5a
Initial clinical presentation / occlusion.
Fig 5b
Initial clinical presentation / occlusion.
Fig 5c
Initial clinical presentation / occlusion.

Fig 5d
Initial clinical presentation / occlusion.
Fig 5e
Final “star-smile”/occlusion.
Fig 5f
Final “star-smile”/occlusion.
Fig 5g
Final “star-smile”/occlusion.
Fig 5h
Final “star-smile”/occlusion.
Fig 5i
Final X-Ray (February, 2015) control showing the 8 implant (AlphaBio Tec)-supported denture on the maxilla and the 6 implant (AlphaBio Tec SPI)-supported denture on the mandible (Lab. = Erick LOYAU).

Case 6
June, 2015: young man (pastry cook), 31 years old demanding a “ROBOCOP” treatment… But nothing else (he is a friend of the man/ case 4). He clearly shows no motivation for a conservative treatment. The patient is also taught to special hygiene practice and occlusion protection night-wearing as well (Figures 6a-6j).

Fig 6a
Initial clinical and radiological.
Fig 6b
Initial clinical and radiological.
Fig 6c
Initial clinical and radiological.
Fig 6d
Initial clinical and radiological.
Fig 6f
Double ALL on 6-ALL ZIRCONE/CERAM-treatment, following the same protocol as case n° 3. Please note the clinical transformation and the nice final X-Ray control (04-05-2016); Implants: AlphaBio Tec ICE in the mandible, while AlphaBio-Tec SPI in the maxilla/Lab.= Erick LOYAU.
Fig 6g
Double ALL on 6-ALL ZIRCONE/CERAM-treatment, following the same protocol as case n° 3. Please note the clinical transformation and the nice final X-Ray control (04-05-2016); Implants: AlphaBio Tec ICE in the mandible, while AlphaBio-Tec SPI in the maxilla/Lab.= Erick LOYAU.
Fig 6h
Double ALL on 6-ALL ZIRCONE/CERAM-treatment, following the same protocol as case n° 3. Please note the clinical transformation and the nice final X-Ray control (04-05-2016); Implants: AlphaBio Tec ICE in the mandible, while AlphaBio-Tec SPI in the maxilla/Lab.= Erick LOYAU.
Fig 6i
Double ALL on 6-ALL ZIRCONE/CERAM-treatment, following the same protocol as case n° 3. Please note the clinical transformation and the nice final X-Ray control (04-05-2016); Implants: AlphaBio Tec ICE in the mandible, while AlphaBio-Tec SPI in the maxilla/Lab.= Erick LOYAU.
Fig 6j
Double ALL on 6-ALL ZIRCONE/CERAM-treatment, following the same protocol as case n° 3. Please note the clinical transformation and the nice final X-Ray control (04-05-2016); Implants: AlphaBio Tec ICE in the mandible, while AlphaBio-Tec SPI in the maxilla/Lab.= Erick LOYAU.

Conclusion

Through continuing education, the practitioner can stay abreast of the latest developments including the most modern equipment and technologies, both of which lead to more efficient treatment and better patient satisfaction. Much can also be learned from listening to our patients as reported in various clinical experiences in this paper.

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