Introduction

Single tooth replacement in the esthetic zone using immediate dental implants (IIPs) has become more or less common practice but does present considerable esthetic challenges [1]. Condemned teeth can be removed using minimally traumatic principles, implants placed, and even immediately restored with non‐loaded transitional restorations, resulting potentially in excellent esthetic, biological, and functional outcomes. However, for patients with compromised sites due to hard and soft tissue losses, achieving success with IIPs becomes far more difficult, given that most established treatment methods require invasive and multiple interventions with significant risk of complications, related in part to the need for elevating soft tissue flaps for surgical access, which will have negative consequences on local blood supply during initial healing [2, 3]. Many clinical studies support the use of delayed implant placement after preparatory autogenous bone block grafting and/or guided bone regeneration (GBR) for the reconstruction of existing bone defects [4, 5], but this requires multiple surgical procedures.

The immediate dentoalveolar restoration (IDR) procedure [6] was designed to streamline treatment in these more challenging cases, minimize the number of surgical appointments and avoid disruption of local blood supply. It can be performed in 360‐degree bone extraction socket defects regardless of the severity of the bone loss. It allows reconstruction of lost tissues during the same surgical session as implant placement, and even includes provisional crown installation. The main advantage of IDR is the simplicity of using autogenous bone harvested from the tuberosity. Bone density at the buccal, palatal, and basal maxillary aspects of the tuberosity is lower than that at other maxillary and mandibular regions [7–9], and easily removed with sharp chisels. Owing to the thinness of their outer cortex, maxillary tuberosity grafts are easily shaped and sufficiently malleable to allow adaptation at the receptor site. At the same time, their cortical structure can act as a natural biologic barrier stabilizing the overlying soft tissues and protecting particulate bone graft packed around the implant [10]. After the graft is shaped according to the defect configuration, it is stabilized in the remaining walls of the defect site in all directions (mesial, distal, and apical) by juxtaposition and bone compaction. Furthermore, the trabecular nature of the harvested graft contributes to rapid revascularization and release of growth factors at the receptor site [11]. Being replete with osteoprogenitor cells and growth factors, it offers an ideal vital graft for use in alveolar bone regeneration. Finally, IDR includes the use of a carefully created immediate provisional restoration promoting soft tissue healing, shaping, and formation of an ideal gingival prosthetic emergence profile [6, 12].

In this chapter, the rationale, indications, and step‐by‐step technique for IDR in compromised tooth sockets are discussed. The use of IDR with osseodensification implant osteotomy site development to improve immediate implant primary stability in compromised extraction sockets is also demonstrated.

Immediate Dentoalveolar Restoration Technique

A first example of IDR is shown in Figure 5.3.1. The patient was presented with a maxillary left canine that had suffered a vertical root fracture (Figure 5.3.1a–c). As per protocol, the patient was prescribed amoxicillin 1 g administered 1 hour before the procedure followed by 500 mg three times a day for 1 week. Following local anesthesia and after making an intrasulcular incision with a microsurgical blade, the tooth was decoronated and extracted with minimal trauma and without raising a mucogingival flap. The socket was carefully curetted to remove all granulation tissue and remaining periodontal attachment, following which an osteotomy was initiated with a pilot bur entering the palatal socket wall at a point within its apical third as per Gluckman et al. [13]. Having established this entry point, site development was continued using a series of Densah^® burs (Versah Corporation, Jackson, MI, USA) to densify and shape the final osteotomy (Figure 5.3.1d) [14].

Following osteotomy completion, implant insertion, and preparation of a transitional restoration, attention was directed to obtaining a corticocancellous bone graft from the left maxillary tuberosity. The transitional restoration was fabricated before obtaining the bone graft, to avoid the latter’s contamination after placement. The socket walls then were probed in the apical–coronal and mesial–distal directions to estimate the size and shape of graft needed. A small, full‐thickness mucoperiosteal flap was raised buccally to expose the underlying tuberosity and a suitably shaped graft outlined and released using bone chisels and a surgical mallet (Figure 5.3.1e). The autograft was manipulated using a rongeur instrument to fit the configuration of the defect. The graft comprised both the outer cortex and underlying cancellous bone (Figure 5.3.1f), but particulate bone also was collected for later packing into any gaps between the block graft and implant (Figure 5.3.1g). It is important to transplant the graft as quickly as possible; therefore, after minor trimming with rongeurs, it should be inserted at the recipient site 1 mm above the level of the implant platform with the cortical side facing the soft tissues and stabilized by compacting the particulate bone fragments between the medullar portion of the block graft and the surface of the implant. The prepared transitional crown can then be connected to the implant (Figure 5.3.1h).

After 3 months of uneventful healing, removal of the transitional crown revealed the soft tissues had maintained their original contour (Figure 5.3.1i), and the treatment was completed with delivery of the definitive restoration (Figure 5.3.1j). A CBCT image taken 6 months after final crown delivery demonstrates thick labial marginal crestal bone (Figure 5.3.1k).

Correct 3D implant positioning in the IDR technique, as in any other implant placement technique, is considered one of the primary prerequisites for success, but choosing the ideal implant diameter also is crucial [12, 15]. Regardless of the tooth being replaced, a gap of approximately 3 mm between the implant and the future socket buccal wall is needed to allow the harvested autogenous cancellous bone graft to be easily inserted.

Another major challenge in applying the IDR technique is achieving adequate implant primary stability sufficient to allow bone reconstruction and immediate provisionalization in a single procedure. Any micro movements of the implant could compromise rapid revascularization of the graft. Using “osseodensification” burs for implant site preparation in sockets being treated with IDR is beneficial here. Osseodensification is a non‐extractive bone preparation method that creates controlled plastic bone deformation rather than actual bone removal [14]. It uses specially designed burs run at speeds of 800–1200 rpm in counterclockwise action. Copious saline irrigation and continuous bur luxation during the procedure provide lubrication between the bur and bone surfaces, minimizing the risk of overheating. The procedure has been biomechanically and histologically validated to immediately increase bone mineral density [16] around the implant periphery via compact autografting of trabecular bone [17], and results in a subsequent springback effect towards the center of the osteotomy increasing implant primary stability [14, 18]. Histologically, the compacted autografted bone particles lead to increased bone volume and bone‐implant contact [19] by acting as nucleating centers of ossification essentially promoting faster new bone formation around the implant [17, 20].

Case Selection

IDR was development for use of IIP in type II sockets, especially subclass B (absence of the middle to coronal two‐thirds of the labial bone plate) and C (absence of the apical one‐third of the labial bone plate) and for type III sockets (loss of buccal bone and soft tissue recession defect) classified by Chu et al. [21]. The first IDR case dates back to 2009 [22] and subsequent work confirmed its applicability in these situations [6, 10, 15, 23]. Figure 5.3.2 depicts a second case of a patient with a compromised tooth due to root fracture.

A third case presented with a failed lateral incisor in the right maxilla (Figure 5.3.3a). The tooth had been previously treated endodontically, but complications led to infection with formation of a large periapical defect and loss of the majority of the buccal plate (Figure 5.3.3b,c). Osteotomy preparation was done using osseodensification burs (Figure 5.3.3d) [23], the implant inserted, and the buccal gap grafted with a tuberosity block (Figure 5.3.3e) and particulate tuberosity bone fragments (Figure 5.3.3f). A temporary crown was connected to the implant (Figure 5.3.3g). After 3 months of site healing, esthetically pleasing soft tissue contours (Figure 5.3.3h) and site anatomy (Figure 5.3.3i) were observed and, once restored, the situation remained stable as seen after 4 years of function (Figure 5.3.3j,k). The corresponding CBCT confirmed complete healing of the apical lesion and reformation of the buccal bone plate (Figure 5.3.3l).

While IDR can become routine at single type II sockets, treating larger cases is possible with experience, as shown in Figure 5.3.4. The patient presented with generalized periodontal disease (Figures 5.3.4a,b). Widespread gingival recession also was seen (Figure 5.3.4c). After flapless, minimally invasive extractions of the seven condemned teeth, osteotomy sites were created in their sockets. Two more osteotomies were created in the healed sites of the right first and left second bicuspid teeth, again without raising a flap (Figure 5.3.4d). Both tuberosities were used to collect as much autogenous bone as possible (Figure 5.3.4e) for use at all seven IIP sites (Figure 5.3.4f). Sutures were used only for the two donor sites. Prepared screw‐retained fixed transitional bridges were immediately inserted (Figure 5.3.4g) and the sites left to heal undisturbed for 3 months (Figure 5.3.4h). Thereafter, all implants were restored with individual implant crowns, which are depicted after 4 years in function in Figure 5.3.4i,j. CBCT images obtained after 5 years in function are shown in Figure 5.3.4k and confirm stable bone levels.

Type III sockets represent an even greater clinical challenge than type II due to the added difficulty of existing soft tissue recessions overlying partially or totally compromised buccal bone walls. For this, we proposed the use of a three‐layered autograft harvested from the maxillary tuberosity (“triple graft”) compromising connective tissue, cortical and cancellous bone [24]. After making an intracrevicular incision around it, the condemned tooth is extracted as gently as possible and without raising a flap. The socket is carefully curetted to remove all granulation tissue and remaining periodontal connective tissue. The socket walls then should be probed apicocoronally and mesiodistally to assess the degree of bone loss. An implant of appropriate diameter is chosen that will leave a buccal gap of at least 3 mm under the overlying soft tissue to receive the autogenous triple layer graft. Osteotomy preparation is then undertaken in the palatal socket wall to develop the ideal 3D position with the aid of a custom bur guide, and the implant inserted to a depth approximately 3 mm apical to the cementoenamel junction of the contralateral teeth. The triple graft then is prepared with more or less the same incisions as the double graft (cortical and cancellous block) except that a partial thickness rather than a full thickness buccal flap is used so as to leave a 1–2 mm thick, soft tissue (gingival connective tissue plus underlying periosteum) layer to be removed still attached to the corticocancellous bone block which then is immediately transplanted to the IIP socket.

Conclusions

This chapter demonstrates effective implant rehabilitation in fresh extraction sockets of compromised teeth with significant alveolar bone defects. Combining the IDR technique with osseodensification implant site preparation will enhance primary stability of implants, a crucial factor for immediate provisionalization.

When appropriately indicated and performed, both techniques can synergistically contribute, enabling implant site preparation and socket bone reconstruction as a minimally invasive approach. This, in turn, promotes improved bone formation and osseointegration.