Nowadays, more and more dentists are placing dental implants using immediate placement protocols. This is because many patients do not prefer waiting for six months after implant insertion before implant loading can be performed. However, despite the advantages of immediate implant loading in the anterior region, there is still a chance for immediate implant treatment failure, especially in the anterior esthetic zone.

This article offers various tricks and tips which can help in selecting, planning and maximizing the success rate of immediately loaded dental implants in the esthetic zone.

1. Be Meticulous with the Case Selection

Remember, it all starts with the case selection. Not every patient is a suitable candidate for immediate implant loading. While selecting a patient or preparing a treatment plan, it is best to list down all the risk factors which may be associated with immediate implant loading in the esthetic zone. Then you should note down the presence and severity of each risk factor in each patient as mild, moderate or severe. In this way, you can create a scoring system which can help you in determining the success of immediate implant loading. Some of the risk factors to be considered include:

1. Smoking
2. Esthetic perceptions
3. Lip line
4. Gingival biotype
5. The shape of the natural tooth crown
6. Underlying infection at the implant site
7. The bone level at the teeth adjacent to the implant placement site
8. Restorative status of neighboring teeth
9. Edentulous span
10. Soft tissue anatomy
11. Bone type and quality

2. Selecting the Right Implant

When it comes to immediate implant loading, primary stability is of utmost importance. In some cases, implants placed under the delayed loading protocol could become Osseointegrated without achieving sufficient primary stability, when they are left undisturbed during the healing process. The same cannot be said about immediately loaded implants since there will inevitably be some movement involved in their case.

The ability to dental implants to achieve primary stability depends on various factors, such as:

• Implant Geometry – research has shown that the conical implant geometry tends to achieve better primary stability when placed in fresh tooth extraction sockets, in comparison to cylindrical implants.
• Implant Diameter – research has shown that the implant diameter should be selected according to the buccopalatal width of the bone rather than its mesiodistal dimension. Kan et al.[1] showed that selecting implant with diameters greater than 5mm can have a negative implant on the implant stability. Also, implants with a diameter less than 4.5mm should be chosen for the anterior region, when considering immediate implant loading.
• Implant positioning – the 3D positioning of the implant is very crucial in determining the success of immediate implantology. Therefore, it is necessary to ensure the optimal gap between the buccal and palatal/lingual wall when the implant is in position. The key is to prevent the implant from drifting buccally. An excellent method is to start drilling the palatal wall while avoiding the root tip.

3. Utilizing the Power of Sub-epithelial Connective Tissue Graft (SCTG)

Various studies have shown that the simultaneous utilization of the SCTG with immediate loading tends to improve the stability of the peri-implant soft tissues. Yoshino et al.[2] compared the stability of immediately loaded implants with or without SCTG. They showed that SCTG in combination with immediate loading provided higher facial soft tissue levels than without SCTG, thereby maximizing the esthetics.

4. Tips Regarding the Prosthetics

Choosing the right type and material of the prosthesis is essential in ensuring implant stability as well as esthetics.

• Using a Provisional Prosthesis – in addition to the definitive prosthesis, a provisional prosthesis has also been shown to maintain the dentogingival architecture around the implant. Some authors recommend the use of PMMA based temporary restorations prepared with the CAD-CAM system, as they have optimal biological and mechanical attributes[3].
• Emergence Profile – a concave emergence profile of the prosthesis will provide a larger volume to the surrounding soft tissues. This has a positive impact on stability as well as esthetic outcomes.

When we talk about immediate loading in the anterior region, two factors are critical; primary stability and esthetics. Immediate implant loading can be successful, provided case selection, treatment planning, and implant selection are correctly done. Without considering these factors, immediate loadings are bound to fail. If implants are placed while keeping the factors mentioned above in mind, you can expect an excellent esthetic outcome and durability of the treatment.

[1] Kan, J. Y., and K. Rungcharassaeng. “Site development for anterior single implant esthetics: the dentulous site.” Compendium of continuing education in dentistry (Jamesburg, NJ: 1995) 22.3 (2001): 221-6.

[2] Yoshino, Shuji, et al. “Effects of connective tissue grafting on the facial gingival level following single immediate implant placement and provisionalization in the esthetic zone: a 1-year randomized controlled prospective study.” International Journal of Oral & Maxillofacial Implants 29.2 (2014).

[3] Güth, Jan-Frederik, and Med Dent. “CAD/CAM-generated high-density polymer restorations for the pretreatment of complex cases: a case report.” Quintessence Int 43 (2012): 457-467.