Welcome to the discussion on immediate implants. When we have to deal with a lost tooth in the front region, that normally asks us to place an implant rather than a conventional bridge, because with a conventional bridge we would have to cut preparations in the neighbouring teeth. So the most biological way of replacing a missed single tooth is going to be the implant. Now, if you want to do that then you want an illusion close to nature that you create with your treatment with implant placement and subsequently, an appropriate prosthetic reconstruction. In doing that, there is no shooting from the hip, no show business. You have to follow the rules of biology. It is a difficult procedure predominantly in the area of aesthetic priority. While it is not so difficult to do with following a few rules, you have here an example where the implant was placed into the extraction socket and then you have six months later, everything in blue shows you addition of bone structures so it heals nicely into the alveolar socket. And we're also happy about the appearance even though here we can criticize that we have somehow the implant shining through. But it basically looks at this single tooth replacement as an illusion close to nature. Unfortunately this doesn't always stay like that and that is the warning sign I may use here because let's say two years later, we have appearances like that. Obviously this is unacceptable today from an aesthetic point of view. Now, why does this happen? Is this because we do something wrong or what is the reason for that? Well, we have realized that immediate implant placing has risks and disadvantages. The implant bed preparation is difficult, the bone augmentation procedures are normally needed and primary soft tissue closure is difficult to obtain. If I want to augment the contours at the same time, I probably don't have enough soft tissue to cover. And this is problematic also in infected sites. Increased risks for facial bone resorption and consequent soft tissue recession are the big risks for immediate implant placement. We have done a systematic review to extrapolate and find out how much that change in the dimensions of the alveolar process is happening within humans. We conclude that in the hard tissues, the horizontal resorption that was much more than the vertical resorption, that is about 29 to 63% much more than what I just show for the vertical resorption at six months. The linear changes vertically are 1 to 1.3 mm but horizontally, the same resorption is about 3.8 mm, showing you how the buccal bone is melting away. The soft tissue changes only. There are linear changes there as well. I want to finish up this presentation by showing you a study on immediate implants placed into the extraction socket. Some of the implants were cylindrical and others were filling in the alveolus a little bit better having a tapered design. This is a 3-centre study that was done in Berne and in Madrid and in Panama. We have 120 patients, 60 for the test group and 60 for the control group. The test group being the tapered implant and the control group being the parallel design implant. Now, this study was supposed to last three years. Now, here you have such a reopening after four months and you see that all of a sudden the gaps that were present in the extraction sockets have disappeared, they are filled up. Overall, most of the gap was filled with bone without the need of any grafting material. And we had significantly greater gap fill with the cylindrical implants, not with the conical ones. There was a significant reduction in the buccal crest contour of about 33% and that was more pronounced in the anterior region when there were thin buccal bony crests when the patient had a history of periodontitis. The factors for instance to consider is the thickness of the bony plate, the buccal plate, the horizontal position of the implants, as I said preferably 2 mm towards the palatal. The vertical position of the implant, as I said 1 mm into the socket. Apical to the crest and finally, smoking habits. They should be a non-smoker and the patient should not have had any history of periodontitis. These are all the factors that influence the esthetic outcome. And in summary, you can see that this is quite difficult to achieve. We should choose a conservative approach, keeping all the tissues and since an extraction leaves an open space, we should have this first filled with soft tissue healing. So, we do generally only type 2 placements today and use a very standardized protocol in our treatment. Give the tissues time to heal. Not everything has to be immediate, immediate, immediate because the failure may also follow immediate. To create the perfect illusion, use a very strict protocol and observe the factors that influence this healing. Thank you very much for your attention.
