The comparative assessment of the of the effectiveness of immediate and delayed dental implantation

Objective: The purpose of this study was to evaluate the outcome of immediate and delayed implant placment protocols. Materials and methods: The 52 patients with missing thoot (from 2014 to 2019) were selected for the study, total 64 implants were placed. All patients presented functional and esthetic complaints and underwent a thorough clinical examination according to a generally accepted scheme. Computed tomography were obtained to determine the osseos structure. To conduct a comparative analysis of the treatments results, two groups were formed: -Basic group of 28 patients -were placed 36 immediate implants. -Control group of 24 patients-3-5 months after extraction of tooth were placed 28 delayed implants. Postoperative outcomes; infection, radio-density, resorption and failure of implants were checked clinically and radiographically using serial orthopantomograms or CT scan. The implants stability were evaluated with measures of resonance frequency analysis (RFA) during the follow-up periods using Osstell Mentor at time of implant placement, after 3-6 months. The functional load on dental implants was performed with ISQ values above 65. Dental prosthetic rehabilitation was performed after 3-6 months of submerged healing in 35 patients. Early dental prosthetic loaded in 17 patients (9 patients in basic group and 8 control group). Results: No serious intraoperative or immediate postoperative complications were noted. After a 24-month follow-up period, the basic group resulted in a mean bone loss of 1.04 and the control group of 1.02mm, there were no statistically signifi cant differences. Clinical comparing delayed and immediate implant placement there were no statistically signifi cant differences effect on soft tissue recession outcomes. Clinical outcome of implants immediately placed into extraction sockets of teeth affected by chronic lesions was examined. 11 Patients with periapical infection and Research Article The comparative assessment of the of the effectiveness of immediate and delayed dental implantation Gagik Hakobyan1*, Lazar Esayan2, Davit Hakobyan3, Gagik Khachatryan4 and Gegham Tunyan5 1Professor, Head of Department of Oral and Maxillofacial Surgery Yerevan State Medical University after M. Heratsi, Armenia 2Professor, Head of Department of Therapeutik Stomatology Yerevan State Medical University after M. Heratsi, Head of the Department of Maxillofacial Surgery of Medical Center MIM, Armenia 3Assistant professor, Department of Oral and Maxillofacial Surgery, Yerevan State Medical University after M. Heratsi, Armenia 4Head of Department postgraduate students Dentistry 5Dental Resident at Yerevan State Medical University after M. Heratsi, Armenia Received: 19 June, 2020 Accepted: 09 November, 2020 Published: 18 November, 2020 *Corresponding author: Gagik Hakobyan, Professor, DMSc,PhD, Mailing addres: 0028 Kievyan str. 10 ap. 65 Yerevan, Armenia, Tel: (+37410)271146; E-mail:


Introduction
The loss of tooth can occur for various reasons, which include trauma, diseases of the dentition (caries or or periodontal disease). It may also occur secondarily or simultaneously with various systemic diseases such as cancer, diabetes mellitus, osteoporosis etc [1][2][3].
Due to tooth loss, not only functional impairment occurs in the maxillofacial region, changes in the esthetics of the patient's appearance, but also violates the psychological status of a patients and discomfort occurs during communication [4].
Dental implants are now commonly used for replacing missing teeth in various clinical situations. Conventional procedure for implant placement involves extraction of offending tooth, waiting 3-4 months for extraction socket to heal, insertion of implant, and again waiting for 3-6 months for integration of implant with surrounding bone; after this procedure, another surgery is necessary to expose the implant and to place a prosthetic abutmentand crown [5].The patient had to wait up to 6-8 months for a lost tooth to be replaced.
To substantially shorten the entire treatment were developed by placement of implant immediately after extraction of tooth. In the modern era, immediate placement of a dental implant concept is gaining popularity, especially for anterior teeth. Immediate placement of a dental implant in an extraction socket was initially described more than 30 years ago by Schulte and Heimke in 1976 [6].
Immediate implant placement is most commonly indicated when tooth extraction is due to trauma, endodontic lesion, root fracture, root resorption, root perforation, unfavourable crown to root ratio (not due to periodontal loss) and bony walls of alveolus are still intact. Contraindications includes presence of active infection, insuffi cient bone (<3 mm) beyond the tooth socket apex for initial implant stability and wide and/or long gingival recession [7].
Reductions in the number of surgical interventions, a shorter treatment time, the presumptive preservation of alveolar bone of the tooth extraction and soft tissue aesthetics have been claimed as the potential advantages of this treatment approach [8]. Also use of bone graft of materials has been shown to result in predictable regenerate, high levels of osseointegration. Several reviews reported that the immediate implant treatment using autogenous bone grafts or xenografts may improve the process of bone formation between the implant and the surrounding socket walls as well as survival rates [9]. Different placement and loading protocols have evolved from the fi rst protocols in order to achieve quicker and easier surgical treatment times. Now immediately placed and immediate loading implants are more predictable and successful than before [10]. However, this approach cannot be applied to every immediate implant patient. In comparison to conventional implant treatment, the ideal state for immediately loaded implants would include adequate bone quality (D2 bone), and minimum implant length of 10 mm, adequate primary stability and avoidance of lateral forces [11].
Primary stability of immediately placed implant seems to be the most important factor in immediate loading. Quirynen, et al. concluded that the incidence of implant failure is signifi cantly higher when combining immediate implant insertion with immediate loading [12]. Ferrara, et al. conducted a study combining immediate placement and early loading of 33 implants and they found satisfactory esthetic and functional results [13].
Despite the many publications on this topic, the choice of an optimal treatment plan in especially after tooth extraction in the esthetics zone of the jaw is an urgent problem of modern implant dentistry.
The purpose of this study was to evaluate the outcome of immediate and delayed implant placment protocols.

Materials and methods
The 52 patients with missing thoot were selected for the study. The ages of the patients ranged between 26 and 43 years (24 males and 28females). Duration of study from 2016 to 2020 at the university clinic in the Department of oral and maxillo facial surgery YSMU All patients had a partially or totally edentulous and presented functional and esthetic complaints. The study was reviewed and approved by the Ethics Committee of the of the Yerevan State Medical University after M. Heratsi (protocol N16, 5.10.17) and in accordance with those of the World Medical Association and the Helsinki Declaration. Informed consent patients were informed verbally and in writing about the study and gave written informed consent.
Patients underwent a thorough clinical examination according to a generally accepted scheme. Preoperative planning includes a careful history and physical exam, in addition to preoperative radiologic investigation, which could include orthopantomogram and/or a computed tomography scan to evaluate for and rule out any contraindication to implant procedure. Computed tomography were obtained to determine 17 patients without it for immediate placement were chosen. No signifi cant differences were found with periapical infection and without in the basic group patients, no signs of infection around the implants were detected at any control visit.
The survival rate of early-loaded implants placed in extraction sockets demonstrated no implants failures. There are no signifi cant differences in implant stability between immediate and delayed implants. Immediately placed implants were included with an initial primary stability over 65 ISQ and 71.1 ISQ delayed implants. The differences in these results were not statistically signifi cant.
Success rate of immediately placed implants 5 years after was 97,8% and delayed implants 98,1%. The survival rate of early-loaded implants placed in extraction sockets 96,2%.

Conclusion:
There are no signifi cant differences in immediate and delayed implants. After dental implant prosthetic rehabilitation, the masticatory function, esthetics of the facial profi le and occlusion was improved. https://www.peertechz.com/journals/international-journal-of-oral-and-craniofacial-science Citation: Hakobyan G, Esayan L, Hakobyan D, Khachatryan G, Tunyan G (2020) The comparative assessment of the of the effectiveness of immediate and delayed dental implantation. Int J Oral Craniofac Sci 6(2): 030-037. DOI: https://dx.doi.org/10.17352/2455-4634.000048 the osseos structure. Data obtained from CT scan procedure can view the virtual 3D model from different angles using the software to customize the treatment plan. Clinical studies took into account: localization of the defect, the presence of the infl ammatory process and the volume of bone tissue in the area of surgical intervention, a combination of direct implantation with other surgical interventions. All patients signed an informed consent for surgery and participation in scientifi c studies.
To conduct a comparative analysis of the results, two groups were formed: -Basic group of 28 patients -were placed 36 immediate implants.
-Control group of 24 patients 3-5 months after extraction of tooth were placed 28 delayed implants.
Total 64 implants Ankylos (Dentsply Implants, Germany) dental implants were installed the diameter of the implants used was 3.75 or 4.2 mm in a variety of lengths (10 to 13 mm), depending on the bony morphology.
The helical conical shape of the Ankilos dental implant weth modifi ed surface is shows is optimal in terms of providing primary stability, and the implant to perform the function of osteocondensers and optimally fi xed in bone tissue.
Based on the clinical picture and radiological data, we have established the following indications for immediate implantation: 1. Tooth injury -dislocation and inappropriateness of its reduction.
2. Fracture in the middle or upper third of the tooth root, especially with an offset.
3. Tooth decay with poorly sealed canals, with remnants of pins or endodontic instruments, the restoration of which is impossible.
Immediate implantation was performed after the completion of bone growth, that is, at the age of over 18-20 years.
Immediate implantation was performed in different clinical situations; upper or lower jaw, anterior or posterior sites, implants with or without guided bone regeneration, and with or without periapical pathology. 16 patients basic group did not require any type of regenerative procedure (no defect), 12 were fi lled with biomaterials (4 is this patients were fi lled with biomaterials and also had a resorbable membrane).
The implantation was carried out with local injection anesthesia, the addition of a vasoconstrictor and its percentage were determined according to indications. The removal of teeth was carried out according to the rules adopted in surgical dentistry, and was carried out by, providing for minimal trauma to the alveoli and its surrounding bones. The excess and infl ammatory changed mucous membrane that has grown into the cavity of the root of the tooth was removed, if there were granulations on the inner surface of the gingival margin, they were scraped. Degranulation of the socket was immediately performed after dental extraction. The bone socket well was washed with a chlorhexidine solution. The choice of implant should be based on the following criteria: exceed the size of the hole of the extracted tooth by 2-4 mm in length and 1-2 mm in width. Choosing an implant from those that were selected before the operation, we checked the size of the depth of the hole and determined the possible bone size for the implant to be inserted into the bone using X-ray data. Bone drilling for implant placement was performed with a guide and forming drill with external cooling of 0.9% sodium chloride solution.
With insuffi cient bone size, more often from the vestibular side, in the area of the central teeth, the formation of the socket was carried out the palatine side on the upper jaw and lingual on the lower jaw. The delivered implant must be tightly fi xed in the bone, if there were voids in the alveolus, they were fi lled with osteoplastic materials, autologous bone particls. When using osteoplastic materials in the implants cervical region, the wound was reliably isolated. With a thin cortical plate near the bottom of the nose, drilling in the bones to deepen the implant was carried out distally from the upper point of the cortical plate, but maintaining the size of the bone between the tip of the implant at least 1-3 mm.
After checking the length and suffi ciency of the soft tissues to close the wound, the absence of tension, we proceeded to the suturing of the soft tissues. At high tension, a laxative incision was made 1 cm long at the transitional fold. The mucoperiosteal fl ap was placed in place, sutured with polyamide thread or thin silk. After the operation, cold was applied for 15 to 20 minutes.
The implants stability were evaluated with measures of resonance frequency analysis (RFA) during the follow-up periods using Osstell Mentor at time of implant placement, after 3-6 months.
Dressings were carried out 2-3 times within 10 days, then examined the patient on the 21st day. Cases in which the area to be rehabilitated in the dental arch had adequate bone height and width and a favorable gingival phenotype, implant immediately loaded in fresh sockets after tooth extraction. Before installing the fi nal crowns, temporary crowns were used to ensure adequate gingival contour.
When a periapical infection was present the implant was not placed immediately, instead a delayed placement protocol was performed. When infection was present, granulation tissue was removed previously and antibiotics were given (Amoxicillin 750mg 1h before the treatment and 750mg every 8hours, 5 days post-operation).
Postoperative outcomes; implant stability, immediate implant survival and success rates, infection, radiodensity, marginal bone loss, failure of implants were checked clinically and radiographically using serial orthopantomograms or CT scan.
After excision of the soft tissues, the cover screw was was fi xed, which remained fi xed for 2weeks. The functional load on dental implants was performed with ISQ values above 65. Before installing the fi nal crowns, temporary crowns were used to ensure adequate gingival contour. Dental prosthetic rehabilitation was performed after 3-6 months of submerged healing in 33 patients. Early dental prosthetic loaded in 19 patients (11patients in basic group and 8 control group).
12 patients of basic group implants insertion and dental prosthetic rehabilitation was undertaken immediate after implantation.
16 patients of basic group dental prosthetic rehabilitation was undertaken after 3-6 months implantation.

Statistical analysis
Statistics were used to calculate and analyze the mean marginal bone loss of implants. The differences between follow-up periods were tested by paired Student's t test. All analyses were carried out using SPSS (SPSS Software Company, Chicago, IL, USA). p values < 0.05 were considered statistically signifi cant.

Results
No serious intraoperative or immediate postoperative complications were noted. At the control examination after 6 months after surgery, an x-ray examination we did not observe any clinical or radiological signs of infl ammation in the area of osteotomy sites and implants.   Clinical outcome of implants immediately placed into extraction sockets of teeth affected by chronic lesions was examined. 9 Patients with periapical infection and 17 patients without it for immediate placement were chosen. No signifi cant differences were found with periapical infection and without in the basic group patients, no signs of infection around the implants were detected at any control visit.
Success rate of immediately placed implants 5 years after was 97,8% and delayed implants 98,1%.The survival rate of early-loaded implants placed in extraction sockets 96,2%.

Case report 1
A 34-year-old famle patient was reported to the Department of Oral Surgery, with complaints of pain and light mobility of 12 tooth for 3 months. Clinical examination revealed in tooth 12 bleeding on probing, gingival recession, and grade I mobility. Radiographic examination of tooth 12 revealed poor prognosis. (Figure 1A,B).
The patient was aware of the poor condition of tooth. She was very concerned about her esthetics and was willing for procedure of immediate implant with immediate loading. Treatment plan included extraction of tooth 12, and immediate placement of implant with immediate loading by temporary crown. and dental implant were selected for insertion. Patient was premedicated with 2 g amoxicillin, 1 h before surgery. Following injection of 4% articaine local anesthetic solution, the tooth were atraumatically removed ( Figure 1C). Extraction socket were thoroughly debrided and inspected with the help of periodontal probe for any defect or possible perforation of cortical plate. Osteotomy sites were prepared with sequential drills, a more palatal positioning of the implants allows a better primary stability in addition to buccal bone preservation. The implants (3.75 x 13mm), were inserted in the prepared osteotomy site with insertion torque of 40 N/cm 2 , and adequate primary stability was obtained. After that stage the biomaterial was placed in the labial gap region between the implant and bone, because the space between implant and bone, when the implant was placed, was greater than 2mm.Periodontal tissue was preserved, respecting aesthetic concepts.
Resonance frequency analysis (RFA) was recorded using an Osstell® transducer (Gothenburg, Sweden) with an ISQ greater than 61, which indicated good bone/implant contact .
Postoperative intraoral periapical radiograph was taken, confi rming the accuracy of placement of implant. Abutment were attached to the implant body and postoperative laser therapy was carried out daily for 7 days. Provisional crown done with laboratory fabricated acrylic crown fi xed to the abutment using light-curing composite. Temporary crown was relieved from occlusion so that they were free of protusive and lateroprotrusive contacts, which might result hat would complicate osseointegration (Figure 2A,B,C).
Appropriate antibiotic and analgesic were prescribed, and standard postoperative instructions were given to the patient. After 3 months, provisional crown were removed and impression was made with closed tray technique. Impression was sent to the laboratory for fabrication crowon. A porcelain fused to metal crowon was fabricated and cemented to the abutments Clinical and radiological observations after 3, 6 months, 1 year, 5 years showed a good clinical and aesthetic effect ( Figure 3A,B,C,D).

Case report 2
A 46-year-old male patient was reported to the Department of Oral Surgery, with complaints multiple missing teeth and teeth roots. He was unsatisfi ed with the esthetic aspects and masticatory function.
Radiographic examination of teeth roots revealed poor prognosis. Upon intraoral examination, partially teeth loss, remaining tooth roots (Figure 4 A,B).    and helium-neon laser therapy. The sutures were removed 7 days after implantation and manufacturing temporary partial denture upper jaw.
The second stage of implantation was started after 5 months. Postoperative radiograph was taken, confi rming the accuracy of placement of implant ( Figure 5B).
Resonance frequency analysis (RFA) was recorded using an Osstell® transducer (Gothenburg, Sweden) with an ISQ greater than 68.The orthopedic stage is completed 15 days after the second surgical stage. Abutments were attached to the implant body and prepared for parallelism and adequate space (Fig. 5C).
The dental defect is restored by a metal-ceramic construction.
The patient regularly appeared for follow-up examinations, 2 times a year. Clinical and radiological observations after 3, 6 months, 1 year, 5 years showed a good clinical and aesthetic effect. During subsequent follow-up examinations, the situation did not change locally ( Figure 5D).

Discussion
Over the years, many solutions have been proposed in order to improve the clinical performance of dental implants [2].
In The Fourth ITI Consensus Conference (November 2009), the advantages and drawbacks of the various points in time for implant placement after tooth extraction were reported.
They concluded that immediate implant placement is a more diffi cult technique than delayed implant placement to allow initial stability and a good prosthetic position. There is also an in-creased risk of mucosal recession. Nonetheless, based on the aesthetic index, 80% of immediate implant sites show satisfactory outcomes. The survival rates for immediate implants are high and comparable to those of implants placed in healing sites [14]. Over time, clinical experience has provided the criteria for immediate implant treatment success: atraumatic tooth extraction, minimal invasive surgical approach, as well as implant primary stability [15].  In some cases with bone defects, bone grafts are necessary, achieving good aesthetic results is diffi cult, as the gingival architecture and soft tissue harmony are not preserved [16]. In the fi rst 6 to 12 months after extraction, buccal bone resorption is progressive if no bone regeneration procedure is adopted, even when there is no excessive trauma during surgery [17]. Several studies have suggested that small gaps between implants and extraction sockets would fi ll with bone grafting procedures or without them. With regard to the gap between the socket wall and the implant, it was reported that if the jumping distance is over 2mm, grafting is recommended.
The esthetics of the implant get enhanced when it is placed palatally and 3 mm to 4 mm apical to the free gingival margin.
In the gap between the implant and buccal bone, to graft the bone and tissue zones, autogenous, allograft, xenograft, and synthetic bone substitutes and/or materials can be used. This method can maximally leave the thin buccal wall undamaged.
The graft material acts as a scaffold which maintains the blood clot for initial healing and the hard and soft tissue volume [21,22].  Based on the results of this report it can be concluded that immediate placement of the implant may be a favorable treatment option if there is suffi cient keratinized gingival tissuesthickness and suffi cient bone volume in the area of the extracted tooth, the absence of acute infl ammation in the well of the extracted tooth socket and good primary fi xation of the implant in extraction socket.

Conclusion
Based on this, immediate implant placement following tooth extraction might be a alternative to delayed implant placement. Immediate placement of the implant prevents atrophy of the alveolar ridge thereby preventing recession of the mucosal and gingival tissues and can be provided better esthetics. However, immediate implant placement requires a careful case selection and a specifi c treatment protocol because it is a more diffi cult to execute than a conventional protocol.

Consent statement
Written informed consent was obtained from the patient for publication of this case report and accompanying images.