Discussion
angulation, PES, tooth
COLLAPSE, CREST
Many treatment protocols and materials are available to replace a natural tooth immediately after extraction, but the best protocol is unclear, especially in the esthetic zone [The relationship between the time of implant placement and the time of extraction can be classified into delayed placement after complete bone healing, immediate-delayed placement after soft tissue healing, and immediate placement, which usually preserves the extraction socket walls [Mareque S. et al. reported in their systematic review that immediate implants and delayed implant placement protocols have similar results radiographically and concerning patient-reported outcomes [Atraumatic tooth extraction was done to decrease the amount of labial bone resorption and maintain the gingival contour, as reported in a previous study. It was observed that atraumatic tooth extraction combined with immediate implant placement provides harmony and aesthetics to the gum line; this is attributed to the preservation of the remaining labial plate of bone during extraction and maintaining the gingiva intact without laceration [When the implant is placed in a 3D position into the bone, there is usually a distance created between the outer surface of the implant fixture and the inner surface of the labial plate. This gap is referred to as the “jumping gap”. A study that identified the histologic outcome of leaving an excessive horizontal jumping gap of 4.2 mm buccolingual without bone grafting, it showed the presence of intimate bone contact until the last implant fixture thread, which is proof that an immediate implant in a socket with intact buccal bone will allow healing and osseointegration without the need for a bone graft [In the study group, the jumping gap was grafted with 50% xenograft bone and 50% autogenous bone, which was collected by low-speed drilling (300 rpm without coolant) from the socket, avoiding the need for any additional surgeries. A pilot study was conducted to compare the difference between high-speed and low-speed drilling in collecting the gold standard of autogenous bone from an intra-oral site without the downside of donor site morbidity and the need for additional surgery. The samples of bone obtained by low-speed drilling showed live cells under optical microscopy, while the bone harvested at high-speed drilling didn’t show either living cells or cell growth. Also, the perfect control of drilling depth as the serrations or marks on the burs are easily visible during drilling is another advantage of the low-speed drilling protocol [Xenografts play an essential role in alveolar bone preservation and can be used as a valuable tool to maintain the dimensions of the extraction socket as well as encourage osteo-conduction and space maintenance [The dual-zone therapy technique means that immediate implant placement into a fresh extraction socket is performed with immediate provisionalization, and the bone grafting material is used to fill the gap until bone level and extend to the soft tissue margin. Results of this therapy show a positive outcome regarding bone healing as well as soft tissue health, giving a satisfactory esthetic outcome. This technique is recommended to attain high esthetic results, especially valuable when the gap between the implant body and the internal wall of the buccal bone is greater than 1.5 mm [The implants were placed using computer-designed surgical guides according to the prosthetically driven implant protocol, which guarantees an ideal implant position. The ideal implant position and angulation would reduce the risk of facial mucosal margin recession, and the esthetic result would be favorable even in the deficient socket [The pink esthetic score (PES) assesses the soft tissue surrounding the implant at 7 points [In our study, the temporary crown was digitally fabricated with an S-shaped emergence profile for maximum extension into the coronal soft tissue around the interim, as reported by Gluckman [The mean results for PES for the study group were 11.58 ± 1.16 post-operatively and increased to 12.42 ± 1.44 after six months, and were 11.75 ± 1.71 post-operatively for the control group and decreased to 11.17 ± 1.53 after six months, which can be attributed to the preservation of the socket wall through the use of the bone graft, which in turn prevented the collapse of the soft tissue contour as reported previously by Noelken R et al. [Based on the results in the present study, it is recommended that whenever the bony dimensions allow immediate implant with provisionalization, if it is possible, it should be the best line of treatment since it greatly enhances the PES and preserves the emergence profile with a highly finished and polished temporary crown. Satisfactory aesthetic outcomes may be achieved with immediate implants placed after the extraction of teeth in the maxillary anterior area of the dentition.The limitations of this study are to investigate the most suitable immediate implant protocol in patients with a defective labial plate of bone and the relationship between long-term mucosal stability, and the position of the facial bone crest. Further research is needed to investigate the relationship between mucosal stability, the type of bone graft material used, and the position and thickness of the facial bone.