IMMEDIATE PLACEMENT OF ENDOSSEOUS IMPLANT IN ESTHETIC ZONE IN EXTRACTION SOCKET Dr. B. Venkat suresh, Professor & H.O.D, Dr.

S.Saritha Devi, Post Graduate Address for correspondence: Dr. B. Venkat suresh,Professor & H. O. D, Dr.S. Saritha Devi(post graduate), Department of Oral and Maxillofacial Surgery, Gitam Dental College & Hospital;Rushikonda Campus Visakhapatnam-530045;Andhra Pradesh;India. dr. bvsuresh@gmail.com

Purpose: This six months study evaluated the esthetic outcome and bone levels of immediately placed and provisionalized maxillary anterior single implants. Materials and Methods: 10 patients(six males,4 females) with an age range of(17-50yrs) were included in this study.10 threaded rough surface implants were placed and provisionalized immediately after each failing had been removed. The definitive restoration was placed 5months later. The patients were evaluated clinically and radiographically on first day of implant placement ,first month, third month, sixth months after implant placement. Results: At the end of 6months all implants remain osseointegrated. The mean marginal bone change from the first day of implant placement to six months was 0.40mm mesially and 0.39mm distally. The mean mesial papilla level changes from first day to 6months was 0.65mm and the distal papilla level changes from first day to 6months was 0.55mm respectively. All patients were very much satisfied with the esthetic outcome and none had noticed any changes at the gingival level. Discussion: Although marginal bone and gingival level changes were

statistically significant from first day to six months of followup, they were well within the clinical expectations. Conclusion: The results of this study suggest that favourable esthetic outcome and osseointegration can be achieved with immediately placed and provisionalized maxillary single implants. Keywords: Immediate implant placement, Immediate provisionalization, esthetics, marginal bone levels,papilla levels. Introduction: Aesthetics play a major role in the lives of everyone. It is a known fact that tooth loss can affect the way an individual looks and it can also can affect the way one feels1 . Teeth usually give support to the mouth, cheeks and jaws. When we have significant tooth loss, this support is lost and the face sinks in , the jaws droop prematurely resulting in older age appearance. Missing teeth affects the way the jaw closes and the remaining teeth begin to drift into these spaces increasing the risk of decay and periodontal problems. The opposing teeth also drift into these missing tooth spaces thus leading to temporomandibular joint problems. Apart from these consequences, tooth loss results in resorption of the supporting bone. The consequences of missing anterior teeth are lisping type of speech, difficulty in taking certain foods, restricted social life, negative impact on patients psychological well being 1. The missing teeth and its supporting oral structures have traditionally been replaced with dentures and partial prosthesis to restore the patients ability to eat, speak and enhance the appearance. These conventional techniques are associated with certain disadvantages. The acrylic denture base in removable partial dentures is brittle. These partial dentures tend to break frequently due to their irregular shape especially those made for the mandibular arch. Removable dentures are most frequently retained with wire clasps which are frequently unaesthetic. Additional forces will be transmitted to the abutment teeth in tooth supported removable dentures which is detrimental to their long term function2 .The disadvantages associated with the fixed partial

dentures are removal of large amount of tooth structure, fracture at metal ceramic junction, difficulty to obtain accurate occlusion in glazed porcelain, unaesthetic appearance of metal ceramic crowns, wear of opposing natural teeth in all ceramic crowns3. Therefore, inorder to overcome the disadvantages associated with these conventional techniques the concept of dental implants has been introduced. There are certain disadvantages associated with this conventional treatment protocol like extended treatment period, need for removable denture during the initial healing period, need for multiple surgeries, post extraction resorption of bone, loss of soft tissues and compromised aesthetics. 5 Therefore, inorder to overcome the problems associated with this conventional treatment protocol the concept of immediate placement and provisionalization of implants has been introduced. The purpose of the present study is to determine the versatality of an endosseous implant placed immediately after the extraction of the tooth. Hence the study is planned to assess the advantages of an immediately placed endosseous implant in fresh extraction tooth sockets. Materials and Methods: This study was conducted in the department of Oral and maxillofacial surgery, Gitam dental College and Hospital, Visakhapatnam. 10 patients with age group 1850 years who reported to the department of Oral and maxillofacial surgery presenting with a single anterior tooth affected by trauma, caries, root resorption, endodontic failure and with the presence of adjacent dentition were selected for the study. Inclusion Criteria: 18 years and above Presence of single anterior tooth affected by trauma, caries, root resorption endodontic failure and with the presence of adjacent dentition.

Presence of adequate and harmonious gingival architecture with the surrounding dentition. Adequate amount of marginal gingiva to underlying bone dimension at the facial aspect (3mm) of the tooth indicated for extraction and interproximal aspect (4-6mm) of the immediate adjacent tooth as ascertained by bone sounding technique. Good oral hygiene Adequate amount of bone to accommodate an implant of minimum dimensions of 3.3mm diameter and 13mm length without the necessity of bone graft.

Exclusion Criteria: Presence of active infection around the tooth indicated for extraction. Any medical history that would complicate the outcome of the study: alcohol, drug dependency, history of smoking, poor general health. History of bruxism, parafunctional habits or lack of stable posterior occlusion. Perforation or loss of labial bony plate following tooth removal or implant osteotomy. Inability to achieve primary implant stability following immediate implant placement. Surgical Procedure: The patients face was cleaned using povidone iodine solution and draped. Local anesthesia using 2% lidocaine with 1:80000 is given in the area of surgical interest in the form of local infiltration. Extraction procedure consists of atraumatic tooth extraction without flap reflection using Bayonet forceps and apex elevators. The extraction socket was irrigated and debrided with normal saline. Osteotomy site is prepared by drilling in sequence from pilot drill (2mm) to that diameter, which we plan for the implant to be placed. The drill is placed at 5-10 degree palatal angulation and 1mm beyond the radiographic apex inorder to establish primary stability. In between the angulation of the implant drill is

checked with paralleling pins. After preparing with final drill, once again the socket is irrigated with normal saline and cleared of from all the debris. Then the implant is delivered to the osteotomy site using the carrier. Then the hexed implant driver is inserted into the implant and ratcheted into its final position with the surgical ratchet. Then the healing screw is fixed to the implant. Within 2 weeks after implant placement provisionalization was done by fixing the abutment to the implant after milling of the abutment. Data Collection: A detailed case history of the patient was obtained. An informed consent was obtained from the patients regarding the surgery. All examinations and data collection were performed by a single examiner. Evaluations were made at 1
st, rd

3 ,6th ,9th months respectively. Following variables recorded pre-operatively and post-

operatively. Pre-operative evaluation Clinically thickness of gingiva at facial aspect, thickness of gingiva at mesio-proximal aspec,thickness of gingiva at disto-proximal aspect were taken. Radiographically height of available bone is measured.In Study model analysis:-mesio-distal space available i.r.t offending tooth, bucco-palatal space available i.r.t offending tooth were taken. Parameters :Soft tissue levels: Mid-facial gingival level from reference line, mesial papilla level from reference line, distal papilla level from reference line were

taken.Bone levels : Mesial marginal bone level from reference point, distal marginal bone level from reference point were taken. Data Interpretation: Soft tissue levels: Are evaluated for a follow up period of 6 months at 1,3,and 6 month intervals using study model.The changes in F.G.L of the implant restoration were evaluated by measuring its distance from the reference line at each time interval.Changes in M.P.L&D. P. L were measured as the distance from the tip of the papilla to the reference line as parallel to the line bisecting the implant restoration, at each interval.The line drawn connecting the F.G.L of the 2 adjacent

teeth is taken as the reference line. Bone levels: Are evaluated for a follow up period of 6 months at 1,3, and 6 month intervals using intraoral periapical

radiographs . I.O.P.A Rs are taken with long cone/paralleling technique and with I.O.P.AR grid. Mesial marginal bone level & distal marginal bone level were measured at each time interval by measuring the distance from the reference point. A +ve value is denoted when implant bone contact is more coronal to the reference point. And a -ve value is denoted when implant bone contact is more apical to the reference point. Reference point is the apical corner of the implant shoulder. PATIENTS ESTHETIC SATISFACTION: (a ) good (b) fair (c) poor

STATISTICAL AND DATA ANALYSIS: MINITAB -14 was used to administer the statistical tests and to draw the graphic representations. ANOVA test is conducted to know the significant mean difference between the timing points of bone levels and gingival levels. Inorder to know the multiple comparison between each and every pair of timing points Schefees Post hoc test is conducted.

Preoperative-IOPAR

Preoperative PreP

Implant with abutment

Temporary restoration

First post-op day

Sixth post-op month

Results: From january 2010 to september 2010 10 patients with age range of 17-50 yrs underwent immediate implant placement and provisionalization. All patients had returned for the sheduled appointments upto the 6months followup. A total of 10 threaded, rough surface, tapered implants were evaluated.

Table-1: Multiple comparisions of mesial marginal bone level Factor(I) Ist day Factor(j) 3rd month 6thmonth 1st month 1st day 3rd month 6th month 3rd month 1st day 3rdmonth 6thmonth 6th month 1st day 3rdmonth 6thmonth Mean difference(i-j) p-Value .843 .551 .271 .843 .957 .736 .551 .957 .954 .271 .736 .954

1st month .1814 .2929 .4071 -.1814 .1114 .2257 -.2929 -.1114 .1143 -.4071 -.2257 -.1143

To know the multiple comparisons between each pair of timing points Scheffes Post Hoc Test is conducted. The above table demonstrates that there is no significant difference between each and every pair of timing points. .
Multiple Com parisons of Distal m arginal bone levels Dependent V ariable: Dis tal Marginal Bone Lev els Schef f e Mean Dif f erence (I-J) .1314 .2571 .3929 -.1314 .1257 .2614 -.2571 -.1257 .1357 -.3929 -.2614 -.1357

(I) FA CTOR First day

1s t Month

3rd Month

6th Month

(J) FA CTOR 1s t Month 3rd Month 6th Month First day 3rd Month 6th Month First day 1s t Month 6th Month First day 1s t Month 3rd Month

P-v alue .949 .719 .387 .949 .955 .708 .719 .955 .944 .387 .708 .944

To know the multiple comparisons between each pair of timing points Scheffes Posthoc test is conducted. The above table demonstrates that there is no significant difference between each and every pair of timing points.
Multiple Com parisons of DIstal Papilla Le ve ls Dependent Variable: Dis tal Papilla Levels Schef f e Mean Dif f erence (I-J) .2071 .4000 .5500 -.2071 .1929 .3429 -.4000 -.1929 .1500 -.5500 -.3429 -.1500

(I) FACTOR First day

1s t Month

3rd Month

6th Month

(J) FACTOR 1s t Month 3rd Month 6th Month First day 3rd Month 6th Month First day 1s t Month 6th Month First day 1s t Month 3rd Month

P-v alue .959 .771 .555 .959 .966 .842 .771 .966 .984 .555 .842 .984

The above table depicts that there is no significant difference between each and every pair of the timing points. Discussion: Missing teeth have traditionally been replaced with dentures and partial prosthesis to restore the ability of the patients to eat, speak and improve appearance. These conventional techniques are associated with certain disadvantages. For removable partial dentures disadvantages like-frequent breakage, unaesthetic appearance due to wire clasps, are present 2 . For fixed partial dentures disadvantages like-Removal of large amount of tooth structure, fracture at metal ceramic junction, difficult to obtain accurate occlusion in glazed porcelain, unaesthetic appearance in case of metal ceramic crowns, wear of opposing natural teeth incase of all ceramic crowns are present3. Inorder to overcome the disadvantages associated with the conventional

techniques the concept of dental implants has been introduced. A Standard clinical protocol has been given for placing dental implants in two stages8.The conventional implant protocol has certain disadvantages like-extended treatment period, need to wear removable dentures, compromised esthetics, osseous and gingival tissue loss following extraction5. Inorder to overcome the disadvantages associated with the conventional two stage/delayed protocol the concept of single stage/immediate protocol has been introduced14. In our study the cumulative implant success rate was 70% after 6 months of function with a follow up period of 6 months. Comparable success rates have been reported when single implants were placed in the aesthetic zone using either the delayed loading approach(97.2%)37 or immediate provisionalization approach(98%)38. Although insignificant differences have been noted in the implant success rates between smooth and rough implant surfaces, recent literature seems to favour a rough surface in achieving greater magnitude and faster rate of osseointegration39. Therefore in immediate provisionalization situations where maximum magnitude and rate of osseointegration is needed implants with surface treatments should be considered. Furthermore threaded implants should be used because they provide the strongest immediate mechanical retention after placement 40. Hence in this study threaded implants (UNITI SYSTEM) were used. In this study statistically significant marginal bone changes were noted at 6 months after immediate provisionalization at the mesial(-0.40 mm) and distal (0.39mm) aspects of the implants, but they were smaller than the mean marginal bone loss of range (0-6mm) observed in implants loaded in the usual delayed protocol after the 1 st year of function41. The low mean marginal bone loss observed after 6 months in the present study may be because of the gradual bone formation in the gaps between the implant and the extraction socket following immediate implant placement. loaded implants38. A

prospective 5-year study of Andersen etal reported bone gain in 88% of immediately

Although the influence of oral hygiene on the implant success has been controversial 42, it is generally agreed that plaque accumulation could induce negative mucosal response. Brushing to the surgical site was not recommended within the first month of implant surgery to minimize unnecessary disturbance to the healing process and oral hygiene was maintained by lightly wiping the area with a cotton swab soaked with 0.12% chlorhexidine gluconate. The mean facial gingival recession was 0.55mm, 6 months after temporary prosthesis placement. In a study by another author a greater mean mid-facial gingival recession of 0.85mm was observed 6months after prosthesis placement. In addition 0.47mm mesial and 0.78mm distal tissue losses were also reported at 12 months 43. In this study the overall mean F.G.L (-0.55mm), and the overall mean M.P.L (0.65mm), and the overall mean D.P.L(0.55mm) following 6 months of follow-up and this is comparable to previously reported amount of changes43,44 Furthermore these gingival tissue changes were within clinical expectations as confirmed by the patients response to the questionnaires , where in a overall satisfaction of good was recorded and no patient had noticed any changes in the gingival architecture around the implant crown throughout the study. The results of this study support the efficacy of this procedure in maintaining the gingival architecture of the tooth indicated for extraction. In this study the implant failure for one patient was due to poor oral hygiene which ultimately led to peri-implantitis. This is similar to the other studies
45

which

reported eight implant losses due to peri-implantitis out of 1475 implants done. In another patient the implant failure can be attributed to the restart of the smoking habit, which he actually stopped 1year prior to our treatment. This is similar to the studies done by an author46 who reported low implant survival rates for smokers with a follow up period of 12-48 months. In another patient the failure of the implant can be attributed to low patient compliance and poor oral hygiene maintenance. This is similar to the studies of the

author 45 who reported eight implant losses out of 1475 implants done, due to poor oral hygiene and low patient compliance.

Conclusion:

The maintenance of the existing anatomical structures is

easier than their

recreation, hence it has been advocated to perform provisionalization with a nonfunctional prosthesis immediately following stage I surgery in immediate tooth replacement . Based on the results of this 6 months study immediate placement and provisionalization of anterior single, rough surface, threaded implants can optimize peri-implant esthetics by maintaining the existing hard and soft tissue architecture of the tooth indicated for extraction. In addition this can minimize the psychological trauma of losing anterior teeth and eliminates the need for removable prosthesis. More long term prospective and controlled clinical studies with a large sample and rough and coated surface of the implant with threads are mandatory to document the effective outcome of this treatment technique . References: 1. Dr. Delaram Hanookai: Missing Teeth: Effects on mental/physical health Journal of South Land Dental Care-2010. 2. J.C. Davenport, R.M. Basker: The Removable Partial Denture Equation: British Dental journal: 2000;189;(8). 3. Dr. Sudhir Pawar: Failures of crown and fixed partial dentures - A clinical survey :International journal of contemporary dentistry 2011;2;(1). 4. Joseph Y.K. Khan, Kitichai Rungcharassaeng: Immediate placement and provisionalization of maxillary anterior single implants: 1 year prospective study :International journal of oral and maxillofacial implants:2003;18;31-39.

5. Adell R, Lekholm U, Rockler B, Branemark PI. A15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981; 10: 6: 387416. 6. Joseph Y.K. Khan, Kitichai Rungcharassaeng: Immediate placement and provisionalization of maxillary anterior single implants: 1 year prospective study :International journal of oral and maxillofacial implants:2003;18;31-39. 7. Bernard JP, Belser UC, Martinet JP, Borgis SA: Osseointegration of Brnemark fixtures using a single-step operating technique. A preliminary prospective oneyear study in the edentulous mandible: Clin Oral Implants Res. 1995 Jun 6 (2):122-9. 8. Marco Degidi, Adriano Piattelli: Five year outcome of 111 immediate nonfunctional Single Restorations: Journal Of Oral Implantology: 2006:32:6. 9. Eivind Andersen: Immediate loading of single-tooth ITI implants in the anterior maxilla: A prospective 5-year pilot study: Clinical Oral Implants Research 2002:13:281-287. 10. F.Butz, H.Aita: Harder and stiffer bone osseointegrated to roughened titanium: J Dent Res 2006:85:6:560-565. 11. Linish Vidyasagar, Peteris Apse: Dental implant design and biological effects on bone-implant interface: Stomatologija, Baltic Dental and Maxillofacial Journal, 2004:6:2:51-54. 12. C.J.Watson, D.Tinsley etal: A 3 to 4 year study of single tooth hydroxyapatite coated endosseous dental implants: British Dental Journal 1999:187:2:90-94. 13. L.W. Lindquist, G.E. Carlsson: Association between marginal bone loss around osseointegrated mandibular implants and smoking Habits: A 10-year follow-up study: J Dent Res 1997 :76(10): 1667-1674. 14. Paula. N. Small and Dennis. P. Tarnow: Gingival Recession Around Implants A 1 Year longitudinal prospective study: Int J Oral Maxillofac Implants

2000;15:4:527532.

15. Tim De Rouck, Kristiaan Collys: Single Tooth Replacement in the Anterior Maxilla by means of Immediate Implantation and Provisionalization: Int J Oral Maxillofac Implants 2008:23:5:897-904. 16. Daniel Buser: Clinical Experience With One-Stage, non-submerged dental implants: Adv Dent Res 1999: 13:153-161. 17. Perry. R. Klokkevold; Thomas.j.Han: How do Smoking diabetes and periodontitis affect outcomes of implant treatment: Int J Oral Maxillofac Implants

2007:22:suppl:173-202.