Posttraumatic use of dental implants immediately after tooth extraction: clinical study

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Article

Reference

Posttraumatic use of dental implants immediately after tooth extraction: clinical study

COVANI, Ugo, et al.

Abstract

Root fracture is a combined injury of cementum, dentin, and pulp. Many of these traumas remain untreated, mistreated, or overtreated. It leads to a more complicated treatment in case of tooth loss. Many different treatment procedures, with a very changeable success rate, have been proposed for years to treat teeth with root fractures. The objective of the following clinical studies was to evaluate the clinical effectiveness of implants placed in fresh extraction sites to treat teeth with horizontal root fracture.

COVANI, Ugo, et al . Posttraumatic use of dental implants immediately after tooth extraction:

clinical study. Journal of Craniofacial Surgery , 2014, vol. 25, no. 3, p. 796-8

DOI : 10.1097/SCS.0000000000000522 PMID : 24785746

Available at:

http://archive-ouverte.unige.ch/unige:111705

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11/07/2018

Posttraumatic Use of Dental Implants Immediately After Tooth Extraction: Clinical Study

Ugo Covani, MD, DDS,* Simone Marconcini, DDS, PhD,* Francesco Ferrini, MD, DDS, Federico Gelpi, DDS, Marco Finotti, DDS, and Antonio Barone, DDS, PhD*

Purpose: Root fracture is a combined injury of cementum, dentin, and pulp. Many of these traumas remain untreated, mistreated, or overtreated. It leads to a more complicated treatment in case of tooth loss.

Many different treatment procedures, with a very changeable success rate, have been proposed for years to treat teeth with root fractures. The objective of the following clinical studies was to evaluate the clinical effectiveness of implants placed in fresh extraction sites to treat teeth with horizontal root fracture.

Methods: The study group included 25 patients (15 men and 10 women) between the ages of 20 and 65 years. After an initial examination and a treatment planning, all of the patients underwent periodontal treatment, which was deemed necessary to favor wound healing.

All the 25 teeth were extracted because of horizontal root fracture located at the level of the middle third. The second-stage surgery was performed 6 months after the initial procedure. The following clinical parameters, presence or absence of mobility, presence or absence of pain, and presence or absence of suppuration, were evaluated in each patient at 6 and 12 months after implant placement. Radiographs were taken using the standard method to evaluate the marginal bone loss.

Results: The healing period was uneventful for all patients. All implants had osseointegrated. After 12 months, patients were asymptomatic and showed no signs of infection or bleeding when probed.

Conclusions: On the basis of this study, implants placed right after tooth extraction are a valid treatment procedure, which induces predictable results as treatment of fractured teeth.

Key Words: Immediate implants, horizontal root fracture, osseointegration

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n the last decade, advances in implant surface technology and continuous clinical research have provided the clinicians with inno- vative and efficient operative protocols to properly treat more and more demanding clinical situations.¹Some of the original prerequisites

of osseointegration have been rediscussed to satisfy the increasing patients’ demand for reduced treatment time, improve aesthetic treatment outcomes, and increase comfort during healing.²

The placement of implants immediately after tooth extraction has proven to be a predictable treatment strategy with a very high success rate.^1,3Immediate implant placement has several advantages, such as reduction of the number of surgical treatments and reduction of the time between the tooth extraction and the placement of the definitive prosthesis.⁴

Most of these traumas remain untreated, mistreated, or overtreated, leading to a more complicated treatment in case of tooth loss.⁵Nowadays, there are several methods to treat severely injured teeth, but the long-term success rates obtained with these operative protocols are still low, and those teeth often need later extraction.^6Y10 Ozbek¹¹suggested a conservative treatment of root fractures below the alveolar crest; Pilleggi and Dumsha¹²suggested root fractures can heal spontaneously, if immediately treated with an adequate therapy; Ferrari et al¹³pointed out that the prognosis of a root fracture is strictly connected to its location and in particular if close to the gingival sulcus. On the basis of these considerations, it has been re- cently observed that the use of an immediate implant could be a valid treatment procedure for the replacement of traumatized teeth. The aim of the present clinical study has been to evaluate the clinical effectiveness of implants placed in fresh extraction sites to treat teeth with horizontal root fracture.

PATIENTS AND METHODS

Twenty-five patients (15 men and 10 women) aged 20 to 65 years were referred to academic and private practices of the authors between 2006 and 2012 and included in this study. All the patients were scheduled for at least 1 single-rooted tooth extraction and an immediate implant placement. Inclusion criteria for the study were as follows: indication for a tooth extraction (intra-alveolar root fracture located at the level of the middle third), presence of at least 4 mm of bone beyond the root apex, absence of acute signs of infection or inflammation in the treatment area, and absence of systemic pathologies that would contraindicate bone healing around implants. No tobacco abuse (maximum 10 cigarettes per day) and no alcohol or drug dependency were accepted. All patients admitted into the study group were required to sign a standard model of in- formed consent to treatment. Each case was carefully evaluated by analyzing diagnostic casts for intra-arch and interarch relationship.

Periapical and panoramic radiographs (Fig. 1) were taken as well as computed tomography scans if needed. All the selected clinical cases required tooth extraction because of a horizontal fracture.

Chlorhexidine mouthwash was used immediately before surgery.

Every tooth extraction was performed with extreme care to preserve the alveolar bone integrity (Fig. 2) by using thin syndes- motome, and the implant was placed with a flapless technique.¹⁴

When an atraumatic technique was not possible during the extraction, a mucoperiosteal flap elevation was applied by performing intrasulcular and vertical incisions extended over the mucogingival

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The Journal of Craniofacial Surgery

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Volume 25, Number 3, May 2014

From the *Department of Surgical, Medical, Molecular Pathology, and Critical Area, University of Pisa, Pisa; and Istituto Stomatologico Toscano, Versilia General Hospital, Lido di Camaiore, Lucca, Italy.

F.F. is in private practice in Pesaro, F.G. in Verona, and M.F. in Milano and Padova, Italy.

Received November 4, 2013.

Accepted for publication November 11, 2013.

Address correspondence and reprint requests to Simone Marconcini, DDS, PhD, Piazza Diaz 10, 55041 Camaiore, Lucca, Italy;

E-mail: s.marconcini1977@libero.it The authors report no conflicts of interest.

Copyright*2014 by Mutaz B. Habal, MD ISSN: 1049-2275

DOI: 10.1097/SCS.0000000000000522

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junction. The implant site was prepared with standard drills under copious saline irrigation. The longest possible implants were placed at the buccal/palatal level of the bone crest without considering the bone height at the mesial and distal level (Fig. 3). All the implants placed showed very good primary implant stability. Twenty-four implants were placed in the maxilla and 1 in the mandible; all the implants used had a microtextured implant surface (Premium; Sweden &

Martina, Padova, Italy). Implant length ranged from 13 to 15 mm with 3.75- to 5-mm diameter. All of the implants showed clinical primary stability. After implant placement, the peri-implant bone defect that had occurred between bone walls and implant surface was char- acterized by absence of fenestration or dehiscence. Therefore, no augmentation procedures were performed. In case of flap elevation, the flap was replaced in the original position and sutured with interrupted sutures around a healing screw as proposed by Lang et al.¹⁵ Antibiotics (amoxicillin 500 mg 4 times daily for 4 days), anti- inflammatory agents (100 mg nimesulide 2 times per day for 4 days), and chlorhexidine mouthwash were prescribed during the postoperative period. A removable prosthesis was worn during the healing process only for aesthetic reasons. During the healing process, patients underwent scaling, oral hygiene instructions, and periodontal treatment if needed, to provide an oral environment, which would be more

favorable to wound healing. The temporary prosthesis was healing- screw bearing with occlusal rests and was relined with soft lining material. Sutures were removed after 7 days. An individualized occlusal template was made to guarantee radiographic reproducibility for the follow-up period. Patients were followed up monthly.

The final follow-up was at 12 months. The following clinical and radiographic parameters: presence or absence of mobility, presence or absence of pain, presence or absence of suppuration, were evaluated for each patient at 6 and 12 months after surgery. The radiographic technique used was the parallel cone, which allows a minimal distortion of images. Radiographs were taken using an individualized occlusal stent to evaluate the presence of peri-implant radiolucencies and marginal bone loss. An implant was considered a success when it fulfilled the criteria defined by Albrektsson et al.¹⁶

RESULTS

The surgical protocol, which combines the extraction of a fractured tooth and the placement of immediate implants, proceeded smoothly. All the patients included in the current study were followed up carefully during 12 months. They were followed up weekly during the first postoperative month and monthly during the rest of the follow-up period.

The postsurgical healing phase was uneventful for all patients.

Pain and swelling were the most frequently mentioned complaints.

At the time of definitive prosthesis placement, no signs of infection or bleeding were detected, and no pockets were found (Figs. 4 and 5).

Periapical radiographs were taken just after the implant placement and at the end of the follow-up period. The total mean distance from implant shoulder to bone crest at baseline wasj0.3 mm. At 6 months after placement, the mean value was 0.5 mm (Table 1). There was no fracture of abutments and/or loss of prosthetic screws. No prostheses needed to be replaced. The only prosthetic complication that occurred (regarding 2 implants) was the loss of the screws that connected the

FIGURE 1.Preoperative periapical radiograph of a maxillary tooth to be extracted.

FIGURE 2.Intraoperative clinical view of the fractured maxillary tooth.

FIGURE 3.An implant is placed and primary stability achieved.

FIGURE 4. Periapical radiograph taken 6 months after placement.

FIGURE 5. Final prosthetic restoration in place.

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abutment to the implant. The implants were deemed successful at 6 months following prosthetic rehabilitation, according to clinical criteria suggested by Albrektsson et al.¹⁶

DISCUSSION

The reliability of dental implants has greatly improved in the last 20 years, providing clinicians with new therapeutic devices for dental rehabilitation that previously were considered unrealistic.

Nowadays, implants placement right after tooth extraction has proven to be a predictable treatment strategy with a very high success rate, and they present the first therapeutic option in the case of a single untreatable tooth.^1,3All the implants placed in this study were clini- cally stable and asymptomatic and did not show any significant bone defects at the end of the follow-up period. The definitive prosthetic restoration took place 4 to 6 months after the first surgery. The current study concentrated on patients with single tooth loss, which made prosthetic rehabilitation easier.

Immediate implant placed in fresh extraction sockets could result in a defect between the implant surface and the surrounding bone walls. When the gap between alveolar bone and implant is bigger than 2 mm, the use of barrier membranes is recommended to obtain bone regeneration and to prevent soft tissue growth at the bone implant interface. However, there are several clinical complications that might occur using barrier membranes, such as bacterial colonization, which can lead to an infection and even to implant failure. Several authors have reported high rates of membranes exposure with implants placed immediately after tooth extraction.^17,18 Kohal et al¹⁸found a very high frequency of membrane exposure during the healing period. The researchers assumed that in the sites with exposed membranes, the amount of regenerated bone was less than that in the sites with retained membrane.

The use of barrier membranes should be therefore carefully evaluated. In their study on immediate implants, Covani et al¹⁹ reported a low frequency of complications during the healing period and a very high survival rate without using barrier membranes.²⁰ On the basis of these findings, grafting material and/or barrier membranes were not used in the current study, showing that small circumferential defects could heal spontaneously. Therefore, within the limits of the study, our clinical results totally agree with those previously reported by the same authors, thus supporting the hypothesis that implant primary stability, integrity of bone walls, maintenance of a firm blood clot, and primary flap closure are sufficient factors to induce spontaneous bone healing in circumferential peri-implant bone defects of less than 2 mm.²¹The pattern of bone rearrange- ment could be induced by new bone apposition to fill the peri-implant defect and, at the same time, by buccal and lingual bone resorption, leading to a width reduction of the alveolar ridge.²²

CONCLUSIONS

Implant placement in fresh extraction site has proved to be a valid treatment procedure. It induces predictable results in fractured untreatable teeth treatment. Moreover, our results seem to suggest that implants placed in fresh extraction sockets, delimiting small circumferential defects not more than 2 mm, could heal with good pre- dictability without any regenerative procedures. No clinical parameters

were used to evaluate the stability and health of soft tissues. However, at the end of the follow-up period, none of the patients showed a negative aesthetic outcome. Additional more extensive, long-term, and well- matched studies are needed to support our hypothesis and to suggest this technique as a routine in the treatment of untreatable intra-alveolar root fracture located at the level of the middle third.

REFERENCES

1. Covani U, Crespi R, Cornelini R, et al. Immediate implants supporting single crown restoration: a 4-year prospective study.J Periodontol 2004;75:982Y988

2. Grunder U, Polizzi G, Goene R, et al. A 3-year prospective multicenter follow-up report on the immediate and delayed-immediate placement of implants.Int J Oral Maxillofac Implants1999;14:210Y216 3. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate

placement of implants into fresh extraction sites: 4 to 7 years retrospective evaluation of 95 immediate implants.J Periodontol1997;68:915Y923 4. Vanden Bogaerde L, Rougert B, Wendelhag I. Immediate\early function

of Branemark System TiUnit implants in fresh extraction sockets in maxillae and posterior mandibles: an 18-month prospective clinical study.Clin Implant Dent Relat Res2005;(suppl 1):S121YS130 5. Wadhwani CP. A single visit, multidisciplinary approach to management

of traumatic tooth crown fracture.British Dental Journal2000;

188:593Y598

6. Birch R, Rock WP. The incidence of complications following root fracture in permanent anterior teeth.Br Dent J1986;160:119Y121 7. Kahabuka FK, Willemsen W, Van’t Hof M, et al. Initial treatment

of traumatic dental injuries by dental practitioners.Endod Dent Traumatol1998;14:206Y209

8. Say EC, Altundal H, Kaptan F. Reattached of a fractured maxillary tooth: a case report.Quintessence Int2004;35:601Y604

9. Gaye F, Mbaye M. Horizontal root fracture in a maxillary central incisors.

Restoration after endodontic treatment.Odontostomatol Trop2002;25:33Y36 10. Sousa-Neto MD, Santos ES, Estrela C, et al. Treatment of middle-apical

level root fracture in necrotic teeth.Aust Endod J2000;26:15Y18 11. Ozbek M, Serper A, Calt S. Repair of untreated horizontal root

fracture: a case report.Dent Traumatol2003;19:296Y297 12. Pilleggi R, Dumsha TC. The management of traumatic dental

injuries.Tex Dent J2003;120:270Y275

13. Ferrari PH, Zaragoza RA, Ferreira LE, et al. Horizontal root fractures:

a case report.Dent Traumatol2006;22:215Y217

14. Covani U, Barone A, Cornelini R, et al. Soft tissues healing around implants placet immediately after tooth extraction without incision:

a clinical report.Int J Oral Maxillofac Implants2004;19:855Y860 15. Lang NP, Tonetti MS, Suvan JE, et al. Immediate implant placement

with transmucosal healing in areas of aesthetic priority. A multicenter randomized-controlled clinical trial I. Surgical outcomes.Clin Oral Implants Res2007;18:188Y196

16. Albrektsson T, Zarb G, Worthington P, et al. The long term efficacy of currently used dental implants: a review and proposed criteria of success.Int J Oral Maxillofac Implants1986;1:11Y25 17. Fugazzotto PA. Maintaining primary closure after guided bone

regeneration procedures: introduction of new flap design and preliminary results.J Periodontol2006;77:1452Y1457 18. Kohal RJ, Mellas P, Hurzeler MB, et al. The effects of guided bone

regeneration and grafting on implants placed into immediate extraction sockets. An experimental study in dogs.J Periodontol1998;69:927Y937 19. Covani U, Bortolaia C, Barone A, et al. Bucco-lingual crestal bone jaw.

Changes after immediate and delayed implant placement.J Periodontol 2004;75:1605Y1612

20. Covani U, Cornelini R, Barone A. Vertical crestal bone changes around implants placed into fresh extraction sockets.J Periodontol2007;78:810Y815 21. Covani U, Barone A, Cornelini R. Bucco-lingual bone remodelling

around implants placed into immediate extraction sockets. A case series.

J Periodontol2003;74:268Y273

22. Botticelli D, Berghlundh T, Lindhe J. Hard-tissue alterations following immediate implants placement in extraction sites.J Clin Periodontol 2004;31:820Y828

TABLE 1.Mean (SD) Vertical Distance (Marginal Bone Loss) Between Implant Shoulder and Marginal Bone Crest at Baseline and 6 Months Later

Baseline 6 Months

Mean SD Mean SD

Mesial 0.7 0.7 0.2 0.6

Distal 1 0.6 0.2 0.5

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*2014 Mutaz B. Habal, MD