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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 78-82

Unconventional implant treatment: Primary teeth as functional provisional restoration


1 Department of Periodontology and Implantology, Faculty of Dentistry, Melaka Manipal Medical College, Melaka, Malaysia
2 Consultant, Expert Dental Care, Kilpauk, Chennai, Tamil Nadu, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Vijendra Pal Singh
Department of Periodontology and Implantology, Faculty of Dentistry, Melaka Manipal Medical College, Jalan Batu Hampar, Bukit Baru, Melaka 75150
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_80_18

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   Abstract 


Replacement of hopeless retained primary teeth with dental implants offers various advantages, such as preservation of the crestal bone and elimination of the need to restore the adjacent teeth. Various methods of temporization have been advocated with the aim to support the peri-implant tissues and esthetics; however, longer chairside time is required to accurately reproduce the interproximal contacts and identify the location of the cervical margin. Recently, few case reports utilized a patient's natural teeth as provisional restorations supported by the immediately placed implants or splinted to the adjacent teeth. The case report presented here illustrates the implant placed through the crown of primary teeth in the maxillary and mandibular first molar and utilization of primary teeth as functional provisional restoration. These primary teeth acts as natural space maintainer, maintaining the peri-implant tissues, during the healing period of implant as well as minimize the chairside clinician's time for the fabrication of temporary prosthesis.

Keywords: Natural tooth pontic, provisional restoration, unconventional implant placement


How to cite this article:
Singh VP, Nettemu SK, Suram V, Nettem S. Unconventional implant treatment: Primary teeth as functional provisional restoration. J Interdiscip Dentistry 2019;9:78-82

How to cite this URL:
Singh VP, Nettemu SK, Suram V, Nettem S. Unconventional implant treatment: Primary teeth as functional provisional restoration. J Interdiscip Dentistry [serial online] 2019 [cited 2019 Oct 15];9:78-82. Available from: http://www.jidonline.com/text.asp?2019/9/2/78/268377




   Clinical Relevance to Interdisciplinary Dentistry Top


  1. Functional provisional prosthesis is important to maintain the peri-implanttissue during healing period of implant.
  2. Utilization of primary teeth as provisional restoration, for maintaining the natural space as well as the function.



   Introduction Top


The prevalence of dental agenesis is 5.5% in Europe and 3.9% in North America; the mandibular second incisor is the most common missing tooth, followed by the maxillary lateral incisor and the maxillary second premolar. Females have a 1.37 times higher prevalence of agenesis than males.[1]

Restorative management of retained hopeless primary teeth in the absence of the permanent successor is always a challenge for the clinician. Compromised esthetics, migration of adjacent teeth, altered occlusion, and supereruption of teeth are the common problems associated with congenitally missing permanent teeth.

General guidelines have been proposed for treatment options for primary retained teeth: retain; retain and modify; extraction and space closure; extraction and prosthetic replacement. When the primary tooth has a poor prognosis for root resorption, caries, periodontal or periapical disease, inadequate esthetics, then the best option is extraction and prosthetic replacement with conventional bridges or implants.[2]


   Case Report Top


A 23-year-old healthy female dental student reported to the Department of Periodontology and Implantology with chief complaint of minor discomfort and swelling in the mandibular posterior region. She did not have any significant medical history. On intraoral clinical examination, retained deciduous maxillary and mandibular first molars were present in the oral cavity. The teeth had no signs of mobility, but the patient was unhappy with their appearance and constant recurrences of gingival inflammation. Her oral hygiene was good.

Radiographic examination revealed missing left permanent maxillary and mandibular first premolars to replace deciduous teeth. The roots of deciduous teeth were resorbing. Being a dental student, she was keen to replace the deciduous teeth with dental implants [Figure 1].
Figure 1: Preoperative (a) Clinical, (b) Orthopantomogram, (c) CBCT

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After understanding the risk of implant failure, treatment plan, and its deviation from the standard treatment protocol, patient agreed and signed a written informed consent.

Treatment

The treatment plan was consisted of placement of immediate implant through the deciduous molars considering that the retaining of the natural anatomic form of deciduous teeth would act as the best functional interim restoration as well as natural space maintainer for the healing period of the implant.

Using a strict sterile protocol under local infiltration, access cavity was prepared in the center of the crown using the round diamond sterile bur. After completion of pulpectomy, osteotomy sites were prepared through the primary teeth crowns using the sequential implant drills until the desired diameter was achieved. Copious saline irrigation was used to flush out any debris of pulp chamber or tooth particles of deciduous tooth in the osteotomy sites, which might interfere with the osseointegration. All four walls of the crown were intact to maintain the anatomy of the crown. No attempt was made to reflect the flap.

Noble active narrow platform (ø 3.5 mm x L 10 mm) implants were placed in the prepared osteotomy sites through maxillary and mandibular deciduous molar. The final implant placement was confirmed in the radiographs in terms of subcrestal placement of implant platform. After placement of cover screw on the implant, the access cavity was sealed using Ledermix (tetracycline and cortisol), temporary restorative material, and composite [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e and [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e. No flaps were reflected thereby no sutures required. The patient was advised to take antibiotic (amoxicillin 500 mg 3 times for 5 days) and analgesic (ibuprofen 400 mg × 3 times for 3 days) and regular teeth brushing to maintain good oral hygiene. After 2 weeks, the patient reported with the gingival inflammation and gingival abscess in the lower deciduous molar region, which was drained using the periodontal curettes under local anesthesia, and antibiotics were prescribed to avoid infection in the deeper tissues.
Figure 2: Maxillary intraoperative (a) osteotomy through the crown of tooth, (b) Radiograph of prepared osteotomy, (c) Implant placement through the crown of tooth, (d) Radiograph of implant placement, (e) Intact primary tooth immediate postoperatively, (f) extracted primary tooth after 5 months, (g) healing abutment placed, (h)Radiograph with healing abutment immidiate after extractionm, (i)Prosthetic crown delivered, (j) Radiograph after prosthetic crown

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Figure 3: Mandibular intraoperative (a) osteotomy through the crown of tooth, (b) Radiograph of prepared osteotomy, (c) Implant placement through the crown of tooth, (d) Radiograph of implant placement, (e) Intact primary tooth immidiate postoperatively, (f) extracted primary tooth after 5 months, (g) healing abutment placed, (h) Radiograph with healing abutment immediate after extraction, (i) Prosthetic crown delivered, ( j) Radiograph after prosthetic crown

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The patient was recalled after 5 months to extract the deciduous teeth and healing abutment were placed over the implants [Figure 2]f and [Figure 2]g and [Figure 3]f and [Figure 3]g. There was neither complication nor discomfort reported by the patient during the healing period. The primary teeth were fully functional before the extraction [Figure 4].
Figure 4: Primary teeth in function

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The peri-implant mucosa was allowed to heal for 2 weeks after healing abutment placement, and impression was made using the custom tray and corresponding impression post for the implant with polyether. Screw-retained porcelain-fused metal crown was delivered in both the implants. The access channel was sealed with the composite [Figure 5] and [Figure 6].
Figure 5: Crown fabricated

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Figure 6: Immediate after prosthesis delivered

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The patient was on regular follow-up. At the end of 1 year after prosthesis in function, clinically, the peri-implant tissues and the crestal bone level were excellent, and no sign of clinical inflammation was found [Figure 7].
Figure 7: Postoperative 1-year follow-up (a) Prosthetic crown in function, (b) Orthopantologram, (c) CBCT

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   Discussion Top


In this case report, a patient with hopeless retained primary first molars in the left maxillary and mandibular arch were replaced by dental implants, without extraction of primary teeth at the time of implant placement. It was taken into the consideration that intact primary teeth would function as the provisional functional restoration during the healing period of the implant. Strict sterile protocol and avoidance of infection during the healing phase is the key for success. The healing was uneventful, both the implants were clinically stable, and no adverse finding was present in radiographs.

According to the original Brånemark protocol, a healing period following tooth extraction has been recommended before implant placement.[3] However, evidence shows that placement of implants into fresh extraction sites can also be considered as a predictable procedure.[4] Tooth removal results in marked reduction in buccal–lingual alveolar bone dimension due to the replacement of bundle bone with woven bone from the inner portion of the socket and the resorption of the outer and crestal bone.[5],[6] This negatively affects the emergence profile.

The decision of whether to deviate from conventional route depends on the expected benefits and the potential risks. The potential risk involved primary failure during the integration period and secondary failure after loading in the longer term. In the absence of postoperative inflammation, the short-term risk of implant failure because of a lack of integration is low; histological data from various studies show that the contact of an implant with a tissue of dental origin results in the creation of a stable interface, at least during the healing period.[7],[8],[9] When implants were placed in contact with fragments of dental tissues, a new interface was created. A new layer of a mineralized cement-like material was reported at places where the implant surface comes into contact with dentin or cement. Implant surfaces in contact with the periodontal ligament may be covered by a periodontal ligament-like structure. Concomitantly, osseointegration is achieved at the rest of the implant surface, which is in contact with bone.[8],[9] In past, various reports demonstrated the unconventional implant placement through or in contact with the residual roots or impacted teeth with follow-up ranges from 2 to 9 years.[10],[11],[12],[13],[14],[15]

Various techniques have been described for the construction of provisional restorations with the aim to support the peri-implant tissues and esthetics.[16],[17] Provisional shells made with autopolymerizing acrylic resin are the most commonly prescribed methods; however, longer chairside time is required to accurately reproduce the interproximal contacts and identify the location of the cervical margin. In recent years few authors reported the utilization of patient's natural teeth as provisional restorations supported by the immediately placed implants[18] or splinted to the adjacent teeth.[19]

We used polyether impression material, which is best known for its rigidity, thereby helps keeping impression copings firmly in place and obtain precise impression.[20]

To the best of our knowledge, we did not find any report or study which used primary teeth as functional provisional restoration during the healing phase of implant. This protocol results in variety of advantages such as preservation of crestal bone around implant, excellent soft tissue contours, highly esthetic, full functional efficiency without loss of space in three dimension, no change in patient's oral hygiene maintenance, cost-effectiveness, less chairside time, and positive psychology for not losing the natural tooth during the healing phase of implant.


   Conclusion Top


Use of primary teeth as an excellent, fully functional yet transient restorative option is one of the innovative treatment methods during healing phase of dental implant. This innovative technique was shown to be very useful in patient's positive psychological response, cost-effectiveness, achieving the excellent soft tissue contours as well as no loss in crestal bone around implant. However, appropriate patient selection, plaque control, and precision during implant placement should be kept in mind to achieve the desired objective.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors would like to thank Dr Stephanie Lee Phei Wei for her support and providing assistance in photographs for this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Polder BJ, Van't Hof MA, Van der Linden FP, Kuijpers-Jagtman AM. A meta-analysis of the prevalence of dental agenesis of permanent teeth. Community Dent Oral Epidemiol 2004;32:217-26.  Back to cited text no. 1
    
2.
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3.
Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416.  Back to cited text no. 3
    
4.
Schwartz-Arad D, Gulayev N, Chaushu G. Immediate versus non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth: A retrospective comparative study. J Periodontol 2000;71:923-8.  Back to cited text no. 4
    
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Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212-8.  Back to cited text no. 5
    
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Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res 2012;23 Suppl 5:1-21.  Back to cited text no. 6
    
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Schwarz F, Mihatovic I, Golubovic V, Becker J. Dentointegration of a titanium implant: A case report. Oral Maxillofac Surg 2013;17:235-41.  Back to cited text no. 7
    
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Bäumer D, Zuhr O, Rebele S, Schneider D, Schupbach P, Hürzeler M. The socket-shield technique:First histological, clinical, and volumetrical observations after separation of the buccal tooth segment – A pilot study. Clin Implant Dent Relat Res 2015;17:71-82.  Back to cited text no. 8
    
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Davarpanah M, Szmukler-Moncler S. Unconventional implant treatment: I. Implant placement in contact with ankylosed root fragments. A series of five case reports. Clin Oral Implants Res 2009;20:851-6.  Back to cited text no. 9
    
10.
Davarpahah M, Szmukler-Moncler S. Unconventional implant placement 2: Placement of implants through impacted teeth. Three case reports. Int J Periodontics Restorative Dent 2009;29:405-13.  Back to cited text no. 10
    
11.
Szmukler-Moncler S, Davarpanah M. Reliability of the root implant interface in unconventionally placed implants: An up to 6-year follow-up of 23 implants covering 3 distinct clinical applications. Clin Oral Implants Res 2009;20:814.  Back to cited text no. 11
    
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Davarpanah M, Szmukler-Moncler S, Davarpanah K, Rajzbaum P, de Corbière S, Capelle-Ouadah N, et al. Unconventional transradicular implant placement to avoid invasive surgeries: Toward a potential paradigm shift. Rev Stomatol Chir Maxillofac 2012;113:335-49.  Back to cited text no. 12
    
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Szmukler-Moncler S, Davarpanah M, Davarpanah K, Rajzbaum P, Capelle-Ouadah N, Demurashvili G. Implants in contact with tissues other than bone. Is there room for a potential paradigm shift? Swiss Dent J 2014;124:149-64.  Back to cited text no. 13
    
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Szmukler-Moncler S, Davarpanah M, Davarpanah K, Capelle-Ouadah N, Demurashvili G, Rajzbaum P. Unconventional implant placement part III: Implant placement encroaching upon residual roots – A report of six cases. Clin Implant Dent Relat Res 2015;17 Suppl 2:e396-405.  Back to cited text no. 14
    
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Davarpanah M, Szmukler-Moncler S, Rajzbaum P, Davarpanah K, Capelle-Ouadah N, Demurashvili G. Unconventional implant placement. V: Implant placement through impacted teeth; results from 10 cases with an 8- to 1-year follow-up. Int Orthod 2015;13:164-80.  Back to cited text no. 15
    
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Degidi M, Nardi D, Daprile G, Piattelli A. Buccal bone plate in the immediately placed and restored maxillary single implant: A 7-year retrospective study using computed tomography. Implant Dent 2012;21:62-6.  Back to cited text no. 16
    
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Tarnow DP, Chu SJ, Salama MA, Stappert CF, Salama H, Garber DA, et al. Flapless postextraction socket implant placement in the esthetic zone: Part 1. The effect of bone grafting and/or provisional restoration on facial-palatal ridge dimensional change – A retrospective cohort study. Int J Periodontics Restorative Dent 2014;34:323-31.  Back to cited text no. 17
    
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Wang WC, Suzuki T. Utilization of extracted teeth as provisional restorations following immediate implant placement – A case report. Singapore Dent J 2015;36:23-8.  Back to cited text no. 18
    
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Suryavanshi HN, Moghe AG, Baonerkar HA, Desai KD. Immediate tooth replacement by natural tooth pontic after tooth avulsion: Our clinical experience. Int J Dent Med Res 2015;1:105-8.  Back to cited text no. 19
    
20.
Kurtulmus-Yilmaz S, Ozan O, Ozcelik TB, Yagiz A. Digital evaluation of the accuracy of impression techniques and materials in angulated implants. J Dent 2014;42:1551-9.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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