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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 132-136

Managing esthetics by immediately placed immediately loaded implants: A case report


Department of Periodontology, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission18-Aug-2019
Date of Acceptance09-Jul-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Anshdha Shah
Department of Periodontology, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Raibareli Road, Uterathia, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_27_19

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   Abstract 


\Immediate implants offer a suitable treatment modality as treatment time is reduced, and postextraction bone loss can be avoided. Temporization of implants in the anterior region is becoming much needed for esthetics as well as helps to avoid the second-stage surgical procedure. A 23-year-old female presented with mobility in lower anterior teeth and radiographic bone loss extending to the apical third. The patient was treated with postextraction immediate implants, and immediate nonfunctional prosthesis was given after evaluation of implant stability quotient by radiofrequency analysis using the Ostell® device. A 7-month follow-up presented successful temporization and osseointegration.

Keywords: Immediate nonfunctional prosthesis, immediate postextraction implants, implant stability


How to cite this article:
Srivastava A, Yadav S, Shah A, Husain S. Managing esthetics by immediately placed immediately loaded implants: A case report. J Interdiscip Dentistry 2020;10:132-6

How to cite this URL:
Srivastava A, Yadav S, Shah A, Husain S. Managing esthetics by immediately placed immediately loaded implants: A case report. J Interdiscip Dentistry [serial online] 2020 [cited 2021 Apr 17];10:132-6. Available from: https://www.jidonline.com/text.asp?2020/10/3/132/304151




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Immediate implant placement in esthetic region with immediate nonfunctional temporary prothesis
  • Increased patient acceptance due to esthetic immediate cemented restoration
  • Good gingival seal provided by the prosthesis provides an esthetic result..



   Introduction Top


Teeth replacement by dental implants has gained popularity among both the patient and the dentist. Dental implants have proven to be a successful and predictable treatment procedure.

Different placement and loading protocols have evolved from earlier protocols to enhance patient comfort. Immediate placement of a dental implant in an extraction socket was initially described More than 30 years ago by Schulte and Heimke in 1976.[1] The advantages of this approach include reduced surgical interventions, shorter treatment time and, most importantly, it prevents hard and soft-tissue loss that occurs immediately after extraction.

Nonfunctional immediate restoration is becoming more acceptable by the clinicians as it provides an aesthetically acceptable option to the patient. The main indication for immediate Temporization in the esthetic zone is to cater to the patient's esthetic and psychological needs.[2],[3]

Implant stability can be defined as the absence of clinical mobility. The stability achieved at the time of implant placement is the primary stability. It is related to the bone quality and quantity and the type of implant. Secondary stability is the stability obtained after osseointegration.[4]

The new resonance frequency analysis system (Osstell™; Osstell AB, Gothenburg, Sweden) uses a magnet activated by a magnetic pulse of approximately 1 ms duration from a probe. After excitation the peg vibrates freely, and the magnet induces an electric voltage in the probe coil, which is the measurement signal sampled by the radio frequency analyzer. The implant stability quotient (ISQ) unit is based on the underlying resonance frequency.[4] and ranges from 1 (lowest stability) to 100 (highest stability) [Figure 1].
Figure 1: Implant stability quotient scale

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Various case reports have described different protocols and have suggested immediate loading of implants placed in fresh extraction sockets.[5],[6],[7] The aim of the present case was to observe and verify the clinical efficacy of the immediate restoration of immediate implants.

Clinical presentation

A 23-year-old female reported, with the complaint of mobility in lower front tooth region for 1-year and desired treatment for the same. On clinical examination, teeth 31, 41 presented with Class III mobility and Type III gingival recession and bone loss up to an apical third of the root. Lateral incisors (32,42) presented with Class II mobility and recession Type II and bone loss extending up to an apical third of the root. The mandibular central and lateral incisors presented with a hopeless prognosis, and therefore, extraction was indicated [Figure 2] and [Figure 3]. The mobility was assessed according to Miller's classification of tooth mobility,[8] and the recession was classified according to Cairo et al. classification.[9]

Pertaining to the patient's desire, a treatment plan was devised with immediate implant placement i.r.t 32, 42, and a nonfunctional fixed transitional multi-unit prosthesis from 32 to 42. The patient was explained that temporization would be planned, on the achievement of appropriate ITV (>32 Ncm) implant stability (≥60) (as determined by the Osstell™ device)[10] after implant placement and her written consent was obtained for the same. The prosthetic rehabilitation FP 2 was planned due to increased crown-height space. The patient had a normal smile line with only 1–2 mm visibility of lower incisal edges; thus, the FP – 2 prostheses did not compromise the esthetics. The patient did not have a deep bite or any parafunctional habits that may have posed contradictions to the treatment plant.
Figure 2: Clinical preoperative view

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Figure 3: Radiographic preoperative view

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   Case Report Top


Phase I therapy was performed to achieve microbial control, and diagnostic casts were fabricated. Preoperative digital radiograph was obtained to determine the height of the socket and available bone, i.e., the distance from the alveolar crest to the Base of the extraction socket, was found to be 6.4 mm for the right lateral incisor and 8.2 mm for the left lateral incisor region. The length of the implant selected Was at least 2mm more than than the length of the available socket to achieve apical anchorage. The buccolingual width of the socket at the crest was determined to be 4.0 mm and 4.2 mm with the use of bone gauge. Thus, implants of size 3.5 mm × 11.5 mm and 3.5 mm × 10 mm were selected for the 32 and 42, respectively. The jumping distance was <1 mm and thus, no bone graft was required.[11] The implants used were tapered implant with the spiral tap, double-threaded (2 mm × 1.2 mm), square-shaped thread with alumina blasted (AB)/acid etched surface treated implants (ADIN Touareg-S).

Complete blood counts, bleeding time, and clotting time were evaluated, and all values were within the physiological range.

Surgical protocol

Following asepsis, atraumatic extractions of lower central and lateral incisors were performed, with the use of extraction forceps. Care was taken to prevent damage to the buccal cortical plate. The extraction sockets were thoroughly curetted and irrigated with saline [Figure 4].
Figure 4: Postextraction socket

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Minimal flap reflection was performed for proper visualization of crestal bone, and osteotomy site was prepared as per the manufacturer's instructions of diameter 3.2 mm. Implants were placed at sites corresponding to the left and right lateral incisors, respectively. The ITV was >35 Ncm for both the implants. ISQ values were measured immediately by Ostell device after implant placement, 70 for left lateral incisor and 67 for the right lateral incisor on the ISQ scale (0–100) [Figure 5]. Since ITV >32 Ncm and ISQ value >60 was achieved, the case was prepared for provisionalization.[12] Straight abutments were then screwed onto the implants, and resorbable vicryl sutures were placed to achieve closure of extraction sockets [Figure 6].
Figure 5: Implant stability quotient measured by Ostell®

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Figure 6: Abutments placed immediately after implant placement

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An impression was taken on the same day with elastomeric and light body impression material. A temporary nonfunctional cement-retained prosthesis from 32 to 42 was given within 24 h made of acrylic material [Figure 7]. The temporary prosthesis was made completely nonfunctional, it was checked for any functional contacts that may have been present, using carbon paper markings, and the contacts were removed before cementation. It was ensured that the margins of the restorations did not impinge on the gingiva, and it allowed for proper hygiene maintenance. A noneugenol cement was used for cementation.
Figure 7: Temporary prosthesis given

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At a follow-up 14 weeks, the ISQ value was 68 for the left central incisor and 67 for the right central incisor. At this appointment, abutment level impression was taken again and the final metal-ceramic, cement-retained prosthesis was delivered [Figure 8], [Figure 9], [Figure 10].
Figure 8: Permanent prosthesis given after 14 weeks

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Figure 9: Postoperative radiograph (7 months)

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Figure 10: Postoperative radiograph (7 months)

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   Discussion Top


Bone undergoes remodeling after tooth extraction, especially within the 1st year. An overall decrease of 4.00 mm in ridge height and 25% loss of total bone volume within the 1st year after tooth extraction has been reported. Thus, an immediate implant placement, where an adequate amount of bone is available, seems a relevant treatment modality with the added psychological benefit for the patient with immediate replacement of missing tooth. This advantage can be further enhanced by planning for a nonfunctional fixed prosthesis.[13]

With the use of nonfunctional fixed prosthesis, a fixed interim restoration that satisfies the esthetic needs of the patient is provided without the risk of excessive forces on the implant.[14]

Histologic studies in animals and humans have confirmed the achievement of osseointegration after immediate loading, provided the micromotion remains <150 μm.[15],[16],[17] A micromotion >150 μm results in fibro-osseous encapsulation.

Immediate provisionalization of dental implants enables the patient to avoid the physical discomfort of wearing a removable interim prosthesis or the psychological trauma of a compromised smile.[18] The provisionalization helps preserve the shape of the interproximal papilla and restore a curved/rounded appearance of the gingival margin and permits healing of the soft tissue with the formation of an adequate mucosal seal thus, eliminating the need for a Stage II surgery.

Provisionalization allows the implants to be splinted together during the initial phase of healing, providing biomechanical advantage.[19] In a restoration with nonocclusal loading, loading occurs from lip and tongue pressure and contact with food but not from occlusal forces of opposing dentition, but any parafunctional habits (tongue thrusting, pen biting) need to be evaluated for before the treatment plan is devised.[19] Although immediate loading might induce micromotions and instability of implants, the mandible has a better bone quality than maxilla in the context of achieving primary implant stability.[18] Adequate loading also provides the advantage of earlier adaptive remodeling of bone around the implant.[20] Controlled mechanical loads lead to increased osteoblast and osteocyte production leading to the accelerated formation of spongy bone. There is also enhanced production of Type I and Type III collagen, and there is a preferential alignment of collagen fibers, which helps determine the quality of bone.[21]

Melson and Lang[22] reported that there was significantly higher bone apposition around loaded implants than the unloaded implants.

Vandamme et al.[21] reported that a significantly higher amount of osteoid was found in contact with the implant with loaded conditions compared to no loading.

Donati et al.[23] performed a histological study where they observed the implant and the peri-implant bone in immediately loaded and nonloaded single tooth implants and concluded that there were no differences in bone-to-implant contact % between test and control implants, the density of newly formed peri-implant bone was significantly higher around test than control implants at 1 and 3 months of healing.

Stanley et al.[24] reported an implant success rate of 95.2% after 1-year for immediately loaded implants in the anterior esthetic region.

In the present case study, the esthetic needs of the patient were fulfilled, by the use of provisional restoration. An increase in the ISQ, from the time of placement upto 14 weeks after implant placement/ non-functional loading, indicates no ill-effects of provisional prosthesis on the stability of the implant in the initial healing period.

The immediate loading of postextraction implants poses a dilemma for the clinician; however, a limited number of clinical papers report on this concept. In the current case, nonfunctional loading was done for immediate implants after determination of ISQ values, which increased for 3 months to values appropriate for functional loading. This case report presented successful temporization in the esthetic region after immediate implant placement.


   Conclusion Top


This case report indicates that immediate provisionalization can be done in postextraction implants if adequate primary stability is achieved as it improves patient acceptance and satisfies the esthetic need.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ortega-Martínez J, Pérez-Pascual T, Mareque-Bueno S, Hernández-Alfaro F, Ferrés-Padró E. Immediate implants following tooth extraction. A systematic review. Med Oral Patol Oral Cir Bucal 2012;17:251-61.  Back to cited text no. 1
    
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Grandi T, Garuti G, Samarani R, Guazzi P, Forabosco A. Immediate loading of single post-extractive implants in the anterior maxilla: 12-month results from a multicenter clinical study. J Oral Implantol 2012;38:477-84.  Back to cited text no. 2
    
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Ericsson I, Nilson H, Lindh T, Nilner K, Randow K. Immediate functional loading of Brånemark single tooth implants. An 18 months' clinical pilot follow-up study. Clin Oral Implants Res 2000;11:26-33.  Back to cited text no. 3
    
4.
Sennerby L, Meredith N. Implant stability measurements using resonance frequency analysis: Biological and biomechanical aspects and clinical implications. Periodontol 2000 2008;47:51-66.  Back to cited text no. 4
    
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Singh M, Kumar L, Anwar M, Chand P. Immediate dental implant placement with immediate loading following extraction of natural teeth. Natl J Maxillofac Surg 2015;6:252-5.  Back to cited text no. 6
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Dwivedi H, Jain R. Immediate loading with single-piece implant following extraction. Indian J Dent Sci 2017;9:39-43.  Back to cited text no. 7
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8.
Glargia M, Lindhe J. Tooth mobility and periodontal disease. J Clin Periodonotol 1997;24:785-95.  Back to cited text no. 8
    
9.
Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: Narrative review, case definition and diagnostic considerations. J Periodontol 2018;89:204-13.  Back to cited text no. 9
    
10.
Del Giudice R, Piattelli A, Grande NM, Cataneo E, Crispino A, Petrini M. Implant insertion torque value in immediate loading: A retrospective study. Med Oral Patol Oral Cir Bucal 2019;24:e398-403.  Back to cited text no. 10
    
11.
Boticelli D, Berglundh T, Buser D, Lindhe J. The jumping distance revisited An experimental study in the dog. Clin Oral Impl Res 2003;14:35-42.  Back to cited text no. 11
    
12.
Milillo L, Fiandaca C, Giannoulis F, Ottria L, Lucchese A, Silvestre F, et al. Immediate vs. non-immediate loading post-extractive implants: A comparative study of implant stability quotient (ISQ). Oral Implantol (Rome) 2016;9:123-31.  Back to cited text no. 12
    
13.
Koh RU, Rudek I, Wang HL. Immediate implant placement: Positives and negatives. Implant Dent 2010;19:98-108.  Back to cited text no. 13
    
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Avvanzo P, Ciavarella D, Avvanzo A, Giannone N, Carella M, Muzio LL. Immediate placement and temporization of implants: Three-to-five year prospective results. J Oral Implantol 2009;35:136-42.  Back to cited text no. 14
    
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Zubery Y, Bichacho N, Moses O, Tal H. Immediate loading of modular transitional implants: A histologic and histomorphometric study in dogs. Int J Periodontics Restorative Dent 1999;19:343-53.  Back to cited text no. 15
    
16.
Ledermann PD, Schenk RK, Buser D. Long-lasting osseointegration of immediately loaded, bar-connected TPS screws after 12 years of function: A histologic case report of a 95-year-old patient. Int J Periodontics Restorative Dent 1998;18:552-63.  Back to cited text no. 16
    
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Piattelli A, Corigliano M, Scarano A, Costigliola G, Paolantonio M. Immediate loading of titanium plasma-sprayed implants: An histologic analysis in monkeys. J Periodontol 1998;69:321-7.  Back to cited text no. 17
    
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Scala R, Ghansi P, Cucchi A, Pistoia E. Postextraction implant placement with immediate provisionalization and finalisation, using a simplified technique: technical notes and a case report. Open Dent J 2012;6:164-8.  Back to cited text no. 18
    
19.
Misch C, Scortecci G. Immediate load and restoration in implant dentistry: rationale and treatment. In: Contemporary Implant Dentistry. 3rd ed. Gurgaon: Elsevier Inc.; 2008. p. 799 -836.  Back to cited text no. 19
    
20.
Lindhe J, Berglundh T, Ericsson I, Liljenberg B, Marinello C. Experimental breakdown of peri-implant and periodontal tissues. A study in the beagle dog. Clin Oral Implants Res 1992;3:9-16.  Back to cited text no. 20
    
21.
Vandamme K, Naert I, Geris L, Vander Sloten J, Puers R, Duyck J. The effect of micro-motion on the tissue response around immediately loaded roughened titanium implants in the rabbit. Eur J Oral Sci 2007;115:21-9.  Back to cited text no. 21
    
22.
Melsen B, Lang NP. Biological reactions of alveolar bone to orthodontic loading of oral implants. Clin Oral Implants Res 2001;12:144-52.  Back to cited text no. 22
    
23.
Donati M, Botticelli D, La Scala V, Tomasi C, Berglundh T. Effect of immediate functional loading on osseointegration of implants used for single tooth replacement. A human histological study. Clin Oral Implants Res 2013;24:738-45.  Back to cited text no. 23
    
24.
Stanley M, Braga FC, Jordao BM. Immediate loading of single implants in the anterior maxilla: A 1-year prospective clinical study on 34 patients. Int J Dent 2017;2017:8346496.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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