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IMMEDIATE PLACEMENT OF IMPLANTS IN EXTRACTION
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ARTICLE 3
IMMEDIATE PLACEMENT OF IMPLANTS IN EXTRACTION SITES OF MAXILLARY IMPACTED CANINES ZIV MAZOR, D.M.D.; MICHAEL PELEG, D.M.D.; MEIR REDLICH, D.M.D., M.SC.
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Background. Treatment of asymptomatic impacted maxillary canines in adults is inevitable when primary canine becomes lost through extraction or exfoliation or when the impacted tooth becomes symptomatic. Treatment alternatives include an orthodontic procedure to bring the unerupted tooth to the dental arch or prosthetic replacement of the missing tooth. The authors describe an alternative treatment that involves immediate placement of implants into extraction sockets of the teeth. Case Description. A patient with bilateral palatally impacted upper canines chose to have the unerupted teeth removed and replaced with implants and crowns. Two hydroxyapatite cylindrical implants were inserted through the alveolar ridge into
With the exception of third molars, the most fre-
quently impacted teeth in adults are maxillary canines. Unerupted permanent canines cause relatively few problems for patients, and some of these teeth remain unerupted and asymptomatic for many years.1 Although a retained primary canine may result in a relatively poor appearance compared with that of a permanent canine, most patients do not seek treatment for a retained primary canine. The reasons why adults have impacted maxillary canines vary. In some cases, the general dentist or orthodontist may not have emphasized the importance of treating the impacted permanent
the extraction sites. The unfilled areas in the extraction sites, around the dental implants, were packed and covered with demineralized freeze-dried bone allograft in conjunction with a collagen membrane barrier. Six months after implantation, computed tomography revealed complete osseous fill of the extraction defects and no bone loss around the implants. The implants were uncovered, and porcelain-fused-tometal restorations were fabricated and placed. Clinical Implications. This treatment modality avoids the need for conventional preparation of teeth as part of prosthetic reconstruction or prolonged orthodontic treatment aimed at bringing the impacted canine to the dental arch. Combining the implantation with bone augmentation preserved the alveolar bone and shortened the treatment period.
tooth when the patient was a child. Or perhaps the parents had an inadequate level of awareness about dental health issues. Some impacted canines simply may never have been diagnosed. Another possibility is that the parent—and later the patient—chose to delay treatment until an esthetic or functional need arose or the impacted tooth became symptomatic. Before initiating orthodontic treatment to resolve the impaction, the dentist must inform the adult patient that teeth that have been impacted for many years sometimes undergo pathological changes that might prevent their eruption.2 It is not always possible to diagnose
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
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1767
C
CLINICAL PRACTICE
Figure 1. Panoramic radiograph showing impacted canines before treatment.
Figure 2. Extraction sites showing extensive deficiency of palatal bone before placement of the implants.
patient must be part of the decision-making process and be fully informed of the potential problems related to treatment. DENTAL IMPLANTS
Replacing missing teeth with dental implants is a common procedure.3,4 Several authors have reported success rates of more than 90 percent for implants placed into fresh
Figure 3. Extraction sites filled with demineralized freeze-dried bone allograft.
pathological changes from a radiograph, unless there has been a loss of follicular sac, and signs of resorption have become evident on the surface of the unerupted tooth. The dentist must carefully inform the patient of the significant possibility of failure when attempting to bring an impacted tooth into the arch. Moving the canine to the dental arch takes considerably longer in an adult than in a child.1 Therefore, the 1768
Considering the risk that the impacted teeth might fail to erupt and the need for a protracted treatment period if eruption was successful, the patient chose a prosthetic approach. extraction sites.5-8 In many cases, the surgeon faces difficulty when immediately placing implants because usually there is a gap between the occlusal section of the implant and the surrounding socket walls. This problem can be resolved by using a variety of grafting mate-
rials with a barrier membrane, which encourages bone to fill the empty space.9-14 The rationale for using barrier membranes is to retain a space defect adjacent to the implant to facilitate clot formation, retention and stabilization. In addition, the membrane prevents the collapse of connective tissue and apical proliferation of epithelium, while attracting and differentiating osteogenic cells; this increases the likelihood of the bone to regenerate around the implant’s coronal portion. CASE REPORT
Diagnosis. The patient in this case did not seek treatment earlier because of the esthetically acceptable primary upper canines and asymptomatic impacted permanent canines (Figure 1). At the age of 45 years, she sought treatment from one of us (Z.M.), which was precipitated by a fracture of the right primary canine and excessive mobility of the left primary canine. (These teeth were later extracted.) We classified the patient’s status as Angle Class I malocclusion, with bilateral palatally impacted canines.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE
A
Figure 5. Panoramic radiograph 12 months after treatment.
B Figure 4. Final porcelain-fused-tometal restorations of the right (A) and left (B) canines.
Treatment options. We suggested both orthodontic and prosthetic options to replace the clinically missing permanent canines. Considering the risk that the impacted teeth might fail to erupt and the need for a protracted treatment period if eruption was successful, the patient chose a prosthetic approach. Two treatment modalities were possible: dan anterior fixed conventional bridge or a semibonded (Maryland-type) bridge with or
without extraction of the impacted canines; dsurgical removal of the impacted teeth combined with placement of implants. The patient chose the second option. Treatment. Since adequate space was available, there was no need to orthodontically reopen the mesiodistal width of the canine area. After local anesthetic was administered, the buccal and palatal flaps were reflected to expose the impacted canines and the alveolar crest. Both canines were extracted and implant osteotomies were performed via the alveolar crest to the extraction sites. Two hydroxyapatite-coated implants (Sulzer Calcitek) that were 3.25 millimeters in diameter and 15 mm in length were inserted. The apical portions of the implants were devoid of bony support since the palatal bone was missing after the extraction (Figure 2). We filled the defects with demineralized freeze-dried bone allograft (Pacific Coast Tissue Bank) (Figure 3), and placed a collagen membrane (Biomend, Sulzer Calcitek) over the allograft and implants. During the six-month healing period, the patient wore a removable partial denture,
which replaced the canines and served as a space maintainer. A panoramic radiograph and computed tomographic scan obtained six months after surgery showed complete osseous fill of the defects surrounding the implants and the bony plate of the palate. When the implants were reexposed for preparation of the final restoration, no sign of bone loss was evident and the implants were clinically stable. We performed a conventional prosthetic procedure, which involved the construction of two fixed porcelain-fused-to-metal crowns on two gold coping abutments (Figure 4). The patient was very satisfied with the final result. One year later, clinical and radiographic examinations revealed satisfactory esthetics, function and marginal bone integrity (Figure 5). CONCLUSION
We have presented a case report that illustrates a unique treatment modality for impacted canines in an adult. The simultaneous placement of an implant into the extraction site of a palatally impacted canine in conjunction with bone grafting shortened the treatment period. We need to
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
1769
CLINICAL PRACTICE emphasize, however, that a prerequisite for immediate placement of an implant into an extraction site is an adequate mesiodistal arch space for subsequent placement of a crown. ■ The authors acknowledge the advice and assistance of Adrian Becker, professor, Department of Orthodontics, Hebrew University, Hadassah School of Dental Medicine, Jerusalem, Israel. 1. Becker A. The orthodontic treatment of impacted teeth. London: Martin Dunitz; 1998:179-98. 2. Azaz B, Shteyer A. Resorption of the crown in impacted maxillary canine: a clinical, radiographic and histologic study. Int J Oral Surg 1978; 7(3):167-71. 3. Adell R, Lekholm U, Rockler B, Brane-
mark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10(6):387416. 4. Van Steenberghe D, Lekholm U, Bolender C, et al. Applica- Dr. Mazor is a periobility of osseointedontist in private grated oral implants in practice. Address the rehabilitation of reprint requests to partial edentulism: a Dr. Mazor, number 5, prospective multiAtarot St., Ra’anana center study on 558 43567, Israel. fixtures. Int J Oral Maxillofac Implants 1990; 5(3): 272-81. 5. Ashman A. An immediate tooth root replacement: an implant cylinder and synthetic bone combination. J Oral Implantol 1990; 16(1):28-38. 6. Yukna RA. Clinical comparison of hydroxyapatite-coated titanium dental implants
Dr. Peleg is a senior
Dr. Redlich is a clin-
staff member,
ical lecturer, Depart-
Department of Oral
ment of Orthodon-
and Maxillofacial
tics, Hebrew
Surgery, The Chaim
University, Hadassah
Sheba Medical
School of Dental
Center, Ramat Gan,
Medicine, Jerusalem,
Israel.
Israel.
placed in fresh extraction sockets and healed extraction sites. J Periodontol 1991;62(7):46872. 7. Gelb DA. Immediate implant surgery: three-year retrospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 1993;8(4):388-99. 8. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol 1997;68(10):915-23. 9. Becker W, Dahlin C, Becker BE, et al. The use of e-PTFE barrier membranes for bone promotion around titanium implants placed into extraction sockets: a prospective multicenter study. Int J Oral Maxillofac Implants 1994;9:32-40. 10. Gher ME, Quintero G, Assad D, Monaco E, Richardson AE. Bone grafting and guided bone regeneration for immediate implants in humans. J Periodontol 1994;65(9):881-91. 11. Bragger U, Hammerle CH, Lang NP. Immediate transmucosal implants using the principle of guided tissue regeneration. II. A cross-sectional study comparing the clinical outcome 1 year after immediate to standard implant placement. Clin Oral Implants Res 1996;7(3):268-76. 12. Augthun M, Yildirim M, Spiekermann H, Biesterfeld S. Healing of bone defects in combination with immediate implants using the membrane technique. Int J Oral Maxillofac Implants 1995;10(4):421-8. 13. Block MS, Kent JN. Placement of endosseous implants into tooth extraction sites. J Oral Maxillofac Surg 1991; 49(12): 1269-76. 14. Kent JN, Block MS. Simultaneous maxillary sinus floor bone grafting and placement of hydroxylapatite-coated implants. J Oral Maxillofac Surg 1989;47(3):238-42.
Copyright ©1998-2001 American Dental Association. All rights reserved.
D
J
A
✷
IO N
A
T
T
CON I
N U
IN G
ED
U
ARTICLE 3
IMMEDIATE PLACEMENT OF IMPLANTS IN EXTRACTION SITES OF MAXILLARY IMPACTED CANINES ZIV MAZOR, D.M.D.; MICHAEL PELEG, D.M.D.; MEIR REDLICH, D.M.D., M.SC.
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B
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A
C
T
Background. Treatment of asymptomatic impacted maxillary canines in adults is inevitable when primary canine becomes lost through extraction or exfoliation or when the impacted tooth becomes symptomatic. Treatment alternatives include an orthodontic procedure to bring the unerupted tooth to the dental arch or prosthetic replacement of the missing tooth. The authors describe an alternative treatment that involves immediate placement of implants into extraction sockets of the teeth. Case Description. A patient with bilateral palatally impacted upper canines chose to have the unerupted teeth removed and replaced with implants and crowns. Two hydroxyapatite cylindrical implants were inserted through the alveolar ridge into
With the exception of third molars, the most fre-
quently impacted teeth in adults are maxillary canines. Unerupted permanent canines cause relatively few problems for patients, and some of these teeth remain unerupted and asymptomatic for many years.1 Although a retained primary canine may result in a relatively poor appearance compared with that of a permanent canine, most patients do not seek treatment for a retained primary canine. The reasons why adults have impacted maxillary canines vary. In some cases, the general dentist or orthodontist may not have emphasized the importance of treating the impacted permanent
the extraction sites. The unfilled areas in the extraction sites, around the dental implants, were packed and covered with demineralized freeze-dried bone allograft in conjunction with a collagen membrane barrier. Six months after implantation, computed tomography revealed complete osseous fill of the extraction defects and no bone loss around the implants. The implants were uncovered, and porcelain-fused-tometal restorations were fabricated and placed. Clinical Implications. This treatment modality avoids the need for conventional preparation of teeth as part of prosthetic reconstruction or prolonged orthodontic treatment aimed at bringing the impacted canine to the dental arch. Combining the implantation with bone augmentation preserved the alveolar bone and shortened the treatment period.
tooth when the patient was a child. Or perhaps the parents had an inadequate level of awareness about dental health issues. Some impacted canines simply may never have been diagnosed. Another possibility is that the parent—and later the patient—chose to delay treatment until an esthetic or functional need arose or the impacted tooth became symptomatic. Before initiating orthodontic treatment to resolve the impaction, the dentist must inform the adult patient that teeth that have been impacted for many years sometimes undergo pathological changes that might prevent their eruption.2 It is not always possible to diagnose
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
✷
1767
C
CLINICAL PRACTICE
Figure 1. Panoramic radiograph showing impacted canines before treatment.
Figure 2. Extraction sites showing extensive deficiency of palatal bone before placement of the implants.
patient must be part of the decision-making process and be fully informed of the potential problems related to treatment. DENTAL IMPLANTS
Replacing missing teeth with dental implants is a common procedure.3,4 Several authors have reported success rates of more than 90 percent for implants placed into fresh
Figure 3. Extraction sites filled with demineralized freeze-dried bone allograft.
pathological changes from a radiograph, unless there has been a loss of follicular sac, and signs of resorption have become evident on the surface of the unerupted tooth. The dentist must carefully inform the patient of the significant possibility of failure when attempting to bring an impacted tooth into the arch. Moving the canine to the dental arch takes considerably longer in an adult than in a child.1 Therefore, the 1768
Considering the risk that the impacted teeth might fail to erupt and the need for a protracted treatment period if eruption was successful, the patient chose a prosthetic approach. extraction sites.5-8 In many cases, the surgeon faces difficulty when immediately placing implants because usually there is a gap between the occlusal section of the implant and the surrounding socket walls. This problem can be resolved by using a variety of grafting mate-
rials with a barrier membrane, which encourages bone to fill the empty space.9-14 The rationale for using barrier membranes is to retain a space defect adjacent to the implant to facilitate clot formation, retention and stabilization. In addition, the membrane prevents the collapse of connective tissue and apical proliferation of epithelium, while attracting and differentiating osteogenic cells; this increases the likelihood of the bone to regenerate around the implant’s coronal portion. CASE REPORT
Diagnosis. The patient in this case did not seek treatment earlier because of the esthetically acceptable primary upper canines and asymptomatic impacted permanent canines (Figure 1). At the age of 45 years, she sought treatment from one of us (Z.M.), which was precipitated by a fracture of the right primary canine and excessive mobility of the left primary canine. (These teeth were later extracted.) We classified the patient’s status as Angle Class I malocclusion, with bilateral palatally impacted canines.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE
A
Figure 5. Panoramic radiograph 12 months after treatment.
B Figure 4. Final porcelain-fused-tometal restorations of the right (A) and left (B) canines.
Treatment options. We suggested both orthodontic and prosthetic options to replace the clinically missing permanent canines. Considering the risk that the impacted teeth might fail to erupt and the need for a protracted treatment period if eruption was successful, the patient chose a prosthetic approach. Two treatment modalities were possible: dan anterior fixed conventional bridge or a semibonded (Maryland-type) bridge with or
without extraction of the impacted canines; dsurgical removal of the impacted teeth combined with placement of implants. The patient chose the second option. Treatment. Since adequate space was available, there was no need to orthodontically reopen the mesiodistal width of the canine area. After local anesthetic was administered, the buccal and palatal flaps were reflected to expose the impacted canines and the alveolar crest. Both canines were extracted and implant osteotomies were performed via the alveolar crest to the extraction sites. Two hydroxyapatite-coated implants (Sulzer Calcitek) that were 3.25 millimeters in diameter and 15 mm in length were inserted. The apical portions of the implants were devoid of bony support since the palatal bone was missing after the extraction (Figure 2). We filled the defects with demineralized freeze-dried bone allograft (Pacific Coast Tissue Bank) (Figure 3), and placed a collagen membrane (Biomend, Sulzer Calcitek) over the allograft and implants. During the six-month healing period, the patient wore a removable partial denture,
which replaced the canines and served as a space maintainer. A panoramic radiograph and computed tomographic scan obtained six months after surgery showed complete osseous fill of the defects surrounding the implants and the bony plate of the palate. When the implants were reexposed for preparation of the final restoration, no sign of bone loss was evident and the implants were clinically stable. We performed a conventional prosthetic procedure, which involved the construction of two fixed porcelain-fused-to-metal crowns on two gold coping abutments (Figure 4). The patient was very satisfied with the final result. One year later, clinical and radiographic examinations revealed satisfactory esthetics, function and marginal bone integrity (Figure 5). CONCLUSION
We have presented a case report that illustrates a unique treatment modality for impacted canines in an adult. The simultaneous placement of an implant into the extraction site of a palatally impacted canine in conjunction with bone grafting shortened the treatment period. We need to
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
1769
CLINICAL PRACTICE emphasize, however, that a prerequisite for immediate placement of an implant into an extraction site is an adequate mesiodistal arch space for subsequent placement of a crown. ■ The authors acknowledge the advice and assistance of Adrian Becker, professor, Department of Orthodontics, Hebrew University, Hadassah School of Dental Medicine, Jerusalem, Israel. 1. Becker A. The orthodontic treatment of impacted teeth. London: Martin Dunitz; 1998:179-98. 2. Azaz B, Shteyer A. Resorption of the crown in impacted maxillary canine: a clinical, radiographic and histologic study. Int J Oral Surg 1978; 7(3):167-71. 3. Adell R, Lekholm U, Rockler B, Brane-
mark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10(6):387416. 4. Van Steenberghe D, Lekholm U, Bolender C, et al. Applica- Dr. Mazor is a periobility of osseointedontist in private grated oral implants in practice. Address the rehabilitation of reprint requests to partial edentulism: a Dr. Mazor, number 5, prospective multiAtarot St., Ra’anana center study on 558 43567, Israel. fixtures. Int J Oral Maxillofac Implants 1990; 5(3): 272-81. 5. Ashman A. An immediate tooth root replacement: an implant cylinder and synthetic bone combination. J Oral Implantol 1990; 16(1):28-38. 6. Yukna RA. Clinical comparison of hydroxyapatite-coated titanium dental implants
Dr. Peleg is a senior
Dr. Redlich is a clin-
staff member,
ical lecturer, Depart-
Department of Oral
ment of Orthodon-
and Maxillofacial
tics, Hebrew
Surgery, The Chaim
University, Hadassah
Sheba Medical
School of Dental
Center, Ramat Gan,
Medicine, Jerusalem,
Israel.
Israel.
placed in fresh extraction sockets and healed extraction sites. J Periodontol 1991;62(7):46872. 7. Gelb DA. Immediate implant surgery: three-year retrospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 1993;8(4):388-99. 8. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol 1997;68(10):915-23. 9. Becker W, Dahlin C, Becker BE, et al. The use of e-PTFE barrier membranes for bone promotion around titanium implants placed into extraction sockets: a prospective multicenter study. Int J Oral Maxillofac Implants 1994;9:32-40. 10. Gher ME, Quintero G, Assad D, Monaco E, Richardson AE. Bone grafting and guided bone regeneration for immediate implants in humans. J Periodontol 1994;65(9):881-91. 11. Bragger U, Hammerle CH, Lang NP. Immediate transmucosal implants using the principle of guided tissue regeneration. II. A cross-sectional study comparing the clinical outcome 1 year after immediate to standard implant placement. Clin Oral Implants Res 1996;7(3):268-76. 12. Augthun M, Yildirim M, Spiekermann H, Biesterfeld S. Healing of bone defects in combination with immediate implants using the membrane technique. Int J Oral Maxillofac Implants 1995;10(4):421-8. 13. Block MS, Kent JN. Placement of endosseous implants into tooth extraction sites. J Oral Maxillofac Surg 1991; 49(12): 1269-76. 14. Kent JN, Block MS. Simultaneous maxillary sinus floor bone grafting and placement of hydroxylapatite-coated implants. J Oral Maxillofac Surg 1989;47(3):238-42.
Copyright ©1998-2001 American Dental Association. All rights reserved.