i “IMMEDIATE PLACEMENT OF IMPLANTS AT SINGLE ROOTED FRESH EXTRACTION SOCKET” - A CLINICAL AND RADIOLOGICAL EVALUATION By Dr. SHYNU SAHIB Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, In partial fulfillment of the requirements for the degree of MASTER OF DENTAL SURGERY In ORAL AND MAXILLOFACIAL SURGERY Under the guidance of Dr. B C SIKKERIMATH M.D.S Professor and Head DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, P.M.N.M DENTAL COLLEGE AND HOSPITAL, BAGALKOT-587101, KARNATAKA. 2015 - 2018
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i
“IMMEDIATE PLACEMENT OF IMPLANTS AT SINGLE ROOTED FRESH
EXTRACTION SOCKET” - A CLINICAL AND RADIOLOGICAL EVALUATION
By
Dr. SHYNU SAHIB
Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka,
In partial fulfillment of the requirements for the degree of
MASTER OF DENTAL SURGERY
In ORAL AND MAXILLOFACIAL SURGERY
Under the guidance of
Dr. B C SIKKERIMATHM.D.S Professor and Head
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY,
P.M.N.M DENTAL COLLEGE AND HOSPITAL,
BAGALKOT-587101, KARNATAKA.
2015 - 2018
Scanned by CamScanner
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LIST OF ABBREVIATIONS
SL. NO ABBREVIATIONS
FULL FORM
1 IOPAR INTRA ORAL PERI APICAL
RADIOGRAPH
2 OPG ORTHOPANTAMOGRAM
3 OPD OUT PATIENT DEPARTMENT
4 BOP BLEEDING ON PROBING
LIST OF TABLES
SL.NO.
TABLE NAME
PAGE NO.
1.
Table 1: Age distribution 26
2.
Table 2: Gender distribution 27
3. Table 3: Site & Aetiology of tooth loss
27
4. Table: 4 Implant fixture size
28
5. Table 5: Clinical evaluation of implants at the time of
their placement
29
6. Table 6 – Evaluation 7 days after surgery
30
7. Table 7 – Evaluation at the time of 3 months after surgery
31
8. Table 8: Radiological evaluation of Mean Mesial Vertical
Crestal Bone resorption measurement
32
9. Table 9: Radiological evaluation of Mean Distal Vertical
Crestal Bone resorption measurement
33
LIST OF FIGURES
SL.NO.
GRAPH NAME
PAGE NO.
1.
Graph 1 showing age distribution 35
2.
Graph 2 showing Gender distribution 35
3. Graph 3 showing Aetiology of extraction
36
4. Graph 4 showing size of implants used
36
5 Graph 5 showing stability of implant
37
6. Graph 6 showing Mean modified plaque index
37
7. Graph 7 showing mean gingival index
38
8. Graph 8 showing Mean vertical crestal bone level in mesial
side
38
9. Graph 9 showing Mean vertical crestal bone level in distal
side
39
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ABSTRACT
“IMMEDIATE PLACEMENT OF IMPLANTS AT SINGLE ROOTED FRESH
EXTRACTION SOCKET” - A CLINICAL AND RADIOLOGICAL
EVALUATION
BACKGROUND AND OBJECTIVES:
The concept of immediate implant placement helps out in many ways like
preserving the alveolar bone, the trauma, relief to the patient from strenuous
appointments and moreover holds a psychological value. Apart from the conventional
methods, placement of implant immediately after the extraction of a poor prognosis
teeth can be done. The objective of the study is to evaluate the outcome of
immediately placed implants in fresh extraction sockets.
METHODS:
Ten patients reporting to the Department of oral and maxillofacial surgery for
extraction of single rooted teeth will be examined and evaluated for receiving an
immediate implant placement. Patients will be followed up at intervals of 1 week, 1
month, 3 months and 6 months. At follow up appointments bone integration will be
assessed with the help of radiovisiography and clinical assessment of the soft tissue
will be performed by measuring the probing depth around the implant, presence or
absence of bleeding on probing and suppuration.
RESULTS:
10 implants were placed in the maxilla (all anterior) while no implants in the
mandible. Clinical evaluation of the implants 3 months after surgery showed good
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periodontal status with absence of Plaque, Bleeding on Probing, Pus Discharge and
Clinical Mobility.No implant failure was observed (100% success rate) in the 3 month
of the pre- loading phase, after which, 8 patients (accounting for 10 implants)
received single unit fixed partial restoration.
INTERPRETATION AND CONCLUSION:
On conclusion we recommend the use of immediate implants as a viable therapeutic
option in improving success, reducing the treatment duration and patient
acceptance.Immediate implants must gain sufficient primary (mechanical) stability for
successful outcome.
KEY WORDS: Osseo integration, Primary stability, Crestal bone
INTRODUCTION
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT 1
INTRODUCTION
This is an era in which dental implants are conquering the field of aesthetic
dentistry. As a result of it, the other routine prosthesis is in a way of fading.
A dental implant is an artificial replacement for a tooth root usually made
from titanium. Schmidt et al. (2001) defines an ideal bone implant material as having
a biocompatible chemical composition to avoid adverse tissue reaction, excellent
corrosion resistance in the physiologic limits, acceptable strength, a high resistance to
wear and a modulus of elasticity similar to that of bone to minimize bone resorption
around the implant1. There are many implant systems available and when
competently use, they all deliver a highly reliable form of treatment. Dental implants
are suitable for most adults with good general health. Loss of teeth in the aesthetic
zone is a traumatic experience with or without compromise in phonetics and function.
Hence in the aesthetic zone implant supported single tooth replacement is one of the
most challenging situations confronting the clinician. The concept of immediate
implant placement helps out in many ways like preserving the alveolar bone, the
trauma, relief to the patient from strenuous appointments and moreover holds a
psychological value2.
When it comes to the history of dental implants, it is quite
a long way back. In 1981, evidence of oldest dental implant was found in the Kalavak
Metropolis in Turkey, which is dated back to 550 B C.
But the introduction of Titanium implants took place after the accidental
discovery of osseointegration of Titanium by Branemark in early 1950s. Soon after
this, the evaluation of various types of dental implants came into the health care
INTRODUCTION
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT 2
market. Different types like based on design attachment, mechanism, surface of
implant, types of material used.
Implants were usually used in a missing tooth region. Taking various
operative and technical considerations into actions, the width and length of implant
should be decided by clinician. Apart from the conventional methods, placement of
implant immediately after the extraction of a poor prognosis teeth can also be done.
This can offer minimum treatment time, psychological benefits and helps in avoiding
another surgical procedure and appointment for implant placement.
For this study, patients with poor prognosis of anterior single rooted teeth with
no other conservative management is possible are selected. Ten patients reporting to
the Department of Oral and Maxillofacial Surgery OPD are chosen. After the
extraction of teeth, for replacing, patients have option of removable prosthesis, fixed
prosthesis and implants. Implants can be used as delayed and immediate. In delayed
implants, after the extraction, patient have to wait till bone formation finishes. It may
take months together. Certain literature says about intermediate placement which is
done by placing implant after a period of 2 to 3 weeks from extraction. But this is not
been widely used because the results is less or equal to the immediate placement.
Immediate placement helps in single appointment work, holds psychological benefits,
it helps in preserving the alveolar bone. The present study aims to evaluate the clinical
and radiological outcome of immediate placement of implants.
OBJECTIVES
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT 3
OBJECTIVES
The objective of the study is to evaluate the outcome of immediately placed
implants in fresh extraction sockets. It is done by regular assesment of
osseointegration as seen on routine radiographs and clinically by checking the
primary stability and bleeding on probing around the region of implant placed.
REVIEW OF LITERATURE
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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REVIEW OF LITERATURE
Thomas G. Wilson and Daniel Buser (1998) done a study on Implants placed in
immediate extraction sites: A report of histologic and histometric analyses of human
biopsies. Five titanium plasma-sprayed implants were biopsied from a human
volunteer 6 months after placement. Four test implants had been placed in immediate
extraction sockets, while one implant was placed in a mature site and served as a
control. The histologic analysis demonstrated that all five implants achieved
osseointegration as demonstrated by light microscopy, whereas a varying degree of
bone-implant contact was observed. The authors concluded that osseointegration may
occur in immediate extraction sites in humans using titanium implants with a plasma-
sprayed surface. The horizontal component of the peri-implant defect was apparently
the most critical factor relating to the final amount of bone-implant contact3.
Paul A Fugazzotto (2002) performed a study to assess the success rate of immediate
implant placement following a modified trephine / osteotome approach. In his study a
technique is presented which utilizes a trephine with 3.0 mm diameter followed by an
osteotome to implode a core of maxillary posterior alveolar bone prior to immediate
implant placement. He concluded that implants can be uncovered by this technique
and it will be an ease for further restoration4.
Nemcovsky CE et al. (2002) conducted a study wherein, healing of marginal defects
around implants placed in fresh extraction sockets was measured. Two implant
placement protocols were compared: delayed-immediate sites primarily closed by a
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P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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rotated palatal flap (RPF) at the time of tooth extraction and implantation after 4–6
weeks and immediate procedures (into fresh extraction sockets) primarily closed by a
rotated split palatal flap (RSPF). Height and width of the marginal defect were
measured at the time of implant placement and after 6–8 months, at second stage
surgery. Significant differences were found for mean percentage reduction of the
defect height and area only between the two implant subgroups within each group5.
Lars Schropp and et al (2003) carried out a prospective clinical study on bone
healing following immediate versus delayed placement of Titanium implants into
extraction sockets. The aim was to compare bone healing and crestal bone changes
following immediate vs delayed placement of titanium dental implants with acid
etched surfaces in extraction sockets. A total of 46 patients, 23 in each group were
randomly allocated and received 1 implant in premolar, canine and incisor region of
maxilla and mandible. The width and depth of marginal bone around implant was
measured clinically at the time of placement and crestal bone changes were evaluated
radiographically by linear measurements. The study has concluded that new bone
formation occurs in infrabony defects associated with immediately placed implants in
extraction sockets6.
Stephen T Chen et al (2004) studied the biologic basis, clinical procedures and
outcomes of immediately placed implants following tooth extraction. The aim of their
study was to review the current literature with regard to survival and success rates
along with clinical procedures and outcomes associated with immediate and delayed
implant placement. A MEDLINE search was conducted for studies published between
1990 and June 2003. From that 10 cases were included with detailed case reports.
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Studies reporting on success and survival rates were required to have follow up
periods of at least 12 months. The study concluded that short-term survival rates and
clinical outcomes of immediate and delayed implants were similar7.
Bianchi AE et al. (2004) evaluate the long-lasting efficacy of a combined surgical
protocol, using immediate implant and subepithelial connective tissue graft for single-
tooth replacement. In the time period from 1990 to 1998, 116 patients were
consecutively admitted for treatment with a total of 116 solid screw ITI-implants
supporting single crowns. Ninety-six patients underwent the proposed combined
treatment (test group), while 20 received only single immediate implants (control
group). The observation time extended from 1 up to 9 years. The 9-year cumulative
survival rate was 100% for both test and control groups8.
Luiz A Lima, Anita M Fuchs-Wehrle and et al (2004) done a study to analyze the
surface characteristics of implants influence their bone integration after simultaneous
placement of implant and GBR membrane. The purpose of this study was to evaluate
the influence of titanium surface characteristics on bone integration of implants, and
to describe the pattern of peri-impiant tissue healing after simultaneous implant
placement and guided bone regeneration. The fraction of implant-bone integration
was much higher in the pristine bone compared to that in the regenerated bone.
Titanium plasma sprayed surfaces positively influenced the fraction of
osseointegration in comparison to machined surfaces for both regenerated and pristine
bone. Furthermore, early membrane removal negatively affected the fraction of bone
defect fill9.
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Cangini F et al. (2005) use an enamel matrix derivative (EMD) and bioabsorbable
barrier membrane to enhance healing following the immediate placement of
transmucosal implants into extraction sockets was assessed. Thirty-two adult patients
scheduled for tooth replacement with dental implants agreed to participate. Following
the insertion of a transmucosal implant into the extraction site, the subjects were
assigned to one of two treatment alternatives of the remaining bone defects around the
implants. They were: 1) the residual bone defects were filled with EMD (EMD group)
or 2) the residual bone defects were covered with a bioabsorbable membrane
(membrane group). Flaps were then coronally positioned around implant cover
screws. At a 12-month follow-up, all of the implants were completely osseointegrated
and successfully functioning, showing a success rate of 100%. Authors concluded that
membrane group obtained more favorable results in terms of both the probing
attachment level and peri-implant position of soft tissues compared to the EMD
group. The use of a bioabsorbable membrane around immediately placed
transmucosal implants enhanced soft and hard tissue healing and might be an
advisable treatment choice particularly in areas with high esthetic demands10.
Cornelini R et al. (2005) evaluate the placement of immediate implants into fresh
extraction sockets. A series of 22 implants cases with a minimum of 12 months
follow- up done. Radiographic assessments were made at baseline to 12 months after
implant placement. Clinical parameters such as plaque score, mucositis score, probing
attachment level, mucosal margin position were measured at baseline to 12 months
after implants placement. Radiographic assessment revealed mean 0.5mm bone
resorption at 12 months. The success rate and radiographic and clinical results were
comparable to those obtained from conventional implants. The authors also describe
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P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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the radiographic method of measuring marginal bone level around peri-implant
surface11.
Roberto Cornelini, Filippo Cangini and et al (2005) had done a study on immediate
restoration of implants placed into fresh extraction sockets for single-tooth
replacement:A prospective clinical study. The aim of the present clinical study was to
evaluate the placement of transmucosal implants into fresh extraction sockets and
their immediate restoration with temporary crowns. Twenty-two patients (15 women
and 7 men; mean age 39 years) who needed a single tooth replaced because of vertical
or horizontal root fracture, caries, endodontic lesions, or periodontal disease were
treated with immediate postextraction implant placement. The implant was then
restored with a screw-retained prosthetic restoration within 24 hours. Radiographic
assessments were made at baseline and 12 months after implant placement. Clinical
parameters, such as plaque score, mucositis score, probing attachment level, mucosal
margin position, variation of gingival level, and variation of papilla position, were
also measured at baseline and after 12 months of follow-up. At 12 months, no
implants had failed. He concluded that within the limits of the present investi- gation,
immediate restoration of single-tooth implants placed in fresh extraction sockets can
be considered a valuable option to replace a missing tooth10.
Peter K Moy, Diana Medina and et al (2005)conducted a study to assess the failure
rates of dental implants and associated risk factors. They collected all the records of
implant cases from the year of 2003 to 1982 in a retrospective cohort study.they
considered all the patient data and procedure details for their study. They got a result
of increasing age, smoking, medically compromised conditions showed an increase in
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P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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failure of implants compared to the normal counterparts. They concluded by quoting
that the overall dental implant failure is low and there is no absolute contraindications
for implant placement. Conditions that were found to be correlated with an increased
risk of failure should be considered during treatment planning and factored into the
informed consent process12.
W. Becker (2006) has conducted a study on treatment planning and surgical steps for
successful outcomes of immediate implant placement. In this study he stressed on
diagnosis and treatment planning and further follow up with radiographs for a
successful outcome. He concluded as the efficacy of immediate implant placement
has been established and shown to be predictable if reasonable guidelines are
followed. Thorough medical and dental histories, clinical photographs, OPG and
IOPA radiographs of the implant site are inevitable13.
Crespi R et al. (2008) did a study to evaluate the radiographic assessment of crestal
bone level changes around the implant placed in the fresh extraction socket. Forty
patients were included in the study. Radiographic assessments were made at baseline,
at 6 months ad at 24 months. After 24-month follow-up period, a cumulative survival
rate of 100% was reported for all implants. Radiographic assessment showed mean
bone loss at 24 months follow up was 1.02+/- 0.53mm bone14.
Botticelli D et al. (2008) evaluate the 5-year clinical outcome of the immediate
implants. One week after the cementation of the prosthesis, a clinical baseline
examination was carried out. Clinical measurements were performed of the following:
plaque, mucositis, probing pocket depth, and soft tissue position. The height of the
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P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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keratinized mucosa was measured at the buccal/lingual aspects. Standardized intra-
oral radiographs were taken. The marginal level of bone to implant contact was
measured and bone level change over time was evaluated. The clinical/ radiographic
measurements were repeated on a yearly basis. Authors concluded that ‘immediate
implants that were loaded after 5–7 months had a high success rate. During the 5-year
interval, no implant was lost, and the mean bone level at the implants was maintained
or even improved15.
Cafiero C et al. (2008) in this cohort study assess the clinical and radiographic
outcomes of immediate transmucosal placement of implants into molar extraction
sockets. Following molar extraction, tapered implants with an endosseous diameter of
4.8mm and a shoulder diameter of 6.5mm were immediately placed into the sockets.
Peri-implant marginal defects were treated according to the principles of guided bone
regeneration (GBR) by means of deproteinized bovine bone mineral particles in
conjunction with a bioresrobable collagen membrane. Eighty-two patients (42 males
and 40 females) were enrolled and followed for 12 months. They contributed with 82
tapered implants. Extraction sites displayed sufficient residual bone volume to allow
primary stability of all implants. No post-surgical complications were observed. All
implants healed uneventfully yielding a survival rate of 100% and healthy soft tissue
conditions after 12 months16.
Stephen T Chen and Daniel Buser (2009)had conducted a study to evaluate clinical
outcomes of implant placed in postextraction sites. Bone augmentation procedures are
effec- tive in promoting bone fill and defect resolution at implants in postextraction
sites, and are more successful with immediate and early placement than with late
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P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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placement. The majority of studies reported survival rates of over 95%. Similar
survival rates were observed for immediate and early placement. Recession of the
facial mucosal margin is common with immediate placement. Risk indicators
included a thin tissue biotype, a facial malposition of the implant, and a thin or
damaged facial bone wall. They also said that early implant placement is associated
with a lower frequency of mucosal recession compared to immediate placement17.
Gökçen-Röhlig B et al. (2010) examine the clinical and radiographic results of
implants placed in fresh extraction sockets for 2 years of function. Ten patients were
presented a treatment protocol involving the extraction of their remaining mandibular
teeth and immediate placement of 4 implants (2 in fresh extraction sockets; test group
(n =20), 2 in mature bone; control group ( n = 20). Descriptive statistics for the
differences between baseline and follow-up values were assessed by chi-square test.
None of the implants lost osseointegration. Authors concluded that placement of
implants in fresh extraction sockets is a reliable treatment alternative18.
Peñarrocha-Diago MA et al. (2011) compare the success rates, after 1 year of
loading, for implants placed immediately after tooth extraction and in healed sites in
patients undergoing extraction of all residual teeth for rehabilitation with a fixed, full-
arch, implant-supported prosthesis. A retrospective case series study was conducted of
38 patients treated from June 2004 to June 2008 by extraction of all remaining teeth
and implant placement in both mature bone and at the extraction site in the same
procedure. After osteointegration, the implants were restored with fixed full-arch
prostheses. The marginal bone loss around the implants was measured after 1 year. A
total of 41 arches were restored in 30 patients, 23 in the maxilla and 18 in the
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P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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mandible. A total of 292 implants were placed, 173 immediately and 119 in mature
bone. Of the 292 implants, 8 failed, 4 in the immediate group and 4 in the
nonimmediate group. The mean bone loss was 0.6 mm at 1 year of loading (0.63 ±
0.18 mm at the immediate implant sites and 0.58 ± 0.26 in mature bone). The mean
success rate was 96.9% overall, 97.7% for the immediate group, and 96.3% for the
nonimmediate group. Authors concluded that enhanced bone healing and remodeling
can take place in fresh extraction socket defects associated with immediately placed
implants. The results of the present study have demonstrated that immediate implant
osseointegration can be as, or more, successful than nonimmediate implantation
during the same healing period19.
Lang NP et al. (2011) estimate survival and success rates of implants and the
implant- supported prostheses, the prevalence of biological, technical and aesthetic
complications, and the magnitude of soft and hard tissue changes following implant
placement immediately into fresh extraction sockets. A study from 1991 to July 2010
was performed to include prospective studies on immediate implants with a mean
follow-up time of at least 1 year. A total of 46 prospective studies, with a mean
follow- up time of 2.08 years, were included. The annual failure rate of immediate
implants was 0.82% (95% CI: 0.48–1.39%), translating into the 2-year survival rate of
98.4% (97.3– 46 99%)20.
Col M Viswambaram, Maj Gen Vimal Arora and et al (2011) did a study for
clinical evaluation of immediate implants using different types of bone augmentation
materials. Two types of graft materials namely Dembone ( freeze dried bone allograft)
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and G Bone ( modified hydroxyapatite) were used in addition to the implant root
form. Then they did a followup for 1 year both clinically and radiographically. They
got a result that no implant was lost and the mean bone level at the implants was
maintained or even improved and they concluded that immediate restoration of single
tooth implants placed in fresh extraction sockets could be considered a valuable
option to replace a missing tooth and use of graft has a synergestic effect in the
prognosis21.
Hayacibara RM et al. (2012) evaluate the success rate of immediate dental implants
placement in mandibular molars within a follow-up period as long as 8 years.
Seventy- four mandibular molar implants after non-traumatic tooth extraction
between 2002 and 2008 were examined in the study. All implants were evaluated
radiographically immediately after prosthesis placement, 1 year after implantation,
and by the end of the experimental period, in 2010. All implants presented clinical
and radiographic stable conditions, that is, 100% success rate. Authors concluded that
immediate implant placement of mandibular molars proved to be a viable surgical
treatment given the high success rate up to 8 years after implantation22.
Atieh MA et al. (2012) evaluate immediate placement and immediate restoration of
strongly tapered wide-diameter implant in fresh mandibular molar extraction sockets.
Twenty-four 8- or 9-mm diameter implants were placed in either a fresh molar
extraction socket or a healed site. All the implants received provisional crowns within
48 h. The provisional crowns were replaced with full ceramic crowns after 8 weeks of
implant placement. The overall implant success rate after 1 year of service for the 24
implants in two treatment groups was 75%. Success rates were 83.3% and 66.7% for
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P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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the delayed and immediate placement groups respectively, with no significant
difference observed between the two groups (P = 0.35)23.
Archana Singh, Aratee and et al (2012) performed a study on immediate implant
placement in fresh extraction socket with early loading. In this study they considered
immediate placement of implants in anterior fresh extraction sockets. As the anterior
region is of prime concern in case of aesthetics, the implant placement is one of the
most challenging situations confronting the clinician. They provided with the case
report of a 20-year-old male patient with fractured upper anterior teeth with poor
prognosis. Presurgical radiographic evaluation was carried out using periapical
radiographs and OPG for appropriate treatment planning. After that an endo osseous
implant was selected. They came to the conclusion that it is possible to achieve
greater efficiency in our efforts to give patient sound, timely and economical
treatment. Even though the procedure is technique sensitive, but it is clear that with
continued innovation we should be able to enhance the outcome24.
A Chandra Sekar, M Praveen and Aarti Saxena (2012) had done a study on
immediate implant placement to analyze the success rate of the procedure by
assessing the stability of implant and changes in the hard and soft tissues surrounding
the implant. The tooth was atraumatically extracted, the socket was prepared to the
required depth and a Biohorizon Implant was inserted followed a week later by
temporization by a bonded restoration. They concluded that atraumatic operating
technique and the immediate insertion of the Implant resulted in the preservation of
the hard and soft tissues at the extraction site25.
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Jordi Ortega-Martínez (2012) done a systematic review on immediate implants
following tooth extraction. The aim of this study is to review the current state of
immediate implants, with their pros and contras, and the clinical indications and
contraindications. Immediate implants have predictable results with several
advantages over delayed implant placement. However, technical complications have
been described regarding this technique. Also, biomaterials may be needed when the
jumping distance is greater than 1mm or any bone defect is present26.
Kirsten W Slagter and Laurens Den Hartog (2014)had done a research interest on
immediate placement of dental implants has shifted from implant survival toward
optimal preservation of soft and hard tissues. The aim of this study is to
systematically assess the condition of implant survival, peri-implant hard and soft
tissue changes, esthetic outcome, and patient satisfaction of immediately placed
single- tooth implants in the esthetic zone. A pooled analysis was performed to
identify factors associated with survival and peri-implant tissue changes after
immediate implant placement. Immediate placement with immediate
provisionalization of dental implants in the esthetic zone results in excellent short-
term treatment outcome in terms of implant survival and minimal change of peri-
implant soft and hard tissue dimensions27.
Sundar Ramalingam and et al (2015) conducted a retrospective study of immediate
implants at single rooted teeth sites for implant survival based on size and site of
placement. This study sought to evaluate the survival of immediate implants at the
maxillary and mandibular single rooted extraction sites. The study included 85
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patients from both genders. The implant survival and its relationship with size and site
are evaluated by odds ratio. They concluded their study as immediate implant
placement in fresh extraction sockets can give predictable clinical outcomes,
regardless of the implant size and site of placement28.
Mayank Singh, Lakshya Kumar and et al (2015) conducted a study on Immediate
dental implant placement with immediate loading following extraction of natural
teeth. In this study, extraction sockets were thoroughly debrided and inspected with
the help of periodontal probe for any defect or possible perforation of cortical plate.
Osteotomy sites were prepared with sequential order of drills, Implants were inserted
in the prepared osteotomy sites with insertion torque of 45 NCm, and adequate
primary stability was obtained. Provisionalization was done with laboratory fabricated
self-cure acrylic (Pyrax Polymers, Roorkee, India) crowns and a followup of 1 week,
1 month, 3 months and 6 months is done. They concluded that immediate implant
placement with immediate loading may be a viable treatment option for cases
requiring earliest restoration of teeth to be extracted. Careful selection of cases, proper
treatment plan and follow-up of surgical and prosthetic protocols are the keys to
success29.
Elise J Zuiderveild and Henry (2015) conducted a study on immediate placement
and provisionalization of an implant after removal of an impacted maxillary canine.
The objective of this report was to describe a surgical approach for removal of a
buccal or palatally located impacted secondary canine, combined with extraction of
the failing primary canine, and immediate placement and provisionalization of an
implant. A window technique was applied for surgical removal of the impacted
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canine. The alveolar crest was preserved. After extraction of the primary canine, the
implant was inserted with primary stability. It is concluded that under premise of
preservation of sufficient bone to achieve primary stability of the implant, removal of
the canines can be combined with immediate placement and provisionalization of the
implant30.
Ole T Jensen (2015) did a study on dental implants, immediate placement and as well
as loading of the implant. He believed in the principle that what happens after
extraction is patterned in the biology and cannot be substantially changed at the
baseline by any effort to replace teeth immediately with implants. Therefore treatment
must be compensatory, treatment should include conjuctive augmentation procedures,
often hard and soft tissues to account for loss of post extraction volume failure. In this
6 month study with a sequence of periapical radiographs of immediately placed
implants in the maxillary arch, he concluded that immediate function requires
adequate implant stability. Immediate function requires prosthetic stability,
particularly when multiple implants are loaded. Factors to consider for immediate
implants into extraction sites are thickness of socket walls, thickness of gingival
drape, optimal position of the implant, and patient factors such as hygiene and
smoking cessation31.
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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MATERIALS AND METHODS
SOURCE OF THE DATA:
Ten patients who require extraction of single rooted tooth and willing for immediate
implant placement reporting to the Department of Oral and Maxillofacial Surgery,
P.M.N.M Dental College and Hospital, Bagalkot are considered for the study.
METHOD OF COLLECTION OF DATA:
Ten patients reporting to the Department of oral and maxillofacial surgery for
extraction of single rooted teeth will be examined and evaluated for receiving an
immediate implant placement. Patients will be explained about the procedure, its
benefits and the prognosis of the treatment. Extraction will be carried out with least
trauma and least cortical bone expansion as it is of prime importance in attaining
primary stability. Implant surfaces will be covered with sutures. Immediate IOPA
radiograph will be taken for assessing the placement depth and angulation of implant
into the bone. Patients will be followed up at intervals of 1 week, 1 month, 3 months
and 6 months. At follow up appointments bone integration will be assessed with the
help of radiovisiography and clinical assessment of the soft tissue will be performed
by measuring the probing depth around the implant, presence or absence of bleeding
on probing and suppuration.
INCLUSION CRITERIA:
! Mean age group of 20 to 50 years old
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
19
! Patients willing for surgery
! Single rooted teeth which are indicated for extraction other than existing
pathology
! Traumatic single rooted teeth indicated for extraction
EXCLUSION CRITERIA:
! Chronic smokers
! Teeth with chronic periapical infections
! Patient with previous implant failure
! Patient with immunocompromised condition
INVESTIGATIONS:
I. Pre-operative and post-operative photographs
II. Routine blood investigations
III. IOPAR
STUDY METHOD:
It includes mainly following four steps:
• Patient selection
• Pre Operative assesment
• Extraction and immediate placement of implant
• Follow up of the Patients- Clinically and Radiographycally
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
20
PATIENT SELECTION
Placement of implant immediately after extraction of teeth is a technique sensitive
procedure. Selection of the patient is an important step in it. A thorough history of the
patient is mandatory mainly to rule out certain tissue abusing habits and underlying
medical condition. A patient is selected by analyzing the inclusion and exclusion criteria.
Once it is fulfilled, a patient is taken and a detailed case history is taken and in the mean
time necessary investigations. like routine blood examination including bleeding time
and clotting time is done. Then IOPA radiograph of extracting teeth is taken. With the
help of IOPAR and clinical examination, the dimensions for the implant which has to be
placed is selected. Informed and written consents were obtained from the patient.
TREATMENT PLAN AND OPERATIVE PROCEDURE
Once the patient is taken for the procedure, a test dose for 2 % Local Anesthesia
with adrenaline is given subcutaneously.
Patient is painted with Betadine 10%. Local anesthesia is administered for extraction
of teeth. Extraction of teeth is carried out as least traumatic as possible. Pretty care
was taken to preserve the buccal cortical bone and moreover the expansion of socket
is also avoided. After the extraction, curettage is done to remove all the granulation
tissue and debris from the socket and a thorough Betadine irrigation is done to make it
a fresh socket.
By comparing also with the extracted root fragment, the ideal implant was chosen.
When it comes to the maxillary anterior region, the drilling direction is more of
palatally to get an adequate bone support. As there is no need of using a pilot drill,
directly sequential drills can be used. Drilling is carried out with the help of physio
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
21
dispenser with a circulating cold saline internal irrigation. Then the implant root form
can be taken for placement with the help of implant driver. After placement, more
precise tightening is done using a Torque Ratchet up to a maximum of 35 Newton.
Primary stability of the implant is achieved and one of the prime concern is to relieve
it from occlusal forces. Tight closure with Vicryl 3-0 round bodied suture is done.
After that the implant placed area is isolated with a Perio Pack.
Immediately after placement an IOPAR is adviced to record the placement and to
analyze implants position, angulation, and relation to adjacent structures.
INSTRUCTIONS GIVEN POST OPERATIVELY
• Bite down and maintain firm pressure on the gauze pack that was placed at the
end of your surgery, Do this for at least minutes.
• Do not rinse or spit for a minimum of 72 hours and longer if possible.
• Saliva should be swallowed.
• Do not brush the teeth in the area of surgery for 48 hours.
• Avoid excess physical activity and exercise.
• Do not smoke
• No force or any sort of pressure in the anterior region where implant is placed
• Eat soft foods and drink lots of fluids, do not drink through a straw for the first
24 hours.
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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FOLLOW UP OF PATIENTS AND METHOD OF
EVALUATION
Patients were followup on 1st week, one month, 3 months and 6
months. On the followup dates patients were instructed to report to Department
of Maxillofacial surgery OPD. A routine and thorough clinical examination is
carried out and an IOPAR in relation to that implant region is taken.
Clinically assessment of the soft tissue will be performed by measuring the
probing depth around the implant, presence or absence of bleeding on probing and
suppuration if any and bone integration will be assessed with the help of
radiovisiography.
CLINICAL EVALUATION
-During Placement we checked for
-Clinical mobility (using a probe)
-Perforation of Buccal or Lingual wall of socket (visual examination)
-At the time of 2nd stage surgery and 3 month after loading:
-Observing Modified Plaque Index, Gingival Index, Pus Discharge & Implant
Mobility at the time of loading.
Modified Plaque Index SCORE CRITERIA 0 No detection of plaque
1 Plaque only recognized by running a probe across the smooth marginal surface of the implant. Implants covered by plasma spray in this area always score 1
2 Plaque can be seen by naked eye 3 Abundance of soft matter
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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Gingival Index SCORE CRITERIA 0 Normal mucosa 1 Mild inflammation 2 Moderate inflammation (redness, oedema and glazing)
3 Severe inflammation (Marked redness, oedema, ulceration as shown by spontaneous bleeding)
Mobility scale was tested manually and graded according to clinical implant mobility index. SCORE CRITERIA 0 Absence of clinical mobility with 500gm in any direction 1 Slight detectable horizontal mobility 2 Moderate visible horizontal mobility upto .5mm 3 Severe horizontal movement greater than .5mm 4 Visible moderate to severe horizontal and any visible vertical movement
RADIOGRAPHIC EVALUATION
IOPA X-Rays were taken before implant placement for treatment planning,
immediately after implant placement, 1month, 3 months and 6 months after implant
placement, at the time of and 3 months after loading to asses crestal Bone Loss and
horizontal Defect Dimensions. A horizontal line tangential to the coronal border of
the implant was used as reference. Measurements from this line to the most coronal
height of the crestal bone on the proximal surfaces around the implant done to
evaluate the mesial and distal vertical crestal height of the bone. Horizontal defect
dimension of bone mesial and distal was measured by mesiodistal dimension between
the implant, measured at the level of implant shoulder and bone around the peri-
implant surface.
We have adopted the method described by Yoo et al. The length (mm) of the implant
was measured on the radiographs. Next the distance between the observed crestal
bone and implant-abutment interface was measured at the mesial and distal implant
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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surfaces. The actual implant length was known based on manufacturing standards. To
adjust the measurements for magnification error, the following equation
was used to determine the corrected crestal bone levels: Corrected crestal bone level= Measured crestal bone level x Actual implant length Measured implant length
IMPLANT SYSTEM
The implant system used in this study is Equinox Myriad™ , the Netherlands. The
implant system offer a wide range of high quality implants that provides improved
bone loading, quick healing period, good function, durability, longevity.
The Myriad™ implant form is based on the Anaform root shaped, tapered body
design which is the most proven and versatile shape for immediate and delayed
implantation.
The Bioprofile thread featured on all Myriad™ implants is an asymmetrical surface
extensive thread. Bioprofile™ essentially comprises one synchronized self tapping
thread composed of three distinct thread profiles that are adapted to three different
levels of bone biology.
All Myriad™ implants carry the unique Nanopore titanium anodic oxidation surface.
This calcium oxidized nano surface results in 11% calcium deposits saturating the
implant surface. Nanopore exhibits three dimensional interconnecting porosities
which is a characteristic that mimics the structure of human cancellous bone.
Myriad-Hybrid™ implants are available in four diameters D3.3, D3.8, D4.5 and D5.7
in lengths L8mm, L9.5mm, L11mm, L13mm and L15mm. The prosthetic platform is
consolidated to one size for common use of all prosthetic components.
MATERIALS AND METHODS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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Drilling Speed and Technique
Correct drilling reduces overheating and subsequent necrosis of surrounding bone.
The Myriad Smart Implants system envisaged for internal irrigation port. The drilling
must be without exerting excessive pressure. The advised speed for D3-D4 types bone
must be about 1500 rpm, for D1-D2 types 2000-2500 rpm. The use of "bone dancers"
technique with intermittent pressure for 1.2 seconds preferable.
Implant kit used in the study was Myriad Smart Direct-To-SiteTM implants.
It contains
1) Pilot Drill ( 2 mm)
2) Twist Drills with various length markings ( 3.3, 3.8, 4.5, 5.7)
3) Locator driver
4) Hexed driver
5) Torque Ratchet
6) Torque driver
STATISTICAL ANALYSIS
The data were entered and analyzed statistically. The Wilcoxon’s Signed Rank test
was used to get the results.
SAMPLE SIZE ESTIMATION
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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SAMPLE SIZE ESTIMATION
Analysis: A priori: Compute required sample size
Input: Tail(s) = One
Effect size dz = 0.80
α err prob = 0.10
Power (1-β err prob) = 0.85
Output: Noncentrality parameter δ = 2.5298221
Critical t = 1.3830287
Df = 9
Total sample size = 10
Actual power = 0.8702413
The sample size has been estimated using the software GPower v. 3.1.9.2
Considering the effect size to be measured (dz) at 80% for One-tailed hypothesis, power of
the study at 85% and the margin of the error at 10%, the total sample size needed is 10.
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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RESULTS
The objective of the study is to evaluate the outcome of immediately placed
implants in fresh extraction sockets. It is done by assesing the osseointegration by
checking the crestal bone level as seen on routine radiographs and clinically by
checking the primary stability and bleeding on probing around the region of implant
placed for a span of 6 months.
Table 1: shows the patients in this study who are in the age group ranging between 20
to 50 years with a mean age of 24 ± 4. It also shows that 75 % of the subjects were
between the ages of 21 and 30 years
Table 1: Age distribution
Age in years No of patients Percentage
0 – 10 years 0
11 – 20 years 0
21 – 30 years 7 75%
31 – 40 years 1 25%
41 – 50 years 0
Total 8 100%
MEAN ± SD 24 ± 4
Table 2: shows Sex distribution of the study group; 6 were male (75 %) and 2 were
female (25 %)
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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Table 2: Gender distribution
Gender Number Percentage
Male 6 75%
Female 2 25 %
Total 8 100%
Table3: shows the site of implant placement, the following observations were made;
10 implants were placed in the maxilla (all anterior) while no implants in the
mandible. It also demonstrates that in maxillary anteriors the chief cause of extraction
of teeth was trauma.
Table 3: Site & Aetiology of tooth loss
Aetiology Site in
Maxilla Caries
Trauma
Failed
endodontics
Root
stumps
Others
Central
incisor
- 5 1 1 1
Lateral
incisor
- 1 - 1 -
Canine - - - - -
Table 4: shows that the most common size (diameter X length) of implant fixture in
maxilla was 3.8 X 11 mm. Implant sizes were chosen depending on the dimensions of
the tooth/ root to be extracted and the bone available.
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
29
Table: 4 Implant fixture size
Site Size in mm
(Diameter X Length)
11 3.8 X 11
21 3.8 X 11
21 3.8 X 11
11 3.8 X 11
22 3.8 X 8
11 3.8 X 11
21 3.8 X 9.5
11 3.8 X 9.5
21 3.8 X 9.5
11 3.8 X 11
Table 5: represents Clinical evaluation of implants at the time of their placement.
Modified plaque index and Gingival index was measured around tooth before
extraction.
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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CLINICAL EVALUATION
Modified
Plaque
Index
Gingival
Index
Implant
Mobility
Score
Perforation
Buccal/Lingual
A 11 0 1 0 A
B 21 1 1 0 A
C 21 1 1 0 A
D 11 1 1 0 A
E 22 1 1 0 A
F 11 0 0 0 A
G 21 1 1 0 A
H 11 1 0 0 A
I 21 1 0 0 A
J 11 1 1 0 A
Table 6 represents clinical evaluation of the implant 7 days after surgery. No
Infection (pus discharge) was observed and post operative inflammation resolved by
the 7th day.
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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Table 6 – Evaluation 7 days after surgery
CLINICAL EVALUATION
Modified Plaque
Index
Gingival
Index
Implant
Mobility
Score
Pus
Discharge/
Bleeding
A 11 0 0 0 A
B 21 0 0 0 A
C 21 1 0 0 A
D 11 0 0 0 A
E 22 0 0 0 A
F 11 0 0 0 A
G 21 0 0 0 A
H 11 0 0 0 A
I 21 0 0 0 A
J 11 0 0 0 A
Table 7 represents clinical evaluation of the implants 3 months after surgery showed
good periodontal status with absence of Plaque, Bleeding on Probing, Pus Discharge,
Clinical Mobility
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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Table 7 – Evaluation at the time of 3 months after surgery
CLINICAL EVALUATION
Modified Plaque
Index
Gingival
Index
Implant
Mobility
Score
Pus
Discharge/
Fistula
A 11 1 0 0 A
B 21 1 0 0 A
C 21 1 0 0 A
D 11 0 0 0 A
E 22 0 0 0 A
F 11 0 0 0 A
G 21 0 0 0 A
H 11 0 0 0 A
I 21 0 0 0 A
J 11 0 0 0 A
Table 8: shows assessment of Vertical Crestal Bone resorption- Mesial. The
result in the present study shows that at the 6th month post operatively,
resorption of minimum of 0.30 mm to maximum 1.6 mm of bone; with mean vertical
bone resorption of 1.04 ± 0.97 mm with P<0.05 shows significant crestal bone loss.
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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Table 8: Radiological evaluation of Mean Mesial Vertical Crestal Bone
resorption measurement
RADIOLOGICAL EVALUATION
Vertical Crestal Bone Measurement - Mesial
Baseline At 1 week 1 month 3month 6 months
A
11
1 1 1.1 1.3 1.3
B 21 -.2 -.2 0 .3 .3
C 21 -2.3 -2 -.8 -.8 -.7
D 11 1.2 1.3 1.5 1.7 2.2
E 22 2.2 2.2 2.2 2.5 2.7
F 11 .6 .6 .6 .9 1.1
G 21 0 0 .3 .5 .5
H 11 0 0 0 .3 .5
I 21 .5 .6 .8 .8 1
J 11 1 1.1 1.3 1.3 1.5
Mean ± SD
.40 ± 1.1 .46 ± 1.1 .70 ± .9 .88 ± .9 1.04 ± .97
Mean bone loss from baseline to M6 is 0.5 ± 0.49
Table 9: shows assessment of Vertical Crestal Bone resorption- Distal. The
RESULTS
P.M.N.M. DENTAL COLLEGE & HOSPITAL, BAGALKOT
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result in the present study shows that at the 6th month post operatively,
resorption of minimum of 0.4 mm to maximum 0.5 mm of bone; with mean vertical
bone resorption of 1.26 ± 0.85 mm with P<0.05 shows significant crestal bone loss
Table 9: Radiological evaluation of Mean Distal Vertical Crestal Bone