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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 87-90

Clinical and esthetic outcome of immediate implant placed in postextraction site with alveolar bone defect using guided bone regeneration


1 Postgraduate Student, Department of Periodontology, Institute of Dental Studies and Technologies, Ghaziabad, Uttar Pradesh, India
2 Professor and Head, Department of Periodontology, Institute of Dental Studies and Technologies, Ghaziabad, Uttar Pradesh, India
3 Associate Professor, Department of Periodontology, Institute of Dental Studies and Technologies, Ghaziabad, Uttar Pradesh, India
4 Senior Lecturer, Department of Periodontology, Institute of Dental Studies and Technologies, Ghaziabad, Uttar Pradesh, India
5 Reader, Department of Periodontology, Institute of Dental Studies and Technologies, Ghaziabad, Uttar Pradesh, India

Date of Submission07-May-2020
Date of Acceptance29-Jul-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dr. Mansi Bansal
Department of Periodontology, Institute of Dental Studies and Technologies, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INPC.INPC_14_20

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  Abstract 


A 50-year-old male presented with nonrestorable fractured upper right first premolar. The implant was placed immediately after extraction, and guided bone regeneration (GBR) was performed simultaneously to correct the dehiscence at the labial aspect. Five months after implant placement, the treatment showed satisfactory results both clinically and radiographically. The periapical radiograph confirmed the complication-free integration of the implant and repair of buccal defect. Thus, immediate implant placement with simultaneous GBR in postextraction sockets with bony defects is a reliable technique with predictable results. However, this protocol is technique sensitive, and a number of guidelines and prerequisites need to be seriously considered, especially good primary stability and correct three-dimensional placement.

Keywords: Dental implant, guided bone regeneration, immediate implant


How to cite this article:
Khurana S, Khatri M, Bansal M, Rehan M, Puri K, Afreen R, Narang R. Clinical and esthetic outcome of immediate implant placed in postextraction site with alveolar bone defect using guided bone regeneration. Int J Prev Clin Dent Res 2020;7:87-90

How to cite this URL:
Khurana S, Khatri M, Bansal M, Rehan M, Puri K, Afreen R, Narang R. Clinical and esthetic outcome of immediate implant placed in postextraction site with alveolar bone defect using guided bone regeneration. Int J Prev Clin Dent Res [serial online] 2020 [cited 2020 Oct 24];7:87-90. Available from: https://www.ijpcdr.org/text.asp?2020/7/3/87/296534




  Introduction Top


Dental implants are considered as the first line of treatment in restoring missing teeth by most of the patients and clinicians. The extraction of teeth can result in up to 50% loss of alveolar ridge width within the first 1–3 years which can complicate implant placement and esthetic outcome of implant procedure. This bone loss is exacerbated if the tooth is removed traumatically or if there are preexisting endodontic or periodontal pathologies and often requires bone augmentation to create ideal gingival contours and esthetics.[1],[2]

The timing of implant placement has been classified into late, early with partial bone healing, early with soft-tissue healing, and immediate placement. Whenever there is adequate bone and soft tissue for implant primary stability, immediate placement and contour augmentation is recommended.[3] The advantages of immediate implant placement are that the amount of bone is greatest at that time and the overall treatment duration and the number of surgical interventions are reduced. Disadvantages are that the procedures are technically demanding, with a significant risk of esthetic complications. Thus, the clinician should be experienced. Esthetic risk assessments should be carefully considered before treatment.[3] Based on a review of the literature, the outcomes of immediate, early, and late implant placement are comparable. However, gingival recession ≥1 mm has been reported in 8%–40.5% of cases, especially in patients with a thin gingival biotype. Moreover, damaged labial alveolar plate or labially malpositioned implants were also reported. Immediate implant placement with simultaneous guided bone regeneration (GBR) can maintain the bone volume and soft-tissue contours. While this technique only requires a single surgical procedure, it is technically demanding.[4]

GBR is an often used procedure for hard-tissue restoration. The treatment concept advocates the regeneration of osseous defects and is predictably attainable through the application of occlusive membranes, which mechanically exclude nonosteogenic cell populations from the surrounding soft tissues, thereby it allows osteogenic cell populations that originate from the parent bone to occupy the osseous wound. The studies suggest that bone regeneration is significantly enhanced when the invasion of soft tissue into osseous defects is mechanically impeded.[5],[6],[7],[8] The clinician has the choice to use GBR procedure with either a simultaneous or a staged approach in the treatment of these defects. Considering the treatment objectives, implant placement simultaneously with GBR procedure is preferred whenever possible in order to minimize the number of surgical interventions. To achieve the optimal results when placing an implant with simultaneous GBR, there are important issues to be considered. The implant needs to be in the correct three-dimensional position[9] and achieve primary stability, and the peri-implant bone morphology should allow for successful bone regeneration. This case report presents a simultaneous approach of GBR and implant placement in the maxillary premolar region with narrow ridge defect.


  Case Report Top


A 50-year-old male patient reported with a chief complaint of broken teeth in the upper right premolar region and need for restoration of the same with fixed prosthesis. The patient gave a history of fracture of the tooth 1 year back. His medical history was noncontributory. His psychological profile was good and had reasonable expectations. The periapical radiograph showed adequate bone height and mesiodistal bone width. Intraoral examination revealed a thick gingival biotype with an 8–10 mm band of attached gingiva. It was explained to the patient that although implants represented an ideal treatment option, it may be required to simultaneously augment the bone in case a bony defect is encountered after extraction as the roots of fractured tooth to be extracted were bulky. The patient showed willingness to the proposed surgical and prosthetic treatment plan.

The first step was the careful extraction of tooth 14 under local anesthesia using a 2% lidocaine solution with a vasoconstrictor. Root fragments were cautiously and carefully removed with a periotome and suitable forceps. The extraction socket was thoroughly debrided with caution to prevent infection, and a thin buccal plate (of <1 mm thick) with dehiscence, 4–5 mm wide, and 5 mm deep was identified after extraction. Implant bed preparation was completed after standard protocols using incremental sharp spiral drills and copious chilled saline. An ideal three-dimensional implant position was obtained mesiodistally, orofacially, and coronoapically. The drill was extended 3–4 mm apically to obtain primary stability. A 13-mm fixture with a rough surface (sandblasted, large grit, and acid-etched) Dentium NR line was put in place. The fixture achieved excellent primary stability. A combined bony defect at the buccal site including a dehiscence-type defect and a 1–2 mm horizontal gap between the residual buccal plate and implant body was found. The exposed surface was still within the alveolar housing of the premaxilla. A localized GBR procedure was then undertaken using bone grafts and a collagen membrane. Bone substitute (autogenous bone chips as extracted from adjacent site mixed with synthetic alloplastic bone graft, Osteon II) was applied directly to the denuded implant surface, and the marginal gap between the buccal plate and implant surface was filled.

Placement of bone substitutes was also gradually extended to the periphery, and an “overbuilding” convexity at the site of tooth 14 was achieved. A bioabsorbable collagen membrane (CollaGuide, Collagen Matrix, Liberal) covered the bone substitute. Periosteum was released surgically to advance the flap, and primary soft-tissue closure was secured with 3-0 sutures to allow submerged healing. The patient received analgesics and antibiotics for 5 days postsurgically. In addition, he was instructed to use a 0.1% chlorhexidine digluconate rinse twice daily and avoid toothbrushing at the surgical site for 2 weeks. Some swelling was noted during the postsurgical healing period which regressed over a period of 1 week. Implant site had favorably healed by 5 months. A periapical radiograph also confirmed that the implant was well-integrated. Thus, a full-thickness flap was raised to expose the implant and to place the healing abutment. At this time, complete healing and coverage of bone defect was observed. After 2 weeks, impression was recorded using an open-tray impression technique, and a metal-ceramic crown was cemented after 5 days of impression [Figure 1].
Figure 1: (a) Preoperative radiograph. (b) Postextraction. (c) Buccal bone defect (occlusal view). (d) Radiograph – Buccal defect. (e) Periosteal release incision. (f) Autogenous graft + Alloplast. (g) Placement of bone graft. (h) Placement of collagen membrane. (i) Five-month surgical re-entry. (j) Radiograph showing bone fill. (k) Abutment in place. (l) Final prosthetic restoration (crown)

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  Discussion Top


Immediate implant placement can take advantage of the maximum amount of bone available, and simultaneous GBR can be performed to maintain the ridge contours and repair bone defects. Thus, this technique was chosen for replacement of tooth in this case. Exposure of implant threads because of insufficient alveolar ridge width or buccal cortical plate fracture during a traumatic extraction might lead to high implant failure rates.[10] Depending on the size and morphology of the defect, various augmentation procedures can be used. The critical requirement for implant success is to achieve initial implant stability before any augmentation procedures because osseointegration cannot be achieved in mobile implants.[11] Among the various graft materials, autografts are regarded as the gold standard bone graft material for GBR because of their osteogenic, osteoinductive, and osteoconductive properties. Because of a limited amount of available autogenous bone and lesser resorption time of autogenous graft, autogenous bone graft was mixed with alloplast with relatively longer resorption time. The composite graft was used to support the area intended for bone augmentation, allow the ingrowth of bone-forming cells, and support bone-implant contact formation. The “overbuilding” of the vestibular contour of the alveolar bone crest was also intended to provide the required support and long-term stability for the overlying soft tissue. To avoid soft-tissue invasion of the graft materials, a collagen membrane with high biocompatibility was applied above the grafted bone as a barrier. A final important step was to close the wound with tension-free flap adaptation that was done with the help of periosteal release incision as the width of attached gingiva in this case was adequate. In recent clinical studies, the application of bone substitutes in conjunction with the placement of barrier membranes successfully covered previously exposed implant surfaces in cases with similar defects.[12],[13],[14] This technique used for the purpose of correcting dehiscence defects and augmenting the ridge laterally seems to be reliable and predictable.

GBR with simultaneous implant placement is recommended only if the implant could be placed in an optimal three-dimensional position with satisfactory primary stability from the existing natural bone (Chen et al., 2009). However, the success of the procedure does not rely only on implant's stability but also on the stability of the grafting material. Botticelli et al. strongly indicated that immediate implant placement might not prevent physiologic modeling/remodeling that can occur on the ridge after tooth removal.[15] The change in the vertical bone level is usually more pronounced at the buccal than the lingual aspect of the ridge because of the early disappearance of the bundle bone which occupied a large fraction of the marginal portion of the buccal bone wall. Therefore, special procedures should be modified to make great efforts to preserve the existing hard and soft tissues at the implant sites such as using minimally traumatic surgical and regenerative techniques. Bone preparation should be relocated palatally to avoid jeopardizing the integrity of the buccal wall of the socket and perforating the facial bone. A void maintained between the implant body and the buccal wall was grafted with bone particles as described above. This method can maximally leave the thin buccal wall undamaged. Additional grafting of the external surface of the buccal bone wall was shown to slightly increase or at least maintain the horizontal dimension of the alveolar bone.


  Conclusion Top


Immediate implant placement with simultaneous GBR in postextraction sockets with bony defects is appealing to clinicians. According to the literature, high implant survival rates and predictable good esthetic outcomes can be achieved with short-term follow-up. Although postextraction bone remodeling will occur irrespective of the placement of an implant,[15] the time saved is truly a great advantage for patients and implant practitioners. Because of a lack of long-term results, this protocol should be used with caution, and a number of guidelines and prerequisites need to be seriously considered. More long-term perspectives and controlled clinical studies are needed to guarantee the success of this approach, especially for esthetic outcomes.

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.
Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313-23.  Back to cited text no. 1
    
2.
Grütter L, Belser UC. Implant loading protocols for the partially edentulous esthetic zone. Int J Oral Maxillofac Implants 2009;24 Suppl: 169-79.  Back to cited text no. 2
    
3.
Chen S, Buser D. Implants in post-extraction sites: A literature update. In: Buser D, Belser U, Wismeijer D (eds). ITI Treatment Guide, Implants in Extraction Sockets. Berlin: Quintessence, 2008;3:9-15.  Back to cited text no. 3
    
4.
Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral Maxillofac Implants 2009;24 Suppl: 186-217.  Back to cited text no. 4
    
5.
Christoph HF, Ronald EJ, Andreas F. A systematic review of the survival of implants in bone sites augmented with barrier membranes in partially edentulous patients. J Clin Periodontol 2002;226:226-31.  Back to cited text no. 5
    
6.
Buser D, Brägger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Implants Res 1990;1:22-32.  Back to cited text no. 6
    
7.
Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg 1988;81:672-6.  Back to cited text no. 7
    
8.
Buser D, Bornstein MM, Weber HP, Grütter L, Schmid B, Belser UC. Early implant placement with simultaneous guided bone regeneration following single-tooth extraction in the esthetic zone: A cross-sectional, retrospective study in 45 subjects with a 2- to 4-year follow-up. J Periodontol 2008;79:1773-81.  Back to cited text no. 8
    
9.
Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: Anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19 Suppl: 43-61.  Back to cited text no. 9
    
10.
Wang HL, Al-Shammari K. HVC ridge deficiency classification: A therapeutically oriented classification. Int J Periodontics Restorative Dent 2002;22:335-43.  Back to cited text no. 10
    
11.
Aspenberg P, Goodman S, Toksvig-Larsen S, Ryd L, Albrektsson T. Intermittent micromotion inhibits bone ingrowth. Acta Orthop Scand 1992;63:141-5.  Back to cited text no. 11
    
12.
Zitzmann NU, Naef R, Schärer P. Resorbable versus nonresorbable membranes in combination with Bio-Oss for guided bone regeneration. Int J Oral Maxillofac Implants 1997;12:844-52.  Back to cited text no. 12
    
13.
Hämmerle CH, Brägger U, Schmid B, Lang NP. Successful bone formation at immediate transmucosal implants: A clinical report. Int J Oral Maxillofac Implants 1998;13:522-30.  Back to cited text no. 13
    
14.
Moses O, Pitaru S, Artzi Z, Nemcovsky CE. Healing of dehiscence-type defects in implants placed together with different barrier membranes: A comparative clinical study. Clin Oral Implants Res 2005;16:210-9.  Back to cited text no. 14
    
15.
Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-8.  Back to cited text no. 15
    


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