|Year : 2014 | Volume
| Issue : 1 | Page : 82-89
Immediate implants in anterior maxillary arch
K Anitha1, S Senthil Kumar2, M. R. Ramesh Babu3, Ramesh Candamourty4, Thirumurugan3
1 Department of Periodontics, Tagore Dental College and Hospitals, Chennai, India
2 Department of Periodontics, Rajah Muthiah Dental College and Hospitals, Annamalai University, Chidambaram, India
3 Departments of Oral and Maxillofacial Surgery, Mahatma Gandhi Post Graduate Institute of Dental Science, Pillaiyarkuppam, Pondicherry, India
4 Departments of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Pondicherry, India
|Date of Web Publication||18-Feb-2014|
Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Pondicherry 607 402
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of the study was to evaluate the osseo-integration and soft tissue status of the endosseous implants placed in immediate extraction socket. Methodology: Seven patients (4 males and 3 females) aged 20-30 years were selected for the study. Nine implants were placed in seven patients in the maxillary arch. All the patients were clinically αnd thoroughly examined. Under local anesthesia, the indicated tooth was extracted. The extracted socket was prepared using standard drills with palatal wall as guide. The longest and widest implants were placed (Hi-Tec Implants). All implants showed good primary stability. The implants used in the study were tapered design endosseous implants with Threaded implants (TI) unit plasma-sprayed surface. Surgical re-entry (secondary surgery) was performed to remove the healing cap after 6 months for supra crestal fabrication. All patients were reviewed periodically at 3 rd and 6 th month interval and the following clinical parameters including modified plaque index (mPlI), modified bleeding index (mBI), probing depth (PD), attachment level (AL), and distance between the implant shoulder and mucosal margin (DIM), distance between the implant shoulder and first bone-implant contact, and Clinical Mobility Index were recorded. The results were computed and subjected to statistical evaluation. Results: The mPlI, mBI, PD, AL, and DIM were evaluated around the implants at baseline, 3 rd and 6 th month intervals and analyzed statistically by Friedman T-test. The results of the above were shown to be statistically non-significant. The distance between the implant shoulder and first bone implant contact was evaluated around the implants at base line, 3 rd and 6 th month intervals. The results proved to be statistically significant (0.01) implying that there was a bone apposition around the implants. Conclusion: During the course of the study, soft tissue status around implants was found to be healthy. Osseointegration as assessed by clinical and radiographic findings was found to be sound.
Keywords: Bone borne implants, dental implants, endosseous implants, immediate implants, osseointegration
|How to cite this article:|
Anitha K, Kumar S S, Babu MR, Candamourty R, Thirumurugan. Immediate implants in anterior maxillary arch. J Nat Sc Biol Med 2014;5:82-9
|How to cite this URL:|
Anitha K, Kumar S S, Babu MR, Candamourty R, Thirumurugan. Immediate implants in anterior maxillary arch. J Nat Sc Biol Med [serial online] 2014 [cited 2017 Nov 24];5:82-9. Available from: http://www.jnsbm.org/text.asp?2014/5/1/82/127293
| Introduction|| |
Smile is an important factor which enhances our beauty. A well-formed complete smile is the basis for facial aesthetics. To bring out a beautiful smile, a full set of dentition is necessary. Teeth, other than its normal function, have a major role in improving the beauty. Missing tooth can become the reason for a distinct shortening of the lower part of face as well as a well-pronounced nasolabial and mentolabial fold. It causes a gradual protrusion of the chin which brings about an aged appearance. Therefore, a full set of dentition is necessary for every individual as it raises ones self-esteem, confidence, beauty, and speech. It also helps in the equal distribution of occlusal forces which in turn maintains a healthy periodontium.
Implant was not considered to be a reliable option until 1952 when Branemark's studies of bone marrow in the rabbit fibula introduced the concept of osseo-integration which he defined as "a direct structural and functional connection between the ordered living bone and surface of load carrying implants".  It involves the incorporation of non-biological material within the human skeleton without initiating rejection phenomenon and allows permanent penetration of soft tissues without initiating chronic inflammatory response. Osseointegration is a dynamic phenomenon which is made possible by the characteristic implant composition. The most widely used dental implant material is titanium and its alloys. Titanium is always covered by an external oxide layer which prevents a direct contact between the host living tissues and potentially harmful metallic ions. The surface layer of titanium oxide is histologically inert, thus permitting the implant to be accepted and gradually surrounded by new bone formation.
As long-term clinical data based on sound research and scientific principles were developed, implant dentistry rapidly became acceptable. A number of studies were carried out in animal models and were proven to be successful.  One of the prerequisites for successful osseointegration has been ossification of extraction socket before the placement of implants. The delay in socket healing coupled with an added surgical stage resulted in greater inconvenience and discomfort to the patient. Complete healing of the socket is also associated with crestal resorption of bone and reduction in the height of alveolar bone for implant placement. Alveolar bone atrophy begins soon after the extraction of the tooth.
To avoid crestal resorption immediate implant placement in the fresh extraction socket was introduced. Schulte was the first one to place immediate implants into fresh extraction sockets in humans.  A number of experimental studies have shown high success rates.  The present study was about immediate implants placed in the extraction socket to evaluate the osseointegration and soft tissue status around implants over a period of 6 months.
| Methodology|| |
Seven patients (4 males and 3 females) from the outpatient Department in Rajah Muthiah Dental College and Hospital, Annamalai University, aged between 20 years and 30 years were selected for the study after obtaining approval of the institutional ethics committee and informed consent of the participants. Nine implants were placed in seven patients.
- Indication for tooth extraction including trauma resulting in tooth fractures or non-restorable crowns
- Adequate volume of bone (bone height and width) to allow placement of implants with minimum diameter of 3.75 mm and minimum length of 13 mm
- Minimum of 4 mm residual bone beyond the root apex
- Bilaterally stable occlusal pattern
- The patient's ability to follow the study protocol and willingness to sign an informed consent form.
- Compromised systemic health condition that inhibited the osseointegration process
- Severe inter-maxillary discrepancy
- Severe parafunctional habits (bruxism or clenching)
- Drug or alcohol abuse
- Poor oral hygiene
- Absence of buccal wall in extraction site.
All cases were clinically thoroughly examined. Diagnostic cast for intra-arch relationship and working model for ridge mapping were fabricated to evaluate the status of the alveolar housing in the site of implant placement. Panoramic and periapical radiographs were also taken [Figure 1].
|Figure 1: (a) Pre-operative view. (b) Diagnostic cast. (c) Pre-operative periapical radiograph|
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On the day of the surgery, patients were instructed to rinse with 2% chlorhexidine mouth wash, and skin preparation was done with betadine prior to surgery and surgical field was isolated. Under local anesthesia, the indicated tooth (fractured right upper central incisor tooth) was extracted and the socket irrigated [Figure 2]. A mucoperiosteal flap was reflected at the proposed site of implant placement to assess the alveolar bone margins. The extracted socket was prepared using standard drills with palatal wall as guide for implant placement. While preparing the socket (osteotomy) in- and- out motion was used. Bone drilling was done intermittently with speed of 800 rpm for 1-2 s and care was taken to flush out debris as the drill was drawn out. The round bur was used initially to maintain angulation and the socket was enlarged with a sequence of 3.5 mm, 4.5 mm, and 5 mm burs. Paralleling pins were used in between to check parallelism with adjacent tooth. Surgery was carried out with reduction gear hand piece with both external and internal irrigation system.
After implant site preparation, periodontal probe was used to check the integrity of the bony wall of the extraction socket. The longest and widest implants of 14-15 mm × 3-5 mm [Figure 3] were chosen and placed at the bucco-palatal level of the bony crest. The placement of implant was completed using surgical manual torque wrench till its final depth. The implant head was covered with cover screw. All implants showed good primary stability. All implants (Hi-Tec Implants, Isreal) used in the study were tapered design double-threaded EZ-selective integrated surface, integrated Hex end osseous implants with TI unit plasma-sprayed surface, the length ranging between 14 mm and 15 mm and diameter 3 mm and 5 mm. After implant placement soft tissue edges were approximated using 3-o black silk to protect the implant site [Figure 4].
|Figure 2: (a) Extraction of 11 doneƒnwith anterior extraction forceps. (b) Extracted tooth. (c) Extracted socket|
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|Figure 3: (a) Implant kit. (b) Physiodispenser and reduction gear hand piece. (c) Titanium implants to be placed. (d) Miscellaneous|
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|Figure 4: (a) Preparation of the implant bed using 3 mm drill. (b) Implant being placed in the extracted socket. (c) Hand wrench being used to check the primary stability. (d) Cover screw being placed. (e) Soft tissue edges being approximated with 3-0 silk to protect implant site|
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Antibiotics (Amoxycillin 500 mg, tid), anti-inflammatory analgesics (Ibuprofen 400 mg and Paracetamol 500 mg tid) were prescribed subsequently for 5 days. Patients were instructed to use 2% chlorhexidine mouth wash. Patients were reviewed subsequently and oral hygiene maintenance was assessed. Suture removal was done on the following 7 th day. Patient received oral prophylaxis and temporary prosthesis 1 week after implant placement. Surgical re-entry was performed to remove the healing cap after 6 months for supracrestal fabrication [Figure 5].
|Figure 5: (a) 3 months post-operative review. (b) After abutment placement. (c) After permanent prosthesis. (d) 3 months post-op radiograph. (e) 6 months post-op radiograph|
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Following implant placement clinical parameters were recorded at baseline, 3, and 6 months intervals.
- Modified plaque index (mPlI) was used to assess plaque accumulation around dental implants. Four surfaces examined included mesial, mid facial, distal, palatal aroundthe implant with the plastic probe and mean score was obtained.
- Modified bleeding index (mBI) was used to assess marginal mucosal condition around dental implants. Four surfaces are examined including mesial, mid facial, distal and palatal around the implant with the plastic probe and mean score was obtained.
- Probing depth (PD) was measured with a plastic probe to the nearest millimeter. Four surfaces are examined including mesial, mid facial, distal, and palatal around implant with the plastic probe and mean score was obtained. 
- Distance between the implant shoulder and mucosal margin (DIM) Four surfaces are examined including mesial, mid facial, distal, and palatal around implant with the plastic probe and mean score was obtained. 
- Attachment level (AL) was calculated by adding PD and DIM to the nearest millimeter. Four surfaces are examined including mesial, mid facial, distal, and palatal around implant with plastic probe and mean score was obtained. 
- Distance between the implant shoulder and bone in contact (DIB) A standardized periapical radiograph was used to measure the distance between the implant shoulder and first bone implant contact on mesial and distal surfaces and mean score was obtained. 
- Mobility test clinical mobility was assessed using the modified version of Lindhe and Nyman.  The implant was loaded with the handle of two dental mirrors in a bucco-lingual direction. The amount of displacement, including intrusion was observed relative to neighboring implant or tooth and scored as follows:
- 0 = No mobility
- 1 = Slight mobility less than 1 mm of movement
- 2 = Moderate mobility 1-2 mm of movement
- 3 = Severe mobility greater than 2 mm of movement intrusion was also observed.
- Peri-implant radiolucency was assessed using standardized periapical radiograph.
The data so obtained were statistically analyzed and results were tabulated in the form of tables and bar diagrams. Freidman test was used to calculate the comparison of mPlI, mBI, DIM, AL, and DIB at baseline 3 and 6 months.
| Results|| |
A total of 7 patients with age group between 20 years and 30 years were chosen for this study. A total of 9 implants were placed in 7 of these patients. Baseline clinical parameters were recorded following implant placement. The healing course after extraction and implant placement was uneventful. All implants were stable, asymptomatic during the healing period. All patients were periodically reviewed at 3 rd and 6 th month intervals and the clinical parameters were recorded. The results were computed and subjected to statistical evaluation.
After implant placement, the average mPlI [Table 1] at the baseline was found to be 0 with the standard deviation of 0. At the end of 3 and 6 months the average mean mPlI was found to be 0.44 and 0.417 respectively (Chart 1). Fried man's non-parametric test (repeated measures) was applied to compare the average mPlI at baseline, 3 rd and 6 th month intervals. The result suggested that the oral hygiene status around the implant was found to be satisfactory throughout the period of study.
|Table 1: Mean and standard deviation of modifi ed plaque index at base line, 3 months, and 6 months|
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After implant placement, the average mBI [Table 2] at the baseline was found to be 0 with the standard deviation of 0. At the end of 3 and 6 months, the average mBI was found to be 0.38 and 0.33 respectively (Chart 3). Fried man's non-parametric test (repeated measures) was applied to compare the average mBI at baseline, 3 rd and 6 th month intervals. The result suggested that the soft tissue status around implant was found to be the satisfactory.
|Table 2: Mean and standard deviation of modifi ed bleeding index at baseline, 3 months, and 6 months|
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[Table 3] shows the DIM measurement. The implant shoulder was supragingival and the measurement was recorded as a negative value. After implant placement, the average DIM at the baseline was found to be −1.99 mm with standard deviation of 0.28. At the end of 3 and 6 months, the average DIM was found to be −2.02 mm and −2 mm respectively. Fried man's non-parametric test (repeated measures) was applied to compare the DIM at baseline, 3 rd and 6 th month intervals. The result indicated no significant changes in DIM after the implant placement in fresh extraction socket. The result suggested that there was no clinically visible gingival recession which might offend the esthetical outcome of implant.
[Table 4] shows PD - measured to the nearest millimeter with a periodontal probe. After implant placement, the average PD at the baseline was found to be 2.09 mm with the standard deviation of 0.20. At the end of 3 and 6 months, the average PD was found to be 2.139 mm and 2.05 mm respectively (Chart 4). Fried man's non-parametric test (repeated measures) was applied to compare the average PD at baseline, 3 rd and 6 th month intervals. The result indicated no significant difference in PD after the implant placement in fresh extraction socket. The result showed that the PD around implant site was without any signs of gingival inflammation.
|Table 3: Mean and standard deviation of distance between the implant shoulder and mucosal margin at base line, 3 months, and 6 months|
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|Table 4: Mean and standard deviation of probing depth at base line, 3 months, and 6 months|
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[Table 5] shows that AL was computed by adding PD and DIM. After implant placement, the average AL at the baseline was found to be 0.13 mm with the standard deviation of 0.11. At the end of 3 and 6 months, the average AL was found to be 0.16 mm and 0.11 mm respectively (Chart 6). Fried man's non-parametric test (repeated measures) was applied to compare the average AL at baseline, 3 rd and 6 th month intervals. The result indicated that no significant changes occurred in AL after the implant placement in fresh extraction socket. The result suggested that the periodontal status around implants was satisfactory.
|Table 5: Mean and standard deviation of the attachment level at base line, 3 months, and 6 months|
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[Table 6] shows that distance from the implant shoulder to the first bone implant contact (DIB) measured with periapical radiographs is taken in a standard manner. After implant placement, the average DIB at the baseline was found to be 2.53 mm with a standard deviation of 0.63. At the end of 3 and 6 months, the average DIB was found to be 2.77 mm and 2.36 mm respectively. Friedman's non-parametric test (repeated measures) was applied to compare the average DIB at baseline, 3 rd and 6 th month intervals. The result indicated that significant change occurred in DIB after implant placement in fresh extraction socket. The P value was 0.01. These results suggest a better bony apposition around implant which is a good sign of osseointegration.
|Table 6: Mean and standard deviation of distance from the implant shoulder to the fi rst bone implant contact base line, 3 months, and 6 months|
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| Discussion|| |
The aim of the study was to evaluate osseointegration and soft tissue status of the endosseous implants placed in immediate extraction socket. A total of 7 patients with age group ranging 25-30 years were chosen for the study based on the selection criteria. Thorough clinical examination was carried out. Soft tissue and hard tissue parameters were recorded, professional oral hygiene care instituted. Clinical parameters were tabulated and subjected to statistical analyses.
The immediate implant success rate was 92% when replacement of teeth extracted because of periodontitis and 95.8% following replacement of teeth extracted for other reasons.  In our present study, all implants were placed in sites following trauma, suggesting that the placement of implant into the extraction socket is highly predictable. The teeth in the site of immediate implant placement should have 3-5 mm of bone beyond the apex.  Teeth without labial plate, systemic complication which interfered in osseointegration were excluded. Indication for extraction included trauma resulting in root fracture and non-restorable crown.
Selection of patients in our study included teeth with 3-5 mm of bone beyond the root apex as described by Schwartz-Arad et al. in 1998.  Teeth with zero wall defects were excluded from the study. Ugo covani in 2007 observed a significant amount of vertical bone absorption without the use of membranes and filling materials.  Use of Expanded polytetrafluoroethylene (ePTFF) membrane lead to complications like exposure and infection of the membrane and also stated that the barrier might disrupt the blood supply of the overlying soft tissue. In our present study immediate implant placement was carried out, without use of barrier membrane and grafting materials to fulfill the objective as mentioned by Ugo Covani.
Wilson  in 1998 evaluated five titanium plasma-sprayed implants which was biopsied from human volunteers 6 months following placement. Four test implants were placed in immediate extraction socket whereas one was placed in mature site which served as a control; osseointegration was evaluated by histometric analysis. The results of the study showed a high level of bone implant contact, which was mainly observed in implant placed at canine area (mean 72.14). In our present study, all immediate implants were placed in the anterior region and osseointegration was clinically and radiographically evaluated, which was also found to be satisfactory.
The oral hygiene status and status of soft tissue of the test sites were evaluated using mP1I and mBI as stated by Antonio Barone  in 2006. The mean plaque score of the present study was found to be 0.417 and 0.33 suggesting that the oral hygiene, soft tissue status was found to be satisfactory.
The primary stability of implant was assessed by resonance frequency analyses, where Implant stability quotient (ISQ) of >60 was considered to be favorable. Shiigai  in 2007 studied 18 single tooth immediate implants and checked primary stability by Ostell's device and suggested that ISQ >62 was considered suitable. In the present study, the primary stability of all implants was manually assessed by insertion torque. The insertion torque was measured by manual torque wrench. All implants studied were Hi-tech implant with insertion torque ranging from 35 Ncm to 40 Ncm which was similar to the other methods of examination. Clinical mobility following implant placement were studied using a modified version of the index by Lindhe and Nyman. In our present study, the osseointegration of implant were assessed by mobility test as suggested by Barzilay et al. in1996. 
Ugo Covani  in 2007 stated that the total mean distance from the implant shoulder to alveolar crest at base line −0.3 ± 0.3 mm and following 6 th month was increased to 0.5 ± 0.5 mm, whereas in our present study, the total mean distance from the implant shoulder to alveolar crest at base line was 2.53 mm, 2.33 mm following 6 th month interval suggesting a favorable vertical reabsorption and augmentation. The reason behind this is that alveolar bone remodeling occurs due to crestal bone absorption and augmentation.
The result of the study conducted by Akimoto et al.  showed that as the gap-width widened around the implant, the area of bone to implant contact histologically decreased, and the point of highest bone implant contact shifted apically and were statistically significant (P < 0.01). In our present study, bone to implant contact and gap width around implant were assessed radiographically and bone implant contact was also found to be statistically significant (P 0.01) which suggested highest bone implant contact resulting in good osseointegration.
The reaction of peri-implant tissue to immediately placed titanium plasma-sprayed implant into extraction socket showed a very high bone-to-implant contact (65-70%) when it was grafted with autogenous bone chip, whereas in the current study neither graft material nor membrane were used along with implant and the bone-implant contact percent was also found to be statistically significant (P 0.01) suggesting that neither graft nor barrier influences the effect of osseointegration. 
The results of the present study were similar to the study conducted in 1999 by Bernard Alliot  who evaluated bone regeneration around non-submerged implants placed immediately in extraction site using a combination of hydroxyapatite and collagen membranes. Following histometric evaluation, it was concluded that use of bio-absorbable materials did not significantly enhance peri-implant bone regeneration in immediate implantation. The present study also demonstrated sound osseointegration of immediate implant without the use of bioabsorbable membrane.
| Summary and Conclusion|| |
A total of seven patients with age group ranging from 25 years to 30 years were chosen for the study based on the selection criteria. Thorough clinical examination was carried out. Soft tissue and hard tissue parameters were recorded. Professional oral hygiene care was instituted. Clinical parameters were tabulated and subjected to statistical analyses and the following results were obtained.
- The oral hygiene status of the patient prior and following implant placement was found to be satisfactory during the period of observation
- The soft tissue status around implants was found to be clinically free of gingival inflammation
- The position of the gingival margin was found to be normal (without gingival recession) during entire period of the study
- No significant changes in PD were observed during the healing period
- No significant changes in AL were observed following implant placement suggesting that the periodontal status around the implants was healthy during 3 rd and 6 th months
- Sound osseointegration as assessed by increased in bone apposition around implant was seen during the period of observation.
Further longitudinal studies with a larger sample volume, with the use of Dental Scan to assess hard tissue, Ostell's Device to check the primary stability of implant should be carried out to improve the result of the study.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]