Immediate Implant Placement After Extraction of Central Incisor in the Maxilla After Injury – Case Report

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clinical case

Maciej R. czerniuk

a, B, D, e

_{, Maciej Zaremba}

B, F

Immediate Implant Placement After Extraction

of Central Incisor in the Maxilla After Injury

– Case Report

Implantacja natychmiastowa po usunięciu górnego zęba siecznego

w następstwie urazu – opis przypadku

Department of Oral Medicine and Periodontal Diseases, institute of Dentistry, Medical University of Warsaw, Poland

A – koncepcja i projekt badania; B – gromadzenie i/lub zestawianie danych; C – opracowanie statystyczne; D – interpretacja danych; E – przygotowanie tekstu; F – zebranie piśmiennictwa

Abstract

Persistent deciduous dentition and lack of permanent tooth buds constitute a serious problem in the population of young patients on the threshold of personal and professional life. This study presents the case of a patient aged 24, who incurred an injury of the upper lip and both central incisors in the maxilla, including a persistent deciduous one without a permanent tooth bud. in the description of the above mentioned case, the authors wish to draw attention to a frequent necessity for simultaneous implementation of resective – regenerative surgical treatment and application of modern operative techniques (Dent. Med. Probl. 2012, 49, 4, 600–606).

Key words: persistent deciduous teeth, trauma, guided tissue regeneration, tissue transplantation, implantation.

Streszczenie

Przetrwałe uzębienie mleczne i brak zawiązków zębów stałych są poważnym problemem w populacji młodych pacjentów stojących u progu osobistego i zawodowego życia. W pracy przedstawiono przypadek 24-letniej pacjent-ki, u której na skutek wypadku narciarskiego doszło do urazu wargi górnej i obu zębów siecznych centralnych szczęki, w tym jednego przetrwałego mlecznego, bez zawiązka zęba stałego. W opisie powyższego przypadku auto-rzy pragną zwrócić uwagę na częstą konieczność wdrożenia chirurgicznego leczenia resekcyjno-regeneracyjnego z jednoczasowym użyciem nowoczesnych technik operacyjnych (Dent. Med. Probl. 2012, 49, 4, 600–606).

Słowa kluczowe: przetrwałe uzębienie mleczne, uraz, sterowana regeneracja tkanek, przeszczep tkanki łącznej,

implantacja.

Dent. Med. Probl. 2012, 49, 4, 600–606

issn 1644-387X © copyright by Wroclaw Medical University and Polish Dental society

among the factors contributing to the oc-currence of periodontal disease, special attention should be paid to orthodontic – occlusive abnor-malities, which seriously limit the possibilities of proper daily oral hygiene, increase possible re-tention of bacterial plaque and frequently impair comfort and phonation [1].

Persistent deciduous dentition and lack of per-manent tooth buds constitute a serious problem in the population of young patients on the threshold

of personal and professional life. The status of com-plementing missing teeth is a serious challenge for doctors who undertake to help a young patient, es-pecially if this problem refers to anterior teeth. The perspective of long-term use of prostheses, both re-movable and fixed, with exclusion of a larger num-ber of pillar teeth is difficult to accept by the pa-tient. in such cases immediate implant – prosthet-ic treatment is applied, frequently accompanied by bone augmentation and gingival surgery [2].

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smoker, without overweight or obesity.

During the dental medical interview, the pa-tient reported that when she was on holidays the previous winter, she was involved in a skiing acci-dent on a slope, during which she incurred an in-jury to the facial skeleton with a cut on the upper lip and a strong impact on both central incisors. The patient received medical assistance at a local hospital, which consisted of stitching the split lip. she was advised to be particularly careful about both central incisors in the maxilla due to their considerable mobility. Because the patient’s regu-lar dentist happened to be a member of her family, after her return it was decided to have a pantomo-graphic X-ray picture taken.

The dentist opted for implementation of en-dodontic treatment of tooth 51 and 21 (superior left central incisor) with the following exclusion of both teeth from occlusion. after three months of treatment, tooth 21 demonstrated stabilization and a significant decrease in mobility, however the ther-apy was less successful for tooth 51. The patient de-livered radiological documentation in the form of pictures: teeth in the relevant area and a pantomo-graph of jaws (Fig. 1 and Fig. 2). she reported no ear-lier periodontal treatment, whereas dental plaque and calculus removal was performed on average once a year. Daily oral hygiene included brushing teeth twice with dental floss cleaning, as well as ap-plication of antiseptic mouthwashes based on chlo-rhexidine solutions about three times weekly, in the evening as an additional hygienic procedure.

During dental physical examination the fol-lowing were observed: full dentition with retained wisdom tooth in the maxilla on the left side, cari-ous cavities class i to iV according to Black’s clas-sification (masticatory and/or proximal surfaces of premolars and molars, surfaces with/without incisal angles of incisors; canines with/without in-cisal angles) in individual teeth treated conserva-tively with fillings, as well as endodontic treatment performed in the maxilla of the right second pre-molar (tooth 15) and in both central incisors on the left and right sides (tooth 51 and 21) (Fig. 1). apart from the incidence of trepanation sites with

appropriate fillings, the above mentioned teeth demonstrated a decidedly darker hue, characteris-tic for this type of therapy. Tooth 51 demonstrated a protrusive deviation and a slight rotation (Fig. 3). Palpable examination of the discussed maxilla re-gion indicated suppuration on pressure exerted around attached gingiva (in health, with alveolar bone lamina of the maxilla and/or mandible), dis-crete fluctuation symptoms, which might suggest suppuration and/or destruction of alveolar bone lamina at least from the oral vestibule, as well as significant mobility (class iii) of tooth 51. Pain to percussion was not observed. The following peri-odontal parameters were observed:

– clinical attachment loss – 2 mm maximum, – periodontal pocket depths – 3 mm maximum, – mobility and furcation – respectively class iii

with reference to tooth 51; no lesions in furca-tions of molar roots were observed,

– bleeding on probing – 16%, – plaque index – 10%.

On the basis of the obtained data, chronic, local-ized and mild periodontal disease was diagnosed.

During the visit at the emergency ward, puru-lent secretion from periodontal tissues was observed, which constituted a potential focus of infection with-in the persistent deciduous central with-incisor with-in the maxilla (51), therefore antibiotic therapy was select-ed with a clindamycin preparation at 0.3 g, adminis-tered three times daily for seven days, as well as with a chemotherapeutic drug – metronidazole at 0.25 g, administered three times daily for seven days.

The patient called on the following day with a written certificate from a GP, allowing extrac-tion of tooth 51 on an outpatient basis, with the protective antibiotic therapy being underway.

Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 1. Zdjęcie pantomograficzne szczęk – widoczny

stan po urazie zębów siecznych centralnych szczęki, zatrzymany ząb 18, ząb 15 po leczeniu endodontycz-nym (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

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The presence of a potential focus of infection within the maxilla was the factor that made the patient accept the decision of the dental surgeon to opt for extraction, with a possibility of intraopera-tive verification with regard to guided bone regen-eration (GBR) and/or guided tissue regenregen-eration (GTR). according to the actual condition and pos-sibilities, a potential immediate implantation was also considered. The scope of such treatment and the patient’s limited temporal availability related to her place of residence created potential possi-bilities for a simultaneous operation.

This eventuality led to collection of alginate im-pressions and bite registration, which allowed the dental technician to construct a temporary mobile prosthetic supplement for the following day.

after administrating 4 ampoules of 1.7 ml (i.e. 6.8 ml) of 4% articaine hydrochloride with epi-nephrine hydrochloride as infiltration anesthe-sia within the median line of the maxilla and con-duction anesthesia into both infraorbital foram-ina, extraction of the persistent deciduous right central incisor was commenced. The alveolus was scooped, a bacterial periapical cyst was removed together with granulation (Fig. 4 and Fig. 5). Due to a lack of destruction in alveolar bone structure, Fig. 2. central incisors in maxilla after endodontic

treatment (from the archives of Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 2. centralne zęby sieczne szczęki po

wdrożo-nym leczeniu endodontyczwdrożo-nym (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 3. Protrusive deviation and rotation of tooth 51

(from the archives of Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 3. Wychylenie protruzyjne i rotacyjne zęba 51 (ze

zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 4. Visible periapical cyst of tooth 51 (from

the archives of Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 4. Widoczna torbiel okołokorzeniowa zęba 51

(ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 5. crown of tooth 51 with resorbed root and

peri-apical cyst (from the archives of Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 5. część koronowa zęba 51 ze zresorbowanym

korzeniem i torbiel okołokorzeniowa (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

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after drilling with a guide drill in this region, the decision to perform immediate implant placement was made. intraoperative measurements allowed drilling of the implant bed with a maintained aes-thetic profile, which was so crucial in the report-ed case (Fig. 6). a bone spreading technique in the operating field was also applied, which potentially ensures a better primary implant stabilization. an implant 3.4 mm in diameter and 13 mm long was screwed in (Fig. 7). in order to aesthetically close the operating field, a connective tissue flap was collected from the palate with the use of the enve-lope technique (Fig. 8). after infiltration anesthe-sia of the palate on the right side with one ampoule

of the previously used preparation (1.7 ml), a con-nective tissue flap was collected. it was placed in physiological saline solution (0.9% nacl). a com-pression suture was applied, closing the collection site (Fig. 9). Then the collected piece was prepared surgically on a wooden laryngological spatula, cleaned of epithelium and subepithelial adipose tissue. in order to increase the volume of maxillary alveolar bone tissue, bone augmentation was per-formed with a bone substitute – xenogenic prepa-ration granules 1–2 mm in diameter (Fig. 10). The prepared site was closed with the collected con-nective tissue and fixed with sutures, tightly clos-ing the alveolus with the implant and augment-ed bone tissue (Fig. 11). subsequent to procaugment-edure Fig. 6. exploratory drilling with a guide drill (from

Ryc. 6. nawiercanie zwiadowcze wiertłem

piloto-wym (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 7. screwing the implant into the implant bed after

tooth 51 – immediate implant placement

Ryc. 7. Wkręcanie implantu w łoże po zębie 51

(ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 8. collection of connective tissue flap from the

pal-ate on the right side (from the archives of Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 8. Pobieranie płata tkanki łącznej z podniebienia

po stronie prawej (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 9. suture closing collection site on the palate

Ryc. 9. szew zamykający miejsce biorcze na

podnie-bieniu (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

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Discussion

The authors reporting the case wish to draw attention to a frequent necessity for the implemen-tation of resective – regenerative surgical treat-ment with the application of modern operative techniques. it concerns GBR (guided bone regen-eration) and GTR (guided tissue regenregen-eration), im-plantation and temporary supplementation as well as to the ultimate implant – prosthetic supplemen-tation [3–4]. This would be impossible without the application of modern techniques of section, soft tissue activation, improvement of bone quality and density – bone spreading and correct suturing [5]. it seems that the presented procedure is an impor-tant element of the restorative therapy of certain periodontal tissue elements and ultimate implant – prosthetic reconstruction. it effectively mini-mizes stress, aesthetic and functional dysfunction, Fig. 10. augmentation with bone substitute (from

Ryc. 10. augmentacja substytutem kostnym (ze

zbio-rów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 11. Fixed fragment of connective tissue tightly

closing the alveolus with implant and augmented bone tissue (from the archives of Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 11. Umocowany fragment tkanki łącznej

zamy-kający szczelnie zębodół z implantem i augmentowaną tkanką kostną (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

completion, the patient had a follow-up guided ra-diographic picture taken in order to check implant positioning (Fig. 12). The treatment itself was tak-en well by the patitak-ent, therefore she was released from the clinic in such condition with the recom-mendation to continue previous drug therapy (as above), with additional administration of a pain killer (mefenamic acid, three times daily in case of pain) and a decongestant (horse chestnut extract, three tablets four times daily). a follow-up visit was scheduled for the following day, when a tem-porary mobile prosthetic supplement constructed by the dental technician was given, with the sup-plement’s retention and stabilization secured by orthodontic arrow clasps. The surgical site was re-lieved. The post-surgery period was without com-plications. The patient called for stitch removal 12 days after the surgery, and after three weeks for a check-up of the temporary prosthetic supple-ment (Fig. 13).

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especially in a patient with persistent deciduous dentition, without permanent tooth buds, who has been troubled for years with the perspective of its loss. The procedure also eliminates a possible fo-cal infection, which could be caused by the perma-nent deciduous tooth along with the cyst and in-flammatory granulation [6]. The operators could

have applied an adhesive bridge, supported and cemented on the right lateral incisor and the left central incisor in the maxilla, as a temporary sup-plement. However, the costs of such a procedure related to construction and fixing with specialized cements were outside the patient’s price range. De-spite that, the performed treatment was very satis-fying for the patient and the operating team due to its complexity, and all are looking forward to the ultimate implant – prosthetic reconstruction. Fig. 12. Guided radiographic picture taken in order

to check implant positioning (from the archives of Department of Oral Medicine and Periodontal Diseases, Medical University of Warsaw – czerniuk M.R.)

Ryc. 12. celowany rentgenogram sprawdzający

pozy-cjonowanie implantu (ze zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

Fig. 13. Temporary prosthetic supplement (from

Ryc. 13. Użytkowane uzupełnienie tymczasowe (ze

zbiorów Zakładu chorób Błony Śluzowej i Przyzębia WUM – M.R. czerniuk)

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Address for correspondence:

Maciej R. czerniuk

Department of Oral Medicine and Periodontal Diseases institute of Dentistry

Medical University of Warsaw Miodowa 18 00-246 Warsaw Poland Tel./fax: +48 22 502 20 36 e-mail: mczerniuk@o2.pl Received: 24.07.2012 Revised: 27.09.2012 accepted: 9.10.2012

Praca wpłynęła do Redakcji: 24.07.2012 r. Po recenzji: 27.09.2012 r.