The International Journal of Periodontics & Restorative Dentistry

Transcription

1 The Interntionl Journl of Periodontics & Restortive Dentistry

2 235 Evlution of Bone Stility nd Esthetic Results After Immedite Implnt Plcement Using Novel Synthetic Bone Sustitute in the Anterior Zone: Results After 12 Months Alert Brroso-Pnell, DDS, PhD 1 Jordi Grgllo-Aliol, DDS, PhD 2 Federico Hérnndez-Alfro, MD, DDS, PhD 3 The im of this study ws to ssess one nd soft tissue chnges fter tooth extrction nd immedite implnt insertion in the nterior mxill. A novel synthetic one grft (VivOss, Strumnn) ws used to fill the gp etween the implnt surfce nd the lveolr one. Implnts with reduced dimeter compred to the size of the socket were used. A fixed or removle provisionl restortion ws provided immeditely fter implnt plcement. Cone em computed tomogrphy (CBCT) scns were tken to evlute one chnges, showing minor vritions fter 12 months of follow-up. To evlute soft tissue chnges, clinicl verticl mesurements were performed. Bsed on the results otined from 15 implnts plced in 14 ptients, it cn e concluded tht the use of n immedite implnt in comintion with synthetic one grft nd immedite provisionliztion seems to e predictle tretment option with stisfctory esthetic results fter 1 yer. Int J Periodontics Restortive Dent 2018;38: doi: /prd Assistnt Professor, Deprtment of Orl nd Mxillofcil Surgery, Interntionl University of Ctloni, Brcelon, Spin. 2 Associte Professor, Deprtment of Orl nd Mxillofcil Surgery, Interntionl University of Ctloni, Brcelon, Spin. 3 Professor nd Chirmn, Deprtment of Orl nd Mxillofcil Surgery, Interntionl University of Ctloni, Brcelon, Spin. Correspondence to: Dr Alert Brroso, Brroso Clinic Dentl, C/ Pujd Creude Plu 11 13, Giron, Spin. Emil: info@clinicrroso.com 2018 y Quintessence Pulishing Co Inc. Immedite implnt therpy is very ttrctive tretment option for the ptient s it reduces the numer of visits nd tretment time nd cn reduce tretment costs nd postopertive complictions. 1 5 However, clinicins should consider immedite implnt therpy techniclly sensitive pproch. It my e chllenging even for highly experienced clinicins to plce the implnt in the prostheticlly correct position in postextrction socket. 6 An inpproprite implnt plcement my led to iologic nd esthetic complictions. 7 For these resons, the clinicin performing immedite implnt tretment must tke into ccount the heling of socket fter tooth extrction, nd especilly the lveolr heling in the nterior zone. This remodeling process hs een widely descried in the literture. After tooth extrction, sustntil decrese in the one volume towrd the pltl spect of up to 50% during the first 12 months ws reported. 5,8 10 More ccentuted chnges fter tooth extrction re expected with decresing uccl one thickness. 11 The mjority (62.9%) of mxillry teeth from icuspid to icuspid demonstrte uccl one plte thickness of < 1 mm. 12 Thus, the immedite implnt should e plced wy from the uccl one, creting spce t the fcil spect of the implnt. 3 Animl nd humn Volume 38, Numer 2, 2018

3 236 studies suggest the use of one grft in this spce. 8,13 15 Clinicl dt is ville on different mterils, ut to dte there is no cler evidence for the superiority of one iomteril over ny others. In the present clinicl study, newly developed synthetic iphsic clcium phosphte grft mteril (VivOss, Strumnn) 16 ws used to fill the gp. The primry im of this prospective clinicl study ws to evlute the potentil of the synthetic one grft to minimize the one remodeling fter tooth extrction in immedite implnts in the esthetic zone. In ddition, the study ims to estlish reltionship etween one remodeling nd chnges in soft tissues. Mterils nd Methods A totl of 15 implnts plced in 14 ptients were included in this study with 1-yer follow-up. The implnts were plced in the esthetic zone in the nterior mxill. All ptients required single tooth extrction due to dvnced cries lesions, periodontlly hopeless teeth, trum/root frcture, or nonretrctle endodontic filure. The study ws conducted fter receiving pprovl from the Ethics Committee of Clinicl Investigtion of the Universitt Interncionl de Ctluny. After explining the possile tretment options nd requirements for prticiption in the study, ptients who signed the informed consent were sujected for study eligiility. The inclusion criteri pplied to this study were s follows: Helthy sujects ged 20 to 75 yers A hopeless single tooth in the mxillry nterior region (incisor, cnine, or premolr) Intct socket wlls fter tooth extrction Asence of dehiscence in the 4 mm most coronl of the uccl one Medium-thick soft tissue iotype Sufficient picl one to llow dequte nchorge/primry stility of the implnt (4 to 5 mm) Ptients who presented the following chrcteristics were excluded from the study: Presence of cute infection Dmged uccl one wll fter tooth extrction Impossiility of reching dequte implnt primry stility in the ntive one Need for surgicl flp to plce the implnt or to regenerte the one Smokers of > 10 cigrettes per dy Antitumor chemotherpy or rdiotherpy in the previous yer Unwillingness to sign the informed consent Full-mouth Plque Index nd full-mouth leeding on proing were recorded for ll enrolled ptients. All ptients were treted y the sme clinicin (A.B.P.). Before surgicl tretment, peripicl rdiogrph nd cone em computed tomogrphy (CBCT) scn of the hopeless tooth were performed for dignosis nd tretment plnning. A cst model ws prepred to mke the surgicl stent nd elorte n dhesive provisionl restortion. Surgicl Protocol Locl nesthesi ws induced y infiltrtion with rticine with drenline 1:100,000. Hopeless teeth were crefully extrcted, nd the presence of n intct uccl one ws checked with periodontl proe. Strumnn Bone Level Roxolid SLActive implnts with dimeter of 3.3 or 4.1 mm were plced in the extrction socket without rising mucoperiostel flp (Fig 1). Implnt dimeter ws chosen sed on the size of the socket, to void intimte contct with the uccl one plte, nd on the mesiodistl spce of the edentulous zone. Different implnt lengths (10, 12, nd 14 mm) were used to rech n dequte primry stility. The implnts were positioned slightly to the pltl side ccording to the surgicl stent, creting spce etween the uccl one wll nd the implnt. The gp ws filled with novel synthetic one grft, composed of 10% hydroxylptite nd 90% ettriclcium phosphte (VivOss, Strumnn). No sutures were used (Fig 2). Regrding the picocoronl positioning of the implnt, the uccl lveolr one pek ws used s reference point. The implnt shoulder ws plced 1 to 2 mm picl to this point. The Interntionl Journl of Periodontics & Restortive Dentistry

4 237 c Fig 1 (top) Hopeless teeth were extrcted crefully (,) nd implnts were plced immeditely using flpless pproch (c). Fig 2 (right) The implnts were plced towrd the pltl one, creting spce on the uccl side of the implnt (), which ws filled with the novel synthetic one sustitute (). All ptients were prescried moxicillin 750 mg for 7 dys fter surgery, nti-inflmmtories nd nlgesic mediction for 4 to 5 dys (iuprofen 600 mg), nd 0.12% chlorhexidine mouthrinse for 7 dys fter intervention twice dy. Prosthetic Procedures c Fig 3 The immedite dhesive provisionl offered support to the soft tissues just fter the extrction nd immedite implnt plcement, nd prevented loss of the one sustitute (,). The gingivl rchitecture ws mintined y the fixed provisionl (c,d). d An dhesive, tooth-supported provisionl restortion, prepred y the lortory, ws immeditely provided to the ptient nd cemented to the pltl surfces of the neighoring teeth. In cses where the overite ws unfvorle or the neighoring teeth hd cermic restortions with difficult dhesion conditions, prtil crylic removle denture without uccl flnge ws used. The provisionl restortions were in close contct with the socket, which voided the loss of the one grft nd supported the soft tissues immeditely postextrction. Gret effort ws mde to wrrnt polished surfce of the resin in contct with the soft tissues to void dverse effects (Figs 3 nd 4). After 4 weeks of heling, the gingivl prt of the provisionl restortion ws modified y dding resin Volume 38, Numer 2, 2018

5 238 Fig 4 In cses where n dhesive provisionl restortion ws not possile (), n crylic removle prtil denture ws dpted to mintin the one sustitute in the gp nd give support to the soft tissues (,c). c Fig 5 The provisionl restortion () ws used to expose the hed of the implnt () nd crete the dequte emergence profile (c). Resin ws dded in increments on the gingivl prt until the heling cp of the implnt ws exposed (d,e). Definitive impressions were tken etween 6 nd 10 weeks fter implnt plcement. On verge, fter 8 weeks the implnts were exposed nd impressions were tken. A customized zirconi utment ws fricted. The idel ntomy of the cementle utment ws wxed up y the lortory technicin. The model ws scnned nd computerssisted mnufctured in zirconi with metl interphse. These two elements were cemented extrorlly with Rely X Unicem (3M ESPE). Finlly, full-cermic crown ws cemented onto the zirconi utment using retrction cord to void sugingivl cement extrusion (Fig 6). c Clinicl nd Rdiogrphic Outcome Mesurements d e composite until the closure cp of the implnt ws exposed. The resin increments were 1 to 1.5 mm per visit; fter two or three visits the implnt ws exposed nd n dequte emergence profile ws creted (Fig 5). To ssess the one stility fter implnt tretment, CBCT scns (Kodk D, Crestrem Helth) were tken just fter tooth extrction nd immedite implnt plcement nd fter 12 months of follow-up (Fig 7). To minimize ptients exposition to unnecessry rdition, reduced field of view ws pplied ccording to implnt position. Five horizontl mesurements were tken with the implnt shoulder s reference The Interntionl Journl of Periodontics & Restortive Dentistry

6 239 Fig 6 A customized zirconi utment ws elorted (), nd full cermic crown ws cemented (). Fig 7 Five horizontl mesurements were tken on the CBCT just fter implnt insertion (). The sme mesurements were repeted fter 12 months (). Fig 8 The five horizontl mesurements from the implnt pltform to 5 mm elow fter implnt plcement. Fig 9 The five horizontl mesurements from the implnt pltform to 5 mm elow 12 months fter implnt plcement. c Fig 10 Three verticl clinicl mesurements were tken to evlute chnges in soft tissues: () from occlusl/incisl surfce to the most coronl point of the mesil ppill, () from occlusl/incisl surfce to the most coronl point of the distl ppill, nd (c) from occlusl/ incisl surfce to the highest point (zenith) of the gingivl mrgin. point. The mesurements were performed from the uccl surfce of the implnt to the most vestiulr point of one (Figs 8 nd 9). The soft tissue chnges were evluted y three verticl mesurements on the dy of the finl restortion delivery nd compred to the sme mesurements tken 12 months fter (Fig 10). Results Of the ptients, 10 were women nd the other 4 were men. The verge ge ws 57.5 yers (rnge: 33 to 69 yers). A totl of 15 implnts were plced. One ws plced in position of centrl incisor, 4 on lterl incisors, 3 first premolrs, nd 7 second premolrs. All implnts were osseointegrted nd in function 12 months Volume 38, Numer 2, 2018

7 240 Tle 1 Quntity of Bone (in mm) t the Lil Prt of the Implnt t Bseline nd 12 Months Implnt P1 0 P1 1 P2 0 P2 1 P3 0 P3 1 P4 0 P4 1 P5 0 P Averge P1 0 = seline mesurement t the implnt pltform; P1 1 = mesurement fter 12 months t the implnt pltform; P2 0 = seline mesurement 1 mm elow implnt pltform; P2 1 = mesurement fter 12 months 1 mm elow implnt pltform; P3 0 = seline mesurement 2 mm elow implnt pltform; P3 1 = mesurement fter 12 months 2 mm elow implnt pltform; P4 0 = seline mesurement 3 mm elow implnt pltform; P4 1 = mesurement fter 12 months 3 mm elow implnt pltform; P5 0 = seline mesurement 4 mm elow implnt pltform; P5 1 = mesurement fter 12 months 4 mm elow implnt pltform. Tle 2 Bone Chnges (in mm) t the Lil Prt of the Implnt Between Bseline nd 12 Months Implnt Tooth position (FDI) P1 P2 P3 P4 P Averge P1= mesurement t implnt pltform; P2= mesurement 1 mm elow the implnt pltform; P3 = mesurement 2 mm elow the implnt pltform; P4 = mesurement 3 mm elow the implnt pltform; P5 = mesurement 4 mm elow the implnt pltform. fter plcement. Therefore, implnt survivl 1 yer fter implnt plcement ws 100%. After 12 months, ll implnts hd on verge > 2 mm of one t the vestiulr site s mesured in the CBCT nlysis, rnging from 3.07 mm t 1 mm elow the implnt pltform to 2.62 mm t 4 mm elow (Tle 1). For implnts 1 nd 3, n sence of one ws oserved t the most coronl point with considerle reduction compred to the seline vlues of 2.9 nd 2.2 mm, respectively (Tle 1). Although ll implnts showed dequte one volume t the uccl site, one chnge, defined s difference in one level etween seline nd 12 months, ws oserved in ll mesurements. The vlues presented in Tle 2 indicte the one chnges fter 12 months t five different points of the implnt. It cn e oserved tht the mjor one chnges occurred t the most coronl point of the implnt: 0.9 mm of one reduction ws oserved t the implnt pltform. After 12 months, the clinicl mesurements reveled soft tissue creeping t the three mesured spects: mesil ppill, zenith of the gingivl mrgin, nd distl ppill (Tle 3). The mesil ppill hd n verge improvement of 0.3 mm. Similrly, n verge improvement of 0.25 mm ws found in the zenith of the gingivl mrgin, except t implnt 14 where 0.5 mm of recession ws detected. An verge creeping of the soft tissues of 0.2 mm ws found t the level of the distl ppill, except for implnt 6, where it decresed y 0.5 mm (Tle 3). The Interntionl Journl of Periodontics & Restortive Dentistry

8 241 Discussion After tooth extrction, certin degree of one remodeling should lwys e expected. So fr, no mechnisms hve een descried to void the collpse of the socket fter tooth loss, ut there re clinicl procedures tht cn minimize the remodeling of the lveolr wlls. 17 The most pronounced chnges occur in the uccl prt of the socket due to the presence of the undle one. 18 It ws previously reported tht plcing the implnt immeditely fter tooth extrction helped to minimize one chnges, 19 ut this concept hs not een confirmed y further clinicl nd niml studies. Despite these findings, fvorle esthetic results fter immedite implnt plcement nd provisionliztion hve een reported. 18,20 However, recession of the fcil soft tissue ws lso descried in retrospective studies with long-term follow-up. 4,21,22 This is clerly relted to the presence of one in the uccl spect of the implnt, supporting the ide tht mintennce of the soft tissues depends on the underlying one. 21 In the present study, different strtegies were pplied to ensure n pproprite quntity of one on the uccl site of the implnt to enhnce the stility of the soft tissue. Implnts with reduced dimeter in comprison to the size of the socket were plced in pltlly oriented position. Following this protocol, gp ws creted etween the implnt nd the inner prt of the uccl one wll of the socket. The use of one grft to fill this gp hs een recommended in Tle 3 Verticl Chnges (in mm) of Soft Tissues After 12 Months Implnt Mesil ppill Gingivl mrgin Distl ppill Averge the literture sed on clinicl nd niml studies. 3,8,13 Different iomterils hve een used, ut so fr none of the one grfts hs een shown to e superior over nother in this indiction. In the present prospective clinicl study, newly developed mteril ws used (VivOss, Strumnn). This mteril hs een considered to hve osteoconductive nd osteoinductive properties. 16,23 A flpless pproch ws used to limit the degree of invsiveness nd to prevent one remodeling. After 1 yer, the 14 sujects in the present study completed the follow-up. Adequte osseointegrtion nd uccl one width could e oserved in the CBCTs. The three-dimensionl rdiologic exmintions showed the lowest verge one thickness t the most picl mesurement, while greter one chnges were detected t the most coronl point, t the level of the implnt pltform. This my e explined y the fct tht for cses 1 nd 3 the implnts were not plced sufficiently elow the crest. Thus, this region is the first to e ffected y verticl resorption of the uccl one plte nd leves the most coronl surfce of the implnt exposed to the soft tissues (Tles 1 nd 2). The verge one reduction t the level of the implnt pltform ws 0.9 mm (Tle 1). This vlue is comprle to those reported y Degidi et l 15 in 2012 using xenogrft to fill the gp round immeditely plced implnts following flpless technique. After 1 yer of follow-up, n verge one chnge of 0.88 mm ws reported, which corresponds to the height of the implnt pltform. 15 In 2014, Lee et l 20 reported 0.12 ± 0.22 mm of one reduction fter 6 months of follow-up, lso using Volume 38, Numer 2, 2018

9 242 xenogrft. 20 Using n llogrft s one sustitute, Spinto nd Glino-Moreno 24 reported horizontl reduction of 0.62 mm fter 12 months of follow-up. When the quntity of one present t the uccl prt of the implnt ws nlyzed, the results of the present study were etter thn those reported y Miymoto nd Om 4 in 2011 using utologous one grft to fill the uccl gp in immeditely plced implnts in the esthetic zone. They showed n verge one width t the implnt pltform level of 0.48 mm fter men follow-up of 31 months. In the present study, using synthetic one grft, the quntity of one t this level ws 2.78 mm fter 12 months (Tle 2). These results re very similr to those otined using xenogrft: 2.08 mm fter 6 months 20 or 2.12 mm fter 12 months. 15 Spinto nd Glindo-Moreno 24 reported n verge one width of 1.19 mm fter 12 months, using llogrft to fill the gp. 24 The difference in results with regrd to the one volume in the uccl prt of the implnt my e further influenced y the heterogenity of the surgicl nd prosthetic protocols. Providing the ptient with n immedite provisionl restortion, either fixed or removle, prevented the loss of the one grft into the orl cvity nd supported the soft tissue immeditely fter tooth extrction. After 12 months, the position of the soft tissue t the mesil ppill, the zenith of the gingivl mrgin, nd the distl ppill hd improved. The highest improvement ws oserved t the mesil ppill (Tle 3). Conclusions Dimensionl one chnges should e expected fter tooth extrction. Within the limits of this study, it ws demonstrted tht the most pronounced one remodeling occurred in the most coronl prt of the crest. Immedite insertion of n implnt fter tooth extrction using flpless technique in comintion with synthetic one grft nd immedite provisionliztion seems to e predictle tretment option showing fvorle esthetic results fter 1 yer of follow-up. However, further studies with longer follow-up re needed to confirm this outcome. Acknowledgments The uthors reported no conflicts of interest relted to this study. References 1. Slgter KW, den Hrtog L, Bkker N, Vissink A, Meijer HJ, Rghoer GM. Immedite plcement of dentl implnts in the esthetic zone: A systemtic review nd pooled nlysis. J Periodontol 2014;85:e241 e Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implnt plcement fter tooth extrction: Immedite, immedite-delyed or delyed implnts? A Cochrne systemtic review. Eur J Orl Implntol 2010;3: Vignoletti F, Snz M. Immedite implnts t fresh extrction sockets: From myth to relity. Periodontol ; 66: Miymoto Y, Om T. Dentl cone em computed tomogrphy nlyses of postopertive lil one thickness in mxillry nterior implnts: Compring immedite nd delyed implnt plcement. Int J Periodontics Restortive Dent 2011;31: Lee CT, Chiu TS, Chung SK, Trnow D, Stoupel J. Altertions of the one dimension following immedite implnt plcement into extrction socket: Systemtic review nd met-nlysis. J Clin Periodontol 2014;41: Bruno V, Bdino M, Scco R, Ctpno S. The use of prosthetic templte to mintin the ppill in the esthetic zone for immedite implnt plcement y mens of rdiogrphic procedure. J Prosthet Dent 2012;108: Chen ST, Dry IB, Reynolds EC. A prospective clinicl study of non-sumerged immedite implnts: Clinicl outcomes nd esthetic results. Clin Orl Implnts Res 2007;18: Schropp L, Wenzel A, Kostopoulos L, Krring T. Bone heling nd soft tissue contour chnges following single-tooth extrction: A clinicl nd rdiogrphic 12-month prospective study. Int J Periodontics Restortive Dent 2003;23: Arújo MG, Lindhe J. Dimensionl ridge ltertions following tooth extrction. An experimentl study in the dog. J Clin Periodontol 2005;32: Arújo MG, Sukekv F, Wennström JL, Lindhe J. Tissue modeling following implnt plcement in fresh extrction sockets. Clin Orl Implnts Res 2006;17: Chppuis V, Engel O, Reyes M, Shhim K, Nolte LP, Buser D. Ridge ltertions post-extrction in the esthetic zone: A 3D nlysis with CBCT. J Dent Res 2013;92(12 Suppl):195S 201S. 12. Brut V, Bornstein MM, Belser U, Buser D. Thickness of the nterior mxillry fcil one wll A retrospective rdiogrphic study using cone em computed tomogrphy. Int J Periodontics Restortive Dent 2011;31: Arújo MG, Linder E, Lindhe J. Bio-Oss Collgen in the uccl gp t immedite implnts: A 6-month study in the dog. Clin Orl Implnts Res 2011;22: Brone A, Ricci M, Clvo-Guirdo JL, Covni U. Bone remodelling fter regenertive procedures round implnts plced in fresh extrction sockets: An experimentl study in egle dogs. Clin Orl Implnts Res 2011;22: Degidi M, Dprile G, Nrdi D, Pittelli A. Buccl one plte in immeditely plced nd restored implnt with Bio-Oss collgen grft: A 1-yer follow-up study. Clin Orl Implnts Res 2013;24: The Interntionl Journl of Periodontics & Restortive Dentistry

10 Miron RJ, Sculen A, Schung Y, et l. Osteoinductive potentil of novel iphsic clcium phosphte one grft in comprison with utogrfts, xenogrfts, nd DFDBA. Clin Orl Implnts Res 2016; 27: Snz M, Cecchinto D, Ferrus J, Pjetursson EB, Lng NP, Lindhe J. A prospective, rndomized-controlled clinicl tril to evlute one preservtion using implnts with different geometry plced into extrction sockets in the mxill. Clin Orl Implnts Res 2010;21: Trnow DP, Chu SJ, Slm MA, et l. Flpless postextrction socket implnt plcement in the esthetic zone: Prt 1. The effect of one grfting nd/or provisionl restortion on fcil ridge dimensionl chnge A restrospective cohort study. Int J Periodontics Restortive Dent 2014;34: Polntonio M, Dolci M, Scrno A, et l. Immedite implnttion in fresh extrction sockets. A controlled clinicl nd histologicl study in mn. J Periodontol 2001;72: Lee EA, Gonzlez-Mrtin O, Fiorellini J. Lingulized flpless implnt plcement into fresh extrction sockets preserves uccl lveolr one: A cone em computed tomogrphy study. Int J Periodontics Restortive Dent 2014;34: Benic GI, Mokti M, Chen CJ, Weer HP, Hämmerle CH, Gllucci GO. Dimensions of uccl one nd mucos t immeditely plced implnts fter 7 yers: A clinicl nd cone en computed tomogrphy study. Clin Orl Implnts Res 2012;23: Kn JYK, Rungchrsseng K, Lozd JL, Zimmermn G. Fcil gingivl tissue stility following immedite plcement nd provisionliztion of mxillry nterior single implnts: A 2- to 8-yer follow-up. Int J Orl Mxillofc Implnts 2011;26: Miron RJ. The rrivl of synthetic one grfts with osteoinductive potentil. J Dent Res 2014;1: Spinto S, Glindo-Moreno P. Evlution of uccl plte fter humn one llogrfting: Clinicl nd CBCT outcomes of immedite nterior implnts in eight consecutive cses. Int J Periodontics Restortive Dent 2014;34:e58 e66. Volume 38, Numer 2, 2018