Case Report International Journal of Dental and Health Sciences Volume 02, Issue 06 MANAGEMENT OF ATROPHIC ANTERIOR MAXILLA USING RIDGE SPLIT TECHNIQUE, IMMEDIATE IMPLANTATION AND TEMPORIZATION Rakshith Hegde 1, Kaiwan Khurshed Shroff 2, Chethan Hegde 3 1.Professor, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences Deralakatte, Mangalore 2.Post-Graduate Student, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore 3.Professor and Head of Department, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore ABSTRACT: The ridge split technique is commonly used in implant dentistry when there is a deficiency in the alveolar ridge in order to avoid extensive hard tissue grafting procedures. Immediate loading of single implants in the esthetic zone is a well-documented and predictable procedure. This case report discusses the replacement of a missing lateral incisor in the maxillary esthetic zone with an implant supported prosthesis in which the alveolar ridge was split to increase the horizontal bone volume, followed by implant placement and immediate temporization. Key Words: Immediate implantation, Ridge split, Temporization. INTRODUCTION One of the greatest challenges in implant dentistry is the replacement of a missing tooth in the maxillary aesthetic zone. Rehabilitation of function and aesthetics have to be taken into consideration during treatment planning. Osseointegrated implants are considered as a time tested and predictable treatment option for rehabilitation of a single missing maxillary anterior tooth. Success rate is estimated at 95% for both immediate and nonimmediate loading. [1,2] Using immediate loading, an implant can be placed and loaded with a provisional tooth so that aesthetics, comfort and partial function can be restored immediately. Immediate loading depends on two primary factors. The first is the ability of the implant to osseointegrate despite external forces which act on it and second is to maintain and stabilize the soft tissue surrounding the implant fixture. The implant should be loaded within 72 hours of implant placement. [3-6] A major problem encountered while placing implants in the maxillary anterior region is the absence of adequate alveolar bone width. This can occur following tooth extraction where the thin labial plate resorbs swiftly leaving only the previous palatal plate intact. [7] In such situations when the alveolar ridge width is inadequate it is often necessary to carry out guided bone regeneration procedures or autogenous block bone grafting. [8,9] As *Corresponding Author Address: Dr Rakshith Hegde.Email: prosthodons@yahoo.co.in
an alternative to these procedures a ridge split technique can be used. MATERIALS AND METHOD A 41-year-old male patient reported to the Department of Prosthodontics with a missing right maxillary lateral incisor. The tooth had been extracted six months prior due to mobility following which the patient had undergone periodontal therapy for the remaining teeth. The patient refused reduction of his adjoining teeth to place a fixed dental prosthesis. Patient was healthy and had no systemic conditions. An implant placement with immediate loading if possible was planned for the patient. TREATMENT PLANNING The edentulous maxillary area was examined clinically (Fig 1) following which diagnostic study models were made and used to carry out ridge mapping. An intra oral periapical radiograph was made (Fig 2) and the height of available bone present from the crest of the ridge up to the floor of the nose was measured for implant placement. It was decided to place a 3.5 x 11 mm Ankylos CX (Dentsply Implants, Germany) implant. Since the width of the ridge at the crest was relatively resorbed a ridge split technique was planned. SURGICAL PROCEDURE The entire procedure was done under local anesthesia, 2% lignocaine with adrenaline was injected in the buccal vestibule and palatal region at the edentulous site. Full thickness Hegde R. et al., Int J Dent Health Sci 2015; 2(6): 1633-1638 mucoperiosteal flap was then raised to expose the crest of the ridge, giving a mid crestal incision. The ridge was split crestally using a BP blade in a mesiodistal movement (Fig 3). Bone expansion was carried out using bone expansion osteotomes up to 8 mm. Once the ridge had been split adequately, a 2mm pilot drill was used up to the full length of 11 mm. Paralleling pin was placed to check for the correct three dimensional position of the osteotomy (Fig 4), following this a 3.2 mm twist drill was used to widen the osteotomy (Fig 5). A 3.5 x 11 mm Ankylos CX (Dentsply Implants, Germany) implant was inserted at 50 Ncm of torque. Primary stability of greater than 35 Ncm of torque was achieved. Judging the angulation of the implant a 3.0 mm regular straight abutment was selected and torqued using a hand ratchet at 15 Ncm torque as per manufacturer s instructions (Fig 6). The flap was approximated and sutured using 4-0 Vicryl suture and an immediate postoperative radiograph was made (Fig 7). RESTORATIVE PROCEDURE A mock up of the missing tooth was done on the diagnostic cast prior to surgery and a putty index of the same was prepared. The abutment access hole was sealed using composite. The putty index was loaded with a bis-acryl temporization material and the temporary was fabricated. After initial setting of the material the crown was removed, finished and polished outside the patient s mouth. The temporary crown was verified to be absent of any centric or eccentric contact with the opposing teeth. The crown was 1634
cemented using a TempBond NE (Kerr Dental) and all the excess cement was removed from the surrounding soft tissue (Fig 8). Patient was given all the required post-surgical instructions and explained maintenance protocol. Suture removal was done after 7 days post-surgery with no immediate post-surgical complications. Patient was followed-up at 3, 6, 12-month intervals. At the 3 month follow up the temporary crown was replaced with a permanent porcelain fused to metal crown (Fig 9). No complications were observed in the 1-year follow-up period (Fig 10). One year post-surgical intra oral periapical radiograph (Fig 11) showed healthy crestal bone levels and stable soft tissue levels. Hegde R. et al., Int J Dent Health Sci 2015; 2(6): 1633-1638 immediate loading. A second stage surgical procedure is also avoided and the adjoining papilla maintained. An important factor in implant placement in the anterior maxilla is the threedimensional position of the implant, the implant should be placed slightly palatally, so that the buccal bone wall is preserved. This prevents future gingival recession and implant exposure. A series of instruments should be used gently to separate the ridge, thus reducing the chances of cortical plate fracture. If there is a fracture of the cortical plate it will not be catastrophic to implant placement but the implant cannot be loaded immediately. [12] DISCUSSION The use of immediate loading technique may be indicated for all cases in which the immediate application of loads to an implant is possible. However, an initial primary stability of 35 Ncm is required to load a single implant prosthesis. Therefore, it is of paramount importance for the clinician to measure the primary stability at the time of implant placement to judge if the implant can be loaded with a provisional prosthesis. Micromovements to the implant should be limited as much as possible by keeping the prosthesis out of centric and eccentric contact and also prevent removal of the provisional prosthesis during the healing phase. [10,11] Restoration of function and esthetics is a major advantage of REFERENCES: CONCLUSION Within the limitations of this case it can be concluded that when the principles of immediate loading are applied correctly a predictable result can be obtained. The function and esthetics of the patient are restored instantaneously. The ridge split technique also helps prevent the need for guided bone regeneration and is more conservative in its approach. However, studies with more follow-up time and controlled clinical trials should be carried out in order to verify the long-term effectiveness of this technique. 1. Andersen E et al. Immediate loading of single-tooth ITI implants in the 1635
Hegde R. et al., Int J Dent Health Sci 2015; 2(6): 1633-1638 anterior maxilla: a prospective 5-year pilot study. Clin Oral Implants Res. 2002; 13(3): p. 281-7. 2. Chaushu G et al. Immediate loading of single-tooth implants: immediate versus non-immediate implantation. A clinical report. Int J Oral Maxillofac Implants. 2001; 16(2): p. 267-72. 3. Cooper LF et al. Immediate mandibular rehabilitation with endosseous implants: Simultaneous extraction, implant placement and loading. Int J Oral Maxillofac Implants. 2002; 17: 517-25. 4. Aparicio C et al. Immediate/early loading of dental implants: A report from the Sociedad Espan ola de Implantes World Congress Consensus Meeting in Barcelona, Spain, 2002. Clin Implant Dent Relat Res. 2003; 5: 57-60. 5. Cochran DL et al. Consensus statements and recommended clinical procedures regarding loading protocols for endosseous dental implants. Int J Oral Maxillofac Implants. 2004; 19: 109-13. 6. Szmukler-Moncler S et al. The timing of loading and the effect of micromotion on the dental implant-bone interface: A review of the experimental literature. J Biomed Mater Res. 1998; 43: 192-203. 7. Scipioni A et al. The edentulous ridge expansion technique: A five-year study. Int J Periodontics Restorative Dent. 1994; 14: 451-9. 8. Hammerle CH et al. The effect of a deproteinized bovine bone mineral on bone regeneration around titanium dental implants. Clin Oral Implants Res. 1998; 9: 151-62. 9. Buser D et al. Localized ridge augmentation with autografts and barrier membranes. Periodontol 2000. 1999; 19: 151-63. 10. Nikellis I et al. Immediate loading of 190 endosseous dental implants: a prospective observational study of 40 patient treatments with up to 2-year data. Int J Oral Maxillofac Implants. 2004; 19(1): 116-23. 11. De Rouck T et al. Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: a review. Int J Oral Maxillofac Implants. 2008; 23(5): 897-904. 12. Calvo Guirado JL et al. Ridge splitting technique in atrophic anterior maxilla with immediate implants, bone regeneration and immediate temporisation: a case report. Journal of the Irish Dental Association. 2007; 53(4): 187-90. 1636
FIGURES: Hegde R. et al., Int J Dent Health Sci 2015; 2(6): 1633-1638 Figure 1 - Intra oral pre-operative view Figure 4- Paralleling rod used to verify parallelism of osteotomy Figure 2- Preoperative intra oral periapical radiograph Figure 5- Final osteotomy prepared Figure 3- Deficient alveolar ridge with initial splitting of the ridge done Figure 6- Abutment torqued 1637
Hegde R. et al., Int J Dent Health Sci 2015; 2(6): 1633-1638 Figure 10- One year follow-up Figure 7- Immediate post-operative radiograph Figure 8- Immediate temporization Figure 11- One year follow-up radiograph Figure 9- Permanent cement retained prosthesis 1638