Authors : Dr. Rahul Nagrath , Dr. Arjun Jawahar Sharma , Dr. Amit Gupta .
Loss of tooth in the aesthetic zone is a traumatic experience with or without compromising in phonetics. Hence, in the aesthetic zone implant supported single/multiple tooth replacement is one of the most challenging situations confronting the clinician. According to traditional Protocols few months of healing period is required for the consolidation of extraction socket. Patients are required to wait for longer period upto 5-6 months or more for replacement of the tooth loss.
Attempts to shorten the overall length of treatment period have focussed on approaches like early or immediate loading following implant placement, immediate implant placement in fresh socket site and immediate implant placement and early or immediate loading.
Immediate implant placement into fresh extraction socket reduces the treatment cost, preserved the gingival aesthetics and increases the comfort of the patient. This case reports describes the procedure for immediate implant placement in fresh extraction sockets with plasma rich fibrin (PRF) membrane, bone graft, provisionalization and progressive loading of the prosthesis.
Unlike PRP, this technique does not require anticoagulants, bovine thrombin or any other gelifying agent. The PRF clot is yielded by a natural polymerization process during centrifugation, and its natural fibrin architecture seems responsible for a slow release of growth factors and matrix glycoproteins during ≥7 days.PRF has a dense fibrin network with leukocytes, cytokines, structural glycoproteinsand also growth factors such as transforming growth factor b1, platelet-derived growth factor, vascular endothelial growth factor and glycoproteins such as thrombospondin-1 during 7 day.Leukocytes that are concentrated in PRF scaffold play an important role in growth factor release,immune regulation,anti-infectious activities, and matrix remodelling during wound healing. The slow polymerization mode of PRF and cicatricle capacity creates a physiologic architecture favourable for wound healing.
Preparation of PRF
Preparation of PRF follows the protocol developed by Choukroun et al in 2001. Blood specimen is collected from the patient and centrifuged at 3000 rpm for 10 minutes or 2700 rpm for 12 minutes.
Applications of PRF
PRF membrane in combination with bone grafts can be used for healing in lateral sinus floor elevation procedures, stabilisation of graft material, socket preservation, wall defects, recession, and filling of cystic cavity.
Extra oral Clinical Applications
PRF is used for dentinogenesis by stimulating cell proliferation and differentiation of Dental Pulp Cells, repair of Achilles tendon repair and articular cartilage, healing of non-healing lower extremity ulcers. PRF can also be used in various facial plastic surgery procedures.
Limitations of PRF
Availability of this biomaterial in larger amounts is a concern because of autologous origin and it can’t be used as allogenic material due to presence of the circulating immune cells and antigenic molecules.
CASE REPORT 1 :
A 47year old male patient reported to the department of prosthodontics in K.D. Dental College Mathura with chief complaint of missing tooth in relation to lower anterior region and mobility in 31,41,42 and wanted to replace his missing teeth. Complete medical and dental history was recorded radiographs and photographs were taken. No systemic disorder were told neither observed in the Investigations. Past Dental history revealed that patient underwent excision of gingiva in upper and lower region 8 years back due to inflammation. Extra oral examination revealed no facial asymmetry and patient did not have any symptoms of temporomandibular disorder.
On intraoral examination mandibular central incisor i.e. 31 were found missing, grade III mobility in 41,42,32 and there was generalised recession and periodontitis. No gross abnormality was noted in the overall soft tissue of lips, cheeks, tongue and pharynx.
A 20 year old male patient presented to the Department of Prosthodontics, Vananchal Dental College and Hospital with chief complaint failed root canal treated tooth of upper front region. Clinical and radiographic examination revealed failed root canal treated tooth with unfavourable prognosis [Figure 1]. All the available treatment options were discussed with the patient and the proposed procedure which included immediate implant placement and early loading. The patient was very conscious about his aesthetic and was very keen for earliest possible restoration of his teeth and so he opted for proposed procedure.
|Figure 1. Pre-operative intraoral frontal view of failed root canal right maxillary central incisor|
Pre-surgical radiographic evaluation was carried out with IOPA, panoramic radiograph for appropriate treatment planning. After proper treatment planning endo-osseous implant (Hi- Tec tapered self threaded, Life Care Devices Private Limited, Isreal) measuring 5 × 13 mm in dimension was selected. Atraumatic tooth extraction is the first and one of the most critical steps of immediate implant placement, the fracture tooth was atraumatically removed [Figure 2].
|Figure 2. Atraumatic extraction of without flap reflection resulted in well preserved bone and soft tissue architecture.|
After extraction, the site was thoroughly degranulated using curettes, the socket irrigated thoroughly with Povidine- Iodine and carefully examined to be certain that the socket walls were intact. The extraction socket was evaluated for osseous defects. All four walls were found intact. A sequential drilling was carried out with drill sequences of 2.2, 2.8, 3.2, 3.65, 4.3 and 5, implant was placed in socket with the insertion torque of 45 Ncm [Figure 3].
|Figure 3. A 5 × 13 mm tapered self-threaded implant was inserted to desired depth after sequential osteotomy|
Implant first thread was placed 1.5 mm apical to crestal bone of the socket and adequate primary stability was obtained. Post-operative periapical radiograph was taken [Figure 4].
|Figure 4. IOPA showing implant placement|
Final impression is made by open window tray technique using with the double-mix impression technique (Virtual VPS putty base, regularset and extra light–body fast set, IvoclarVivadent). Healing cap (Hi-Tec HC-3 gingival former Life Care Device Private limited, Isreal) was secured on the implant. The patient was administered an analgesic (ibuprofen 800 mg, every 4 to 6 hours as needed) for 7 days and a systemic antibiotic (amoxicillin 500 mg, 3 times daily) for 7 days. Furthermore, he was advised to rinse with a 0.1% chlorhexidinedigluconate solution four times a day for 5 weeks.
The impression was poured with type-IV stone (Ultrarock, KalabhaiKarsonPvt.Ltd., Mumbai) and master cast obtained was mounted on a semi adjustable articulator. The working cast was then sent to laboratory for fabrication of CERCON® Zirconia crown (DentsplyCeramco, York, PA). After 2 weeks of healing period, the implant was loaded with cement retained Zirconia crown [Figures 5].
|Figure 5. Final prosthesis|
Final cementation was performed with adhesive resin (RelyXUnicem transparent, 3M ESPE, St Paul, MN). Postoperative follow up was done at 15 days, 1 month, 2 months, 3 months, 6 months, 1 year, 1.5 years and 2 years later [Figure 6].
|Figure 6. The two-year postoperative radiograph confirms favorable conditions at the bone-to-implant interface.|
Dental implant therapy is one of the recent treatment modality for replacement of missing teeth Immediate implant and early loading may be a good treatment option in the loss of anterior teeth.10 It is seen that the success rate in maxilla is 66%-95.5% and in mandible 90%-100%.11
Aesthetic is one of the a major concern for immediate implant placement, When implant placement is delayed for a period of time after tooth extraction, soft tissue healing may provide opportunities to maximize tissue volume to achieve proper flap adaptation and acceptable soft tissue esthetics. However, this advantage is offset by resorption of bone and loss of ridge dimensions. so prior to extraction of tooth it was aesthetically evaluated to comprehensively assess the potential implant placement site.
Belser, Buser and Higginbottom defined an esthetic implant crown as one in harmony with the perioral facial structures. In addition, the soft tissues, including, height, volume, color, texture and contours, should be in harmony with the surrounding teeth. Finally, the restoration should imitate the natural appearance of the missing tooth.12A proper treatment plan was made which included surgical and restorative protocol to gain the well defined aesthetic goals.
Bone loss after tooth extraction has an importantissue in dentistry. Resorption of the buccal wall of the extraction socket may lead to significant disadvantages, especially in the anterior part of the maxilla. To reduce the problems resulting from this loss of bone, dental implants have been placed into fresh extraction sockets.13
For the success of any.immediately placed implant to succeed, primary (mechanical) stability must be sufficient to enable the implant to resist micromovement until sufficient biologic stability (secondary stability) is adequately established. 14To achieve the sufficient primary stability the minimum insertion screw has to be equal or superior to 32 N/cm and the micro movement of the implant should not exceed 150 um.
To attain good initial stability we selected implants 2 mm longer than the socket length and excess preparation was done 2 mm beyond the socket, with initial drilling followed by sequential drilling15,16so In this case report, primary stability was achieved and no need for bone augmentation and implant is loaded after 2 week and during 2 years of follow-up there is minimum bone loss occur.
Immediate implant placement following tooth extraction has been found to be a viable and predictable solution to tooth loss. This case report demonstrates that it is possible to achieve greater efficiency in our efforts to minimally invasive surgical technique, ease of procedure and shorter time involved together with minimum postextraction complications are the important advantages of this method.
This procedure is technique-sensitive and may be more difficult to executethan the conventional procedure. Therefore, we we should be able to enhance the service and treatment offered to our patients in regard to our treatment time, patient comfort, cost and aesthetics.
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