Immediate placement and provisionalization of an implant after removal of an impacted maxillary canine: two case reports
© Zuiderveld et al.; licensee Springer. 2015
Received: 27 January 2015
Accepted: 20 May 2015
Published: 30 May 2015
Single immediate implant replacement is accompanied by excellent survival rates and a favorable esthetic outcome. The objective of this report was to describe a surgical approach for removal of a buccal or palatally located impacted secondary canine, combined with extraction of the failing primary canine, and immediate placement and provisionalization of an implant. A window technique was applied for surgical removal of the impacted canine. The alveolar crest was preserved. After extraction of the primary canine, the implant was inserted with primary stability. Finally, the exposed surfaces of the implant were covered with a 1:1 mixture of autologous bone and Bio-Oss®. At the 1-year evaluation, both implants were successfully osseointegrated and in function. Esthetics were excellent. It is concluded that under premise of preservation of sufficient bone to achieve primary stability of the implant, removal of the canines can be combined with immediate placement and provisionalization of the implant.
KeywordsDental implants Maxillary impacted canine Immediate implant Immediate placement Immediate provisionalization
Maxillary canines are the second most impacted teeth (20 % of all impacted teeth); the prevalence in general population is approximately 2 %. Most impacted cuspids are located palatally, with a palatal/buccal ratio of 8:1 [1–4].
There are several known treatment options for impacted canines to align them into the dental arch. The most widely used option is orthodontic traction after surgical exposure. An alternative is autotransplantation of the impacted canine optionally combined with orthodontic treatment, e.g., when only orthodontic repositioning is not possible or unsuccessful [4–6]. In general, these treatment options use the patient’s own teeth to encounter the clinical problem. The advantages of this aspect are functioning as normal teeth, normal dentofacial development, and maintenance of the alveolar bone. Prognosis of autotransplantation is significantly dependent on the stage of root development, with lower risk of failure in teeth with open apex . Success rates for autotransplantation, mentioned in the literature, lie between 82 and 99 % . Disadvantages of both treatment options for alignment of impacted canines into the dental arch are a long treatment time and high costs, not to mention the unpredictable final outcome [2, 9, 10]. Surgical exposure followed by orthodontic traction is associated with damage to supporting structures such as bone loss, root resorption, and gingival recession [2, 10]. The most frequently reported complications in autotransplantation are root resorption or ankylosis, pulp necrosis, and reduction of final root length [5, 7]. Replacement of a failing single tooth, such as a failing primary canine with an impacted secondary canine, through a single implant is another reasonable treatment option [3, 4, 6]. Single implant treatment in this respect is not widely applied yet, but should be considered, if orthodontic treatment and autotransplantation are not feasible because of factors such as canine location, severity of impaction and age of the patient, or when the patient is not willing to encounter conventional treatment options because of treatment duration, morbidity, and costs [4, 6, 9]. With regard to prosthodontic rehabilitation of a single implant, the concept of immediate single implant placement and provisionalization is not yet a standard treatment , but there is a growing interest in immediate tooth replacement, particularly in the esthetic region.
Applying an immediate protocol means shortening of the treatment duration as only one surgical intervention is needed and no need for a temporary prosthesis. Thus morbidity and costs of the treatment are reduced [12–14].
According to the literature, immediate implant placement is accompanied by survival rates comparable to conventionally placed implants [12, 15]. With regard to immediate provisionalization, it is not yet set that the esthetic outcome is more favorable . However, immediate provisionalization of the immediately placed implant is presumed to give better support to the surrounding peri-implant tissue for preservation of the original architecture, conditions which are in favor for an optimal esthetic result [3, 11, 15, 16].
The objective of the present report was to describe a surgical approach for removal of an impacted secondary canine, either located buccally or palatally, combined with extraction of the primary canine and immediate placement and provisionalization of an implant.
Intra-oral examination revealed a healthy, well maintained dentition. Clinically, adequate bone volume was thought to be present at the future implant site as well as favorable conditions for an implant crown with an anatomical design.
Preoperatively, a cast was made for planning the preferred position of the implant from a prosthodontic perspective. Next, a transparent acrylic resin template (Vertex Castapress; Vertex-Dental BV, Zeist, the Netherlands) was made of this cast with the future implant crown in the preferred position. This template was transferred to a surgical guide. Care was taken to design the surgical guide as such that the guide channel allowed for screw retaining of the provisional restoration.
The patient was instructed to follow a soft diet, to avoid exerting force on the provisional restoration, and to continue the chlorhexidine rinse (Corsodyl; GlaxoSmithKline) for 7 days. For pain control, 600 mg ibuprofen (Brufen Bruis 600; Abott BV, Hoofddorp, the Netherlands) was prescribed, to be taken three times daily for the time period needed. Two weeks following surgery, the sutures were removed.
This case report describes two approaches for immediate replacement of a failing primary canine and an impacted secondary canine, viz. one for impacted cuspids located at the buccal side of the maxilla and one for impacted cuspids located at the palatal side of the maxilla, by an immediately placed and provisionalized single implant. With both approaches, esthetically satisfying results were achieved, comparable with other case reports [3, 6, 10]. Removal of an impacted canine causes an evident bone defect, which can be a possible limitation of the proposed technique, because it may be difficult or even not possible to place the implant with enough primary stability .
In order to preserve as much bone as possible during the surgical removal of the impacted tooth, it is important to localize the impacted tooth and to judge whether a buccal or palatal approach will preserve most of the native bone by three-dimensional radiographical imaging. Such an approach is supported by recent literature claiming that evaluation of a CBCT image favors treatment planning [5, 9]. Even though in both cases, a significant amount of bone had to be removed to expose the impacted cuspid, proper pre-operative planning still allowed for immediate implant placement and immediate provisionalization because of enough primary stability of the implant.
Characteristic for the bone defect in both cases was preservation of the coronal part of the alveolar crest, especially the labial bone plate. According to Kan et al. the presence of ideal pre-existent soft and hard conditions are a prerequisite for immediate implant placement and provisionalization. Particularly, an intact labial bone plate is important to minimize facial gingival recession [17, 18].
Furthermore, an implant system was used, which claims to achieve good primary stability in a small amount of bone, which allowed for immediate provisionalization [19, 20]. This is consistent with recent literature that claims when good primary implant stability is achieved, in the presence of sufficient bone volume, single implants should be provisionalized immediately for preservation of the pre-operatively existing tissue conditions in order to achieve a favorable esthetic outcome [12, 21–24].
But, in order to avoid significant facial hard and soft tissue loss due to the remodeling process after tooth extraction, jeopardizing the final esthetic result, a bone grafting procedure is necessary .
Although immediate implant placement and provisionalization is a desired treatment option, it is not possible to apply to young still growing patients. In this case, orthodontic treatment or autotransplantion are indicated .
In addition, a primary canine is smaller in all dimensions, but especially in its mesio-distal dimension, compared to a secondary canine. In order to place an implant crown with comparable dimensions as the contralateral secondary canine to achieve symmetry, sufficient mesio-distal space is needed. This can be a limitation of the proposed technique because when insufficient space is available, orthodontic treatment is still needed to create enough space for an implant crown with an anatomical design.
It is concluded that under premise of preservation of sufficient bone to achieve primary stability of the implant, removal of the canines can be combined with immediate placement and provisionalization of the implant.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
cone beam computed tomography
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