PDF - Dental and Medical Problems

clinical case
Dent. Med. Probl. 2012, 49, 4, 600–606
ISSN 1644-387X
© Copyright by Wroclaw Medical University
and Polish Dental Society
Maciej R. CzerniukA, B, D, E, Maciej ZarembaB, 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 pacjentki, 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 autorzy 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.
Among the factors contributing to the occurrence of periodontal disease, special attention
should be paid to orthodontic – occlusive abnormalities, which seriously limit the possibilities of
proper daily oral hygiene, increase possible retention of bacterial plaque and frequently impair
comfort and phonation [1].
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. The status of complementing missing teeth is a serious challenge for
doctors who undertake to help a young patient, especially if this problem refers to anterior teeth. The
perspective of long-term use of prostheses, both removable and fixed, with exclusion of a larger number of pillar teeth is difficult to accept by the patient. In such cases immediate implant – prosthetic treatment is applied, frequently accompanied by
bone augmentation and gingival surgery [2].
Immediate Implant Placement
601
Case Report
A 24-year-old female, a student, reported to
the Emergency Ward of the Department of Oral
Medicine and Periodontal Diseases, Medical University of Warsaw. The patient did not have a referral from a dentist. The cause for the visit was
the mobility of tooth 51 (persistent deciduous central right incisor).
During a general medical interview, the patient denied the presence of any systemic diseases.
Family history was clean, the patient was a nonsmoker, without overweight or obesity.
During the dental medical interview, the patient reported that when she was on holidays the
previous winter, she was involved in a skiing accident on a slope, during which she incurred an injury 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 regular dentist happened to be a member of her family,
after her return it was decided to have a pantomographic X-ray picture taken.
The dentist opted for implementation of endodontic 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 therapy was less successful for tooth 51. The patient delivered radiological documentation in the form of
pictures: teeth in the relevant area and a pantomograph of jaws (Fig. 1 and Fig. 2). She reported no earlier 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 application of antiseptic mouthwashes based on chlorhexidine solutions about three times weekly, in the
evening as an additional hygienic procedure.
During dental physical examination the following were observed: full dentition with retained
wisdom tooth in the maxilla on the left side, carious cavities class I to IV according to Black’s classification (masticatory and/or proximal surfaces
of premolars and molars, surfaces with/without
incisal angles of incisors; canines with/without incisal angles) in individual teeth treated conservatively with fillings, as well as endodontic treatment
performed in the maxilla of the right second premolar (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
Fig. 1. Pantomographic picture of the jaws – visible condition after injury to incisors in maxilla, retained tooth 18,
tooth 15 after endodontic treatment (from the archives of
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 endodontycznym (ze zbiorów Zakładu Chorób Błony Śluzowej
i Przyzębia WUM – M.R. Czerniuk)
appropriate fillings, the above mentioned teeth
demonstrated a decidedly darker hue, characteristic for this type of therapy. Tooth 51 demonstrated
a protrusive deviation and a slight rotation (Fig. 3).
Palpable examination of the discussed maxilla region indicated suppuration on pressure exerted
around attached gingiva (in health, with alveolar
bone lamina of the maxilla and/or mandible), discrete 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 periodontal 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 furcations of molar roots were observed,
– bleeding on probing – 16%,
– plaque index – 10%.
On the basis of the obtained data, chronic, localized and mild periodontal disease was diagnosed.
During the visit at the emergency ward, purulent secretion from periodontal tissues was observed,
which constituted a potential focus of infection within the persistent deciduous central incisor in the
maxilla (51), therefore antibiotic therapy was selected with a clindamycin preparation at 0.3 g, administered 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 extraction of tooth 51 on an outpatient basis, with the
protective antibiotic therapy being underway.
602
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 wdrożonym leczeniu endodontycznym (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)
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 intraoperative verification with regard to guided bone regeneration (GBR) and/or guided tissue regeneration
(GTR). According to the actual condition and possibilities, 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 possibilities for a simultaneous operation.
M.R. Czerniuk, M. Zaremba
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 periapical 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)
This eventuality led to collection of alginate impressions 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 epinephrine hydrochloride as infiltration anesthesia within the median line of the maxilla and conduction anesthesia into both infraorbital foramina, 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,
Immediate Implant Placement
603
Fig. 6. Exploratory drilling with a guide drill (from
the archives of Department of Oral Medicine and
Periodontal Diseases, Medical University of Warsaw
– Czerniuk M.R.)
Fig. 8. Collection of connective tissue flap from the palate on the right side (from the archives of Department
of Oral Medicine and Periodontal Diseases, Medical
University of Warsaw – Czerniuk M.R.)
Ryc. 6. Nawiercanie zwiadowcze wiertłem pilotowym (ze zbiorów Zakładu Chorób Błony Śluzowej
i Przyzębia WUM – M.R. Czerniuk)
Ryc. 8. Pobieranie płata tkanki łącznej z podniebienia
po stronie prawej (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
(from the archives of Department of Oral Medicine
and Periodontal Diseases, Medical University of
Warsaw – Czerniuk M.R.)
Fig. 9. Suture closing collection site on the palate
(from the archives of Department of Oral Medicine
and Periodontal Diseases, Medical University of
Warsaw – Czerniuk M.R.)
Ryc. 7. Wkręcanie implantu w łoże po zębie 51
(ze zbiorów Zakładu Chorób Błony Śluzowej
i Przyzębia WUM – M.R. Czerniuk)
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 aesthetic profile, which was so crucial in the reported 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 envelope technique (Fig. 8). After infiltration anesthesia of the palate on the right side with one ampoule
Ryc. 9. Szew zamykający miejsce biorcze na podniebieniu (ze zbiorów Zakładu Chorób Błony Śluzowej
i Przyzębia WUM – M.R. Czerniuk)
of the previously used preparation (1.7 ml), a connective tissue flap was collected. It was placed in
physiological saline solution (0.9% NaCl). A compression 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 performed with a bone substitute – xenogenic preparation granules 1–2 mm in diameter (Fig. 10). The
prepared site was closed with the collected connective tissue and fixed with sutures, tightly closing the alveolus with the implant and augmented bone tissue (Fig. 11). Subsequent to procedure
604
Fig. 10. Augmentation with bone substitute (from
the archives of Department of Oral Medicine and
Periodontal Diseases, Medical University of Warsaw
– Czerniuk M.R.)
Ryc. 10. Augmentacja substytutem kostnym (ze zbiorów Zakładu Chorób Błony Śluzowej i Przyzębia WUM
– M.R. Czerniuk)
completion, the patient had a follow-up guided radiographic picture taken in order to check implant
positioning (Fig. 12). The treatment itself was taken well by the patient, therefore she was released
from the clinic in such condition with the recommendation 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 temporary mobile prosthetic supplement constructed
by the dental technician was given, with the supplement’s retention and stabilization secured by
orthodontic arrow clasps. The surgical site was relieved. The post-surgery period was without complications. The patient called for stitch removal
12 days after the surgery, and after three weeks
for a check-up of the temporary prosthetic supplement (Fig. 13).
M.R. Czerniuk, M. Zaremba
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 zamykający szczelnie zębodół z implantem i augmentowaną
tkanką kostną (ze zbiorów Zakładu Chorób Błony
Śluzowej i Przyzębia WUM – M.R. Czerniuk)
Discussion
The authors reporting the case wish to draw
attention to a frequent necessity for the implementation of resective – regenerative surgical treatment with the application of modern operative
techniques. It concerns GBR (guided bone regeneration) and GTR (guided tissue regeneration), implantation and temporary supplementation as well
as to the ultimate implant – prosthetic supplementation [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 important element of the restorative therapy of certain
periodontal tissue elements and ultimate implant
– prosthetic reconstruction. It effectively minimizes stress, aesthetic and functional dysfunction,
Immediate Implant Placement
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 pozycjonowanie implantu (ze zbiorów Zakładu Chorób
Błony Śluzowej i Przyzębia WUM – M.R. Czerniuk)
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 focal infection, which could be caused by the permanent deciduous tooth along with the cyst and inflammatory granulation [6]. The operators could
605
Fig. 13. Temporary prosthetic supplement (from
the archives of Department of Oral Medicine and
Periodontal Diseases, Medical University of Warsaw
– Czerniuk M.R.)
Ryc. 13. Użytkowane uzupełnienie tymczasowe (ze
zbiorów Zakładu Chorób Błony Śluzowej i Przyzębia
WUM – M.R. Czerniuk)
have applied an adhesive bridge, supported and
cemented on the right lateral incisor and the left
central incisor in the maxilla, as a temporary supplement. However, the costs of such a procedure
related to construction and fixing with specialized
cements were outside the patient’s price range. Despite that, the performed treatment was very satisfying for the patient and the operating team due to
its complexity, and all are looking forward to the
ultimate implant – prosthetic reconstruction.
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M.R. Czerniuk, M. Zaremba
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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: [email protected]
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.
Zaakceptowano do druku: 9.10.2012 r.