Journal of Craniofacial Surgery

Post-traumatic use of dental implants right after tooth extraction: clinical studies.--Manuscript Draft--

Manuscript Number: SCS-13-1344

Full Title: Post-traumatic use of dental implants right after tooth extraction: clinical studies.

Short Title: Post-traumatic use of dental implants

Article Type: Clinical Studies

Keywords: Immediate implants, horizontal root fracture, osseointegration.

Corresponding Author: Simone Marconcini, DDS, PhDUniversity of PisaPisa, Italy ITALY

Corresponding Author SecondaryInformation:

Corresponding Author's Institution: University of Pisa

Corresponding Author's SecondaryInstitution:

First Author: Ugo Covani, MD, DDS

First Author Secondary Information:

Order of Authors: Ugo Covani, MD, DDS

Simone Marconcini, DDS, PhD

Francesco Ferrini, MD, DDS

Federico Gelpi, DDS

Marco Finotti, DDS

Antonio Barone, DDS, PhD

Order of Authors Secondary Information:

Manuscript Region of Origin: ITALY

Abstract: AbstractPurpose: The root fracture is a combined injury of cementum, dentin and pulp. Many ofthese traumas remain untreated, mistreated, or over treated. It leads to a morecomplicated treatment in case of tooth loss. Many different treatment procedures, witha very changeable success rate, have been proposed for years in order to treat teethwith root fractures. The object of the following clinical studies was to evaluate theclinical effectiveness of implants placed in fresh extraction sites in order to treat teethwith horizontal root fracture.Methods: The study group included twenty-five patients (15 males and 10 females)between the age from 20 and 65. After an initial examination and a treatment planning,all of the patients underwent periodontal treatment which was deemed necessary tofavour wound healing.All the 25 teeth were extracted due to horizontal root fracture located at the level of themiddle third. The second stage surgery was performed 6 months after the initialprocedure. The following clinical parameters - presence or absence of mobility,presence or absence of pain, presence or absence of suppuration were evaluated ineach patient at 6 and 12 months after implant placement: . Radiographs were takenusing the standard method to evaluate the marginal bone loss (MBL).Results: The healing period was uneventful for all patients. All implants hadosseointegrated. After 12 months, patients were asymptomatic and showed no signs ofinfection or bleeding when probed.Discussion and Conclusions: On the basis of this study, implants placed right aftertooth extraction are a valid treatment procedure, which induces predictable results astreatment of fractured teeth.

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Turin, 4th

November 2013

Dear Dr. Habal,

I am sending you the manuscript “Post-traumatic use of dental implants right after tooth

extraction: clinical studies”, which I would like to submit to your attention.

I hope our work will meet your approval for publication in the Journal of Craniofacial Surgery.

I look forward to hearing your comments.

Yours sincerely,

Simone Marconcini

Corresponding author:

Dott. Simone Marconcini

Piazza Diaz 10,

55041 Camaiore (Lu)

Italy.

Fax: +39 0584 985334

Tel: + 39 0584 98531

E-mail : s.marconcini1977@libero.it

*Cover Letter

Post-traumatic use of dental implants right after tooth

extraction: clinical studies. Ugo Covani MD, DDS*, Simone Marconcini DDS, PhD**, Francesco Ferrini MD DDS***

Federico Gelpi DDS****, Marco Finotti DDS*****, Antonio Barone DDS, PhD******.

* Full Professor - Department of Surgical-, Medical-, Molecular-Pathology and of Critical

Area University of Pisa, Via Paradisa 2, 56124 Pisa Italy and Istituto Stomatologico Toscano,

Versilia General Hospital, Via Aurelia 335, Lido di Camaiore (LU), Italy.

** Research Fellow - Department of Surgical-, Medical-, Molecular-Pathology and of Critical

Area University of Pisa, Via Paradisa 2, 56124 Pisa Italy and Istituto Stomatologico Toscano,

Versilia General Hospital, Via Aurelia 335, Lido di Camaiore (LU), Italy.

*** Private practice, Pesaro, Italy.

**** Private practice, Verona, Italy.

***** Private practice, Milano and Padova, Italy.

****** Assistant Professor - Department of Surgical-, Medical-, Molecular-Pathology and of

Critical Area University of Pisa, Via Paradisa 2, 56124 Pisa Italy and Istituto Stomatologico

Toscano, Versilia General Hospital, Via Aurelia 335, Lido di Camaiore (LU), Italy.

Corresponding author:

Dott. Simone Marconcini

Piazza Diaz 10,

55041 Camaiore (Lu)

Italy.

Fax: +39 0584 985334

Tel: + 39 0584 98531

E-mail : s.marconcini1977@libero.it

*Manuscript (All Manuscript Text Pages in MS Word format, including Title Page, References and Figure Legends)

Abstract

Purpose: The root fracture is a combined injury of cementum, dentin and pulp. Many of these

traumas remain untreated, mistreated, or over treated. It leads to a more complicated treatment in

case of tooth loss. Many different treatment procedures, with a very changeable success rate, have

been proposed for years in order to treat teeth with root fractures. The object of the following

clinical studies was to evaluate the clinical effectiveness of implants placed in fresh extraction sites

in order to treat teeth with horizontal root fracture.

Methods: The study group included twenty-five patients (15 males and 10 females) between the

age from 20 and 65. After an initial examination and a treatment planning, all of the patients

underwent periodontal treatment which was deemed necessary to favour wound healing.

All the 25 teeth were extracted due to horizontal root fracture located at the level of the middle

third. The second stage surgery was performed 6 months after the initial procedure. The following

clinical parameters - presence or absence of mobility, presence or absence of pain, presence or

absence of suppuration were evaluated in each patient at 6 and 12 months after implant placement:

. Radiographs were taken using the standard method to evaluate the marginal bone loss (MBL).

Results: The healing period was uneventful for all patients. All implants had osseointegrated. After

12 months, patients were asymptomatic and showed no signs of infection or bleeding when probed.

Discussion and Conclusions: On the basis of this study, implants placed right after tooth extraction

are a valid treatment procedure, which induces predictable results as treatment of fractured teeth.

Key words: Immediate implants, horizontal root fracture, osseointegration.

Introduction

In the last decade, advances in implant surface technology and continuous clinical research have

provided the clinicians with innovative and efficient operative protocols to properly treat more and

more demanding clinical situations (1). Some of the original prerequisites of osseointegration have

been re-discussed in order to satisfy the increasing patients’ demand for reduced treatment time,

improve aesthetic treatment outcomes, and increase comfort during healing (2).

The placement of implants immediately after tooth extraction has proven to be a predictable

treatment strategy with a very high success rate (1,3). Immediate implant placement has several

advantages, such as reduction of the number of surgical treatments and reduction of the time

between the tooth extraction and the placement of the definitive prosthesis (4).

Most of these traumas remains untreated, mistreated or over treated leading to a more complicated

treatment in case of tooth loss (5). Nowadays there are several methods to treat severely injured

teeth but the long term success rates obtained with these operative protocols is still low and those

teeth often need later extraction (6,7,8,9,10). Ozbeck (2003) suggested a conservative treatment of

root fractures below the alveolar crest (11) ; Pileggi and co-workers (2003) suggested root fractures

can heal spontaneously, if immediately treated with an adequate therapy (12); Ferrari et al. (2006)

pointed out that the prognosis of a root fracture is strictly connected to its location, and in particular

if close to the gingival sulcus (13). On the basis of these considerations, it has been recently

observed that the use of an immediate implant could be a valid treatment procedure for the

replacement of traumatic teeth. The aim of the present clinical studies has been to evaluate the

clinical effectiveness of implants placed in fresh extraction sites in order to treat teeth with

horizontal root fractured.

Materials and Methods

Twenty-five patients (15 males and 10 females) aged 20 to 65, were referred to academic and

private practices of the authors between 2006 and 2012, and included in this study. All the patients

were scheduled for at least one single-rooted tooth extraction and an immediate implant placement.

Inclusion criteria for the study were: indication for a tooth extraction (intra-alveolar root fracture

located at the level of the middle third), presence of at least 4 mm of bone beyond the root apex,

absence of acute signs of infection or inflammation in the treatment area and absence of systemic

pathologies that would contraindicate bone healing around implants. No tobacco abuse (maximum

10 cigarettes \ day) and no alcohol or drug dependency were accepted. All patients admitted into the

study group were required to sign a standard model of informed consent to treatment. Each case

was carefully evaluated by analysing diagnostic casts for intra and inter-arch relationship. Periapical

and panoramic radiographs (Fig. 1) were taken as well as computed tomographies if needed. All the

selected clinical cases required tooth extraction due to a horizontal fracture. Chlorhexidine

mouthwash was used right before surgery during 1 minute.

Every tooth extraction was performed with extreme care to preserve the alveolar bone integrity

(Fig. 2) by using thin syndesmotome and the implant was placed with a flapless technique (14).

When an a-traumatic technique was not possible during the extraction, a mucoperiosteal flap

elevation was effected by performing intrasulcular and vertical incisions extended over the

mucogingival junction. The implant site was prepared with standard drills under copious saline

irrigation. The longest possible implants were placed at the buccal/palatal level of the bone crest

without considering the bone height at the mesial and distal level (Fig. 3). All the implants placed

showed very good primary implant stability. Twenty-four implants were placed in the maxilla and 1

in the mandible; All the implants used had a microtextured implant surface (Premium, Sweden &

Martina, Padova, Italy). Implant length ranged from 13 to 15 mm with an implant 3.75-5 mm

diameter. All of the implants showed clinical primary stability. After implant placement, the peri-

implant bone defect that had occurred between bone walls and implant surface was characterized by

absence of fenestration or dehiscence. Therefore, no augmentation procedures were performed. In

case of flap elevation, the flap was replaced in the original position and sutured with interrupted

sutures around a healing screw as proposed by Lang et al. (2007) (15) . Antibiotics (Amoxicillin

500 mg 4 times daily for 4 days), anti-inflammatories (1 g Nimusulide 1 time daily for 4 days) and

Chlorhexidine mouthwashes were prescribed during post-operative period. Removable prosthesis

was worn during the healing process just for aesthetic reasons. During the healing process, patients

underwent scaling, oral hygiene instructions, and periodontal treatment if needed, to provide an oral

environment, which would be more favourable to wound healing. The temporary prosthesis was

healing-screw bearing with occlusal rests and was relined with soft lining material. Sutures were

removed after seven days. An individualized occlusal template was made to guarantee radiographic

reproducibility for the follow-up period. Patients were followed monthly.

The final follow-up was at 12 months. The following clinical and radiographic parameters - :

presence or absence of mobility; presence or absence of pain; presence or absence of suppuration

were evaluated for each patient at 6 and 12 months after surgery. The radiographic technique used

was the parallel cone, which allows a minimal distortion of images. Radiographs were taken using

an individualized occlusal stent to evaluate the presence of peri-implant radiolucencies and

marginal bone loss (MBL). An implant was considered a success when it fulfilled the criteria

defined by Albrektsson and associates (15).

Results

The surgical protocol which combines the extraction of a fractured tooth and the placement of

immediate implants proceeded smoothly. All the patients included in the present study were

followed carefully during 12 months. They were followed weekly during the first post-operative

month and monthly during the rest of the follow-up period.

The post-surgical healing phase was uneventful for all patients. Pain and swelling were the most

frequently mentioned complaints. At the time of definitive prosthesis placement, no signs of

infection or bleeding were detected and no pockets were found (Fig. 4-5). Periapical radiographs

were taken just after the implant placement and at the end of the follow-up period. The total mean

distance from implant shoulder to bone crest at baseline was -0.3 mm. At 6 months after placement,

the mean value was 0.5mm (TAB.1). There was no fracture of abutments and\or loss of prosthetic

screws. No prostheses needed to be replaced. The only prosthetic complication that occurred

(regarding two implants) was the lost of the screws that connected the abutment to the implant. The

implants were deemed successfully at 6 months following prosthetic rehabilitation, according to

clinical criteria suggested by Albrektsson and associates (1986) (16).

Discussion

The reliability of dental implants has greatly improved in the last 20 years, providing clinicians with

new therapeutic devices for dental rehabilitation that previously were considered unrealistic.

Nowadays implants placement right after tooth extraction has proven to be a predictable treatment

strategy with a very high success rate, and they present the first therapeutic option in the case of a

single untreatable tooth (1,3). All the implants placed in this study were clinically stable,

asymptomatic, and did not show any significant bone defects at the end of the follow-up period.

The definitive prosthetic restoration took place 4/6 months after the first surgery. The present study

concentrated on patients with single tooth loss, which made prosthetic rehabilitation easier.

Immediate implant placed in fresh extraction sockets could result in a defect between the implant

surface and the surrounding bone walls. When the gap between alveolar bone and implant is bigger

than 2 mm, the use of barrier membranes is recommended to obtain bone regeneration and to

prevent soft tissue growth at the bone implant interface. However, there are several clinical

complications which might occur using barrier membranes, such as bacterial colonization, which

can lead to an infection and even to implant failure. Several authors have reported high rates of

membranes exposure with implants placed immediately after tooth extraction (17,18). Kohal et al.

(1998) found a very high frequency of membrane exposure during the healing period (19). The

researchers assumed that in the sites with exposed membranes, the amount of regenerated bone was

less then in the sites with retained membrane.

The use of barrier membranes should be, therefore, carefully evaluated. In his study on immediate

implants, Covani et al. reported a low frequency of complications during the healing period and a

very high survival rate without using barrier membranes (20). On the basis of these findings,

grafting material and\or barrier membranes were not used in the present study, showing that small

circumferential defects could heal spontaneously. Therefore, within the limits of the study, our

clinical results totally agree with those previously reported by the same authors , thus supporting the

hypothesis that implant primary stability, integrity of bone walls, maintenance of a firm blood clot,

as well as primary flap closure are sufficient factors to induce spontaneous bone healing in

circumferential peri-implant bone defects <2 mm (21). The pattern of bone rearrangement could be

induced by new bone apposition to fill the peri-implant defect, and, at the same time, by buccal and

lingual bone resorption, leading to a width reduction of the alveolar ridge (22).

.

Conclusion

Implant placement in fresh extraction site has proved to be a valid treatment procedure. It induces

predictable results in fractured untreatable teeth treatment. Moreover, our results seem to suggest

that implants placed in fresh extraction sockets, delimiting small circumferential defects not >2 mm,

could heal with good predictability without any regenerative procedures. No clinical parameters

were used to evaluate the stability and health of soft tissues. However, at the end of the follow-up

period none of the patients showed a negative aesthetic outcome. Additional more extensive, long

term, and well matched studies are needed to support our hypothesis and to suggest this technique

as a routine in the treatment of untreatable intra-alveolar root fracture located at the level of the

middle third.

References

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crown restoration: a 4-year prospective study. Journal of Periodontology 75 2004; 982-988.

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Table 1. Mean vertical distance (MBL) (+\- SD) between implant shoulder and marginal Bone

crest at baseline and 6 months later.

Baseline

Mean SD

6 Months

Mean SD

Mesial

0.7 0.7

0.2 0.6

Distal

1 0.6

0.2 0.5

FIGUREs LEGEND

Figure 1. Pre-operative periapical radiograph of a maxillary tooth to be extracted.

Figure 2. Intra-operative clinical view of the fractured maxillary tooth.

Figure 3. An implant is placed and primary stability achieved.

Figure 4. Periapical radiograph taken 6 months after placement.

Figure 5. Final prosthetic restoration in place.

Table 1. Mean vertical distance (MBL) (+\- SD) between implant shoulder and marginal Bone

crest at baseline and 6 months later.

Baseline

Mean SD

6 Months

Mean SD

Mesial

0.7 0.7

0.2 0.6

Distal

1 0.6

0.2 0.5

Table

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