Immediate postextraction implantation with provisionalization of two primary canines and related impacted permanent canines: a case report


D'Amato, S.; Redemagni, M.

International Journal of Periodontics and Restorative Dentistry 34(2): 251-256

2016


This study presents a case of replacing two maxillary primary canines and related impacted permanent canines with two single implants, in conjunction with grafting lost hard tissue. By using immediate postextraction implant placement and provisionalization protocols, the stability of the implant was ensured while bypassing the bony void created by the removal of the primary canines. In this respect, a minimum healing period of 1 year was originally planned to evaluate the gingival esthetics before the final step was carried out. By the time the final restorations were fitted, the graft and tissues were stable. The time involved not only placed biology on the clinician's side, but also helped the patient to spread the cost over time. In modern esthetic dentistry, harmonious results can be achieved relatively quickly when the prerequisites for esthetic success have already been met, but, as this case demonstrates, human biology often requires more time and patience for augmented hard and soft tissues to heal and mature.

251
Immediate
Postextraction
Implantation
with
Provisionalization
of
Two
Primary
Canines
and
Related
Impacted
Permanent
Canines:
A
Case
Report
Over
the
past
decade,
there
has
been
a
dramatic
rise
in
the
esthetic
expectations
of
patients,
especially
in
the
case
of
an
impacted
tooth,
in
both
conventional
and
implant
prosthodontics.
Impaction
of
maxillary
canines
is
a
frequently
encountered
clini-
cal
problem
that
usually
requires
an
interdisciplinary
approach
to
treatment.
Surgical
exposure
of
the
impacted
tooth
and
the
complex
orthodontic
mechanisms
used
to
align
the
tooth
into
the
arch
may
lead
to
varying
amounts
of
damage
to
supporting
structures,
along
with
a
long
treatment
duration
and
finan-
cial
burden
on
the
patient.
There-
fore,
it
is
worthwhile
to
focus
on
the
means
of
early
diagnosis
and
inter-
ception
of
this
clinical
situation.'
The
management
of
an
impact-
ed
canine
often
leads
to
an
inad-
equate
width
of
attached
gingiva,
which
can
be
a
risk
factor
for
future
gingival
recession
and
associated
complications.
Uncovering
a
labial-
ly
impacted
maxillary
canine
can
be
performed
by
gingivectomy,
api-
cally
positioned
flap
surgery,
or
a
closed
eruption
technique.
Choos-
ing
the
right
technique
is
some-
times
difficult.
2
Salvatore
D'Amato,
MD,
DDS'
Marco
Redemagni,
MD,
DDS
2
This
study
presents
a
case
of
replacing
two
maxillary
primary
canines
and
related
impacted
permanent
canines
with
two
single
implants,
in
conjunction
with
grafting
lost
hard
tissue.
By
using
immediate
postextraction
implant
placement
and
provisionalization
protocols,
the
stability
of
the
implant
was
ensured
while
bypassing
the
bony
void
created
by
the
removal
of
the
primary
canines.
In
this
respect,
a
minimum
healing
period
of
1
year
was
originally
planned
to
evaluate
the
gingival
esthetics
before
the
final
step
was
carried
out.
By
the
time
the
final
restorations
were
fitted,
the
graft
and
tissues
were
stable.
The
time
involved
not
only
placed
biology
on
the
clinician's
side,
but
also
helped
the
patient
to
spread
the
cost
over
time.
In
modern
esthetic
dentistry,
harmonious
results
can
be
achieved
relatively
quickly
when
the
prerequisites
for
esthetic
success
have
already
been
met,
but,
as
this
case
demonstrates,
human
biology
often
requires
more
time
and
patience
for
augmented
hard
and
soft
tissues
to
heal
and
mature.
(Int
J
Periodontics
Restorative
Dent
2014;34:251-256.
doi:
10.11607/prd.1612)
'Aggregate
Professor,
Department
of
Head,
Neck
and
Oral
Surgery,
Facolta
di
Medicina
e
Chirurgia,
Seconda
University
degli
Studi
di
Napoli,
Italy.
2
Private
Practice,
Lomazzo
(Como)
and
Milan,
Italy.
Correspondence
to:
Dr
Marco
Redemagni,
V.
Trento
23,
22074
Lomazzo
(Como),
Italy;
fax:
+390296778831;
email:
©2014
by
Quintessence
Publishing
Co
Inc.
Volume
34,
Number
2,
2014
Fig
1
Preoperative
view
of
two
maxillary
primary
canines
restored
with
two
all-ceramic
crowns
with
a
poor
esthetic
appearance.
4.
Fig
2
Occlusal
view
of
the
two
primary
canines.
252
mandibular
canines
more
than
the
position
and
impaction
level
of
the
teeth
.
3
The
following
case
presenta-
tion
details
the
treatment
used
in
a
patient
who
presented
with
two
maxillary
primary
canines
in
need
of
extraction
because
of
their
ex-
cess
mobility
and
the
presence
of
two
impacted
canines
that
pre-
vented
the
insertion
of
two
imme-
diate
postextraction
implants.
Clinical
case
A
27-year-old
woman
presented
to
the
dental
office
complaining
about
the
esthetic
appearance
of
her
two
maxillary
primary
canines.
There
were
no
other
complaints
or
health
problems
(Figs
1
and
2).
The
canines
had
been
restored
years
ago
with
two
all-ceramic
crowns,
and
now
their
hypermo-
bility
and
poor
esthetic
condition
called
for
extraction.
Radiographic
examination
re-
vealed
the
presence
of
normal
interproximal
bone
crests,
which
are
necessary
for
obtaining
a
sat-
isfactory
papilla
in
implant
therapy
(Fig
3).
However,
the
presence
of
two
palatally
impacted
canines
ruled
out
treatment
with
two
im-
mediate
postextraction
implants.
The
volume
occupied
by
the
teeth
was
evaluated
using
computed
to-
mography.
Because
the
periodon-
tal
space
was
evident,
extraction
did
not
appear
difficult,
and
there
was
enough
bone
to
achieve
pri-
Moreover,
if
the
impacted
orthodontic
extrusion
is
contraindi-
mary
stability
in
both
the
corona!
canine
is
in
a
palatal
position
cated.
In
addition,
age
influences
and
apical
directions
around
the
and
the
patient
is
older,
surgical-
the
treatment
success
of
impacted
impacted
canines.
The
International
Journal
of
Periodontics
&
Restorative
Dentistry
253
Fig
3
At
the
radiographic
examination,
the
presence
of
correct
interproximal
bone
peaks
are
evident,
along
with
two
impacted
canines.
emi
6
7
4
16
Fig
4
With
a
limited
osteotomy,
the
two
impacted
canines
were
visualized.
S
L
-
Fig
5
The
postextraction
sockets
immediately
after
tooth
extraction.
Surgical
procedure
Before
surgery,
a
full-mouth
pro-
fessional
prophylaxis
appoint-
ment
was
scheduled.
The
patient
was
premedicated
1
hour
before
surgery
with
2
g
penicillin
and
clavulanic
acid
(augmentin
1
g,
GlaxoSmithKline)
to
continue
with
2
g
per
day
for
6
days.
The
first
step
included
the
ex-
traction
of
the
two
impacted
per-
manent
canines.
An
intrasulcular
palatal
incision
was
made,
and
a
full-thickness
flap
was
elevated
from
the
maxillary
right
first
premo-
lar
to
the
left
first
premolar,
with-
out
vertical
releasing
incisions
and
while
preserving
the
papillae.
A
limited
osteotomy
around
the
crown
of
the
canines
was
per-
formed,
the
follicular
tissue
was
re-
moved
by
the
use
of
curettes,
and
the
teeth
were
extracted
using
only
a
straight
elevator
(Figs
4
and
5).
The
second
step
included
the
extraction
of
the
primary
canines,
initially
with
the
use
of
a
syndes-
motome
followed
by
a
very
gentle
technique
to
preserve
as
much
of
the
anatomical
site
as
possible
and
not
crack
the
alveolar
walls.
After
extraction,
the
alveolar
bone
was
explored
using
a
peri-
odontal
probe
to
assess
its
integri-
ty
and
to
determine
which
implant
diameter
to
use.
The
implants
were
inserted
2
to
3
mm
apical
to
the
free
gingi-
val
margin,
close
to
the
margin
of
the
palatal
bone
wall,
with
proper
three-dimensional
placement.
4
It
appeared
logical
to
insert
an
im-
plant
of
sufficient
length
for
opti-
mum
anchoring
(Figs
6
and
7).
1
Volume
34,
Number
2,
2014
F
••
Oh'
Fig
8
The
two
provisional
screw-retained
restorations
at
1-year
postsurgery.
Fig
9
The
transmucosal
path
created
by
the
correct
contour
of
the
provisional
restoration.
254
Fig
6
An
implant
was
positioned
with
an
implant
carrier
in
the
ideal
three-dimensional
position.
The
flap
was
repositioned
pas-
sively
and
sutured
with
multiple
single
sutures
that
were
removed
10
days
after
surgery.
It
was
decided
against
a
soft
tissue
graft
buccally
because
the
deciduous
roots
had
almost
the
same
diameter
as
the
implants
and
the
canine
prominence
was
still
in
Fig
7
The
implant
apical
bone
anchorage
is
visible
bypassing
the
postextractive
void.
place,
precluding
the
necessity
of
filling
the
implant-buccal
bone
gap
with
biomaterial.
Prosthetic
procedure
An
individually
screwed
provisional
crown
was
relined
for
each
side
with
acrylic
resin
(Yates-Motloid)
up
to
the
sandblasted
provisional
base
mounting
(Dentsply
Friadent),
which
according
to
the
manufac-
turer
can
be
used
as
a
provisional
abutment.
After
resin
polymeriza-
tion,
the
provisional
crown
was
re-
moved
and
some
resin was
added
to
fill
the
gap
between
the
crown
and
base,
and
the
provisional
was
finished
with
the
transmucosal
part
given
a
concave
shape,
more
pro-
nounced
buccally
than
palatally
and
interproximally.
The
provisional
was
screwed
in
by
hand,
maintaining
stability
with
two
fingers
so
as
not
to
transmit
any
force
to
the
implant.
Finally,
the
screw
access
hole
was
filled
with
cotton
and
covered
with
composite
(Filtek,
3M
ESPE).
The
occlusion
was
checked
and
both
contacts
in
centric
relation
and
in
protrusive/lateral
move-
ments
were
removed
(Fig
8).
The
patient
was
instructed
to
avoid
chewing
on
the
treated
area
for
3
months
and
to
avoid
brush-
ing
for
the
first
2
weeks.
A
0.2%
chlorhexidine
rinse
was
prescribed
for
2
weeks.
Thereafter,
conven-
tional
brushing
and
flossing
were
permitted.
The
patient
kept
the
provisional
for
12
months,
then
an
impression
was
taken,
according
to
the
Hinds
method.
5
The
use
of
an
abutment
capable
of
faithfully
replicating
the
transmucosal
path
created
by
the
correct
contour
of
the
provisional
restoration
is
a
prerequisite
for
ob-
taining
optimal
results
(Fig
9).
Fur-
thermore,
a
custom-made
abutment
allows
positioning
of
the
finishing
line
no
deeper
than
1.5
mm
inside
The
International
Journal
of
Periodontics
&
Restorative
Dentistry
11
Fig
10
The
zirconia
abutment
in
situ.
The
surrounding
tissue
did
not
present
any
signs
of
ischemia
because
the
provisional
replicated
the
transmucosal
design.
Fig
11
The
1-year
postinsertion
view
of
the
final
restoration
with
optimal
tissue
healing
(technician:
Mr
Giancarlo
Cozzolino).
255
the
sulcus,
as
in
preparing
a
natural
tooth
for
a
crown.
This
makes
it
eas-
ier
to
remove
the
excess
cement,
which
has
been
associated
with
signs
of
peri-implant
disease
in
the
majority
(81%)
of
cases.°
A
zirconium
custom-made
abutment
was
fabricated
and
screwed
onto
the
implant
using
24
Ncm
of
torque;
a
definitive
all-
ceramic
crown
was
then
cemented
(Figs
10
to
12).
Discussion
An
implant-supported
restoration
should
meet
clear-cut
esthetic
re-
quirements,
especially
when
replac-
ing
a
single
unit
in
the
anterior
region.
The
achievement
of
stable
results
is
dependent
upon
many
factors,
such
as
the
quantity
of
ke-
ratinized
mucosa,
thickness
and
height
of
buccal
and
interproximal
bone,
appropriate
surgery,
implant
position,
and
shape
and
material
of
the
transmucosal
implant
pros-
thetic
components4•
7
'
8
The
goal
of
this
case
report
was
to
extract
two
impacted
canines,
creating
only
palatal
access
and
pre-
serving
the
buccal
and
interproximal
bone
and,
consequently,
the
papil-
lae
and
soft
tissues.
Primary
implant
stability
was
achieved
because
the
small
root
diameter
of
the
two
primary
ca-
nines
left
a
large
amount
of
bone,
the
residual
pseudo
postextraction
alveolar
socket
of
the
two
perma-
nent
canines
was
bypassed,
and
the
apical
part
of
the
implant
was
placed
in
a
portion
of
intact
and
stable
bone.
In
this
manner,
the
primary
stability
of
the
implants
was
so
good
that
it
was
possible
to
immediately
provisionalize
the
patient.
The
immediate
loading
tech-
nique
has
an
unquestionable
ad-
vantage
because
the
interpapillary
and
gingivoalveolar
fibers
preserve
the
interproximal
bone
peaks
when
the
interdental
peri-implant
tissues
are
provided
with
immediate
sup-
port
from
a
healing
screw
or
an
im-
mediate
provisional
restoration.
9
Moreover,
the
transmucosal
portion
of
the
provisional
restora-
tion
was
concave
because
this
de-
sign
better
preserves
and
maintains
tissue
stability
over
time.
The
tissue
Volume
34,
Number
2,
2014
,
t
ic
p
Fig
12
The
final
radiograph
at
1
year
after
def
nitive
crown
cementation
(2
years
from
implant
placement)
demonstrated
functional
implant
integration.
256
appears
healthy,
having
a
clear
pink
color
and
sometimes
a
characteris-
tic
orange-peel
aspect
resembling
that
around
natural
teeth.
A
concave
abutment
provides
more
space
for
the
connective
tis-
sue
around
the
abutment,
creating
a
sort
of
0-ring
that
functions
as
a
barrier
for
the
bone-implant
inter-
face.
8
10
11
Furthermore,
using
an
abut-
ment
made
from
a
highly
biocom-
patible
material
such
as
zirconia
makes
it
possible
to
avoid
placing
any
other
metal, including
gold
al-
loy,
within
the
transmucosal
path
or
covering
the
titanium
abutment
with
ceramic.
Both
procedures
have
been
shown
to
be
incapable
of
establishing
a
link
with
the
sur-
rounding
mucosal
tissue
through
hemidesmosomes.
12
Conclusion
The
esthetic
rehabilitation
of
pa-
tients
with
functionally
compro-
mised
dentition
frequently
involves
an
unconventional
approach.
A
correct
esthetic
diagnosis,
treat-
ment
plan,
and
material
selection
are
critical
factors
in
a
successful
restoration.
A
team
approach
that
includes
the
clinicians,
the
labora-
tory
technician,
and
the
patient
is
essential
for
achieving
the
desired
resu
It.
Acknowledgments
The
authors
reported
no
conflicts
of
interest
related
to
this
study.
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