|Year : 2011 | Volume
| Issue : 2 | Page : 58-63
Evaluation of implants placed into fresh extraction sockets in the maxillary anterior region: A clinico-radiographic study
Srinivas Sulugodu Ramachandra1, Mallanagouda Patil2, Dhoom Singh Mehta2
1 Department of Periodontology, Kanti Devi Dental College and Hospital, Mathura, Uttar Pradesh, India
2 Department of Periodontology and Implantology, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Web Publication||30-Dec-2011|
Srinivas Sulugodu Ramachandra
Department of Periodontology, Kanti Devi Dental College and Hospital, Delhi-Agra National Highway # 2, P.O. Chhatikara, Mathura - 281 006, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The purpose of this study is to determine the survival rate of dental implants placed immediately into fresh extraction sockets in the maxillary anterior region by clinically evaluating the peri-implant soft tissue health and by radiographically evaluating the bone height mesial and distal to the implants.
Materials and Methods: Patients with maxillary anterior teeth indicated for extraction were selected. Indicated teeth were extracted, sockets were prepared and implants were placed into prepared sockets. After the integration period, prostheses were cemented. Patients were reviewed at three-month intervals after prosthesis placement for a period of one year with evaluation of all clinical and radiographic parameters.
Results: Causes for extraction of teeth were root fractures, endodontic failures, internal resorption, external resorption, teeth with open apex and over-retained deciduous teeth. The mean plaque index and gingival index showed a decrease in values during the follow-up period. All implants were immobile. Radiographic analysis using Image J software (of the peri-apical radiographs) showed significant bone remodeling around the neck of the implants. Immediate implant survival rate was 100% during one-year follow-up.
Conclusion: Thus, with regard to implant survival, there seems to be no reason to refrain from placement of implants into extraction sockets in the maxillary anterior region when the sites are carefully selected.
Keywords: Dental implants, extraction sockets, peri-implant defects
|How to cite this article:|
Ramachandra SS, Patil M, Mehta DS. Evaluation of implants placed into fresh extraction sockets in the maxillary anterior region: A clinico-radiographic study. J Dent Implant 2011;1:58-63
|How to cite this URL:|
Ramachandra SS, Patil M, Mehta DS. Evaluation of implants placed into fresh extraction sockets in the maxillary anterior region: A clinico-radiographic study. J Dent Implant [serial online] 2011 [cited 2020 Sep 22];1:58-63. Available from: http://www.jdionline.org/text.asp?2011/1/2/58/91281
| Introduction|| |
Traditional methods of dental implant placement have been progressively modified. One of the modified protocols is immediate implant placement, which involves simultaneous placement of implants into fresh extraction sockets, thereby avoiding the need for a second surgical procedure for the patient and clinician.  W Schulte first reported placement of a Tubingen dental implant into a fresh extraction socket.  Implants placed immediately into fresh extraction sockets have shown high percentage of clinical success when implant sites were carefully selected. ,, However, predominantly soft cancellous bone of this region combined with the high esthetic demands of the maxillary anterior region throw up many challenges during successful placement and restoration of the implant. The aim of this study was to determine the survival rate of dental implants placed immediately into fresh extraction sockets in the maxillary anterior region by clinically evaluating the peri-implant soft tissue health and by radiographically evaluating bone height mesial and distal to the implants.
| Materials and Methods|| |
Patients with maxillary anterior teeth indicated for extraction were selected. Inclusion criteria were patients with good oral hygiene (as measured by minimal plaque score) in the age group of 18-50 years and presence of a single failing tooth with intact adjacent dentition. Indications for extraction of teeth were root fractures, endodontic failures, internal resorption, external resorption, teeth with open apex and over-retained deciduous teeth. Only teeth with sufficient bone present apical to the extraction sockets were included. Exclusion criteria were perforation and/or loss of labial bony plate following extraction. Teeth with acute infection were excluded. Patients with medically compromised conditions, occlusal problems, history of smoking and insufficient inter-arch space were also excluded from the study. Patients were informed about the procedure, and a written informed consent was obtained.
Eleven patients, each having one maxillary anterior tooth indicated for extraction were selected and eleven implants were placed into fresh extraction sockets [Maestro® dental implant system (BioHorizons, Birmingham, AL)]. Modified plaque index,  gingival index,  probing depth at four sites around implants (mesial, labial, distal and lingual/palatal) using True Pressure - Sensitive (TPS® ) probe,  and mobility of implants according to clinical implant mobility scale  were assessed at baseline, 3 months, 6 months, 9 months and 12 months after implant placement. Periapical radiographs using long cone paralleling technique and orthopantomographs were taken.
The pre-operative classification  proposed by Salama and Salama was used to categorize the cases and only type I extraction sites were selected [Figure 1] and [Figure 2]. After achieving local anesthesia, sulcular incisions were placed on the tooth indicated for extraction. Full thickness flaps were elevated using periosteal elevators. Careful rotatory movements of the forceps were used to remove the teeth. Teeth were extracted as atraumatically as possible without causing any damage to the bone. Sockets were irrigated with saline and curetted to remove infected tissue.
|Figure 1: Pre-operative photograph of maxillary right lateral incisor. Tooth had fractured after endodontic treatment. Periodontal biotype around the tooth is of thick variety|
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|Figure 2: Periapical radiograph of fractured endodontically treated maxillary right lateral incisor|
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After extraction of the teeth, sockets were examined for any fracture of the walls of the socket [Figure 3]. Drilling was done according to the manufacturer's instructions. Countersinking was not done. Implants were placed into the prepared sockets [Figure 4]. In all cases, primary stability was noted. In five cases, defects were observed between the implant and walls of the prepared socket. Defects between the implant and walls of the socket were measured. Defects between the implants and socket wall were less than 2 mm, hence bone grafts were not placed. In cases, where primary closure was not achieved, semilunar incisions were placed to achieve adequate flap mobility and subsequent flap closure.
|Figure 3: After extraction of the tooth. Note all the walls of the socket are intact. Inset shows the extracted tooth|
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Patients were prescribed antibiotics and analgesics. Antibiotic capsule amoxicillin 500 mg (Capsule Amox, Ce-Chem Pharmaceuticals, Bangalore, India) was given thrice daily for seven days. Analgesic tablet nimesulide 100 mg (Tab Oxin 100, Syno-Chem Pharmaceuticals, New Delhi) was prescribed twice daily for 5 days. One week later sutures were removed. Patients were reviewed every 15 days in the first month and then every three months up to one and half year. Six months after implant placement in the maxilla and four months after implant placement in the mandible, second stage surgery was initiated. Prostheses were cement-retained type and zinc polycarboxylate cement was used for crown cementation [Figure 5] and [Figure 6].
|Figure 6: Periapical radiograph showing successful bone formation around the implant|
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Descriptive data are presented as mean standard deviations and percentage post-treatment changes. These data were compared to baseline and analyzed by paired 't' test and unpaired 't' test for two group comparisons (Full mouth v/s Implant). Categorical data was analyzed by Fischer's exact test.
| Results|| |
At second-stage surgery, all peri-implant defects were completely filled. Post-surgical healing was uneventful in all cases. All implants were clinically immobile. In 11 patients with a mean age of 23.1 years ± 6.0, immediate implant survival rate was 100% during one-year follow-up.
The mean plaque index and gingival index showed a decrease in values at baseline, 6 months, 9 months and 12 months. The mean probing depth and standard deviation on the mesial, mid-buccal, distal and lingual sites are given on [Table 1]. None of the values were statistically significant.
Radiographic image analyses using Image J software on the mesial and distal sites were done [Table 2] and [Table 3]. Intraoral periapical radiographs taken at baseline, 3 months, 6 months, 9 months and 12 months using long cone paralleling technique were subjected to radiographic analysis using Image J software. After selecting the region of interest, bone height from a fixed reference point on the implant was assessed. In our cases, lower border of the crest module of the implant was taken as fixed reference point and bone height on the mesial and distal sites were assessed. Bone height from the alveolar crest to the lower border of the crest module was measured. Statistical analysis of these results found that significant bone remodeling occurred on both mesial and distal sites.
|Table 2: Radiographic analysis using Image J software from crest module of the implant to the mesial alveolar crest (statistical analysis)|
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|Table 3: Radiographic analysis using Image J software from crest module of the implant to the distal alveolar crest (statistical analysis)|
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| Discussion|| |
Implant-supported prosthesis represents one of the main achievements in the history of dental implant therapy. However, one of the aspects of the originally suggested protocols, i.e. time span relative to tooth extraction, was based on empirical observations than on scientific evidence, and has been questioned.  Collapse of the soft and hard tissues following tooth extraction is frequently associated with significant bone resorption, remodeling and bone deformity. After tooth extraction, bone undergoes rapid resorption: On an average, 23% of the bone mass is lost within the first six months following extraction, and another 11% is lost within the following two years. 
Preservation and integrity of the labial cortical plate is critical for the success of immediate implants. So atraumatic extraction of the teeth has to be done. Use of periotome and careful use of rotatory movements of the forceps during extraction of the teeth will provide an extraction socket with a intact labial cortical plate.  Countersinking was not done in our cases as it would thin the labial cortical plate, which would result in gingival recession. In the intact socket, a critical component of the peri-implant defect is the size of the horizontal defect, which is the longest distance in a perpendicular direction from the implant surface to the socket wall.  This distance has also been known as jumping distance.  Studies have demonstrated that for implants with a horizontal dimension of 2 mm or less, spontaneous bone healing and osseointegration takes place if the implant has a rough surface. , Out of 11 cases, five cases showed existence of peri-implant defects; however, the dimension of the defects was less than 2 mm, hence bone grafts were not placed. The absence of bone defects greater than 2 mm was probably due to the strict case selection criteria. Radiographic evaluation of the bone forms a very important and viable means of detecting health and stability of bone around the implant. Remodeling of bone around implants placed in fresh extraction sockets showed a healing pattern with new bone apposition around the implant's neck and horizontal and vertical bone resorption.
Successful implant therapy in the maxillary anterior region requires that prime importance be given to soft tissue aesthetics. Two types of periodontal soft tissue biotypes are noticed. i) Thick, flat periodontal biotype, which has fibrotic gingiva resistant to recession, wide zones of attached gingiva and thick underlying alveolar bone, which is resistant to resorption. Ideal implant soft tissue esthetics can be achieved in this biotype without modifications to routine surgical protocols.  ii) Thin periodontal biotype has thin, friable gingiva, with minimal amounts of attached gingiva and thin underlying alveolar bone, which is frequently dehisced or fenestrated.  Soft-tissue grafts, either before or in conjunction with extraction and implant placement, can help augment and offset the expected soft tissue recession.  In our study, none of the 11 cases showed any soft tissue deformity. These results are due to the selection of only type I extraction sites, which have a thick periodontal biotype according to the pre-operative classification proposed by Salama and Salama. 
| Conclusion|| |
In the present study, all the implants placed in the maxillary anterior region immediately after extraction were immobile, and did not show any signs of peri-implantitis during the follow-up period. Recession was also not noticed in any of the cases. Radiographically, significant bone remodelling was noticed around the neck of the implants. These good results are primarily due to the selecting sockets with intact buccal cortical plate and those having a thick, flat periodontal biotype. Further studies with larger populations and longer follow-up are necessary to corroborate and reinforce the positive outcomes of the study.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]