Results of Carrying out the Surgical State of Implantation with the Use of Direct and Delayed Techniques

Results of Carrying out the Surgical State of Implantation with the Use of Direct and Delayed Techniques

 

Lungu Valeriy. Associate Professor, Candidate of Medicine, the Odessa National Medical University, Oral Surgery Chair. Ukraine

Topicality

The unambiguous technique for insertion of implants to be selected by the doctors does not exist up to now: just after extraction of a tooth or after some time till entire healing of alveolar socket of extracted tooth with full-fledged osseous tissue capable to support a load passing to the bone by a dental prosthesis formed instead of it. The need for carrying out a dental implantation is dictated by the fact that 70 % of the adult population of Ukraine (older than 45) suffers from partial or complete adentia. One of basic reasons causing premature loss of teeth is lies in generalized periodontitis (Photo 1, 2, 3, 4).

Photo 1. Orthopantomogram of a 59-year-old patient M. Generalized periodontitis of IV degree, atrophy of the alveolar process height in the lateral portions of mandible.
Photo 2. Orthopantomogram of a 45-year-old patient P. Generalized periodontitis of III degree.
Photo 3. Patient Yu. Periodontitis of IV degree, preoperative examination.
Photo 4a. Examination of the oral cavity of a 49-year-old patient S. before extraction of teeth.
Photo 4b. Preoperative orthopantomogram of a 49-year-old patient S.
 
When selection of one or another technique for treatment, a doctor, as a matter of fact, must solve one and the same questions: what is better for the patient? The final selection in favour of one or another implantation technique should be made with due account of every known and significant factors. The overwhelming majority of doctors prefer Late Delayed Implantation Techniques believed to be more reliable nevertheless the fact that interim period since extraction of tooth till commencement of treatment with the use of these techniques makes up 4 – 6 months being carried out (subject to absence of sequelae) during another same period of time. Finally, the pre-prosthetic period lasts for about 8 – 12 months being unacceptable for the majority of patients. This entails a patient’s refusal from implantation techniques and agreement to removable dental prosthesis or bridge constructions. The task of maximum shortening of the period since insertion of implant till the moment of prosthetics as well as the question of direct implantation, that is, implantation just after tooth extraction occupy an important place among all problems of implantology. The direct dental implantation becomes more and more popular as compared with delayed techniques because it makes possible to save time since the moment of commencement of treatment till obtainment of prosthesis.

Purpose:

To compare indices of implant survivability and roentgenologic changes of bone level around the implants inserted straight after extraction of parodontal teeth and after long-term usage of removable dental prosthesis.

Materials and methods:

There were 48 patients of the age from 44 to 88 with chronic periodontitis of III – IV degrees whose “hopeless” teeth were extracted for orthopedic indications being replaced with inserted implants (the 1st group consisting of 13 patients) and the patients with maxillary or mandibular terminal defects or complete secondary adentia using removable dental prosthesis at the least for a year till insertion of implants (the 2nd group consisting of 35 patients) being treated for the period since 2008 till 2011, Alpha Dent Implants , different sizes and models was used for implantation. The patients had contraindications neither for surgery in the oral cavity nor for insertion of implants. The treatment was planned on the basis of diagnostic models and data of orthopantomograms. The results of this work were analyzed by comparison of the patients’ photos and orthopantomograms before surgery and after the one – straight after implantation and 4 – 6 months after usage of temporary fixed plastic prosthesis on the implants. When complete maxillary or mandibular adentia, at the least 2 implants were inserted to assure support of prosthesis with 16 (8+8) implants being inserted maximally (Photo 5, 6, 7).
Photo 5.Orthopantomogram of a 75-year-old patient R., two supporting implants.
Photo 6.A 80-year-old patient V., apparent atrophy of jaws prevents carrying out the implantation without preliminary augmentation , however the patients of elderly age group don’t agree to additional surgery.
Photo 7.Postoperative orthopantomogram of a 45-year-old patient P. Direct implantation.

The osteoplasty wasn’t carried out. The assessment criteria established in the first days after surgery are as follows: absence of complaints, clinically apparent inflammatory phenomena, nasal hemorrhage and numbness of lower lip and chin. Absence of implant mobility and sensations of pain when percussion before fixation of temporary plastic prosthesis, absence of periimplantitis phenomena on the control roentgenogram (Photo 8, 9).

Photo 8. Rarefication of osseous tissue surrounding the distal implant on the left – periimplantitis.
Photo 9. A 55-year-old patient Zh., control X-ray image in 6 months after usage of temporary dental prosthesis.

Results and their discussions:

There were 437 implants inserted during the aforementioned period, 22 of them were lost before the stage of prosthetics in the average making up 4.9 % by two groups and failing to differ considerably from the data cited by various authors in the reports and literature. In the 1st group reimplantation was carried out in 5 cases (2.4 %) being carried out in 17 cases (7.4 %) in the 2nd group. Taking into account the total quantity of implants inserted in each group (1st group – 208 pieces, the 2nd group – 229 pieces) it is possible to come to the conclusion that the nearest results of implant functioning don’t differ from the average statistical ones. However it was noted that the quantity of periimplantites and reimplantations in the 2nd group is three times as much as in the 1st group. There are two basic problems in this case: atrophy of the alveolar process height and absence of drainage when the osseous wound compression.
After tooth extraction a bony socket is being restored under the protection of a clot of blood. The retraction of a clot into the socket promotes migration of fibroblasts, the mechanism of osteolysis starts up as the result of osteoclastic activity of blood monocytes. The lysis of alveolar socket walls is in parallel accompanied with growing of epithelial elements and formation of scar tissue. For lack of functional load the restoration of osseous wound lasts for 3 – 6 months. Finishing of basic bone regeneration processes declares itself in formation of attached gingival part in the area alveolar socket of extracted tooth and appearance of a loopy osseous structure seen on the X-ray image (Photo 10, 11, 12).
 
Photo 10.A 75-year-old patient R., control X-ray image in a month after extraction of 32 and 33 mandibular teeth, the alveolar sockets of extracted teeth are easy to read nevertheless restoration of the mucous membrane. It was made a complete removable dental prosthesis.
Photo 11.Incomplete restoration of the osseous tissue under prosthesis after 6 months.
Photo 12.Complete adentia of mandible, atrophy in the lateral portions of jaw with preserved alveolar height at the frontal site.

Reduction of the alveolar process height – osseous atrophy is most evident under the influence of removable dental prosthesis (example of Wolf’s law – a function determines a form) (Photo 13, 14a, 14b).

Photo 13. A 55-year-old patient Zh., critical atrophy of alveolar height, long-term use of removable dental prosthesis.
Photo 14a. Absence of apparent atrophy in the osseous areas with parodontal or impacted teeth.
Photo 14b. Practical absence of the alveolar crest caused by long-term wearing of the removable dental prosthesis.
 
When chronic adentia, the quality of bone is attributed to the 4th type, with its quantity corresponding to criteria D and E according to Lekholm and Zarb index (Lekholm & Zarb, 1985). Prolonged wearing of removable dental prosthesis and more frequent shifts worsen the situation. This considerably reduces the opportunity to use intraosseous implants due to high degree of probable injury of inferior alveolar nerve and penetration of mucous membrane of the maxillary sinus. Available implantation techniques don’t stipulate drainage of the osseous wound with the torque- rotational force (30 – 35 N/cm2) being a determinative factor. The implant insertion surgery is carried out in the infected oral cavity stipulating inevitable infection of the bone bed designated for implant. Developing edema of osseous wound injured and suppressed by the implant (the outflow is blocked) is not determined visually because the exudate can’t get away from the bone. This results in compression of the bone marrow cells, blood and lymphatic vessels as well as the nerves by exudative edema disturbing the osseous tissue trophism more that the injury itself. Thus local hypoxia raises the risk of postoperative sequelae along with worsening of the reparative osteogenesis. The drawbacks of delayed implantation include the need for performance of two-three surgeries instead of one failing to be the joyous facts for the patient “by virtue of determination itself” as it has become popular to say. The surgeon always works approximately, and prognostication of results of his work depends upon a functionally substantiated plan of treatment, knowledge of the mechanisms of wound healing and surgery technique at that. The assessment criteria of performed treatment success are represented by the long-term results of the treatment techniques being used and functioning of implants.
 
Insertion of implant into the osseous tissue of maxilla or mandible compromised by periodontitis is risky and prevents hoping for achievement of necessary integration with the bone. However extraction of tooth with periapical granuloma and the granulation tissue locating lengthwise the root and being determined ad oculus reduces the risk of postoperative sequelae to a considerable extent (Photo 15, 16).
 
Photo 15.Removal of granulations
Photo 16.Alveolar sockets left after curettage

The direct implantation isn’t accompanied by a process of atrophy of the osseous tissue of the alveolar process as after tooth extraction and waiting so till complete restoration of the osseous wound (Photo 17, 18).

Photo 17. Control orthopantomogram of a 49-year-old patient S. in 2 months after implantation.
Photo 18. Temporary prosthesis inserted in 2 – 3 weeks makes it possible to preserve occlusion along with a short-term social adaptation of the patient.

The direct implantation subject to thorough curettage of the alveolar socket observes the moment of drainage of the osseous wound. None of the implants comply with the form of the root of tooth. Insertion of a round “root” with the axial slots into an oval alveolar socket of extracted tooth makes it possible to provide for outflow of exudate with easily attainable primary stability by insertion of the implant 2 – 3 mm lower from the bottom of alveolar socket.

These are the key moments of successful implantation. The degree of inflammation after tooth extraction, activation of reparative processes and the rate of healing of an alveolar socket are directly dependent upon the severity and duration of injury, extraction or non-extraction of granulations from the alveolar socket. The availability of granulomas and cysts, deep parodontal recesses is accompanied by the defect in walls of the alveolus. In these cases a delayed implantation is recommended. A single-stage implantation is contraindicated at availability of acute inflammatory processes in the periodontal tissues especially at the stage of suppurative inflammation.
In fact both the direct and delayed techniques are characterized by the positive qualities of their own, and therefore should be applied by known indications.

Conclusions:

The positive properties stated below may be treated as the obvious advantages of direct implantation:
  • an implant is inserted into the mandible or maxilla immediately after tooth extraction or 10 – 30 days later, and so the osseous atrophy has no time to change its relief;
  • a patient is subjected to a surgery only once;
  • considerable reduction of the total time of treatment, quicker restoration of the patient’s appearance, functions of speech, food intake, usual tempo of life, work, communication, etc. remain almost undisturbed;
  • the reparative processes developing after tooth extraction are simultaneously progressing in the direction of the implant integration into the osseous tissue;
  • considerable reduction of a doctor’s and patient’s expenditures of time, and material resources necessary for attainment of necessary result.
August 10, 2018
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