Stela Šušnjar


Stela, kako radije voli da bude napisana kao Stella, je sveprisutna i tamos i vamos, jako je ljubazna i u silnoj želji da pacijentima uvek izađe u susret čak i u nemogućim situacijama često dolazi u sukob sa nama ostalima, Puno šeta, živi zdravo, jede ogromne količine zelene salate i ništa joj nije teško, mada katkad i ona gunđa.

Unconventional Implant Placement Through Impacted Maxillary Canine – A Case Report

Ivona Bjenjaš, DDS*
Tamara Ristić, DDS, PhD**
Djordje Pejanović, DDS, PhD**
Nenad Milinković, DDS***

*Dental clinic “BGD Osmeh” Francuska 25 11000 Belgrade
**Faculty of Dentistry Pancevo Žarka Zrenjanina 179, 26000 Pancevo
***Dental SM D.O.O. Bulevar Oslobođenja 152 11000 Belgrade


This case report should contribute in gaining more knowledge and experience in treating toothless region with impacted tooth using implant therapy without necessary extraction of impacted teeth and to report on short term data.


Protocols and indications of implant dentistry are constantly evolving. Regarding both doctors and patients wishes, many surgical techniques have been modified to circumvent adjunctive procedures and streamline care for those desiring tooth replacement.

Keeping up with this so-called “convenience profile” of treatment alternatives which aim is to minimize number of surgical procedures, morbidity and cost while increasing case acceptance, this article outlines an unconventional approach to help a patient with implant rehabilitation. This treatment plan represented a less invasive option that was not explored by other clinicians during a number of previous consultations which involves placement of dental implants directly through a maxillary impacted canine.

In 2009, the first two clinical papers dealing with implants deliberately placed in contacts with dental tissues were published.1

Since then more cases of impacted teeth were treated with success2,3 and the main idea was to extend these surgical protocols to inserting implants through residual roots4,5 or in contact with radicular dentin while seeking the esthetic optimization6,7.

Materials & Methods

66 years old female patient, needed therapy of the upper right partial edentulous maxilla.  Old PMF fixed partial denture was loosened and the extraction of the tooth 12 was indicated. Tooth 15 was indicated for the root treatment and post. Region 14 and 13 were indicated for implant therapy.

The impacted right upper canine was discovered on CBCT. Patient knew about it, but it was completely asymptomatic for years and no other surrounding pathology couldn’t be seen on CBCT (Figure 1). Patient wanted to avoid surgical extraction of impacted canine, so she was presented with alternative but not so much researched therapy plan: to insert implant through the impacted tooth. Patient was informed about possibility of implant failure and necessity to extract impacted canine and bone augmentation of the site if that happens, at no cost. After everything was explained, patient signed an informed consent.

CBCT small FOV teeth 15-11
Figure 1 – CBCT small FOV teeth 15-11
Implant planning on CBCT
Figure 2 – Implant planning on CBCT

Dental status was taken. To reduce the patient x-ray exposure following ALARA recommendation only small FOV on CBCT was done.

Extraction of the impacted tooth was avoided because of expected massive bone loss and possible complications (Figure 2). The tooth 12 was extracted. There was no buccal plate after extraction, so this site was excluded for immediate implant placement. Region of 13 and 14 were determined for implant placement. Two osteotomies were made with standard bur protocol, but more intensive drilling and cooling was necessary because impacted canine was massive, and thickness of enamel was around 1.5mm in drilling area. Two C-Tech implants were placed through the impacted tooth in region 13 (EL 3,5×11) and 14 (EL 3,5×9) (Figure 3). Primary stability was achieved on 60N/cm. The wound was sutured with 4,0 Nylon.

Figure 3 – Implantation

Control CBCT was taken, expected positions of implants were achieved (Figures 4, 5, 6). Patient was prescribed with antibiotic therapy Sinacillin 0.5g 3×1 for seven days and Ibuprofen 0.4g if needed.

Control CBCT small FOV - 1
Control CBCT small FOV - 2
CBCT small FOV slice along Y plane
Figure 6 – CBCT small FOV slice along Y plane


No postoperative pain, swelling or bleeding was reported by the patient. After seven days sutures were removed, the wound healing was uneventful. Tooth 15 was treated and CoCrMo post was made.

After four months implants were uncovered without any difficulties and healing caps were

placed (Figure 7). Patient was rehabilitated with E-max Cad bridge (Figure 8)

Healing caps
Figure 7 – Healing caps
Definitive restauration
Figure 8 – Definitive restauration


Epidemiologic data show that, after the third molars the canines are the most frequently impacted teeth7,8 Impaction rate ranges from 0,07% to 1,3% for the mandibular canine and from 1% to 3% for the maxillary8,9,10 Therefore canine impactions cannot be considered an uncommon finding9. However patients seek for rehabilitation of those sites and unconventional procedures must be taken into consideration in some cases.

When we discuss stability of implants in impacted teeth a combination of three types of interface can be anticipated according to the literature.

  1. A dentin implant interface in contact in the root11,12,13,14
  2. A newly created ligament close to the ligament of the impacted tooth or at some distance from it when space is left around the implant11,12,14,15
  3. A bone implant interface (osseointegration) where the implant is in contact with the bone11,12,14

Clinicians should ensure that approximately 50% of implant surface is in contact with the bone to obtain osseointegration and clinical stability in the longer term2.

Fear of exposing the pulp of impacted tooth during this procedure is justified but till now surprisingly no postoperative pain was recorded. There is no clear explanation for this, but Warrer et al. explicitly reported that the pulp of drilled roots left in contact with implants appeared normal after three months of healing of the monkey12. Surgery is always performed under sterile conditions so the impacted roots remain uncontaminated.


There are only a few case reports done with placing implants into impacted teeth. Protocol deviation is justified in situations when expected bone loss is compromising implant therapy afterward. There should be more studies confirming the safety of such procedures. This unconventional protocol is challenging in a long term outcome but is certainly much more acceptable for the patient as well for the clinician.


1.Davarpanah M, Szmukler-Moncler S. Unconventional implant treatment. I. Implant placement in contact with ankylosed root fragments: A series of 5 case reports. Clin Oral Implants Res 2009;20: 851-6.

2. Davarpanah M, Szmukler-Moncler S. Unconventional implant treatment. II. Implant placed through impacted teeth. 3 case reports. Int J Periodontics Restorative Dent 2009; 29: 405-13.

3. Szmukler-Moncler S, Davarpanah K, Davarpanah M, Rajzbaum P, Capelle-Ouadah N, Demurashvili G. Implants in contact with tissues other than bone. Is there room for a potential paradigm shift? Swiss Dental J 2014; 124: 149-56.

4. Szmukler-Moncler S, Davarpanah M. Reliability of the root- implant interface in unconventionally placed implants: an up to 6-year follow-up of 23 implants covering 3 distinct clinical applications. Clin Oral Implants Res 2009; 20: 814 (abstract).

5.Szmukler-Moncler S, Davarpanah M, Davarpanah K, Capelle-Ouadah N, Demurashvili G, Rajzbaum P. Unconventional implant placement. III. Implant placement encroaching residual roots. A report of 6 cases. Clin Implant Dent Related Res 2014; Jul 17. doi: 10.1111/cid.12256. [Epub ahead of print].

6. Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis N, Fickl S. The socket-shield technique: a proof-of-principle report. JClin Periodontol 2010; 37: 855-62.

7. Kan JY, Rungcharassaeng K. Proximal socket shield for interimplant papilla preservation in the esthetic zone. Int J Periodontics Restorative Dent 2013; 33: e24-31.

8. Jarjoura K, Crespo P, Fine JB. Maxillary canine impactions: Orthodontic and surgical management. Compend Contin Educ Dent 2002;23:23–26.

9. Chu FCS, Li TKL, Lui VKB, Newsome PRH, Chow RLK, Cheung LK. Prevalence of impacted teeth and associated pathologies—A radiographic study of the Hong Kong Chinese population. Hong Kong Med J 2003;9:158–163.

10. Cooke J, Wang HL. Canine impactions: Incidence and management. Int J Periodontics Restorative Dent 2006;26: 483–491.

11. Buser D, Warrer K, Karring T, Stich H.Titanium implants with a true periodontal ligament: An alternative to osseointegrated implants? Int J Oral Maxillofac Implants 1990;5:113–116.

12. Warrer K, Karring T, Gotfredsen K.Periodontal ligament formation around different types of dental titanium implants.I. The self-tapping screw type implant system. J Periodontol 1993;64:29–34.

13. Guarnieri R, Giardino L, Crespi R,Romagnoli R. Cementum formation around a titanium implant: A case report.Int J Oral Maxillofac Implants 2002;17:729–732.

14. Gray JL, Vernino AR. The interfacebetween retained roots and dental implants: A histologic study in baboonsJ Periodontol 2004;75:1102–1106.

15. Parlar A, Bosshardt DD, Ünsal B, Çetiner D,Haytaç C, Lang NP. New formation of peri-

odontal tissues around titanium implants in a novel dentin chamber model. Clin Oral

Implants Res 2005;16:259–267.

Source: C-Tech

Helbo terapija – istraživanja

Treating impaired wound healing in retromolar bone grafts

Dr. J. Neugebauer, Dr. F. Kistler, Dr. S. Kistler, Dr. F. Vizethum, Dr. D. Rothamel, Dr. M. Scheer, Prof. J. Zöller

EDI Journal, 09/2012


The impact of antimicrobial photodynamic therapy in an artificial biofilm model

Dr. M. Schneider, Dr. G. Kirfel, Dr. M. Berthold, Prof. Dr. M. Frentzen, PD Dr. F. Krause, PD Dr. A. Braun

Lasers in Medical Science, 10/2011


Photodynamic therapy in aggressive periodontitis

Prof. Dr. T. Auschill, Prof. Dr. N. Arweiler, Dr. M. Pietruska, Dr. J. Pietruska, Dr. M. Blaes, Prof. Dr. A. Sculean

IADR General Session, San Diego, März 2011


The impact of laser irradiation during aPDT in an artificial biofilm model

Dr. M. Schneider, PD Dr. A. Braun

SPIE BiOS: Lasers in Dentistry XVII. January 22nd – 27th, San Francisco, USA (2011)


The effect of a single episode of antimicrobial photodynamic therapy in the treatment of experimental periodontitis. Microbiological profile and cytokine pattern in the dog mandible

Dr. R. Oliveira, Prof. Dr. A. Novaes, Dr. G. Garlet, Dr. R. de Souza, Dr. M. Taba, Dr. S. Sato, Dr. S. de Souza, Dr. D. Palioto, Prof. Dr. M. Grisi, Dr. M. Feres

Lasers in Medical Science; 2011


Full mouth antimicrobial photodynamic therapy in fusobacterium nucleatum – infected periodontitis patients

PD Dr. Dr. B. Sigusch, Dr. M. Engelbrecht, A. Völpel, A. Holletschke, Dr. W. Pfister, Dr. J. Schütze

Journal of Periodontology, 2010


Zastosowanie terapii fotodynamicznej aPDT w stomatologii

Waclaw Steczko DDS

Sztuka Implantologii 2/2010


Photodynamic therapy in periodontal therapy: Microbiological observations
from a private practice

Prof. Dr. G. Romanos, Dr. B. Brink

General Dentistry, March/April 2010


Effect of aPDT on Osteoblast Adherence and Growth in Vitro

Dr. Dr. M. Scheer, PD Dr. J. Neugebauer, PD Dr. Dr. D. Rothamel, T. Fienitz, Dr. L. Ritter, Prof. Dr. Dr. J. Zöller

Academy of Osseointegration, Orlando, Florida, USA, 03/2010


Review of Photodynamic Therapy of Periodontal Diseases

Dr. Hayder Al-Waeli, Jordan University of Science & Technology

AEEDC DUBAI 2010, 09 – 11 März


The impact of antimicrobial photodynamic therapy on Streptococcus mutans in an artificial biofilm model

Dr. M. Schneider, PD Dr. A. Braun

SPIE BiOS: Lasers in Dentistry XVI, 01/2010




*Odontoiatra, Libero Professionista, Roma
**Odontoiatra, Libero Professionista, Heidelberg, Germania


One-year outcomes of repeated adjunctive photodynamic therapy during periodontal maintenance: a proof-of-principle randomized controlled clinical trial

Martina Lulic, Isabelle Leiggener Görög, Giovanni E. Salvi, Christoph A. Ramseier, Nikolaos Mattheos, Niklaus P. Lang

Prince Philip Dental Hospital, The University of Hong Kong, Hong Kong, China; School of Dental Medicine, University of Bern, Bern, Switzerland; School of Medicine and Oral Health, Griffith University, Gold Coast, Qld, Australia

J Clin Periodontol 2009

The comparison of photodynamic and antibiotic therapy in patients with aggressive periodontitis: Preliminary results

Prof. Dr. Milan Petelin, Dr. Boris Gaspirc, Dr. Eva Scaleric

University Medical Centre, Department of Oral Medicine and Periodontology, Ljubljana, Slovenia

ISOLA Congress 09/2009, Vienna

Phenothiazine Chloride and Soft Laser Light have a Biostimulatory Effect on Human Osteoblastic Cells

Elisabeth Stein, Jadranka Koehn, Walter Sutter, Constanze Schmidl, Vesna Lezaic, Gabriele Wendtlandt, Franz Watzinger, Dritan Turhani

Photomedicine and Laser Surgery, Volume 27, Number 1, 2009

Antimicrobial Photodynamic Therapy in the Non-Surgical Treatment of Aggressive Periodontitis: Cytokine Profile in Gingival Crevicular Fluid, Preliminary Results

Rafael Ramos de Olivera, Humberto Oswaldo Schwartz-Filho, Arthur Belém Novaes Jr., Gustavo Pompermaier Gralet, Raphael Freitas de Souza, Mário Taba Jr., Sérgio Luis Scombatti de Souza, Francisco Jeter Ribeiro

Journal of Periodontology 2009

Photodynamic therapy as an adjunct to non-surgical periodontal treatment: a randomized controlled clinical trial

N. Christodoulides, D. Nikolidakis, P. Chrondros, J. Becker, F. Schwarz, R. Rössler, A. Sculean

Journal of Periodontology 2008

Photodynamic therapy as adjunct to non-surgical periodontal treatment in patients on periodontal maintenance: a randomized controlled clinical trial

P. Chrondros, D. Nikolidakis, N. Christodoulides, R. Rössler, N. Gutknecht, A. Sculean

Lasers Med Sci 2008

Clinical and Microbiological Study of Laser-assisted Periodontal Therapy

Birgit Brink, Georgios E. Romanos

IADR, September 26-29. 2007, Thessaloniki, Greece

Initial Therapy of Peri-implantitis by Anti-microbial Photodynamic Therapy

P. Scherer, J. Neugebauer, V.E. Karapetian, J. E. Zöller

ADI, 3-5 May 2007, Birmingham, UK

Antimicrobial Photodynamic Therapy in the Non-Surgical Treatment of Aggressive Periodontitis: A Preliminary Randomized Controlled Clinical Study

Rafael R. de Oliveira, Humberto O. Schwartz-Filho, Arthur B. Novaes Jr., Mário Taba Jr.

Journal of Periodontology, Juni 2007

Biostimulation of bone marrow cells with a diode soft laser

Dortbudak O, Haas R, Mallath-Pokorny G.

Clin Oral Implants Res. 2000 Dec; 11(6): 540-5. Department of Oral Surgery, School of Dentistry, University of Vienna, Vienna, Austria.

Effect of low-power laser irradiation on bony implant sites

Dortbudak O, Haas R, Mailath-Pokorny G.

Clin Oral Implants Res. 2002 Jun; 13(3): 288-92. Department of Oral Surgery, Dental School, University of Vienna, Austria.

Lethal photosensitization for decontamination of implant surfaces in the treatment of peri-implantitis

Dortbudak O, Haas R, Bernhart T, Mailath-Pokorny G.

Clin Oral Implants Res. 2001 Apr; 12(2): 104-8. Department of Oral Surgery, School of Dentistry of the University of Vienna, Vienna, Austria.

Social media