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

Aim

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.

Introduction

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 success^2,3 and the main idea was to extend these surgical protocols to inserting implants through residual roots^4,5 or in contact with radicular dentin while seeking the esthetic optimization^6,7.

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.

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.

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.

Results

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)

Discussion

Epidemiologic data show that, after the third molars the canines are the most frequently impacted teeth^7,8 Impaction rate ranges from 0,07% to 1,3% for the mandibular canine and from 1% to 3% for the maxillary^8,9,10 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 root^11,12,13,14
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 implant^11,12,14,15
3. A bone implant interface (osseointegration) where the implant is in contact with the bone^11,12,14

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.

Conclusion

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.

References

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