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‫‏‬Immediate implant placement

5 years follow up of extraction & immediate implantation of tooth with peri-apical pathosis Samier Askar, DDS,* and Tamer Abu Sada, DDS ±

* Post graduate stidues in Oral pathology, Completence University, Madrid, Spain, Private practice, Ramallah, Palestinian Authority. ± Private practice, Ramallah, Palestinian Authority.

Abstract This case report is presented to enable clinicians to do immediate implantation & loading even if there’s peri-apical pathosis under the tooth in the site of future implant position. A clinical case is presented to describe the technique. Pre-medicate the patient with Anti Biotics,Gentle Extraction of the tooth, all the lesion must be cleaned very well until sound bone felt all over the defect, implant selection is very important( Wide threating, suitable diameter and length). Primary stability achievement also very important for immediate loading(over 35 Ncm) and finally place the prosthetic contact free. Key words: Immediate Implantation, Immediate loading, Implant selection, primary stability, contact free. Introduction Dental Implants have become the first option in treating missing teeth. Immediate Implant placement and loading have become important for patients’ comfort. It reduces surgical procedures and bone loss. One of the requirements of immediate implant placement is implant primary stability. Peri- apical pathosis of the replaceable tooth impairments the probability of primary stability. This case report express the method for immediate placement of dental implant after extraction of infected tooth with peri-apical pathosis.

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DentalImplants Implantshave havebecome becomethe thefirst firstoption optioninintreating treatingmissing missingteeth. teeth.Immediate ImmediateImplant Implant Dental placement and loading have become important patients’ comfort. It reduces surgical placement and loading have become important forfor patients’ comfort. reduces surgical placement and loading have become important for patients’ comfort. ItItreduces surgical Figure 1. Pre-Op X-Rays Figure 2. Socket debridFigure 3. Implant placem procedures and bone loss. procedures and bone loss. procedures and bone loss. ‫‏‬Immediate implant placement of patient demonstrated a 2. ement after gentle extrNcm force with torque which Figure 1. Pre-Op X-Rays debrid3. Implant placement 35 35 Figure 1. Pre-Op X-RaysFigure FigureSocket 2. Socket debrid-Figure Figure 3. Implant placement with One of the requirements of immediate implant placement is implant primary stability. Oneof ofthe therequirements requirementsofofimmediate immediate implant placement implant primary stability. One implant placement isisimplant primary stability. > Failed with broken action. ble immediate loading. demonstrated a ement after gentle extr-extr-NcmNcm forceforce torque which indicate possiof RCT patient demonstrated a ement after gentle torque which indicate possiPeriapical pathosis of replaceable tooth impairments the probability of primary stability. of patient Periapical thethe replaceable tooth impairments theimmediate probability primary stability. Periapical pathosis ofofthe replaceable tooth impairments the probability ofofprimary stability. 5pathosis years follow up of extraction & Failed RCTRCT with broken action. ble immediate loading. instrument and large periFailed with broken action. ble immediate loading. This case report express method immediate placement of dental implant after extractioninstrument and large periThis case report express thethe method forfor immediate placement dental implant after extraction This case report express the method for immediate ofofdental implant after extraction implantation of tooth withplacement peri-apical pathosis andtooth large periapicalinstrument lesion in #10 of infected tooth with periapical pathosis. infected tooth with periapical pathosis. ofofinfected tooth with periapical pathosis. apical lesion in tooth #10 #10 apical lesion in tooth ‫‏‬Samier Askar, DDS,* and Tamer Abu Sada, DDS ±

Case presentation Case presentation Case presentation Case presentation

(22)associated with pain. (22)associated with pain.pain. (22)associated with

A 46-years female patient presented with with a with chief ofcomplaint a pain inof tooth #10(22). A 46-years female patient presented with a chief a pain in tooth #10(22). 46-years female patient presented achief chief complaint ofaof apain pain tooth #10(22). AA46-years female patient presented acomplaint complaint inintooth #10(22). Radiographic Examination revealed a broken instrument inside the canal with large Peri-apical Radiographic Examination revealed a broken instrument inside canal with large Peri-apical Radiographic Examination revealed broken instrument inside thethe canal with large Peri-apical Radiographic Examination revealed aabroken instrument inside the canal with large Peri-apical pathosis (Figure 1). The patient refused temporary restoration and asked for final one. pathosis(Figure The patient refused temporary restoration and asked final one. pathosis(Figure 1).1). The patient refused temporary restoration and asked forfor final one. pathosis(Figure 1). The patient refused temporary restoration and asked for final one. Extraction and Immediate Implantation were suggested. The patient accepted the treatment Extraction and Immediate Implantation were suggested. The patient accepted treatment plan. Extraction and Immediate Implantation were suggested. The patient accepted thethe treatment plan. Extraction and Immediate Implantation were suggested. The patient accepted the treatment plan. plan. Inform consent was signed after detailed explanation of treatment plan. Inform consent was signed after detailed explanation ofofthe treatment plan. Inform consent was signed after detailed explanation thethe treatment plan. Figure 4. Implant in itsinsiteits Figure 5. Angulated abutment 6. days later abutment Figure 4: Implant its proper Figure 6. 33days abutment Figure 5. Angulated abutment Figure 4. inImplant Figure 5. Angulated abutment Figure Figure 6. 3later days later abutment Inform consent was signed after detailed explanation of the treatment plan. placed and impression taken checked. site. site. checked. placed and impression taken. Tooth #10 was scheduled extraction, Patients were instructed in of chlorhexidine proper proper checked. placed and impression taken. Tooth #10 was scheduled for extraction, Patients were instructed ininthe use ofofchlorhexidine Tooth #10 was scheduled forfor extraction, Patients were instructed thethe useuse chlorhexidine Tooth #10 was scheduled for extraction, Patients were instructed in the use of chlorhexidine digluconate chemical control of plaque, which commenced 3 days prior to surgery andFigure 4. Implant in its Figure 5. Angulated abutment Figure 6. 3 days la digluconate the chemical control ofofplaque, which commenced 3 3surgery days prior totosurgery and digluconate forfor thethe chemical control plaque, which commenced days prior surgery and digluconatefor for the chemical control of plaque, which commenced 3 days prior to and continued 10 days postoperative. Antibiotic prophylaxis involved daily administration The toothsite. was extracted and the root was measured. A gentle avulsion technique was used toand Page 2 2 checked. placed impres continued 10 days postoperative. Antibiotic prophylaxis daily ofof2of continued for 10days days postoperative. Antibiotic prophylaxis involved daily 2 2proper Page continuedfor forfor 10 postoperative. Antibiotic prophylaxis involved dailyinvolved administration of administration 2 administration minimize trauma to the surrounding tissues, and the socket was thoroughly debrided (figure 2). grams of amoxicillin & clavulanic acid, 2surgery hours before surgery and 5 days after. grams amoxicillin && clavulanic acid, beginning 2beginning hours before and for 5 days after. grams ofofofamoxicillin acid, beginning 22hours before surgery and for after. grams amoxicillin &clavulanic clavulanic acid, beginning hours before surgery and for5for 5days days after. Osteotomies were prepared with the aid of a surgical template and implants with micro-textured On the day of surgery, the patient was anesthetized via local via infiltration in theinfiltration maxilla. ininthe the day of surgery, the patient was anesthetized local in maxilla On the day of the patient was anesthetized local infiltration maxilla OnOn the day ofsurgery, surgery, the patient was anesthetized viavia local infiltration thethe maxilla surfaces (Conical groovy implant,AB-Dental,Ashdod-Israel) were placed in accordance with the manufacturer’s protocol, 16 mm implant was inserted to achieve 5 mm bone anchorage in sound bone above the cyst cavity (Figure 3). Implant inserted into its proper position at the middle of the space slightly palataly with high preservati- on of the buccal plate, 1 mm below the bone crest to preserve the aesthetic zone and bone height). Bone substitute (Crused cancellous bone, Pacific Coast Tissue Bank,Los Angeles,CA) inserted to fill the gap between implant and the socket wall (Figure 4). Figure 2:2. Socket debridement after Figure 3: Implant placement withplacement Figure1. 1: X-Rays ofX-Rays patient Figure 1. Pre-Op Figure 2. Socket debridFigure 3. Implant with Figure Pre-Op X-Rays Figure debridFigure 3.3.Implant placement with 353535 Figure 1.Pre-Op Pre-Op X-Rays Figure 2.Socket Socket debridFigure Implant placement with gentle extraction 35 Ncm force torque which indicate demonstrated a Failed RCT with of patient demonstrated ement after gentle extr- Ncm Ncm force torque which indicate possiofofpatient demonstrated aa aement after gentle extrforce torque which indicate possipatient demonstrated ement after gentle extrNcm force torque possible immediate loading which indicate possibroken. instrument and large Failed RCT broken action. immediate loading. Failed RCT with broken action. ble immediate loading. periapical lesion inwith tooth #10 (22) Failed RCT with broken action. bleble immediate loading. associated with pain instrument and large periinstrument and large periinstrument and large periapical lesion in tooth apical lesion in tooth #10#10 26apical lesion in tooth #10 (22)associated with pain. (22)associated with pain. (22)associated with pain.

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Angeles,CA) inserted to fill the gap between implant and the socket wall(Figure 4).

y implant,AB-Dental,Ashdod-Israel) surfaces (Conical groovy implant,AB-Dental,Ashdod-Israel) were placed in accordance with were theplaced in accordance with the , 16 mm manufacturer’s implant was protocol, inserted 16 to achieve mm implant 5 mmwas bone inserted anchorage to achieve in sound 5 mm bone anchorage in sound ‫‏‬Immediate implant placement ity(Figure bone above 3). > the cyst cavity(Figure 3). proper Implant position inserted at 5 theyears into middits le proper of theposition space at the middpalataly le of with the& high space slightly palataly with high follow upslightly of extraction immediate and the root was measured. A gentle avulsion technique was used to cal plate, preservati1 mm on below of the thebuccal bone crest plate,to 1 preserve mm below the the aesthetic bone crest zonetoand preserve the aesthetic zone and implantation of tooth with peri-apical surrounding tissues, and the socket was thoroughly debrided (figure 2). pathosis titute(Crused bone height). cancellous Bone substitute(Crused bone, Pacific Coast cancellous Tissue Bank,Los bone, Pacific Coast Tissue Bank,Los red with the aid of‫‏‬Saamier surgical template and implants with micro-textured Askar, DDS,* and Tamer Abu Sada, DDS ±4 Figure 7. . next day crown placed fill the Angeles,CA) gap between inserted implant to fill andthe thegap socket between wall(Figure implant4).and theafter socket wall(FigureFigure 4). 8. 3 years after. y implant,AB-Dental,Ashdod-Israel)days were placedplacement. in accordance with the of implant implant placement , 16 mm implant was inserted to achieve 5 mm bone anchorage in sound ity(Figure 3). proper position at the midd- le of the space slightly palataly with high ccal plate, 1 mm below the bone crest to preserve the aesthetic zone and titute(Crused cancellous bone, Pacific Coast Tissue Bank,Los fill the gap between implant and the socket wall(Figure 4).

Figure 8: 33years afterafter. implant wn placed Figureafter 7. . 4next day crown placed Figure after 8. 4years Figure 7: placement ent. days of implant next placement. implant placement day crown

Figure 9. OPT years later. Figure 9:8. OPT years later Figure 333years after.

Figure 5 years later. Figure 10. 510. years later.10.late Figure 5 years

implant placement

Askar et al

Askar et al

Figure 11. Periapical X-ray Figure of11. Periapical X-ray after 5 after 5 years implantation of implantation years of implantation Figure 11. Periapical X-ray after 5 years

An angulated abutment checked to ensure crown position on implant (Figure 5), after that placed after 4 suturing was done. Conclusion days of implant 3 days later after implant placement the patient recalled for sutures removal and angulated placement ImmediateConclusion Implant and loading can be done in compromised bone as this presented case (Failed abutment was put over the implant. Impression was taken for final crown (Figure 6). Immediate Implant and loading can be done in compromised bone as this presented case (Failed RCT withperiapical large periapical pathosis). RCT with large pathosis). One day after, crown was ready and delivered to the patient (Figure 7). Curettage, cleaning of the whole area up to good bone quality and primary stability are the main necessities for success. After 3 years of Implant placement the patient returned, she showed a little cervicalCurettage, porcelaincleaning of the whole area up to good bone quality and primary stability are the main Conclusion wn placed after 4 Figure 8. 3 years after. necessities for success. crack but the patient didn’t want to replace the crown(Figure 8). Follow–up x-ray reveal bone in loading Immediate Implant and can be done in compromised bone as this presented case (Failed Credits and Special Appreciation the periapical pathosis location (figure 9). RCT with large periapical pathosis). ent. implant placement An angulated abutment checked to ensure crown position on implant (Figure 5), after that cleaningDrof the wholeProsthodontist, area up to good bone quality and primary stability are the main Zeev Ormianer, DICOI 5 years later the patient returned for annual check-up (Figure 10). No bone lossCurettage, was visible suturing was done. Credits andDirector, Special Appreciation Oral Implants Prosthodontic Clinic necessities for success. Department of Oral Rehabilitation (Figure 3 days later after implant placement the 11). patient recalled for sutures removal and angulated School of Dental Medicine

Figure 9. OPT 3 years later. Figure 9. OPT 3 years later.

abutment was put over the implant. Impression was taken for final crown (Figure 6). One day after, crown was ready and delivered to the patient (Figure 7). checked An angulated to ensure crown abutment position checked on implant to ensure(Figure crown5), position after that on implant (Figure 5), after that After 3 years of Implant placement the patient returned, she showed a little cervical porcelain suturing done. crackwas but the patient didn’t want to replace the crown (Figure 8). Follow–up x-ray reveal bone in t placement 3 days later the patient after implant recalled placement for sutures patient and recalled angulated for sutures removal and angulated the peri- apical pathosis location (figurethe 9).removal he implant. abutment Impression was over was the taken implant. forforfinal Impression crown (Figure was taken 6).10). No forbone finalloss crown (Figure 6). 5 years laterput the patient returned annual check-up (Figure was visible (Figure 11). as ready Oneand daydelivered after, crown to the was patient ready(Figure and delivered 7). to the patient (Figure 7).

Figure 9. OPT 3 years later. placement After 3the years patient of Implant returned, placement she showed the patient a little returned, cervical porcelain she showed a little cervical porcelain 28 n’t want cracktobut replace the patient the crown(Figure didn’t want 8). to replace Follow–up the crown(Figure x-ray reveal bone 8). Follow–up in x-ray reveal bone in checked to ensure crown position on implant (Figure 5), after that

Tel-Aviv University Dr. Zeev Ormianer, Prosthodontist, DICOI Director, Implants Prosthodontic Clinic Credits andOral Special Appreciation Department of Oral Rehabilitation School of Dental Medicine Dr Zeev Ormianer, Prosthodontist, DICOI Director, Oral Implants Prosthodontic Clinic Tel-Aviv University

Department of Oral Rehabilitation School of Dental Medicine Tel-Aviv University Page 3

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>

‫‏‬Immediate implant placement

5 years follow up of extraction & immediate implantation of tooth with peri-apical pathosis ‫‏‬Samier Askar, DDS,* and Tamer Abu Sada, DDS ±

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around single tooth implant. Int J Oral Maxillofac Impl 2001;16(1):61-67. 12. Small PN, Tarnow DP, Cho SC. Gingival recession around wide-diameter versus standarddiameter implants: A 3- to 5-year longitudinal prospective study. Pract Proced Aesthet Dent 2001;13(2):143-146. 13. Cocchetto R, Vincenzi G. Delayed and immediate loading of implants in the aesthetic zone: A review of treatment options. Pract Proced Aesthet Dent 2003;15(9):691-698. 14. Hermann JS, Schoolfield JD, Nummikoski PV, et al. Crestal bone changes around titanium implants: A methodologic study comparing linear radiographic with histometric measurements. Int J Oral Maxollofac Impl 2001;16(4):475-485. 15. Morris HF, Ochi S. The influence of implant design, application, and site on clinical performance and crestal bone: A multicenter, multidisciplinary clinical study. Dental Implant Clinical Research Group (Planning Committee). Implant Dent 1992;1(1):49-55. 16. Buser D, Dula K, Belser U, et al. Localized augmentation using guided bone regeneration. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent 1993;13:29–45. 17. Gher M, Quintero G, Assad D, et al. Bone grafting and guided bone regeneration for immediate dental implants in humans. J Periodontol 1994;65:881–891.

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Samier Askar and Tamer Abu Sada