USE OF IMMEDIATE DENTAL IMPLANTS

 
This article is about the use of dental implants with immediate loading and cortical osseointegration in parts of the jaw with retentiated, dystopic teeth.
Authors:
V.A. Rybak, E.I. Fesenko — Center for Oral and Maxillofacial Surgery, Kiev Regional Clinical Hospital, Ukraine;
V.G. Klimentyev — European Dental Center, Kiev, Ukraine.
The dentist’s tactics in relation to retined, doped teeth is based on indications, either surgical or orthodontic. In cases of partial adentia and the need for implantation in the presence of retentive distoped fangs, premolars using cylindrical two-stage implants, implant placement is allowed with an inclination of no more than 30 degrees with respect to the orthopedic design, by virtue of the requirements. Therefore, the dentist resorted either to the tactics of removing the doped teeth or to the surgical opening of the doped teeth and their subsequent orthodontic extraction into the dentition.
The use of implants with immediate loading and cortical osseointegration allowed us to avoid traumatic intervention in the upper jaw to remove these teeth or the option of prolonged orthodontic treatment to extend these teeth.
In English-language literature and in the countries of the former Soviet Union, there is a difference in terminology in relation to teeth that are localized in the jaw in an atypical place or position and whose teething time is untimely.
Retained teeth are observed when teething permanent teeth: more often — upper canines and lower wisdom teeth, less often — small molars and upper wisdom teeth.
The lower wisdom teeth are more often doped, less often the upper fangs and wisdom teeth, as well as the upper and lower premolars. Dystopia in the upper jaw is noted towards the vestibule of the mouth, in the oral cavity itself, onto the hard palate, towards the anterior wall and the zygomatic process of the maxillary bone. On the lower jaw — towards the vestibule of the mouth, towards the body, angle and branch of the lower jaw.
Retention of the tooth (retentio dentis; Lat. Retentio — retention, retention; synonym. Tooth retention) — delay in the eruption of a normally formed permanent tooth.
Complete retention — an uncut tooth is completely located in the bone tissue. Allocate 3 degrees of complete retention of teeth.
A semi-dentured tooth is an incomplete teething through the bone tissue of the jaw or mucous membrane.
Dystopia (dystopia; dys- + Greek. Topos — place, position). This is the wrong position in the dentition of the erupted tooth or the abnormal (displaced) position of the tooth in the jaw (Fig. 4.3.9-4.3.10). Supercomplete teeth are found, but very rarely.
In the sanguine-speaking world, the term impacted teeth is used to describe retentiated, dystopic teeth (impacted from the English — tightly or motionlessly wedged in). In dentistry, the term defines teeth that cannot or cannot penetrate into their normal functional position, and are thus pathological and need treatment2.
Thus, the English term is a general term for all detailed terms of dystopian, retarded teeth.

Tooth extraction

The surgical method for the removal of retarded, dystopian teeth is applicable in cases where to treat the teeth, any of the methods of treatment no longer makes sense. When planning removal, you must follow the surgical technique according to an X-ray examination. Bone preservation is recommended using a classic opening with tooth segmentation. Access to the removal of retarded, dystopian fangs on the upper jaw from the surface of the closest location. Labically located fangs are often removed using an elevator. Palatine localized fangs require removal of the crown, followed by segmentation of the root. Longitudinal segmentation of the root of palatine fangs is convenient and allows you to save the bone. With a large recline of the palatal flap, the use of the palatine plate prevents the formation of a hematoma.

Surgical opening (skeletonization)

  Surgical discovery is an intervention that promotes the natural eruption of retained teeth. Öhman and Öhman examined 542 retained teeth in 389 patients. In these studies, the tooth crowns were surgically opened with the removal of tissues in the most suitable for the movement of teeth.
Teething was allowed for up to 24 months or until the equator of the tooth crown reaches the level of the mucous surface. Out of 542 teeth, failure was noted only in 16 cases (teething failure after 24 months or other complications). The age of the patients was not flaccid, a success factor, although all patients reached 19 years of age.
More often, surgical opening is combined with fixation of orthodontic fixators to the teeth, providing active guidance of the retained tooth in an ideal position.

Orthodontic opening surgery

   
Preliminary orthodontic treatment is necessary to create the necessary space in the dental arch for the retained tooth and support. The use of various orthodontic elements is shown, including polycarboxylate crowns and pins integrated into tooth structures. But both of these techniques are rarely used because of problems in accessibility to pickling under braces / buttons.
Placing metal ligatures around the neck is a common orthodontic technique, but this technique is considered relatively invasive. Clinical data from 1981 testified to external resorption as a possible complication of the wide opening of the cement-enamel compound (CES), which is necessary for the location of the cervical ligature. This complication was studied by Kohavi and colleagues in 1984 on 23 patients who underwent surgical opening and fixation of the cervical ligature to the tooth. The teeth were divided into two groups: some had a “slight opening” to position the strip without exposing the CEC, others had a “significant opening” including bone removal, complete removal of the follicular sac and complete opening of the CEC. These data indicated significantly greater damage with the technique of significant opening and the authors recommend avoiding opening the neck of the tooth to place the cervical ligature. Although the use of orthodontic elements such as magnets is recommended for the movement of teeth, the most common method is the use of pickling braces.
This is usually done with a conservative opening of the tooth, removing only the necessary amount of soft and hard tissues needed to fix the bracket, avoiding the opening of the CES.
Research compares a simple opening with packing to create a gingival teething path with opening and pickling under a bracket. Iramaneerat and colleagues determined that there is no difference in the total time of orthodontic treatment for both techniques.
Pearson and colleagues noted that the use of braces is more expensive and more often requires reoperation. However, brace fixation is a more popular procedure.
With retated palatine incisors, a typical surgical opening involves discarding a full-layer palate flap, classic opening of the tooth and fixing the bracket to its palate surface. If the tooth is located near the edge of the flap, then soft tissue can be removed to leave the crown open; the wound is then packed gently during the initial healing period. If the tooth is deeply doped, it may be more appropriate to displace the soft tissue flap, leaving the ligature attached to the fixed bracket through soft tissue near the apex of the crest.
The technique of flap displacement is evaluated according to the consequences on the periodontium. Clinical results indicate a minimal effect on periodontium with closed teething.

Distant tooth transplantation.

    Justified as an alternative to other methods of treating dystopic teeth. It can be indicated for patients of mature age who cannot be given the classic orthodontic movement of a canine or premolar. Sagne
and Thilander studied 47 patients with 56 fangs that were transplanted. During the operation, a wide opening of the dystopic tooth and its movement into the dental arch, stabilization by orthodontic equipment is necessary. After 6-8 weeks, endodontic treatment is started with a paste based on calcium hydroxide. Root canal filling is performed 1 year after the intervention. These studies have shown success in 54 of 56 transplanted fangs.

Clinical Case No. 1

A patient born in 1964 (Fig. 1 initial situation) turned to the clinic with the desire to replace the defects of the teeth with non-permanent dentures. At the OPTG, 2 palatally located dystopian fangs were found. Orthodontic treatment to remove given teeth into the dentition in the absence of space for 23 teeth, a small number of supporting teeth, the duration of such treatment, was rejected by the patient-doctor decision immediately. Atypical extraction of dystopic teeth had the risk of trauma to the remaining teeth of the anterior group, the formation of an orthoantral fistula on the right, frightening the severity of the intervention for the patient. The installation of classical cylindrical implants would require the required maximum 30 ° in the ratio of the body of the implants to the axis of the orthopedic structures. A joint decision by the dentist-patient made a decision to preserve 2 asymptomatic palatine located dystopian fangs, removing 16, 24.25 teeth, endodontic treatment of 15, 11.21, 22 teeth, placing 8 implants on the upper jaw (Fig. 1-1) with immediate loading and cortical integration. 3 of them were installed in the tuber-wedge-shaped region. The installation of these implants was carried out according to the principles of basal implantology, which allow implants to be installed unparalleled and at an angle of more than 30 ° to the future orthopedic structure, installing them in the cortical layer of the jaw loading in the first two days from the day of implantation with two splinting structures.
In this work, the surgical principles of orthopedics-traumatology were used. According to which, implants should be fixed in the cortical plate and bone areas free from resorption (in their practice, there are no bone sections similar to the alveolar ridge) and avoid the installation of parallel implants. For non-parallel implants, splinted by a plate, create high macroretorency inside the bone. And such a divergence during installation reduces the risk of loosening of implants and increases their resistance to stress in various directions [2].
After implant placement, impressions were immediately taken. Temporary splinting orthopedic structures were cemented the next day for up to six months.
After half a year, the stage of permanent prosthetics with zirconium oxide bridge structures was carried out.
 
Fig. 1 The condition of the oral cavity before surgery in 2011.
 
 
Fig. 2 Condition one and a half years after implantation.
 
 
Fig. 3 Type of cemented bridge structures based on zirconium oxide in a year and a half from the moment of implantation and immediate loading.

CONCLUSIONS

The risk of damage to the anatomical structures, the duration of treatment, or the invasiveness of interventions may cause a patient-doctor to refuse treatment with classical implants in the presence of dystopian teeth.
Using the principle of traumatology for the immediate loading of plates for osteosynthesis, having established a sufficient number of stable, non-parallel implants, they were splinted with bridges with immediate use. The success of the chosen treatment tactics in conditions of asymptomatic dystopian fangs confirms our result after 1 year of function.
Thus, we provided the patient with the opportunity to avoid traumatic surgery to remove teeth, rehabilitation period, long-term orthodontic treatment, giving a chance to get permanent structures with the possibility of immediate function.
Having the technique of installing implants with immediate loading and cortical osseointegration, the dentist will be able to offer his patients a better option compared to most surrounding doctors.

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27.11.2019