468
Clinical Comparison of HydroxyapatiteCoated Titanium Dental Implants Placed in Fresh Extraction Sockets and Healed Sites* Raymond A. The
Yukna
dental implants in fresh extraction sockin healed sites in 14 patients. Systematic secompared placement adjacent documentation obtained was quential regarding periodontal health, radiographie bone and the time of implant placement, at uncovering, and from at levels, implant stability 8 to 24 months (mean 16 months) after loading and restoration delivery. There were no significant differences in any clinical parameter between those implants placed in fresh extraction sockets and those placed in healed areas. Periodontal health, maintenance of crestal bone levels, and implant stability were excellent for implants placed in both types of recipient sites. The results of this study suggest that hydroxyapatite-coated dental implants can be successfully placed in fresh extraction sockets utilizing otherwise standard implant placement techniques, and that they appear to clinically perform equally well in fresh sockets and healed sites. J Periodontal 1991; 62:468-472. placement of hydroxyapatite-coated
ets was
to
Key Words: Dental implantation; dental implants; hydroxyapatite; osseointegration.
implants utilizing the 2-stage osseointegration placetechnique offer a major advance in the prosthetic replacement of lost teeth. While the major thrust with this form and type of implants has been to help secure complete dentition prostheses in totally edentulous arches,1"3 an even more common application in periodontal practice may be to replace isolated missing teeth or a small segment of missing teeth.4-5 Standard procedures require a mature healed edentulous alveolar ridge in which to place the implant fixture. When teeth are extracted, a healing period up to 9 months is recommended for maturation of the socket bone before placing the implants (unpublished data).6 This substantially extends the total treatment time. There has been increasing interest in the concept of placing dental implants into fresh extraction Dental
ment and utilization
sockets (unpublished data).7"14 Several metallic surface and hydroxyapatite (HA)-coated implant systems have reported favorable clinical success rates over a varying number of years.1"5'7'1419 Interest in HA-coated implants centers on findings of a more rapid, complete, and predictable bone contact (osseointegration) with the HA-coated surface than with a metallic surface as seen on both a light and electron microscopic level.20 37 The rapid attachment to and incorporation of HA-coated implants by the alveolar bone in healed edentulous areas led
'Department of Surgical Dentistry, University of Colorado School of Dentistry, Denver, CO; private practice, Denver, CO.
speculation that placement of such implants in fresh extraction sockets might also be successful. Serendipitous findings from 4 such previous uses by the investigator had shown clinical extrusive, lateral, and rotational immobility as early as 3 months in this application. If routinely successful, the procedure would save several months of treatment and waiting time prior to definitive prosthesis fabrication. While there are isolated case reports of such successful extraction socket placement of dental implants, (unpublished data)712 no organized clinical trial has been reported to date on the use of these implants as abutment supports for small "fixed" partial dentures when used as immediately implanted tooth root replacements. The purpose of this study was to compare the clinical healing of HA-coated cylindrical dental implants when placed in fresh extraction sockets and healed alveolar bone sites. to
MATERIALS AND METHODS Patients 18 to 65 years old screened at the University of Colorado School of Dentistry who were not accepted for treatment at the school and/or private patients in the practice of the author who appeared to be good medical, psychological, and social risks for the use of dental implants and the associated surgery and whose treatment plan could include the use of dental implants for small edentulous areas were interviewed for possible participation in this study. Women of childbearing potential were administered a home pregnancy test within 1-
Volume 62 Number 7
YUKNA
469
1. Patient DS M/28/C. Sites: #29 fresh; #30 healed. Buried 6 months; restored 16 months. A. Pre-treatment clinical picture of existing mandibular fixed partial denture from #29-31. Tooth #31 had a questionable prognosis and #29 was deemed hopeless (mirrow view).
Figure
week prior to the procedure and only those female patients with a negative pregnancy test were entered into the study. Patients were considered for participation in this study if they were partially edentulous and would benefit from replacement of 2 to 4 teeth utilizing implant fixtures as abutment supports without involving natural teeth. One of the abutment implants for each bridge would be placed in a fresh extraction socket and the other in a healed bone area. Therefore, patients had to have both a healed and a planned fresh extraction site for implantation. The tooth/teeth to be removed had to be amenable to simple, relatively atraumatic extraction so as to preserve the lateral alveolar walls. Periodontal and periapical pathology had to be minimal and removable by means of socket curettage. Additionally, some intact bone apical to the socket had to be present. Informed written consent approved by the University of Colorado Health Sciences Center Humans at Risk Committee was obtained after verbal and written explanations to the patients of the experimental nature of the fresh socket implantation procedure and the need for increased documentation. Alternative treatment options were also presented. Documentation included intraoral and extraoral radiographs utilizing Stents with markers, Kodachrome slides, study casts, clinical measurements, and completion of an implant Evaluation Form and follow-up data collection cards. Placement of Integral1 implants in healed edentulous areas followed established technique as outlined in the manufacturers technical brochures. Essentially the procedure involved reflection of a full thickness mucoperiosteal flap, careful slow speed drilling under external and internal irrigation of receptor holes of appropriate width and depth, insertion of the cylindrical implant body to or slightly below the alveolar crest, and primary flap closure. No grafting was used in any of the healed area sites. These procedures are basic to the atraumatic placement of all
Calcitele, Inc., Carlsbad,
CA.
Figure 1. B, I. C, and 1. D. Same patient as Figure I.A. Implant-borne fixed partial denture supported by implants in fresh sockets #29 and healed site #30 after 16 months (mirrow view).
2-stage endosseous dental implants, but the armamentarium varies slightly from system to system. When implants were placed in fresh extraction sockets, several slightly different steps and procedures were employed. Gentle atraumatic tooth extraction was accomplished. In the case of multi-rooted teeth, coronectomy and individual re-
470
J Periodontol July 1991
HA-COATED IMPLANTS IN EXTRACTION SOCKETS
Figure 2. Patient CS FI32IC. Sites #14 fresh; #13 healed. Buried 8 months; restored 12 months. A. Pre-treatment radiograph showing #14 present and healed edentulous area #13. B. One year postrestorative radiograph demonstrating no appreciable difference in bone level between the two types of recipient sites. -
Figure
I.F. Same patient
as
Figure I.A. Sixteen month postrestorative
radiograph showing similar bone levels and osseous contours adjacent to both the fresh socket #29 and healed area #30 implants. Note HA augmentation particles associated with anterior implant. moval of the separated roots was performed. Socket debridement with curets and files was performed to remove any infected or inflammatory tissue as well as remnants of the periodontal
ligament. Socket shaping and deepening was accomplished with appropriate sizing drills so that maximum lateral contact could be achieved with the placed implant body. Generally, this required selecting a proximal or the lingual wall or line angle area as the lateral surface of the preparation site to achieve as close a fit38 as possible. The appropriate length and width implant was then placed with the superior aspect of the healing screw even with or slightly apical to the socket walls. Since the shape of the socket did not conform to the cylindrical shape of the sizing drill (and implant), in all cases Calcitite 20-40 or Calcitite 40-60 (depending on the volume and dimensions of the remaining space) was used to fill any void.39 Non-metallic instruments were used to place the graft material and handle the implants so as not to damage or disturb the HA coating of the implants. In order to obtain soft tissue coverage of the fresh socket implants, pedicle grafts, submucosal dissection, and/or aux-
iliary wound closure materials were utilized. A normal postoperative course was followed. No temporary prostheses were used so as to avoid inadvertent trauma to the implant placement sites. All patients were placed on either penicillin-type or tetracycline-type antibiotics for 10 days postsurgically. Appropriate analgesics and vitamin supplements of zinc gluconate 100 mg and folk acid 1.0 mg, each b.i.d., were prescribed. In the event of premature uncovering due to flap shrinkage, local, gentle oral hygiene and bacterial control measures were instituted and consisted mainly of swabbing with a cottontipped applicator and Listerine* or Peridex.§ None of the implants were uncovered and/or loaded with a prosthesis of any type until at least 6 months after placement. Implant uncovering was accomplished by means of a partial
thickness apically positioned flap to preserve or increase the zone of keratinized gingiva around the dental implants. Titanium healing cuffs were placed to allow for 2 to 4 weeks soft tissue maturation. Subsequently, the same type of abutment head (non-fluted for removable prosthesis) was used for all implants and then connecting fixed partial dentures. *Warner-Lambert Co., Morris Plains, NJ. §Procter and Gamble, Cincinnati, OH.
Volume 62 Number 7
YUKNA
Table 1. Clinical Results Following Placement of HA-Coated Implants in Fresh Extraction Sockets and Healed Recipient Sites*
Fourteen
One of Each Type in Each Patient 8 Months of Loading Fresh
(mm.)1'
Probing depth (mm.)' Bleeding on probing*
Mobility§
0.9 0.2 3.8 1.1 0
0.4" 0.2 1.2 0.7
Healed
0.8 0.3 3.2 1.0 0
± ± ±
±
0.3 0.2 1.0 0.6
value > > > >
0.30 0.30 0.10 0.20 0
*From edge of abutment head at time of restoration. Implants restored > 8 months (mean 16 months, range 8 to 24 months). Mean of 2 measurements (M + D) per implant on standardized radiographs. *Mean of four measurements (M, F, D, L) per implant. Evaluated using Miller classification with restorative superstructure removed. Mean ± S.D. Mean value per patient determined and these means used in calculations and statistical analysis by Wilcoxon Signed Rank Test.
Qinical evaluations of soft and hard tissue œnditions around the implants were made at the time of loading (delivery of the superstructure fixed partial denture) and every 4 months following loading up to 24 months. Radiographie bone levels referenced to the top of the implant body, gingival margin position change (recession), and probing depth measured from the abutment head margin, bleeding on probing, and clinical mobility of the individual implants were recorded at each evaluation point. Evaluation Data were initially collected on specially designed implant Evaluation Forms and follow-up cards and then stored and analyzed by computer. Wilcoxon signed rank test analysis was performed to determine any differences between the fresh socket and healed socket implants regarding soft tissue or bone
changes.40
RESULTS Fourteen patients (9 females and 5 males) 30 to 60 years old (mean 49.6), who had received dental implants in both fresh extraction sockets and healed edentulous sites and had those implants restored with fixed partial dentures connecting the pairs of implants for at least 8 months (mean 16 months, range 8 to 24 months) are reported here. All 28 implants healed and functioned well. Data in Table 1 reflect the last evaluation point for each pair of implants. There were no significant differences in any clinical parameter between those implants placed in fresh extraction sockets and those placed in healed areas or among the evaluation times. Periodontal health, maintenance of crestal bone levels, and implant stability were excellent for both types of recipient sites
(Table 1).
exposure occurred. Clinical examples are presented in Figures 1 and 2.
patients, >
Bone level change Recession (mm.)*
471
Premature uncovering of the implant head and healing screw occurred in 7/14 fresh site implants and 4/14 healed site implants. These early exposures did not appear to adversely affect the clinical findings in either group of implants. Very few, if any, of the HA graft material particles appeared to be lost from the fresh socket sites even if early healing screw
DISCUSSION The results of this study suggest that HA-coated dental implants can be successfully placed in fresh extraction sockets utilizing slight modifications of otherwise standard implant placement techniques, and that they clinically integrate equally well in fresh sockets and healed sites. These findings are similar to the case reports of Golee7 and suggest that these HA-coated implants are applicable for immediate placement in fresh extraction sockets. This application enhances the usefulness of these types of implants. The results also parallel those for other types of implant systems in healed
areas.1-5'15-19
Several modifications in technique are often necessary when utilizing fresh extraction sockets as an implant site. Since there are almost always voids lateral to the implants, a compatible grafting/bone filling material such as allogeneic freeze-dried bone or particulate hydroxyapatite would seem to be of use to fill in the extra space.39 Some investigators have also used a guided tissue regeneration-based technique for this
purpose.11-41-42
Soft tissue coverage of the fresh socket implant site is often difficult because of the soft tissue opening left by the removed tooth. When possible, a pedicle flap and/or submucosal dissection should be developed so that soft tissue can be extended to cover the socket area. This often causes a reduction in vestibular depth and creates a mucogingival problem that must be corrected during the uncovering procedure. Even under the best of circumstances, premature uncovering of the implant head and healing screw occasionally occurred. As little function as possible was applied to the exposed implant heads and oral hygiene measures utilizing application of an antibacterial moutnrinse with a cotton-tipped applicator several times daily were emphasized. All implants were allowed to integrate for at least 6 months. This time frame was selected based on wound healing studies of socket repair after extraction. While shorter times have been advocated for HA-coated implants in healed areas, it is unknown if a shorter healing time may be sufficient for implants placed in fresh extraction sockets. The results of this study suggest that placement in fresh extraction sockets, thereby shortening total treatment time, may be an additional application of HA-coated dental implants.
Acknowledgments This study was supported by a grant from Calcitek, Inc. which provided implant parts and patient subsidization for this study. All of the treatment was performed in the private practice of the author, and all analyses and conclusions were made independently by him. The administrative, organizational, and clinical support of Charlotte Yukna was vital to the completion of this project. In addition, the clinical assistance of Terrie Taylor and Anya Fritz; restorative dentistry provided by Drs. Bonnie Ferrell and Marc Schwartz; the bibliographic verifi-
472
provided by Elizabeth Strother, preparation efforts of Candee Lambert recognized. cation
and the are
manuscript appreciated and
REFERENCES
Worthington P, Eriksson RA. The long-term of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986; 1:11-25. Albrektsson T. A multicenter report on osseointegrated oral implants. J Prosthet Dent 1988; 60:75-84. Albrektsson TA, Dahl E, Enbom L, et al. Osseointegrated oral implants. A Swedish multicenter study of 8139 consecutively inserted Nobelpharma implants. / Periodontol 1988; 59:287-296. van Steenberghe D. A restorative multicenter evaluation of the survival rate of osseointegrated fixtures supporting fixed partial prostheses in the treatment of partial edentulism. J Prosthet Dent 1989; 61:217223. Finger I, Block M, Kent J. Four year results with posterior mandibular integral implants. J Dent Res 1989; 68(Spec. Issue): 901 (Abstr. 278). Laney WR. Selecting edentulous patients for tissue-integrated prostheses. Int J Oral Maxillofac Implants 1986; 1:129-138. Golee TS. Three year clinical review of HA-coated titanium cylinder implants. / Oral Implantai 1988; 14:437-454. Todescan R, Pilliar RM, Melcher AH. Healing of immediate dental implants in a small animal model. J Dent Res 1988; 67(Spec. Issue): 347 (Abstr. 1878). Ross SE, Strauss T, Crossetti HW, Gargiulo AW. The immediate placement of an endosseous implant into an extraction wound: A clinical case report using the RosTR System. Int J Periodontics Restorative Dent 1989; 9:35^11. Woolfe SN, Kenney EB, Keye G, Taylor D, O'Brien M. Effect of implantation of titanium implants into fresh extraction sockets. JDent Res 1989; 68(Spec. Issue): 962 (Abstr. 762). Lázárra RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent 1989; 9:333-343. Barzilay I, Graser GM, Catón J, Shenkle G. Immediate implantation of pure titanium implants into extraction sockets. / Dent Res 1988; 67 (Spec. Issue): 142(Abstr. 234). Quayle AA, Cawood J, Howell RA, Eldridge DJ. The immediate or delayed replacement of teeth by permucosal intra-osseous implants: the Tubingen implant system. Part I. Implant design, rationale for use and preoperative assessment. Brit Dent J 1989; 166:365-370. Quayle AA, Cawood J, Howell RA, Eldridge DJ. The immediate or delayed replacement of teeth by permucosal intra-osseous implants: the Tubingen implant system. Part II. Surgical and restorative techniques. Brit Dent J 1989; 166:403^110. Kent JN, Block MS, Misiek DJ, Finger IM, Guerra LR. Hydroxylapatite-coated dental implants pilot clinical results of 216 implants. JDent Res 1987; 66(Spec. Issue): 249(Abstr. 1141). Patrick D, Zosky J, Lubar R, Buchs A. The longitudinal clinical efficacy of Core-Vent dental implants: A five year report. J Oral Implantai 1989; 15:95-103. Kent JN, Block MS, Finger IM, Guerra L, Larsen H, Misiek DJ. Biointegrated hydroxylapatite-coated dental implants: 5 year clinical observations. J Am Dent Assoc 1990; 121:138-144. Kirsch A, Ackermann KL. A ten year clinical report on the IMZ implant system; oral rehabilitation of the partially totally edentulous patient. Technical report OMS909, Interpore International, Irvine, CA, January 1989. Smithloff M, Fritz ME. The use of blade implants in a selected population of partially edentulous adults. A ten year report. J Periodontol 1982; 53:413^115. Cook SD, Kay JF, Thomas KA, Jarcho M. Interface mechanics and histology of titanium and hydroxylapatite-coated titanium for dental implant applications. Int J Oral Maxillofac Implants 1987; 2:15-22.
1. Albrektsson T, Zarb G,
efficacy
2. 3.
4.
5. 6. 7.
8.
9.
10.
11.
12.
13.
14.
15.
-
16.
17.
18.
19.
20.
J Periodontol July 1991
HA-COATED IMPLANTS IN EXTRACTION SOCKETS
21. Weinlaender M, Kenney EB, Beumer J, Moy , Plenk Jr . Comparison of implant-bone interfaces in three different implant systems. / Dent Res 1989; 68(Spec. Issue): 963 (Abstr. 770). 22. Gammage DD, Bowman AE, Meffert RM, Cassingham RJ, Davenport WA. A histologie and scanning electron micrographie comparison of the osseous interface in loaded IMZ and Integral implants. Int J Periodontics Restorative Dent 1990; 10:125-135. 23. Block MS, Kent JN, Finger IM, Mohr G. Loaded HA-coated and grit titanium implant in dogs. / Dent Res 1988; 67(Spec. Issue): 178
24.
(Abstr. 523). Tracy BM, Doremus RH. Direct electron microscopy studies of the bone-hydroxylapatite interface. / Biomed Mater Res 1984; 18:719-
726. 25. Denissen HW, Veldhuis AAH, van den Hoof A. Hydroxyapatitetitanium implants. In: van Steenberghe D, ed. Tissue Integration in Oral and Maxillofacial Reconstruction. Amsterdam: Excerpta Medica; 1986: 372-388. 26. de Putter C, de Lange GL, de Groot K. Permucosal oral implants of dense hydroxylapatite: Fixation in alveolar bone. In: van Steenberghe D., ed. Tissue Integration in Oral and Maxillo-facial Reconstruction. Amsterdam: Excerpta Medica; 1986: 389-394. 27. Kawahara H. Today and tomorrow of bioceramics. / Oral Implantai 1979; 8:411^132. 28. Akagawa Y, Satomi , Hashimoto M, Nikai H, Tsuru H. Histological study on hydroxylapatite (HAP)-coated endosseous implant. / Dent Res 1987; 66(Spec. Issue): 250 (Abstr. 1146). 29. Meffert RM, Block MS, Kent JN. What is osseointegration? Int J Periodontics Restorative Dent 1987; 7(4): 9-21. 30. Geesink RGT, de Groot K, Klein CPAT. Chemical implant fixation using hydroxylapatite coatings. Clin Orthop 1987; 225:147-170.— 31. Block MS, Kent JN, Kay JF. Evaluation of hydroxylapatite-coated titanium dental implants in dogs. / Oral Maxillofac Surg 1987; 45:601-607. 32. Kay JF. Bioactive surface coatings: Cause for encouragement and caution. / Oral Implantai 1988; 14:43-54. 33. Soballe K, Hansen ES, Brockstedt-Rasmussen H, et al. Stimulation of osteopenic bone ingrowth into porous-coated implants by hydroxylapatite coating. Acta Orthop Scand 1988; 59 (Suppl 227): 123. 34. Kay JF. Current and new developments in bioactive coatings. / Dent Res 1989; 68(Spec. Issue): 862 (Abstr. S34). 35. de Lange GL, de Putter C, de Groot K, Burger EH. A clinical, radiographic, and histological evaluation of permucosal dental implants of dense hydroxylapatite in dogs. JDent Res 1989; 68:509-518. 36. Kwan J, Meffert RM, et al: SEM and EDS analysis of the interface between host bone and hydroxylapatite coated titanium dental implants. Research Report. New Orleans: Louisiana State University, Dental School, 1990. 37. deLange GL, dePutter C, deWijs FLJA. Histological and ultrastructural appearance of the hydroxylapatite-bone interface. J Biomed Mater Res 1990; 24:829-845. 38. Carlsson L, Rostlund T, Albrektsson B, Albrektsson T. Implant fixation improved by close fit. Cylindrical implant-bone interface studied in rabbits. Acta Orthoped Scand 1988; 59:272-275. 39. Kraut RA. Indications for use of porous hydroxyapatite at time of endosteal implant placement. Compendium 1989; 10:322-325. 40. Emrich LJ. Common problems with statistical aspects of periodontal research papers. J Periodontol 1990; 61:206-208. 41. Dahlin C, Sennerby L, Lekholm W, Linde A, Nyman S. Generation of new bone around titanium implants using a membrane technique: An experimental study in rabbits. Int J Oral Maxillofac Implants 42.
1989;4:19-25. Nyman S, Lang NP, Buser D, Bragger U. Bone regeneration adjacent to titanium dental implants using guided tissue regeneration: A report of two cases. Int J Oral Maxillofac Implants 1990; 5:9-14.
Send reprint requests to: South, Denver, CO 80222.
Dr. R. A.
Yukna, 5050 Cherry Creek Drive
Accepted for publication January 25,
1991.
Clinical Comparison of HydroxyapatiteCoated Titanium Dental Implants Placed in Fresh Extraction Sockets and Healed Sites* Raymond A. The
Yukna
dental implants in fresh extraction sockin healed sites in 14 patients. Systematic secompared placement adjacent documentation obtained was quential regarding periodontal health, radiographie bone and the time of implant placement, at uncovering, and from at levels, implant stability 8 to 24 months (mean 16 months) after loading and restoration delivery. There were no significant differences in any clinical parameter between those implants placed in fresh extraction sockets and those placed in healed areas. Periodontal health, maintenance of crestal bone levels, and implant stability were excellent for implants placed in both types of recipient sites. The results of this study suggest that hydroxyapatite-coated dental implants can be successfully placed in fresh extraction sockets utilizing otherwise standard implant placement techniques, and that they appear to clinically perform equally well in fresh sockets and healed sites. J Periodontal 1991; 62:468-472. placement of hydroxyapatite-coated
ets was
to
Key Words: Dental implantation; dental implants; hydroxyapatite; osseointegration.
implants utilizing the 2-stage osseointegration placetechnique offer a major advance in the prosthetic replacement of lost teeth. While the major thrust with this form and type of implants has been to help secure complete dentition prostheses in totally edentulous arches,1"3 an even more common application in periodontal practice may be to replace isolated missing teeth or a small segment of missing teeth.4-5 Standard procedures require a mature healed edentulous alveolar ridge in which to place the implant fixture. When teeth are extracted, a healing period up to 9 months is recommended for maturation of the socket bone before placing the implants (unpublished data).6 This substantially extends the total treatment time. There has been increasing interest in the concept of placing dental implants into fresh extraction Dental
ment and utilization
sockets (unpublished data).7"14 Several metallic surface and hydroxyapatite (HA)-coated implant systems have reported favorable clinical success rates over a varying number of years.1"5'7'1419 Interest in HA-coated implants centers on findings of a more rapid, complete, and predictable bone contact (osseointegration) with the HA-coated surface than with a metallic surface as seen on both a light and electron microscopic level.20 37 The rapid attachment to and incorporation of HA-coated implants by the alveolar bone in healed edentulous areas led
'Department of Surgical Dentistry, University of Colorado School of Dentistry, Denver, CO; private practice, Denver, CO.
speculation that placement of such implants in fresh extraction sockets might also be successful. Serendipitous findings from 4 such previous uses by the investigator had shown clinical extrusive, lateral, and rotational immobility as early as 3 months in this application. If routinely successful, the procedure would save several months of treatment and waiting time prior to definitive prosthesis fabrication. While there are isolated case reports of such successful extraction socket placement of dental implants, (unpublished data)712 no organized clinical trial has been reported to date on the use of these implants as abutment supports for small "fixed" partial dentures when used as immediately implanted tooth root replacements. The purpose of this study was to compare the clinical healing of HA-coated cylindrical dental implants when placed in fresh extraction sockets and healed alveolar bone sites. to
MATERIALS AND METHODS Patients 18 to 65 years old screened at the University of Colorado School of Dentistry who were not accepted for treatment at the school and/or private patients in the practice of the author who appeared to be good medical, psychological, and social risks for the use of dental implants and the associated surgery and whose treatment plan could include the use of dental implants for small edentulous areas were interviewed for possible participation in this study. Women of childbearing potential were administered a home pregnancy test within 1-
Volume 62 Number 7
YUKNA
469
1. Patient DS M/28/C. Sites: #29 fresh; #30 healed. Buried 6 months; restored 16 months. A. Pre-treatment clinical picture of existing mandibular fixed partial denture from #29-31. Tooth #31 had a questionable prognosis and #29 was deemed hopeless (mirrow view).
Figure
week prior to the procedure and only those female patients with a negative pregnancy test were entered into the study. Patients were considered for participation in this study if they were partially edentulous and would benefit from replacement of 2 to 4 teeth utilizing implant fixtures as abutment supports without involving natural teeth. One of the abutment implants for each bridge would be placed in a fresh extraction socket and the other in a healed bone area. Therefore, patients had to have both a healed and a planned fresh extraction site for implantation. The tooth/teeth to be removed had to be amenable to simple, relatively atraumatic extraction so as to preserve the lateral alveolar walls. Periodontal and periapical pathology had to be minimal and removable by means of socket curettage. Additionally, some intact bone apical to the socket had to be present. Informed written consent approved by the University of Colorado Health Sciences Center Humans at Risk Committee was obtained after verbal and written explanations to the patients of the experimental nature of the fresh socket implantation procedure and the need for increased documentation. Alternative treatment options were also presented. Documentation included intraoral and extraoral radiographs utilizing Stents with markers, Kodachrome slides, study casts, clinical measurements, and completion of an implant Evaluation Form and follow-up data collection cards. Placement of Integral1 implants in healed edentulous areas followed established technique as outlined in the manufacturers technical brochures. Essentially the procedure involved reflection of a full thickness mucoperiosteal flap, careful slow speed drilling under external and internal irrigation of receptor holes of appropriate width and depth, insertion of the cylindrical implant body to or slightly below the alveolar crest, and primary flap closure. No grafting was used in any of the healed area sites. These procedures are basic to the atraumatic placement of all
Calcitele, Inc., Carlsbad,
CA.
Figure 1. B, I. C, and 1. D. Same patient as Figure I.A. Implant-borne fixed partial denture supported by implants in fresh sockets #29 and healed site #30 after 16 months (mirrow view).
2-stage endosseous dental implants, but the armamentarium varies slightly from system to system. When implants were placed in fresh extraction sockets, several slightly different steps and procedures were employed. Gentle atraumatic tooth extraction was accomplished. In the case of multi-rooted teeth, coronectomy and individual re-
470
J Periodontol July 1991
HA-COATED IMPLANTS IN EXTRACTION SOCKETS
Figure 2. Patient CS FI32IC. Sites #14 fresh; #13 healed. Buried 8 months; restored 12 months. A. Pre-treatment radiograph showing #14 present and healed edentulous area #13. B. One year postrestorative radiograph demonstrating no appreciable difference in bone level between the two types of recipient sites. -
Figure
I.F. Same patient
as
Figure I.A. Sixteen month postrestorative
radiograph showing similar bone levels and osseous contours adjacent to both the fresh socket #29 and healed area #30 implants. Note HA augmentation particles associated with anterior implant. moval of the separated roots was performed. Socket debridement with curets and files was performed to remove any infected or inflammatory tissue as well as remnants of the periodontal
ligament. Socket shaping and deepening was accomplished with appropriate sizing drills so that maximum lateral contact could be achieved with the placed implant body. Generally, this required selecting a proximal or the lingual wall or line angle area as the lateral surface of the preparation site to achieve as close a fit38 as possible. The appropriate length and width implant was then placed with the superior aspect of the healing screw even with or slightly apical to the socket walls. Since the shape of the socket did not conform to the cylindrical shape of the sizing drill (and implant), in all cases Calcitite 20-40 or Calcitite 40-60 (depending on the volume and dimensions of the remaining space) was used to fill any void.39 Non-metallic instruments were used to place the graft material and handle the implants so as not to damage or disturb the HA coating of the implants. In order to obtain soft tissue coverage of the fresh socket implants, pedicle grafts, submucosal dissection, and/or aux-
iliary wound closure materials were utilized. A normal postoperative course was followed. No temporary prostheses were used so as to avoid inadvertent trauma to the implant placement sites. All patients were placed on either penicillin-type or tetracycline-type antibiotics for 10 days postsurgically. Appropriate analgesics and vitamin supplements of zinc gluconate 100 mg and folk acid 1.0 mg, each b.i.d., were prescribed. In the event of premature uncovering due to flap shrinkage, local, gentle oral hygiene and bacterial control measures were instituted and consisted mainly of swabbing with a cottontipped applicator and Listerine* or Peridex.§ None of the implants were uncovered and/or loaded with a prosthesis of any type until at least 6 months after placement. Implant uncovering was accomplished by means of a partial
thickness apically positioned flap to preserve or increase the zone of keratinized gingiva around the dental implants. Titanium healing cuffs were placed to allow for 2 to 4 weeks soft tissue maturation. Subsequently, the same type of abutment head (non-fluted for removable prosthesis) was used for all implants and then connecting fixed partial dentures. *Warner-Lambert Co., Morris Plains, NJ. §Procter and Gamble, Cincinnati, OH.
Volume 62 Number 7
YUKNA
Table 1. Clinical Results Following Placement of HA-Coated Implants in Fresh Extraction Sockets and Healed Recipient Sites*
Fourteen
One of Each Type in Each Patient 8 Months of Loading Fresh
(mm.)1'
Probing depth (mm.)' Bleeding on probing*
Mobility§
0.9 0.2 3.8 1.1 0
0.4" 0.2 1.2 0.7
Healed
0.8 0.3 3.2 1.0 0
± ± ±
±
0.3 0.2 1.0 0.6
value > > > >
0.30 0.30 0.10 0.20 0
*From edge of abutment head at time of restoration. Implants restored > 8 months (mean 16 months, range 8 to 24 months). Mean of 2 measurements (M + D) per implant on standardized radiographs. *Mean of four measurements (M, F, D, L) per implant. Evaluated using Miller classification with restorative superstructure removed. Mean ± S.D. Mean value per patient determined and these means used in calculations and statistical analysis by Wilcoxon Signed Rank Test.
Qinical evaluations of soft and hard tissue œnditions around the implants were made at the time of loading (delivery of the superstructure fixed partial denture) and every 4 months following loading up to 24 months. Radiographie bone levels referenced to the top of the implant body, gingival margin position change (recession), and probing depth measured from the abutment head margin, bleeding on probing, and clinical mobility of the individual implants were recorded at each evaluation point. Evaluation Data were initially collected on specially designed implant Evaluation Forms and follow-up cards and then stored and analyzed by computer. Wilcoxon signed rank test analysis was performed to determine any differences between the fresh socket and healed socket implants regarding soft tissue or bone
changes.40
RESULTS Fourteen patients (9 females and 5 males) 30 to 60 years old (mean 49.6), who had received dental implants in both fresh extraction sockets and healed edentulous sites and had those implants restored with fixed partial dentures connecting the pairs of implants for at least 8 months (mean 16 months, range 8 to 24 months) are reported here. All 28 implants healed and functioned well. Data in Table 1 reflect the last evaluation point for each pair of implants. There were no significant differences in any clinical parameter between those implants placed in fresh extraction sockets and those placed in healed areas or among the evaluation times. Periodontal health, maintenance of crestal bone levels, and implant stability were excellent for both types of recipient sites
(Table 1).
exposure occurred. Clinical examples are presented in Figures 1 and 2.
patients, >
Bone level change Recession (mm.)*
471
Premature uncovering of the implant head and healing screw occurred in 7/14 fresh site implants and 4/14 healed site implants. These early exposures did not appear to adversely affect the clinical findings in either group of implants. Very few, if any, of the HA graft material particles appeared to be lost from the fresh socket sites even if early healing screw
DISCUSSION The results of this study suggest that HA-coated dental implants can be successfully placed in fresh extraction sockets utilizing slight modifications of otherwise standard implant placement techniques, and that they clinically integrate equally well in fresh sockets and healed sites. These findings are similar to the case reports of Golee7 and suggest that these HA-coated implants are applicable for immediate placement in fresh extraction sockets. This application enhances the usefulness of these types of implants. The results also parallel those for other types of implant systems in healed
areas.1-5'15-19
Several modifications in technique are often necessary when utilizing fresh extraction sockets as an implant site. Since there are almost always voids lateral to the implants, a compatible grafting/bone filling material such as allogeneic freeze-dried bone or particulate hydroxyapatite would seem to be of use to fill in the extra space.39 Some investigators have also used a guided tissue regeneration-based technique for this
purpose.11-41-42
Soft tissue coverage of the fresh socket implant site is often difficult because of the soft tissue opening left by the removed tooth. When possible, a pedicle flap and/or submucosal dissection should be developed so that soft tissue can be extended to cover the socket area. This often causes a reduction in vestibular depth and creates a mucogingival problem that must be corrected during the uncovering procedure. Even under the best of circumstances, premature uncovering of the implant head and healing screw occasionally occurred. As little function as possible was applied to the exposed implant heads and oral hygiene measures utilizing application of an antibacterial moutnrinse with a cotton-tipped applicator several times daily were emphasized. All implants were allowed to integrate for at least 6 months. This time frame was selected based on wound healing studies of socket repair after extraction. While shorter times have been advocated for HA-coated implants in healed areas, it is unknown if a shorter healing time may be sufficient for implants placed in fresh extraction sockets. The results of this study suggest that placement in fresh extraction sockets, thereby shortening total treatment time, may be an additional application of HA-coated dental implants.
Acknowledgments This study was supported by a grant from Calcitek, Inc. which provided implant parts and patient subsidization for this study. All of the treatment was performed in the private practice of the author, and all analyses and conclusions were made independently by him. The administrative, organizational, and clinical support of Charlotte Yukna was vital to the completion of this project. In addition, the clinical assistance of Terrie Taylor and Anya Fritz; restorative dentistry provided by Drs. Bonnie Ferrell and Marc Schwartz; the bibliographic verifi-
472
provided by Elizabeth Strother, preparation efforts of Candee Lambert recognized. cation
and the are
manuscript appreciated and
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Send reprint requests to: South, Denver, CO 80222.
Dr. R. A.
Yukna, 5050 Cherry Creek Drive
Accepted for publication January 25,
1991.
