Dr. Rachana Gaikwad1, Dr. Jyoti Temburane2, Dr. Arti Gangurde3

1Oral Implantology Student

2. Professor and Head of Department

3Associate Professor

Department of Prosthodontics and Crown & Bridge

Government Dental College and Hospital, Mumbai

Abstract

Tooth loss is a common problem in adults. The negative effects of tooth loss are decreased chewing, speech malfunction, reduced aesthetics, and migration of adjacent teeth. Many types of dental prosthetics can be used to prevent these negative effects, such as removable partial dentures, adhesive resin dentures, fixed partial dentures, and dental implants each having its own advantages and disadvantages.

Dental Implants have been widely used for effective replacement of missing teeth with a greater survival rate for completely edentulous, partially edentulous and single tooth restorations

A preoperative assessment holds an important role for evaluation of surrounding structures, vital nerves and blood vessels. Easy retrievability is the main advantage of screw retained crowns making it favourable for the clinicians. Therefore, to gain a combined advantage of retention and less chances of periimplantitis, a screw retained prosthesis is advisable. The case report demonstrates the placement of implant in mandibular right first molar region with conventional screw retained prosthesis.

 Key Words: Dental Implant, mandibular molar, missing molar replacement, Screw cement retained prosthesis

 

Introduction

Loss of teeth results in aesthetic and functional impairment, leaving people more vulnerable to psychological disorders, low self-perception and even social exclusion. The art and science of replacing the missing teeth and those with the hopeless prognosis requires a thoughtful combination of many aspects of dentistry including patient’s education, prevention of further dental disease, sound diagnosis, periodontal therapy, experienced surgical skill, occlusal considerations and post relative maintenance.

Dental implant prosthesis has been widely used to effectively replace missing teeth with a survival rate from 93% to 95%. Implants successfully rehabilitate form, function and aesthetics while restoring the patient’s confidence. The treatment comprises of surgically placing the implant that simulate the root form of the tooth in first step and the loading the implant once the healing is completed.

For successful implant therapy adequate alveolar ridge dimensions and bone quality is essential which can hold the implant and provide good aesthetics and proper function.

This case report highlights the implant placement in the mandibular right first molar region with screw-retained prosthesis.

 

Case report  

A 30 years old male patient reported to the department of prosthodontics with chief complaint of difficulty while chewing on the lower right back region of jaw due to missing teeth(fig1). Patient had a history of extraction with the tooth one year ago and wanted a replacement with the same. There was no other relevant dental and medical history. The patient’s family history was non-contributory.

Pre-Operative Site

Fig.1: Pre-Operative Site

The patient was explained about the various treatment modalities available along with their pros and cons. These includes removable partial denture, tooth supported fixed partial denture and implant prosthesis. The patient decided to go for the implant prosthesis as he was well aware about the significant results of the same.

Treatment Plan

  Oral prophylaxis was done. Oral hygiene instructions were given to the patient. In subsequent visit oral hygiene maintenance was satisfactory. On intra-oral examination the periodontal status of the patient was healthy. Diagnostic impressions were made using alginate and poured with the dental stone and diagnostic casts were made.

Pre-operative radiograph was taken with the region 46. CBCT scan was performed of mandibular arch using Trio 3 shape scanner. The scan revealed that the bone type was D2 with porous cortical and dense trabecular bone as per the Classification given by Misch et al in 1988 Bone height- 15.8mm from crest and bone width-3.9mm at crest and 4.8 mm at 1.1 mm below the crest. Osstem Implant size of 3.5 x12 mm with mini head was selected following Rule of 1, 2, 3 and 7.  Before the surgical procedure that patient was informed about the procedure and a written consent was taken.

 

 Surgical Procedure:

Once the patient was seated on the operating chair, first extraoral scrubbing with povidone iodine and then intraoral with 0.2% chlorhexidine gluconate mouthwash was done. 2% lignocaine hydrochloride with 1:80000 adrenaline local anaesthesia was administered by giving a regional inferior alveolar and lingual nerve block. After checking the subjective and objective symptoms of anaesthesia a mid-crestal incision was made at the edentulous space. The mucoperiosteal flap was reflected. 1mm of crestal bone reduction was carried out to achieve desired width of 4.8mm. The first drill was made with lance drill with Osstem implant taper kit. Sequential drilling was done till 3.2 x10 mm, just short of final drill. (fig2).

Osteotomy Prepared

Fig.2: Osteotomy Prepared

Radiograph Taken After Implant Placement

Fig.3: Radiograph Taken After Implant Placement

The implant was placed.  An Osstem implant fixture TS 3.5*12 was placed with an adequate torque of 30 Ncm. Radiograph was taken immediately after the placement, and cover screw was placed. Flap closure done with interrupted sutures with 3-0 Vicryl ,

 

 Post operative care:

Patient was prescribed post operative antibiotics and warm saline gargles to promote wound healing. Instructions given to avoid any undue stresses on the surgical site.

 Second stage surgery:

 After a healing period of 3 months IOPA was checked for signs of osseointegration. Second stage surgery done by raising mucogingival flap, cover screw removal and Healing abutment placement. Patient was recalled after 15 days to check healthy gingival tissue cuff around healing abutment. (fig4).

Healing Abutment Is Placed After 3 Months

Fig.4: Healing Abutment Is Placed After 3 Months

 Prosthetic procedure:

 After the second stage surgical healing was found to be excellent and healthy gingival tissue was formed around the healing abutment. A putty and light body open tray impression was made with Osstem mini impression coping (fig.5). Implant analogue was attached to the coping and impression was poured. Pattern resin jig trial evaluated by IOPA radiograph (fig. 6). In subsequent visits custom-made abutment was evaluated for fit and occlusal clearance for ceramic (fig.7).

Final Impression

Fig.5: Final Impression

Jig Trial

Fig.6: Jig Trial

Metal Try-In

Fig.7: Metal Try-In

The final restoration of screw retained metal ceramic crown checked in place with IOPA radiograph which showed perfect fit. The prosthesis was screwed intraorally with torque of 35 Ncm. Access hole was blocked with Teflon tape to cover screw and tooth colored composite.  Implant Protective Occlusion was given in the prosthesis. (fig.8).

Final Restoration1Final Restoration2

Fig.8: Final Restoration

Discussion

 Implant dentistry is being commonly used for restoring both partially and completely edentulous jaws successfully. For achieving successful osseointegration, initial implant stability is one of the fundamental pre-requisites and must be maintained for the entire healing period. Implant stability is influenced by 3 factors i.e. the implant (material, design and dimensions of the fixture), the patient (quality and quantity of bone) and the operator (surgical technique).

 Alternate treatment options considered for this case were a removable partial denture which can contribute to alveolar bone loss, also it has very low satisfaction rate. Another option being fixed partial denture would have compromised adjacent tooth to a certain limit. Therefore the 30 years old young patient was an ideal case for implant with healthy bone and healing capacity.

 

 Conclusion

There are many types of prosthesis to replace a single tooth such as removable prosthesis, a resin bonded restoration, a three-unit fixed prosthesis and a screw retained implant prosthesis. Single tooth implant provides considerable advantages over other prosthetic treatment. Implant will provide support, a more stable occlusion, preservation of bone and simplification of the prosthesis, and more aesthetics and comfort for the patient. This case report demonstrates placement of an implant in a healthy bone followed by screw retained prosthesis.

                                               

  References

[1]. Kumar NS, Sowmya N, Mehta DS, Kumar PS. Minimal guided bone regeneration    procedure for immediate implant placement in the aesthetic zone. Dent Res J. 2013;10 (1): 98-102.

[2]. Hudieb M, AL Khader M, Mortaja S, Abusamak M, Wakabayashi N, Kasugai S. Impact of bone augmentation of facial bone defect around Osseo integrated implant: a three-dimensional finite element analysis. Dent J 2021,9(10):114.

[3]. El Askary AS. Aesthetic considerations in anterior single tooth replacement. Implant Dent 1999; 8:61-67.

[4]. Spielman HP. Influence of the implant position on the aesthetics of the restoration. Pract Periodontics Aesthet Dent. 1996; 8:897-904.

[5]. Simeone P, De Paoli C, De Paoli S, Leofreddi G, Sgaro S. Interdisciplinary treatment planning for single-tooth J Esthet Restor Dent. 2007; 19(2): 79-88.

[6]. Winkler S. Morris H.S. and S. Ochi. Implant survival to 36 months as related to length and diameter. Ann Periodontol.2000.5:22-31.

[7]. Johnson K. A study of the dimensional changes occurring in the maxilla following tooth extraction. Aust Dent J.1969.14:241-244.

[8]. Lam RV. Contour changes of the alveolar process following extractions. J Prosthet Dent. 1960. 10:25-32.

[9]. Huang, Y.H. Xiropaidis A.V. Sorensen R.G. Albandar J.M. Hall J. and U.M. Wikesjo. Bone formation at titanium porous oxide (Ti Unite) oral implants in type IV bone. Clin Oral Implants Res. 2005. 16:105-111.

[10]. Batuski JD, Wang HL. Common implant aesthetic complications. Implant Dent.2007; 16(4): 340-8.

[11]. Papaspyridakos P. Implant success rates for single crowns and fixed partial dentures in general dental practices may be lower than that achieved in well controlled universities and specialty settings. J Evid Dent Pract.2015;15:30-2.

[12]. Eufinger H, Konig S, Eufinger A. The role of alveolar ridge width in dental implantology. Clin Oral Investig.1997;1(4): 169-77.

[13]. Shadid R. Sadaqa N. A comparison between screw and cement retained implant prostheses. A literature review. J Oral Implantol. 2012; 38:298-307.

[14]. Wittneben J.G. Joda T. Weber H.P. Bragger U. Screw retained vs. cement retained implant- supported fixed dental prosthesis. Periodontol 2000.2017;73:141-151.

[15]. Heo Y.K., Lim Y.J. A newly designed screw and cement retained prosthesis and its abutments. Int J Prosthodont. 2015; 28:612-614.

[16]. Garcia- Gazaui S., Razzoog M., Sierraalta M., Saglik B. Fabrication of screw retained restoration avoiding the facial access hole: a clinical report. J Prosthet Dent 2015; 114:621-624

[17]. Misch CE. The importance of dental implants. Gen Dent .2001; 49:38-45.

[18]. Z Iataric DK, Celebic A, Valentic- Peruzovic M. The effect of removable partial dentures on periodontal health of abutment and non abutment teeth. J Periodontal. 2002; 73(2): 137-44.

[19]. Frank RP, Milgrom P, Leroux BG, Hawkins NR. Treatment outcomes with mandibular removable partial denture: A population based study of patient satisfaction. J Prosthet Dent. 1998;80(1):36-45.