Evaluation of the Clinical Success of Immediate Loading Implant in the Aesthetic Zone: An In Vivo Study

Abstract

Aim:

The aim of the current study was to assess the clinical success of immediate loading implant in the esthetic zone.

Materials and Methods:

20 patients with 20 teeth to get replaced were selected for the study. All patients underwent a pre-surgical preparation followed by draping. Following stringent asepsis, necessary precaution was taken to not to injure the socket wall while removal of tooth. After removal, socket was thoroughly cleaned and curetted with saline and betadine. Using physiodispenser and drills, socket was properly prepared for implant insertion taking care of irrigation with saline to avoid heating of socket while drilling. Implants were then placed with initial stability with hand motion followed by complete insertion with hand ratchet. Black silk sutures were used to close the socket. Patients underwent the first control one week after surgery. They were recalled at the 1^st, 3^rd and 6^th months to evaluate the following parameters to assess the success of immediate implant placement: mobility, soft tissue conditions (gingival index and probing pocket depth (PPD)), and a graded scale ranging from “very satisfied” to “very unsatisfied” were employed to subjectively evaluate patient contentedness.

Results:

During the 1^st and 3^rd months, 100% mobility was absent. But on the 6^th month, the implant of 3 patients (15%) was mobile. The maximum gingival index score was noted in the 1^st month (1.02 ± 0.01) and reduced more in the 3^rd month (0.74 ± 0.08). The probing depth was more in the 1^st month (3.88 ± 0.10) and it was reduced in the 3^rd month (3.02 ± 0.12). Significant difference was not found between different times of intervals. 14 patients were very satisfied, 5 patients were fairly satisfied, and 1 was fairly unsatisfied.

Conclusion:

The current study concluded that immediate implant placement in the esthetic zone has a better success rate with good patient acceptance.

INTRODUCTION

Modern dentistry has witnessed, over the last decades, a rapid and continuing evolution of techniques in different fields. Concerning the implant-rehabilitation protocols, they have been redefined over the years as a result of new knowledge in implant surgery and in order to satisfy patients' increasing expectations in terms of comfort, esthetic, and shorter treatment period.[1]

Loss of teeth involves a physiological remodeling of the alveolar bone with subsequent soft-tissue modification. Bone atrophy are often adequate to 50% when 5–6 months moving principally in the horizontal dimension, predominantly on the buccal aspect, with relation to the vertical dimension, continued slowly, however steady throughout life. Bone resorption could cause a narrower and shorter ridge, thereby compromising the purposeful and esthetic rehabilitation.[2]

Concerning the implant-rehabilitation protocols, many protocols for implant placement have been proposed to overcome this time gap and the associated loss of tissue. These protocols for implant placement include: immediate placement, that is, immediate implant placement in an extraction socket; early placement, that is, early implant placement 4 to 8 weeks after tooth removal; delayed placement, that is, early implant placement (delayed) 12 to 16 weeks after tooth removal; and late placement, that is, late implant placement more than 6 months after extraction.[3] To provide rapid replacement of the tooth, prevent alveolar bone collapse during healing period, shorten treatment protocol, and reduce patient discomfort or inconvenience, immediate implants were introduced as a protocol for implant placement.[4] Hence the present study was conducted to assess the clinical success of immediate loading implant in the esthetic zone.

MATERIALS AND METHODS

Selection of patients

The present study was performed in the department of periodontics, Kalinga institute of Dental Sciences, Bhubaneswar, India. 20 patients with 20 teeth scheduled to be replaced were selected for the study. Inclusion criteria included: presence of a minimum of one poor prognosis anterior tooth (caries, root resorption, endodontic failure); presence of good gingival architecture with surrounding dentition, systemically healthy subjects; presence of at least 4 mm of bone beyond root apex at the sites planned for implant placement; and maintenance of good oral hygiene. Chronic smokers, patients with cardiac pacemakers, patients with bleeding disorders, patients with parafunctional habits such as bruxism were excluded from the study.

Sample size calculation and surgical procedure

The sample size calculation was done by using formula. “n” was the required sample size, “z_{1 – α/2}” was a constant; its value for a two-sided test was 1.96 for 95%, “d” was the absolute precision at 20% = 0.2. All patients underwent a pre-surgical preparation followed by draping. Following stringent asepsis, local anesthesia was administered by infiltration employing 2% lignocaine hydrochloride containing 1:200000 adrenaline, which was injected both buccally and on the lingual or palatal side to attain anesthetic effects. After giving anesthesia, atraumatic extraction was done with help of luxators and other instruments. Necessary precaution was taken to not to injure the socket wall while removing the tooth, and avoid excessive force with conservation of gingival margins.

After removal of tooth, socket was thoroughly curetted and cleaned with saline and betadine. Using physiodispenser and drills, socket was properly prepared for implant insertion taking care of irrigation with saline to avoid heating of socket while drilling. Implants were then placed with initial stability with hand motion followed by complete insertion with hand ratchet. Black silk sutures were used to close the socket. Postoperative instruction and medications were given and recalled after one week for suture removal. After implant placement, the provisional restoration was prepared. After four months, with adequate tissue healing and the emergence profile correctly created, the final impression was taken and crown was fixed.

Postoperative phase

In the postoperative phase, the patients were instructed to take an antibiotic regimen for five days and to take analgesics as required. They were also informed to rinse the wound area with 0.2% chlorhexidine, three times a day for the first two weeks, then to brush for the next six weeks with a soft bristle toothbrush. Patients were also asked to take a soft diet and avoid mastication at the newly rehabilitated sites for eight weeks.

Intraoral periapical radiographs (IOPAR) were taken at the site of the inserted implant and patients underwent the first control, one week after surgery. They were recalled in the 1^st, 3^rd and 6^th months to assess the following parameters in order to assess the success of immediate implant placement: mobility (present and absent), soft tissue conditions (gingival index, and probing pocket depth (PPD)), and a graded scale ranging from “very satisfied” to “very unsatisfied,” employed to subjectively evaluate patient contentedness.

Statistical analysis

Data were presented as means ± standard deviation. SPSS software version 20.0 was used to analyze the gathered data. Quantitative data was assessed with t test while Chi-squared test as well as Fischer's exact test were used to analyze qualitative data. A P value lower than 0.05 indicated statistical significance.

RESULTS

Table 1 reveals the evaluation of the implant's mobility at different intervals. In the 1^st and 3^rd month, 100% mobility was absent, but in the 6^th month the implant of 3 patients (15%) was mobile. However, no statistically significant difference was found.

Table 1.

Evaluation of implant mobility at different intervals

Intervals	Mobility
	Present		Absent
	No	%	No	%
1st Month	0	0	20	100%
3rd Month	0	0	20	100%
6th Month	3	15%	17	85%
Fischer exact test χ2=8.184, P value=0.864

Table 2 shows the intra group comparison of gingival index between different time of intervals. The maximum gingival index score was noted in the 1^st month (1.02 ± 0.01) and reduced further in the 3^rd month (0.74 ± 0.08). There was no significant difference found between different times of intervals.

Table 2.

Intra group comparison of gingival index between different time of intervals

Different times of Intervals	Mean±SD	t	P
1st Month	1.02±0.01	9.256	0.348
3rd Month	0.74±0.08
6th Month	0.82±0.06

The probing depth was more in the 1^st month (3.88 ± 0.10) and reduced in the 3^rd month (3.02 ± 0.12). No significant difference was found between different times of intervals [Table 3].

Table 3.

Intra group comparison of probing depth between different time intervals

Different times of Intervals	Mean±SD	t	P
1st Month	3.88±0.10	10.190	0.819
3rd Month	3.02±0.12
6th Month	3.46±0.16

Overall patient satisfaction was assessed in Table 4. 14 patients were very satisfied, 5 patients were fairly satisfied, and 1 was fairly unsatisfied.

Table 4.

Assessment of overall patient satisfaction

	Patient satisfaction level
	Very satisfied	Fairly satisfied	Fairly unsatisfied	Very unsatisfied
Immediate implant placement	14	5	1	0

χ²=2.814, P=0.664

DISCUSSION

In recent times, there has been a tremendous change in the treatment modalities and outlook used in dentistry. Dental implants are to this day considered to be a major advance in the relief of misplaced and missing teeth, as it has a huge number of benefits. The timing of implant placement after tooth removal has been a matter of discussion in dental implant treatment. 12 months of waiting period or more than that to allow socket healing has been the gold standard protocol. Various alternatives to this approach may be considered in order to reduce the waiting time.[5]

Different authors have tried to improve this bone implant contact so as to improve the long-term prognosis of implant therapy by way of constantly changing the nature of various implant surfaces, and have achieved variable success with each of these modifications. Immediate loading of implant is taught with its own risks. The initial healing time is very important for the success of the implant and one of the very important factors to be considered is the bone implant contact during this period.[6]

In the present study, clinical mobility of the implant was evaluated. Except for 3 implants (15%) which endured mobility of Grade 1 at 6^th month of follow-up, no mobility was endured by any of the implants at all the three follow-up visits that were listed in the 1^st, 3^rd, and 6^th months. Micro movements of the implant was found because of subject has applied forces on the implant system in the early healing time. The presence of micro movements at the interface between bone and implant can, in fact, affect the bone healing period and osseointegration, leading to a slight rallying of the implant.[7]

Sekine H et al.[8] mentioned that the movement of healthy implant should be lower than 75 micrometers and that it is considered as zero clinical mobility. A study by Winkler S et al.[9] stated that the presence of connective tissue between the implant and bone was considered as clinical failure for an endosteal root-form implant.

Though, all studies demonstrated that immediate implant placement into infected extraction sockets can be successful, (provided that proper antiseptic protocols are followed), the literature also suggests that there are factors such as primary stability at the time of implant placement, implant positioning, socket anatomy, soft tissue morphology, tooth position, implant system used, and administration of antiseptic protocols which could change the predictability of success of immediate placement of implants into infected extraction sockets.[10]

CONCLUSION

The current study concluded that immediate implant placement in the esthetic zone has a better success rate with good patient acceptance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.