Holtzclaw et alFigure 3: Atraumatic xtraction of single rooted tooth. Figure 4: Mandibular molar sectioned into two pieces.and the majority of premolars. The roots of of the root superior to the furcation. Addition-these teeth tend to have a tapered shape ally, while the roots of single rooted teeth taperwith the majority of their attachment sur- and narrow apically, the roots of multi-rootedface area located coronally.6 During atrau- teeth often flare apart from one another. It ismatic removal of these teeth, thin blades the flaring of these roots which makes it nearlyare used to sever the PDL fibers attach- impossible to remove an intact molar with-ing to the coronal aspect of the root. Once out damaging the supporting alveolar bone.these coronal fibers, which comprise the larg-est area of attachment for the tooth, are sev- Atraumatic Extraction ofered, the tapered nature of the single root Multi-Rooted Teethallows for relatively simple removal (figure 3). Extraction of multi-rooted teeth without dam- Multi-Rooted Teeth aging the supporting bone poses a problem. Because the roots of these teeth often flareMulti-rooted teeth include molars and some pre- apically, extracting the tooth in a coronal direc-molars. In a study of root anatomy, Gher and tion without damaging the bone is often impos-Vernino found that 56% of maxillary first pre- sible. It is a simple matter of physics: a widemolars had 2 roots with a bifurcation located in base prevents removal through a smaller hole.the middle third of the root.7 Canines and inci- This same concept is utilized in the design ofsors may be multi-rooted, but these tend to be flared arrowheads. After the arrowhead piercesanomalies rather than the norm. Unlike single the flesh or bone, the flared base preventsrooted teeth which have the majority of their its removal. If extraction of the arrowhead isattachment located at the coronal aspect of the attempted forcefully, significant tissue damageroot, multi-rooted teeth have only 1/3 of their ensues. Multi-rooted teeth with flared rootstotal attachment located in the coronal portion are not much different. If this type of tooth is The Journal of Implant & Advanced Clinical Dentistry • 49
Holtzclaw et alFigure 5: Maxillary molar sectioned into three pieces. Figure 6: Intact furcal bone after extraction.forcefully removed intact with forceps, one ing sectioning of the teeth, an elevator isof two things will happen. Either the tooth is used to gently manipulate the separated seg-going to fracture, making its removal that much ments. To protect the septal bone apical tomore difficult, or the supporting bone is going the furcation of the multi-rooted teeth (figureto fracture allowing for removal of the tooth. 6), the rotary bur or piezosurgical device canIn the latter scenario, the patient has been be stopped just short of the base of the fur-done a disservice as additional surgical tech- cation. This small remaining portion of intactniques will be required to repair the extrac- tooth structure easily fractures during manipu-tion site. Fortunately, with modern extraction lation with the elevators. This is the traditionaltechniques, these scenarios can be avoided. way to remove multi-rooted teeth via sectioning. The simplest way to remove multi-rooted A modern update to this technique isteeth in an atraumatic fashion is to convert the employment of the periotome. With the perio-mult-rooted tooth into multiple single rooted tome, a thin blade is advanced down thesegments. This can be accomplished by cut- PDL severing the fibers that attach the boneting the multi-rooted tooth into multiple pieces to the cementum of the root. This tends towith the aid of a surgical drill or peizosurgical be a slow and tedious process as a mal-device. Mandibular teeth are typically sec- let is often required to advance the periotometioned bucolingually into two pieces (figure down the tight PDL space. A recently intro-4) while maxillary teeth are sectioned in a “Y” duced device called a Powertome® essen-fashion into three pieces (figure 5). The multi- tially automates use of the periotome. Withrooted mandibular tooth is converted into two the Powertome® a thin periotome-like blademesial and distal segments while the maxillary is attached to a handpiece that is controlledteeth are converted into three mesiobuccal, via foot pedal. Activation of the foot pedaldistobuccal, and palatal segments. Follow- moves the Powertome® blade to a preset tap50 • Vol. 3, No. 7 • December 2011
Holtzclaw et al CASE SERIES Case 1 Atraumatic removal of mandibular first molar (figures 8-10). Figure 8Figure 7: Powertome™ blade used on molar PDL.that is programmed into Powertome® con- Figure 9trol unit. The Powertome® blade only taps on Figure 10the downstroke, creating a controlled amountof force that eliminates the need for malleting. In the cases demonstrated in this paper,the Powertome® was used prior to section-ing teeth (figure 7) with a rotary bur handpiece. Use of the Powertome® in this fash-ion significantly improved ease of extraction ofthese multiple rooted teeth. In cases of singlerooted teeth, the Powertome® is often the onlytool necessary for removal of the tooth. Con-verting the multiple-rooted tooth into numeroussingle rooted segments, allows for extractionsimilar to a single rooted incisor or canine. The Journal of Implant & Advanced Clinical Dentistry • 51
Holtzclaw et alCase 2Atraumatic removal of maxillary first molar (figures 11-14).Figure 11 Figure 12Figure 13 Figure 1452 • Vol. 3, No. 7 • December 2011
Case 3 Holtzclaw et alAtraumatic removal of mandibularfirst molar (figures 15-17). AADDVVERETIRSETWISITHEFigure 15 TODAY!Figure 16 Reach more customers with the dental profession’s first truly interactive paperless journal! Using recolutionary online technology, JIACD provides its readers with an experience that is simply not available with traditional hard copy paper journals.Figure 17 WWW.JIACD.COM The Journal of Implant & Advanced Clinical Dentistry • 53
Holtzclaw et alCase 4Atraumatic removal of maxillary first molar (figures 18-21).Figure 18 Figure 19Figure 20 Figure 2154 • Vol. 3, No. 7 • December 2011
Correspondence: Holtzclaw et alDr. Dan Holtzclaw711 W. 38th Street DisclosureSuite G5 The authors report no conflicts of interest with anything mentioned in this paper.Austin, TX [email protected] References 1. C ontemporary Oral and Maxillofacial Surgery, 3rd Edition. Perterson, Ellis, Hupp, Tucker. Mosby, St. Louis. 1998; p. 208. 2. A lbrektsson T, Jansson T, Lekholm U. Osseointegrated dental implants. Dent Clin North Am 1986; 30(1):151-174. 3. S hulman LB. Surgical considerations in implant dentistry. Int J Oral Implantol 1988; 5(2):37-41. 4. B lus C, Szmukler-Moncler S. Atraumatic tooth extraction and immediate implant placement with Piezosurgery: evaluation of 40 sites after at least 1 year of loading. Int J Periodontics Restorative Dent 2010; 30(4):355-363. 5. T homson PJ. Minimising trauma in dental extractions: the use of the periotome. Br Dent J 1992; 172(5):179. 6. L evy AR, Wright WH. The relationship between attachment height and attachment area of teeth using a digitizer and a digital computer. J Periodontol. 1978 Sep;49(9):483-5. 7. Gher M, Vernino A. Root anatomy: a local factor in inflammatory periodontal disease. Int J Periodontics Restorative Dent 1981;1(5):52-63. ATTENTIONPROSPECTIVE AUTHORSJIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] The Journal of Implant & Advanced Clinical Dentistry • 55
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Complication of Inferior Alveolar Canal Perforation Yong During Immediate Implant Placement into a Fresh Mandibular Molar SocketDr. Loong T. Yong1 AbstractThis case report illustrates perfora- placement immediately into fresh extraction tion of the superior cortex of the infe- socket of a mandibular molar. The method to rior alveolar canal following implant prevent this complication is also discussed.KEY WORDS: Dental implant, inferior alveolar nerve, tooth extraction, complication 1. National Dental Center, Singapore The Journal of Implant & Advanced Clinical Dentistry • 59
YongFigure 1a: Buccal view of tooth #19 with extensive decay. Figure1b: Occlusal view of tooth #19. Note tissue keratinization and ideal soft tissue contours. Introduction which must be combined in most patients with a bone-grafting technique to eliminate peri-The original implant surgical protocol proposed implant bone defects.3 This technique has aby Branemark1 involves open flap access, step- number of proposed advantages such as pres-wise osteotomy of the bony ridge, implant ervation of bone and soft tissue, decreasedplacement followed by good primary closure. total treatment time, reduced number of surgi-If the patient presents with a failing tooth, cal procedures, reduced overall cost and betterextraction must be performed and the socket patient acceptance.3,4 However, discrepanciesallowed to heal for a duration of three to between the size of the implant and sockets,six months before replacement with a den- poorly vascularized infected bone at the implanttal implant can be considered. After com- site and difficulty to control three dimensionalplete socket healing has taken place, bony implant position and primary stability are someridge and soft tissues deficiencies that ren- of the surgical challenges that operators face.4der the site unsuitable for implant placement Therefore, this unique procedure is gener-need to be addressed first. A variety of hard ally not recommended for the novice surgeon.3and soft tissue ridge augmentation may beused but overall treatment time is prolonged. This article describes a case of imme- diate implant placement into a fresh man- Immediate implant placement may be dibular molar extraction socket performeddefined as implant placement immediately fol- by an experienced Oral & Maxillofaciallowing tooth extraction and as part of the same Implant Surgeon whereby the inferior alve-surgical procedure,2 or as implant placement olar canal is unintentionally perforated.immediately following extraction of a tooth60 • Vol. 3, No. 7 • December 2011
YongFigure 2a: Panoramic radiograph of the case. Figure 2b: CBCT showing the location of the inferior alveolar canal in relation to the root apex of tooth #19.Figure 3a: Sectioned tooth #19 following extraction. Figure 3b: Extraction socket #19 demonstrating intact buccal and lingual walls. Case Report assessment included documentation of any sig-Clinical Evaluation nificant past medical history, general health statusThe patient was a 49 year old male that presented and smoking habits. The patient did not presentwith a failing mandibular left molar that required with significant medical or systemic issues thatextraction followed by replacement with a den- would compromise dental implant success. Clini-tal implant (Figures 1a, 1b). Standard clinical cal assessment included extra-oral examination The Journal of Implant & Advanced Clinical Dentistry • 61
YongFigure 4: Surgical stent used for implant osteotomy Figure 5: Directional indicator pin used for implantdrilling. placement.Figure 6: Implant osteotomy (occlusal view). tissue, preferably keratinized, would remain cir- cumferentially around the healing abutment fol-followed by intra-oral examination. Thereafter, lowing flapless implant placement. The mandibularimplant site specific evaluation was carried out left molar was indicated for extraction as it wasjointly with a prosthodontist. This consisted of deemed to have a poor restorative prognosisinter-occlusal space, dental examination as well because of an enlarged buccal wall cavity whichas hard and soft tissue assessment. In particular, had pulpal involvement and subgingival extension.soft tissue assessment consisted of evaluatingthe biotype, volume and dimensions of mucosa Radiographic Assessmentto ensure that at least 2 to 3 mm of attached soft Radiographic investigations (Figures 2a, 2b) consisted of a routine panoramic film and cone beam computed tomography (CBCT). The sur- geon then evaluated the radiographs to confirm the possibility of implant placement immedi- ately into the extraction socket. This is based on bone volume sufficiency for the intended implant extension apically beyond the root api- ces crestal to the inferior alveolar canal. Based on the above findings, the patient fulfilled the criteria for immediate implant placement into the socket of the mandibular left molar. A surgical guide was fabricated to assist62 • Vol. 3, No. 7 • December 2011
YongFigure 7a: Dental implant placement. Figure 7b: Healing abutment placement.Figure 8: Placement of bioactive glass in defects around Figure 9: Placement of collagen membrane over implantdental implant. and bioactive glass.in a prosthodontically favorable place- surface, International Team for Implantology,ment of the implant and the case sched- Straumann® AG, Waldenburg, Switzerland).uled for immediate single stage placementof a 12mm length, wide diameter (4.8mm) Surgical Procedure and Outcomeparallel ITI implant with a 6.5mm diame- The patient was prescribed oral amoxicillin 1.0ter Wide Neck polished transmucosal col- gram an hour pre-operatively. The surgical pro-lar (Sandblasted Large-Grit Acid–Etched cedure was carried out under local anesthesia The Journal of Implant & Advanced Clinical Dentistry • 63
YongFigure 10a: Immediate post-surgical radiograph. Note Figure 10b: Immediate post-surgical panoramicclose proximity of dental implant to inferior alveolar nerve radiograph.and incomplete packing of bioactive glass around dentalimplant.Figure 11: Radiograph at 3months. Figure 12: Tissue healing at 3 months.in sterile surgical conditions. The tooth was lux- a surgical bur. The buccal and lingual walls ofated carefully with a periotome before introduc- the socket were fortunately preserved intact (Fig-ing the forceps to deliver the tooth. However, ure 3b) following tooth removal. A surgical stentthe extraction was complicated by repeated (Figure 4) was then used to guide the osteotomyfractures of the crown and had to be eventually of the implant site throughout the procedure.removed in pieces (Figure 3a) by sectioning with The site preparation was carried out to an64 • Vol. 3, No. 7 • December 2011
YongFigure 13: Final prosthetic restoration. with a handpiece at the recommended torque and final seating done manually with a wrench. The finalintended depth of 12mm for the placement of seating was confirmed when the implant bottomedthe implant (Figure 5). The planned crestal posi- out at the base of the osteotomy and did not showtion of the implant head was 3mm beneath the further apical movement. The transmucosal pol-gingival margin and the subsequent drilling depth ished collar was also verified to be at the correctcarried out according to this reference. The sur- crestal position 3mm beneath the gingival margingical guide was used throughout to ensure a for proper crown emergence. The patient did notprosthodontically favorable placement of the have further complains of any pain or discomfort dur-implant along with copious irrigation. In addition, ing the implant insertion. The implant had good pri-the osteotomy sites were directly cooled with mary stability. The fixture mount was then removedirrigation by removing the drills in the sequence. and a healing abutment placed (Figure 7b). The residual peri-implant socket defect was grafted During the drilling the patient complained of with alloplastic bioactive glass bone substituteincreased painful sensitivity as the drills were (Figure 8) and a collagen dressing over the entirereaching the final depth. At one point, he felt site secured with a figure of 8 suture (Figure 9).extreme pain and the drilling process was haltedfor inspection of the osteotomy. However, there Immediate post operative panoramic andwas no pulsative bleeding observed from the periapical radiographs were taken. It was notedbase of the implant preparation. A final lavage of from these radiographs that the superior cor-the osteotomy was carried out to ensure a debris tex of the inferior alveolar canal showed loss offree site before inserting the implant (Figure 6). cortical continuity at the apical tip of the implant (Figures 10a, 10b). The bioactive glass bone sub- The implant was then inserted (Figure 7a) first stitute was also noted to be incompletely con- densed around the middle third of the implant. The patient was informed of the find- ings and discharged with post opera- tive antibiotics and analgesics. Standard post operative instructions were also given The patient was followed up a week post sur- gery and did not present with any mental par- esthesia. Subsequently he was followed up at one and 3 months post surgery. Radiographs showed improvement in the tissues surrounding the implant (Figure 11) and the patient reported no paresthesia. Soft tissue healing around the implant healing abutment was excellent (Figure 12). The patient was then referred for prosth- odontic restoration of the implant (Figure 13). The Journal of Implant & Advanced Clinical Dentistry • 65
Yong Discussion foration of the superior cortex of the canal would have been avoided in this otherwise unevent-Immediate implant placement into fresh extrac- ful outcome with a satisfactory restorative result.tions sockets can be considered as a challengingprocedure for the implant surgeon. The technical Conclusiondemands of atraumatic tooth extraction, preser-vation of soft and hard tissue architecture, oste- Immediate implant placements into freshotomy preparation using regularly shaped drills extractions sockets of mandibular molarsin an otherwise irregularly shaped tooth socket, must be carefully planned and executed byimplant insertion with primary stability achieve- experienced surgeons for a favorable out-ment, grafting of the residual peri-implant socket come. The surgeon must be prepared to alterdefect and stabilization of the entire site pres- the surgical plan to avoid complications. ●ent as a surgical protocol only to be under-taken by trained and experienced personnel. Correspondence: Dr. Loong T Yong Surgical complications have been well docu- Consultant Oral & Maxillofacial Surgeonmented6,7 including bony dehiscence/perfora- National Dental Centertion of the bony housing during site preparation, 5, Second Hospital Aveincomplete seating of cover screw and/or healing Singapore (168938)abutment and lack of primary stability. In addi- Tel: +65 63248942tion to the mentioned difficulties, the surgeon Fax: +65 63248899needs to also factor in anatomical roadblockssuch as the nasal floor, maxillary sinus cavity, and Disclosurein this particular case, the inferior alveolar canal. The authors report no conflicts of interest with anything mentioned in this article. In retrospect, the author feels that the follow- Referencesing lapses had occurred resulting in this compli- 1. B ranemark P-I, Zarb GA, Albrektsson T: Tissue-Integrated Prostheses:cation. Firstly, the treatment planning with thecone beam CT should have been more care- Osseointegration in Clinical Dentistry. Chicago, IL, Quintessence,1985, p 211.ful. The scans were not manipulated in line withthe path of implant insertion (Figure 2b), causing 2. H ammerle CH, Chen ST, Wilson TG, et al. Consensus statements andmiscalculation in the bony adequacy above the recommended clinical procedures regarding the placement of implants incanal for placement of a 12 mm length implant. extraction sockets. Int J Oral Maxillofac Implants 2004:19(Suppl):27.Secondly, at the first instance when the patientcomplained of pain during drilling, a decision 3. G lossary of Oral and Maxillofacial Implants 2007.should have been made to change the depth ofdrill to 10mm instead of 12mm. This is because 4. C hen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placementanecdotally, pain and sensitivity would usu- of implants following tooth extraction: review of biologic basis, clinicalally be experienced as the drills approach within procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;192mm away from the canal. The author felt that Suppl:12-25.should the above precautions were taken; per- 5. B ecker W.Immediate implant placement: diagnosis, treatment planning and treatment steps/or successful outcomes. J Calif Dent Assoc. 2005 Apr;33(4):303-10. 6. B ecker W, Dahlin C, Becker BE, Lekholm U, van Steenberghe D, Higuchi K, Kultje C. The use of e-PTFE barrier membranes for bone promotion around titanium implants placed into extraction sockets: A prospective multicenter study. Int J Oral Maxillofac Implants 1994;9:31-40. 7. G omez-Roman G, Kruppenbacher M, Weber H, Schulte W. Immediate ostextraction implant placement with root-analog stepped implants: Surgical rocedure and statistical outcome after 6 years. Int J Oral Maxillofac Implants 001;16:503-513.66 • Vol. 3, No. 7 • December 2011
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Management of Bilateral Severe Gingival Haque et al Recessions in a HIV Positive Individual with Lateral Sliding FlapsShaziya A. Haque, DDS, MS1 • Shilpa Kolhatkar, DDS, MDS2 Crystal McIntosh, DDS, MS3 • Monish Bhola DDS, MSD4 James R. Winkler, DDS, PhD5AbstractBACKGROUND: Aggressive tooth brush- RESULTS: Root coverage of 80% (#22)ing and plaque induced inflammation around and 50% (#27) was achieved. At 6labially prominent teeth are common rea- months, stability of root coverage withsons for recession. Severe recession defects minimal probing depths and a thickwere present on labially prominent teeth band of keratinized tissue was observed.#22 and #27 in a HIV- positive individual. CONCLUSION: This case report illus-METHODS: Lateral sliding flaps (LSF) were trates that successful root coverage can beselected for root coverage because they obtained in a HIV positive individual using LSF.have good vascularity. Healing patterns of thedonor and the recipient sites were uneventful. KEY WORDS: Gingival recession, gingival graft, HIV 1. Private Practice, Odessa, TX, USA 2. Associate Clinical Professor, Department of Periodontology and Dental Hygiene, University of Detroit Mercy, School of Dentistry, Detroit, MI; Private Practice, Troy, Michigan3. Associate Professor Department of Periodontology and Dental Hygiene, Howard University College of Dentistry, Washington, DC4. Associate Professor, Department of Periodontology and Dental Hygiene, Director of Post Graduate Periodontics, Co-Director of Implant Dentistry, University of Detroit Mercy, School of Dentistry, Detroit, MI; Private Practice, Waterford, Michigan 5. Chair of Department of Periodontology and Dental Hygiene, Director of Post Graduate Programs, University of Detroit Mercy, School of Dentistry, Detroit, MI; Private Practice, Farmington Hills, Michigan The Journal of Implant & Advanced Clinical Dentistry • 69
Haque et al Introduction Figure 1: Preoperative clinical view of mandibular canines.The most recent World Health Organization data successful root coverage of bilateral severeestimates that 33 million (30-36 million) people recession seen on mandibular canines in a HIV-are affected globally with the human immuno- positive patient by utilizing lateral sliding flaps (LSF).deficiency virus (HIV).1 In the United States,approximately 1.1 million individuals are living Case Reportwith diagnosed or undiagnosed HIV.2 The useof highly active antiretroviral therapy (HAART) A 44-year-old African American male was referredhas significantly reduced mortality and morbid- to the University of Detroit Mercy, Department ofity due to the HIV infection3 and decreased Periodontology, Detroit, Michigan for a periodon-the progression of HIV to acquired immuno- tal consultation. His chief complaint was sen-deficiency syndrome (AIDS) by 42%.3 The sitivity on the mandibular left and right canineseffectiveness of HAART is dependent on past which was primarily due to the presence ofmedical history, stage of HIV disease, demo- severe gingival recession. The patient was diag-graphic characteristics, presence of co-morbidi- nosed with HIV in June 2001 and was regularlyties, HAART drug regimes, drug duration and the monitored by his physician. No other systemicuse of antifungal prophylaxis and compliance.4,5 conditions were reported and he denied any his- tory of smoking or alcohol intake. His antiret- Recognizing the oral lesions associated with roviral therapy included Atazanavir (Reyataz®,HIV is often the primary concern of the dental Bristol-Myers Squibb Company) Ritonavir andpractitioner, however many patients also rou- Emtricitabine (Norvir®, Abbott Laboratories)tinely require comprehensive dental treatment. and Tenofovir (Truvada®, Gilead Sciences, Inc.).Outcomes of nonsurgical periodontal treatmentin HIV positive patients have shown to be com- A thorough intraoral dental examinationparable to the general population6 but limited revealed crowding of the mandibular anterior teethinformation is available to guide dentists on how with bilateral labio-version and rotation of theto adequately mange the surgical dental needs mandibular canines (figure 1). The presence ofof HIV positive patients. Complications follow-ing extraction of teeth in the HIV positive popu-lation have been studied frequently.7,8 Otherdental treatments like the placement of dentalimplants,9-14 root canal therapy,15 -16 and restorativetreatment15 have also been reported. However,there is paucity of data regarding the surgicalmanagement of periodontal needs in this group.To our knowledge, there is only one other descrip-tion of root coverage on a non-restored surfacein a HIV positive patient in which a soft tissuewas used.18 In this case report, we demonstrate70 • Vol. 3, No. 7 • December 2011
Haque et alFigure 2a: Pre-surgical radiographic view of tooth #27 Figure 2b: Pre-surgical radiographic view of tooth #22with minimal interproximal bone loss. with minimal interproximal bone loss.severe recession measuring 11 mm (#27) and 10 (figures 3a and 3b), the recession defects weremm (#22) on the mid-facial surfaces was noted. categorized as a Miller Class III.19 The patient wasAn occlusal analysis revealed that #22 was in a presented with two treatment options for the man-cross-bite relationship with tooth #10 and an agement of his severe gingival recession. The firstedge-to-edge relationship was present between treatment required orthodontic therapy to correct#7 and #27. The gingival tissues were inflamed the malocclusion combined with soft tissue graftsand erythematous on #22 and #27 while the gin- for root coverage on #22 and #27. The alterna-giva around the incisors displayed minimal clinical tive treatment plan consisted of only the periodon-signs of inflammation. Copious amounts of plaque tal surgery to provide root coverage using LSF.were present on the mandibular canines and the The patient chose the latter treatment option dueprobing depths ranged from 2 mm to 3 mm. A to financial limitations. An informed consent wasradiographic exam revealed no carious lesions or obtained for the procedure and the patient wasany root surface anomalies. When tooth vitality advised that complete root coverage may notwas tested, both teeth responded normally to cold be possible due to the severity of the recession.stimulus (Cold Snap Freeze Spray, Benco Dental,Grand Rapids, MI). Based on the radiographic His pre-surgical laboratory values were: CD4+(figures 2a and 2b) and the clinical examinations T-lymphocyte count 404 cells/mm3, viral load 4,800 copies/ml, platelet count 292,000 plate- The Journal of Implant & Advanced Clinical Dentistry • 71
Haque et alFigure 3a: Preoperative clinical view of tooth #27 showing Figure 3b: Preoperative clinical view of tooth #22 showingmidfacial recession measuring 11mm. midfacial recession measuring 10mm.Figure 4: The initial incision started approximately 1.5mm Figure 5: Reflection of a full thickness flap. Periostealapical to the gingival margin of tooth #26 and extended releasing incisions were made to ensure passive movementmesially to tooth #25. A vertical incision was made at the of the flap.mucogingival junction and was connected to the initialincision at #25.72 • Vol. 3, No. 7 • December 2011
Haque et alFigure 6: The pedicle flap was coronally advanced and Figure 7: Post operative view at 2 weeks. The sutures weresutured with silk sutures. removed with gentle debridement around the graft sites.lets/ml, absolute neutrophils 2.8 x 103/µL and a were then elevated and periosteal releasing inci-total white cell count 5.3 x 103/µL. His hemo- sions were made to ensure passive adaptation ofglobin was 13.3 g/dL and the hematocrit was the flaps (figure 5). Root conditioning (125mg38.7%. The vital signs were recorded prior to the tetracycline/1mL of saline) was performed for twosurgical procedure and profound anesthesia was minutes. The pedicle flap was coronally advancedachieved. Minimal recontouring of the root sur- and sutured slightly coronal to the cementoenamelfaces on #22 and #27 was performed using a junction (CEJ) with 4-0 silk (Ethicon Inc, Johnsonround end flame-shaped carbide bur (7406 Bras- & Johnson, Cornelia, GA) (figure 6). A similar sur-seler, Savannah, GA) primarily to facilitate flap gical procedure was performed to obtain root cov-adaptation. The root surfaces were thoroughly erage on #22. No periodontal dressing was used.debrided using hand instruments and the gingi-val margins were de-epithelialized on the mesial The patient was prescribed 0.12% chlorhexi-and distal surfaces of both the teeth using a dine gluconate (CHX) mouth rinse and an anal-15C blade (Stainless Steel Surgical Blade Miltex gesic (ibuprofen 800mg 1 tablet TID prn) forInc., York, PA). The initial scalloped incision was the management of the pain. Verbal and writtenstarted 1.5mm apical to the gingival margin of post-operative instructions provided to the patient#26 and extended mesially to #25. A vertical inci- included no brushing at the surgical sites for 2sion was made which started at the mucogingival weeks, gentle rinsing with CHX and limited facialjunction of #25 and connected to the initial inci- movements. The patient was recalled for post-sion (figure 4). Full thickness mucoperiosteal flap operative assessment at 1, 2, 4, 12 and 24 weeks. Uneventful healing of the donor sites was The Journal of Implant & Advanced Clinical Dentistry • 73
Haque et alFigure 8a: Postoperative view at 24 weeks. 6 mm of root Figure 8b: Postoperative view at 24 weeks. 8 mm of rootcoverage on tooth #27 was achieved. This translates to coverage on tooth #22 was achieved. This translates to50% root coverage. 80% root coverage on tooth #22.observed. At all the post-surgical visits, gen- between 2 mm to 3 mm and the recipient sitetle debridement of the surgical sites was per- showed good color match along with signifi-formed using hand instruments. At the 1 week cant gain in keratinized tissue (figures 8a and b).post-surgical visit, the patient admitted to usinga toothpick on #27. This disrupted the heal- Discussioning of the surgical site on #27. The patient wasinstructed to leave the surgical sites undisturbed Several authors have investigated dentist’s atti-to facilitate healing. Sutures were removed at tudes in the treatment and dental management ofthe 2 week post-surgical visit (figure 7). At the HIV positive patients.20 Many dental professionals6 month post-surgical visit, despite the pres- assume that treating HIV positive patients involvesence of plaque around the teeth, the root cover- greater risk of infection and post operative com-age appeared to be stable. The recession defect plications. This is not unsurprising because ofdecreased from 11 mm to 5 mm on #27 and on the immunosuppresed state associated with HIV.#22 recession defect reduced in height from One might hypothesized that this would lead to10mm to 2mm. The probing depths remained disturbance in the normal healing pattern follow- ing invasive dental procedures. In fact numer-74 • Vol. 3, No. 7 • December 2011
Haque et alous studies have refuted this assumption7,21 and and Cafesse28 reported a mean gain of 3.15 mmhave found no differences in post surgical com- of keratinized tissue and 2.69 mm of root cover-plications or infection rates following common age which translated to 69% of root coverage atsurgical dental procedures. A recent report con- 6 months postoperatively. However, they reportedcluded HIV positive patients do not experience an average gingival recession of 1.10 mm and agreater tooth loss when compared to individuals mean loss of keratinized tissue of 1.25 mm aroundnot diagnosed with HIV.22 Thus, we can expect the donor area. These results were comparable toHIV positive patients to seek comprehensive den- other studies by Smuckler25 reporting 72% of roottal care including surgical interventions aimed at coverage at 9 months post surgery and Sullivan29correcting the presence of gingival recession. who reported an average of 3.50 mm root cover-In fact, there are only two case reports which age. In our case, we achieve a 6 mm of root cov-describe successful soft tissue grafting proce- erage on #27 and 8 mm on #22. This translatesdures in HIV positive patients. The first report23 to 80% root coverage on #22 and 50% on #27.published was that of a 50 year old HIV posi- Importantly, we did not experience any recessiontive male with a 30 pack year history of smoking. at the donor sites because of the sub-marginal incision design. At the 6 month post-surgical visit, The authors used two large free soft tis- we noted stability of root coverage. Despite oursue grafts to increase the depth of the vesti- best efforts to encourage meticulous oral hygiene,bule in the mandibular premolar and anterior we noticed the presence of plaque on #27. Theregions. Despite the patient’s lack of smok- patient was given oral hygiene instructionsing cessation both the donor and the recipi- and motivated to practice optimal oral hygiene.ent sites healed remarkably well. There was anabsence of delayed or altered wound healing. ConclusionThe second report24 described the use of a lat-eral sliding flap combined with resin modified To our knowledge, this is the first case reportglass ionomer for the treatment of an isolated that demonstrates successful coverage ofrecession defect. The authors reported reduc- non-restored surfaces with severe reces-tion in probing depth, gain in clinical attachment sion defects in a non-hemophiliac HIV positivelevel and the presence of wide band of kera- patient. We hope that this will encourage prac-tinized tissue over the restored root surface. titioners to explore other surgical periodontal treatments options for this population group. ● In the patient described in this report, the deci-sion to use LSF was based on the severity of the Correspondence:recession and because free soft tissue grafts are Shaziya Haque, DDS, MSunpredictable when attempting to cover broad 1508 North Grandview, Suite 1denuded roots. A connective tissue graft was not Odessa, TX, 79765feasible because an inadequate amount of keratin- Fax: 432 550 2427ized tissue was present to cover the graft. Numer- Email: [email protected] studies have reported root coverage rangingfrom 86 to 94% when using LSF.25-27 Guinard The Journal of Implant & Advanced Clinical Dentistry • 75
Haque et alDisclosure 15. Kolhatkar, S, Khalid,S, Rolecki, A, Bhola, M, Winkler, JR. Immediate dentalThe authors report no conflicts of interest with anything mentioned in this article. implant placement in HIV-positive patients receiving highly active antiretroviral therapy: A report of two cases and a review of the literature of implants placedReferences in HIV –positive individuals. Journal of Periodontology 2011(82)3: 505-511.1. P iot P, Bartos M, Ghys PD, Walker N, Schwartlander B. The global impact of 16. Alley BS, Buchanan TH, Eleazer PD. Comparison of the success of root canal HIV/AIDS. Nature. 2001;410(6831):968-973. therapy in HIV/AIDS patients and non-infected controls. General Dentistry. 2008; 56(2):155-157.2. H all HI, Song R, Rhodes P. Estimation of HIV incidence in the United States. JAMA. 2008;300(5):520-529. 17. Cooper H. Root canal treatment on patients with HIV infection. Int Endod J. 1993; 26(6):369-371.3. E gger M, Hirschel B, Francioli P. Impact of new antiretroviral combination therapies in HIV infected patients in Switzerland: prospective multicentre study. 18. B lanco-Carrion J, Linares-Gonzalez A, Batalla-Vazquez P, Diz-Dios P. Morbidity Swiss HIV Cohort Study. BMJ. 1997;315(7117):1194-1199. and economic complications following mucogingival surgery in a hemophiliac HIV- infected patient: a case report. J Periodontology. 2004; 75(10):1413-1416.4. F ielden SJ, Rusch ML, Levy AR. Predicting hospitalization among HIV-infected antiretroviral naive patients starting HAART: determining clinical markers and 19. Miller PD, Jr. A classification of marginal tissue recession. Int J Periodontics exploring social pathways. AIDS Care. 2008; 20(3):297-303. Restorative Dent. 1985; 5(2):8-13.5. M anzardo C, Zaccarelli M, Aguero F, Antinori A, Miro JM. Optimal timing and best 20. Comfort AO, Vandana M, Cuttress T, Tuisuva J, Morse Z, Maimanuku L. Attitude/ antiretroviral regimen in treatment-naive HIV-infected individuals with advanced practices of oral healthcare provider to management of HIV/AIDS patients in disease. J Acquir Immune Defic Syndr. 2007; 46 Suppl 1:S9-18. the Pacific. Pac Health Dialog. 2004; 11(1):26-30.6. J ordan RA, Gangler P, Johren HP. Clinical treatment outcomes of periodontal 21. Campo J, Cano J, del Romero J, Hernando V, Rodriguez C, Balcones A. Oral therapy in HIV-seropositive patients undergoing highly active antiretroviral complication risks after invasive and non-invasive dental procedures in HIV- therapy. Eur J Med Res. 2006; 11(6):232-235. positive patients. Oral Dis. 2007; 13(1):110-116.7. D odson TB. HIV status and the risk of post-extraction complications. J Dent Res. 22. E ngeland CG, Jang P, Alves M, Marucha PT, Califano J. HIV infection and 1997; 76(10):1644-1652. tooth loss. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2008; 105(3):321-326.8. D odson TB, Perrott DH, Gongloff RK, Kaban LB. Human immunodeficiency virus serostatus and the risk of post extraction complications. Int J Oral Maxillofac 23. K olhatkar S, Mason S, Winkler JR, Bhola M. Bilateral vestibuloplasty utilizing Surg. 1994; 23:100-103. palatal soft tissue grafts in a HIV-positive patient. California Dental Association. 2009; 37(9):467-470.9. A chong RM, Shetty K, Arribas A, Block MS. Implants in HIV-Positive Patients: 3 Case Reports. Journal of Oral maxillofacial Surgery. 2006; 64:1199-1203. 24. Kolhatkar S, Haque SA, Winkler JR, Bhola M. Root coverage in an HIV- positive individual: combined use of a lateral sliding flap and resin-modified10. R ajnay ZW, Hochstetter RL. Immediate placement of an endosseous root-form glass ionomer for the management of an isolated severe recession defect. J implant in an HIV-positive patient: Report of a case. Journal of Periodontology. Periodontology. 2010; 81(4):632-640. 1998; 69(10):1167-1171. 25. Smuclker H. A laterally positioned mucoperiosteal pedicle graft in treatment of11. S hetty K, Achong RM. Dental implants in the HIV-positive patient – Case report denuded roots. Journal of Periodontology. 1976; 47(10):590-595. and review of the literature. General Dentistry. 2005; 53(6):434-437. 26. Guinard EA, Caffesse RG. Treatment of localized gingival recessions. Part I.12. S tevenson GC, Riano PC, Moretti AJ, Nichols CM, Engelmeier RL, Flaitz Lateral sliding flap. J Periodontology. 1978; 49(7):351-356. CM. Short-term success of osseointegrated dental implants in HIV-positive individuals: a prospective study. J Contemp Dent Pract. 2007; 8(1):1-10. 27. C affesse RG, Guinard EA. Treatment of localized gingival recessions. Part II. Coronally repositioned flap with a free gingival graft. J Periodontology. 1978;13. Strietzel FP, Rothe S. Implant-Prosthetic Treatment in HIV-infected Patients 49(7):357-361. Receiving Highly Active Antiretroviral Therapy: Report of Cases. The International Journal of Oral and Maxillofacial implants. 2006; 21:951-956. 28. Guinard EA, Caffesse RG. Treatment of localized gingival recessions. Part III. Comparison of results obtained with lateral sliding and coronally repositioned14. Glick M, Abel SN, Muzyka BC, DeLorenzo M. Dental complications after flaps. J Periodontology. 1978; 49(9):457-461. treating patients with AIDS. J Am Dent Assoc. 1994; 125(3):296-301. 29. S ullivan H, Dinner D, Carman D. Clinical evaluation of laterally positioned flap. I.A.D.R. 1971; Abstract No 466.ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] • Vol. 3, No. 7 • December 2011
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Mankani et alDental Implants in Children and Adolescents: A Literature ReviewDr. Nivedita Mankani1 • Dr. Ramesh Chowdhary2 • Dr. Brajesh A Patil3 Dr. Nagaraj E4 • Dr. Poornima Madalli4AbstractEdentulism is usually associated with the have been provided with implant-supported aging patient. However, total or partial construction. Consequently, little is known tooth loss also affects young individu- about the outcome of the osseointegration pro-als, mainly as a result of trauma, decay, ano- cedure in young patients, and until now only adontia, or congenital and acquired jaw defects limited number of case presentations have beeninvolving the alveolar processes. For elderly reported. This article reviews the current literaturepatients, the use of oral implants has become to discuss the use of dental implants in growingan accepted treatment modality for edentu- patients and the influence of maxillary and man-lism, and most of today’s knowledge regarding dibular skeletal and dental growth on the stabil-implants is based on such practice. There has ity of those implants. It is recommended to waitbeen hesitation to perform implant therapy for for the completion of dental and skeletal growth,growing children, hence few children to date except for severe cases of ectodermal dysplasia.KEY WORDS: Dental implants, Ectodermal dysplasia, Alveolar bone growth, Adolescents, Hypodontia. 1. Senior lecturer, Department Of Prosthodontics, PMNM dental college and hospital, Bagalkot, India. 2. Professor, department of Prosthodontics, HKE’S dental college and hospital, Gulbarga, Karnataka, India. 3. Associate Professor, S. Nijalingappa medical college and hospital, Bagalkot, Karnataka, India. 4. Senior lecturer, Department Of Prosthodontics, PMNM dental college and hospital, Bagalkot, India. The Journal of Implant & Advanced Clinical Dentistry • 79
Mankani et al Introduction patients creates special problems because their jaws are in a period of active, dynamicIndividuals with well known inborn craniofacial growth. Since data concerning the clinical useanomalies such as cleft lip and palate, apert syn- of implant are limited at the present time, a defi-drome, crouzon syndrome, hemifacial microso- nite protocol for their use has not been devel-mia, hypohidrotic ectodermal dysplasia as well oped, though opinions have been expressed.8as acquired defects in the facial region result-ing from trauma or tumor surgery often require Clinicians should have an understand-extensive prosthetic intervention. Therefore, ing of the potential risks involved in plac-prosthodontists involved in the clinical applica- ing implants in jaws that are still growingtion of new treatment methods and strategies and developing and consider the effectalso ought to implement their use in individu- that implants have on craniofacial growth.9als with rare disorders and form a natural part ofthe treatment team in children as well as adults.1 Review Treatment comprises many different treat- Implant dentistry has evolved into a reasonablyment modalities and today often includes implant predictable treatment modality for the majority ofsupported prosthesis as the final link in a chain patients. Successful integration and restoration ofof prosthetic replacement for the missing teeth.2 implants is now the expected outcome. Not manyBut the use of implants in the growing individual long-term studies have been published; there-differs significantly from implants placed in the fore critical evaluation of present data is required.adult patients. In adults consideration is givento bone quality and quantity, potential for func- According to smith et al.10 implant use in chil-tion, esthetics and appliance design. In children dren with ectodermal dysplasia is a treatmentsimilar considerations are required; however of choice, since its placement in the mandibu-there is an additional factor: growth. A wide vari- lar anterior region of a 5 year old patient did notety of changes occur, both in the dentition and affect adjacent tooth buds. Prosthesis remodel-the jaws of the growing patient. Only by recog- ing was performed due to implant submergence.nizing such changes can a rational approach Brugnolo et al.11 noted the infraocclussion ofto implants in the growing individual be made.3 implants placed in patients aged 13 to 14.5 years, secondary to vertical growth, and prosthe- From a physiologic standpoint, the con- sis was redesigned. Anteroposterior and trans-servation of bone may be the most important verse growth seemed not to negatively influencereason for the use of dental implants in grow- the implants position. Guckes et al.12 describeding patients, 4,5 and it even may be beneficial in a case of 3-year-old patient with ectodermal dys-some cases to stimulate alveolar bone devel- plasia in which dental implants located in theopment.6 Other factors that favor implant mandible and maxilla have not moved despiteplacement in children are their excellent local growth. During the 5-year follow up, the prosthe-blood supply, positive immunobiologic resis- sis was remodeled to accommodate eruption oftance and uncomplicated osseous healing.7 the maxillary teeth and facial growth. Kearns et al.13 did not find evidence of restriction to trans- However, the use of implants in young80 • Vol. 3, No. 7 • December 2011
Mankani et alverse and sagittal growth due to implant use in from an implant-supported oral rehabilitation.children with ectodermal dysplasia. Prosthesis Bjork,17,18 implanted pins in the jaws of chil-remodeling was necessary in some patients sec-ondary to implant submergence. Lederman et dren for longitudinal cephalometric studies andal.7 in their 7 year follow up with a mean length reported that those in the path of erupting teethof 35.5 months, reported a 90% success rate were displaced and those placed in resorptiveon 42 endosseous dental implants placed in 34 areas were lost. Pins placed in areas of apposi-patients aged 9 to 18 years. There was a positive tional bone growth became embedded. Oesterle3soft and osseous tissue reaction to the implants, compared dental implants to ankylosed primaryand most of the failures occurred because of teeth. They wrote that ankylosis arrests both den-subsequent traumatic injuries sustained during tal eruption and alveolar bone formation in thethe healing phase after implant placement. The affected area. An osseointegrated implant wouldmajor complication reported was the failure of behave much like an ankylosed primary tooth, withdental implants to respond to the vertical growth the same lack of alveolar growth and dental erup-of adjacent teeth and alveolus due to ankylosis. tion, and thus it would appear to submerge into the alveolus. The authors proposed that implants According to OpHeji,14 implants inserted placed in the posterior maxilla in children mightinto pediatric patients do not follow the regular become buried to the point that the apical por-growth process of the craniofacial skeleton and tion may become exposed as the nasal and antralare known to behave similar to ankylosed teeth floor remodel. They also warned the possibility ofresulting in both functional and esthetic disad- loss of implants in the anterior maxilla because ofvantages. Rossi and Andreasen,15 found that resorption in the infradental fossa and nasal floor.they could interfere with the position and theeruption of adjacent tooth germs, thus result- In another similar study by Cronin RJ et al, 19ing in potential severe trauma of the patient. the authors discussed rotational growth of theThese and many other adverse effects have mandible as related to implants in children with aresulted in a very restrictive indication for dental strong rotational growth pattern. Posterior teethimplants in those individuals who have not com- continue to erupt along with continued alveolarpleted craniofacial growth yet.14 However, there growth to maintain the occlusal plane, possiblyare exceptions, for instance children who suf- causing implants to become deeply buried withinfer from extended hypodontia or even anodontia, the mandibular alveolar process. Children with-congenital syndromes such as ectodermal dys- out this rotational growth would not be expectedplasia (characterized by an aplasia or dysplasia to exhibit this same submergence of implants.of tissues of ectodermal origin – hair, nails, skin,teeth).16 In affected patients, the extensive lack of Animal studiesboth deciduous and permanent teeth results inatrophy and a reduced growth rate of the affected Thailander et al.20 concluded that osseointe-alveolar processes. Recent reports suggest that grated implants in pigs remained stable in placethese pediatric patients can benefit remarkably and either became buried in alveolar bone, cre- ating a deviation of the erupting adjacent teeth, or were lost because of bone resorption. They The Journal of Implant & Advanced Clinical Dentistry • 81
Mankani et alrecommended that implants not be placed Several aspects of craniofacial skel-posterior to the canines during active growth. etal growth seem relevant for implant inser-Additionally adjacent tooth germs exhibited mor- tions in growing children with hypodontia.phologic changes and disorders of eruption. Both the maxilla and the mandible are dynami- In another similar study done by Senne- cally changing during childhood. Behaving similarrby et al.21 it was shown that endosseous to ankylosed teeth, implants cannot participateimplants placed in young pigs have limited the with the maxillary growth processes of drift andeffects of ankylosed teeth. Placed in alignment displacement, 22 resulting in unpredictable implantwith adjacent teeth, the implants did not par- dislocations during growth or, if implants are fixedticipate in growth processes, resulting in an together, there are maxillary growth disturbances.infraocclusion and multidimensional disloca-tion when compared with the developing teeth. Because of the resorptive aspects of maxil- lary growth at the nasal floor and the anterior Discussion surface of the maxilla, unpredictable implant dis- locations in vertical and anteroposterior direc-The benefits of implant use in growing patients tion can occur and even implant losses haveare as important as the concerns for their pre- to be expected. Transversal growth of the max-mature use. It is a controversial matter and not illa occurs mostly at the midpalatal suture.many reports have been published; therefore, Consequently, fixed implant constructionsan individual and careful diagnosis and treat- crossing the midpalatal suture will result in ament plan are required. As the dental implants transversal growth restriction of the maxilla. Allin children are a new treatment modality, the in all, the insertion of implants in the growingimpact that a bone-supported prosthesis might maxilla should be avoided until early adulthood.4have on facial growth or, conversely, how growthmight influence the longevity and esthetics of In the mandible, however, the transversalthe implant prosthesis is not very clearly known. skeletal or alveolodental changes are less dra- matic as in the maxilla. In the posterior mandi- There are 2 primary concerns, first, if implants ble, growth changes occur predominantly in lateare present during several years of facial growth, childhood with large amounts of anteroposterior,do they face a danger of becoming embed- transverse and vertical growth.22 Additionally, theded, relocated, or displaced as the jaws grow? mandible undergoes rotational growth, resultingAny of these outcomes is possible because particularly in verticle alterations.22,23 When sev-implants, in contrast to teeth, are not capable eral teeth are present, vertical growth is a majorof compensatory eruption or other physiologic aspect of dental height increase and results inmovements. Second concern is the effect of anteroposterior compensatory changes in theprosthesis on growth. Can a rigid prosthesis dentition. Consequently implants would remainattached to implants bridging a growth area in an infraocclusal position and would probablyinhibit growth? As a corollary, are there design be displaced in the anteroposterior direction.24 Inchanges that must be incorporated into such the anterior mandible however, alveolar growthprosthesis to compensate for growth changes? seems relatively small when teeth are miss-82 • Vol. 3, No. 7 • December 2011
Mankani et aling.24 The majority of the transversal growth of aspects to consider include the individual sta-the mandible occurs quite early in childhood, tus of the existing dentition, the functional statusthe anteroposterior growth occurs mainly at the of mastication and phonetics, esthetic aspectsposterior mandible.23 However, in children with and emotional psychological well being.28 Finally,severe hypodontia, the anterior mandible might both the parents and the child have to be compli-represent probably the most suitable site of ant to implant treatment and implant hygiene.13implant placement.24 In the last few years, sev- According to the 1988 national institute of healtheral case reports of implant insertions in the ante- consensus development conference on dentalrior mandible of children have been published. implants at Bethesda, child patients with ecto- dermal dysplasia could benefit from the use of In a monocentric prospective study sur- dental implants. The published reports aboutvival rate of implants placed in the ante- implant used in young patients are as yet veryrior mandible of pediatric patients with limited, and long-term clinical studies are neces-ectodermal dysplasia was reported with 91%.25 sary for sound conclusions. If the goals of treat- ment planning favors implant use before skeletal Interestingly, some reports have demon- maturation, parents must be informed about ben-strated that craniofacial morphology did not dif- efits and possible complications, and carefulfer significantly between implant treated and attention must be given to prosthesis design.non treated children with ectodermal dyspla-sia, suggesting that treatment with intraos- Conclusionseous dental implants did not necessarilyinterrupt normal craniofacial growth, as assumed 1. Implant location, the sex of the patient, and thebefore.26 But, in the long run, implants located skeletal maturation level are the most importantat anterior mandible probably seem affected factors in the final decision of when toby the mandibular growth rotation, which can place implants.result in a change in implant angulation.27 2. It is still recommended to wait for the comple- Implant timing tion of dental and skeletal growth expect for severe cases of ectodermal dysplasia. ●The finding of the ideal time of implant treatmentin children seems quite difficult because many Correspondence:different aspects have to be considered whilefinding the best individual treatment strategy. Dr. Nivedita MankaniNevertheless, reports in the literature describeplacement of implants as early as 3 years12 or Senior lecturer5 years of age.11 But the safest time to placeimplants seems to be during the lower portion Department Of Prosthodonticsof the declining adolescent growth curve at ornear adulthood that can be determined by ceph- P M N M Dental College and Hospitalalographic radiographs, serial measure of stat-ure or handwrist radiographs.24 Other relevant Bagalkot - 587101 Karnataka, India [email protected] The Journal of Implant & Advanced Clinical Dentistry • 83
Mankani et alDisclosure 11. B rugnolo E, Mazzocco C, Cordioli G, Majzoub 21. Sennerby L, Odman J, Lekholm U and ThilanderThe authors report no conflicts of interest with Z. Clinical and radiographic findings following B. Tissue reactions towards titanium implantsanything mentioned in this article. placement of single tooth implants in young inserted in growing jaws: a histological study in patients – case reports. Int J Periodont Rest Dent the pig. Clinicl Oral Implants Research 1993: 4:References 1996; 16: 421-433. 65-75.1. B ergendal B. the role of prosthodontists in 12. G uckes AD, McCarthy GR and Brahim J. Use of 22. Enlow, DH. (1990). Facial growth. 3rd edition. habilitation and rehabilitation in rare disorders: the endosseous implants in a 3-year-old child with Philadelphia, USA: Saunders publishers. ectodermal dysplasia experience. Int J Prosthodont ectodermal dysplasia: case report and 5-year 2001: 14: 466-470. follow-up. Pediatric dentistry 1997; 19: 282-285. 23. S kieller V, Bjork A and Linde-Hansen T. Prediction of mandibular growth rotation evaluated from a2. B ergendal B. prosthetic habilitation of a young 13. K earns G, Sharma A, Perrott D, Schmidt B, Kaban longitudinal implant sample. American journal of patient with hypohidrotic ectodermal dysplasia and L and Vargervik K. Placement of endosseous orthodontics 1984; 42: 400-411. oligodontia: a case report of 20 years of treatment. implants in children and adolescents with Int J Prosthodont 2001; 14: 471-479. hereditary ectodermal dysplasia. Oral surgery, 24. O esterle LJ. Implant considerations in the Oral pathology, Oral medicine, Oral radiology growing child. In: Higuchi KW, ed. Orthodontic3. O esterle LJ, Cronin RJ, Ranlyd DM. Maxillary and Endodontics 1999; 88: 5-10. applications of osseointegrated implants implants and growing patients. Int J Oral maxillofac 2000: 133-159. Chicago, USA: Quintessence implants 1993; 8: 377-387. 14. OpHeji DG, Opdebeeck H, Van Steenberghe D and publishing co. Quirinen M. Age as compromising factor or implant4. C ronin RJ, Oesterle LJ. Implant use in growing insertion. Periodontology 2000; 33: 172-184. 25. G uckes AD, Scurria MS, McCarthy GR, Brahim patients. Dent Clin North Am 1998; 42: 1-35. JS. Prospective clinical trial of dental implants in 15. R ossi E and Andreasen JO. Maxillary bone growth persons with ectodermal dysplasia. Journal of5. M ehrali MC, Baraoidan M, Cranin AN. Use of and implant positioning in a young patient: a case Prosthetic Dentistry 2002: 88: 21-25. endosseous implants in treatment of adolescent report. International Journal of Periodontics and trauma patients. N Y State Dental J 1994; 60: Restorative Dentistry 2003; 23: 113-119. 26. J ohnson EL, Roberts MW, Guckes AD, Bailey LJ, 25-29. Phillips CL and Wrig JT. Analysis of craniofacial 16. K ramer FJ, Baethge C and Tschernitschek H. development in children with hypohidrotic6. E scobar V, Epker BN. Alveolar bone growth in Implants in children with ectodermal dysplasia: A ectodermal dysplasia. American journal of response to endosteal implants in two patients case report and literature review. Clin Oral Impl medical genetics 2002; 112: 327-334. with ectodermal dysplasia. Int J Oral Maxillofac Res 2007; 18: 140-146. Surg 1998; 27: 445-447. 27. B ecktor, KB, Becktor, JP and Keller, EE. Growth 17. B jork A. Growth of the maxilla in three dimensions analysis of a patient with ectodermal dysplasia7. L edermann PD, Hassel TM, Hefti AF. as revealed radiographically by the implant treated with endosseous implants: a case report. Osseointegrated dental implants as alternative method. Br J Orthod 1977; 4: 53-64 International journal of oral and maxillofacial therapy to bridge construction or orthodontics in implants 2001; 16: 864-874. young patients: Seven years of clinical experience. 18. B jork A. Variations in the growth pattern of the Peadiatr Dent 1993; 15: 327-332 human mandible: A longitudinal radiographic 28. N unn JH, Carter NE, Gillgrass Tj, Hobson RS, study by the implant method. J Dent Res 1963; Jepson NJ and Nohl FS. The interdisciplinary8. W estwood RM, Duncan JM. Implants in 42: 400-411. management of hypodontia: background and role adolescents: a literature review and case reports. of pediatric dentistry. British dental journal 2003; Int J Oral Maxillofac Implants 1996; 11: 750. 19. C ronin RJ, Oesterle LJ, Ranley DM: Mandibular 194: 245-251. implants and the growing patient. Int J Oral9. B rahim JS. Dental implants in children. Oral Maxillofac Implants 1994; 9: 55-62. maxillofacial surgery Clin N Am 2005; 17: 375-381. 20. T hilander B, Odman J, Grondahl K. Aspects on10. Smith RA, Vargervik K. Placement of an osseointegrated implants inserted in growing endosseous implant in a growing child with jaws: A biometric and radiographic study in ectodermal dysplasia. Oral Surg Oral Med Oral young pigs. Eur J Orthod 1992; 14: 99-109. Pathol 1993; 75: 669-673.ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] • Vol. 3, No. 7 • December 2011
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