This article is about the use of dental implants with immediate loading and cortical osseointegration in the areas of the jaws with impacted, dystopic teeth.
V.А. Rybak, Е.I. Fesenko - Center for Oral and Maxillofacial Surgery of Kyiv Regional Clinical Hospital, Ukraine;
V.G. Klymentiev - European Stomatology Center, Kyiv, Ukraine.
Tactics of dentists towards impacted, dystopic teeth is based on the indications, either surgical or orthodontic. In cases of partially edentia and need of the implantation the presence of impacted, dystopic canines, premolars using two-stage cylindrical implants implant formulation is allowed to tilt no more than 30 degrees with respect to the prosthesis, because of the requirements. Therefore, the dentist resorted to the tactics of extraction of dystopic teeth or to the surgical opening of the dystopic teeth and their subsequent orthodontic removal into the tooth row.
The use of implants with immediate loading and cortical osseointegration allowed us to avoid the traumatic intervention on the upper jaw to remove these teeth or the version of long orthodontic treatment with the removal of these teeth.
In the English-language literature and in post-Soviet countries there are differences in terminology with respect to the teeth, which are localized in the jaw in atypical place or position and timing of the eruption of which has been mistimed.
Impacted teeth are observed in the eruption of permanent teeth: more often - upper canines and lower wisdom teeth, less often - small molars and upper wisdom teeth.
Lower wisdom teeth are more likely to be dystopic, less often - the upper canines and wisdom teeth, as well as upper and lower premolars. Dystopia is marked on the upper jaw to the side of the vestibule of the mouth, directly in the mouth cavity, in the solid palate towards the front wall and the zygomatic process of the maxilla. In the mandible - toward the vestibule of the mouth, in the direction of the body, angle and branch of the mandible.
Tooth retention (retentiodentis; lat. retentio - holding, determent; syn. teething retardation) - delay of timing of eruption of permanent properly formed teeth.
Full retention is an unerupted tooth completely situated in the bone. They distinguish 3 stages of full tooth retention.
Half-impacted tooth is an incomplete eruption of the tooth through the bone of the jaw or mucosa.
Dystopia (dystopia; dys- + Gr. Topos - place, position). This is an incorrect or abnormal position (offset) of the erupted tooth in the dental row in the jaw (Fig. 4.3.9-4.3.10). Supernumerary teeth occur, but very rarely.
In the English-speaking world a term impacted teeth (impacted from English - tightly wedged or fixed) is used to describe impacted, dystopic teeth. In dentistry, the term defines the teeth that cannot or will not be able to erupt into their normal functional position, and thus are pathological and require treatment 2.
Thus, the English term is an umbrella for all the detailed terms for impacted, dystopic teeth.
Surgical removal of impacted, dystopic teeth is applicable in cases where to treat teeth with some of the treatment methods does not make sense. When planning the removal the surgical technique according to an X-ray study should be followed. Preservation of bone using classic opening with segmentation of the tooth is recommended. Access to the removal of impacted, dystopic canines in the upper jaw from the surface of the nearest location. Labially positioned teeth are often removed by elevator. Palatal localized canines require removal of the crown with the following segmentation of the root. Longitudinal segmentation of the root of palatal located canines is convenient and allows you to save the bone. With a large tilting palatal flap, the use of palatal plate prevents the formation of a haematoma.
Surgical opening (skeletonization)
Surgical opening is an intervention that promotes the natural eruption of impacted teeth. Öhman and Öhman studied 542 impacted teeth in 389 patients. In these studies, the teeth crowns were surgically opened with the removal of the tissue in the most suitable place for the movement of teeth.
Teething is allowed up to 24 months or until the equator of the crown of the tooth reaches the level of the mucosal surface. In only 16 cases of 542 teeth failures were observed (failure of eruption after 24 months or other complications). Patient age is not a factor for success, although all patients have reached 19 years old.
Most often, a surgical opening is combined with orthodontic retainers fixed to the teeth, providing active direction of the impacted tooth in an ideal position.
Surgery opening with orthodontic excretion
Preliminary orthodontic treatment is needed to create the necessary space in the dental arch for the impacted tooth and support. The use of a variety of orthodontic elements, including polycarboxylate crowns and pins integrated into the tooth structure is indicated. But both of these techniques are rarely used due to problems in access to the etching under the braces / buttons.
Location of metal ligatures around the neck is the usual method of orthodontic reference, but this technique is relatively invasive. Clinical data of 1981 showed the outer resorption as a possible complication of wide open cement-enamel junction (CEJ) which is necessary for the location of the cervical ligature. This complication has been studied by Kohavi and colleagues in 1984 on 23 patients who underwent surgical fixation of the cervical opening and ligatures to the tooth. The teeth were divided into two groups: some had a "slight opening" for the location of the strips without unsheathing CEJ, the other had a "significant opening" including removal of the bone, the complete removal of the follicular sac and complete opening of the CEJ. These data indicated significantly more damage with significant opening technique and the authors recommend avoiding the opening neck of the tooth to accommodate the cervical ligature. Although the use of orthodontic elements such as magnets is recommended for the movement of the teeth, but the most common method is to use a seed dressing braces.
It is usually performed with a conservative opening of the tooth, removing only the required number of hard and soft tissue necessary to fix the bracket avoiding opening the CEJ.
Studies have compared the simple opening with packing for obtaining gingival trails for eruption with the opening and etching under the bracket. Iramaneerat and colleagues determined that there is no difference in the total time of orthodontic treatment for both techniques.
Pearson and colleagues noted that the use of braces is more costly and often required reoperation. Still, fixing the bracket is a more popular procedure.
When impacted palatal located incisors typical surgical opening includes dropping of full layer of palatal flap, classic opening of the tooth and fixing the bracket to its palatal surface. If the tooth is located near the edge of the flap the soft tissue can be removed to leave the crown open; wound is then packed gently during the initial healing period. If the tooth is deeply dystopic offset soft-tissue flap, leaving the ligature attached to a fixed braces through the soft tissue near the top of the ridge may be more appropriate.
Appliances of flap displacement is estimated on the implications on the periodontium. Clinical results indicate a minimal effect on the periodontium with closed eruption.
Transplantation of dystopic teeth
It is justified as an alternative to other treatments of dystopic teeth. It may be indicated for patients of mature age who cannot have classical orthodontic movement of the canine or premolar. Sagne
and Thilander studied 47 patients with 56 teeth that were transplanted. During the operation a wide opening dystopic tooth and its movement in the dental arch, the stabilization of orthodontic equipment is necessary. After 6-8 weeks, endodontic treatment begins with a paste based on calcium hydroxide. Filling the root canal is performed 1 year after the intervention. These studies have shown success in 54 of the 56 transplanted canines.
КCLINICAL CASE NO.1
The patient born in 1964 (Fig. 1 the initial situation) came to the clinic with a desire to replace dental defects of the fixed dentures. In orthopantomogram 2 palatal located dystopic canines were seen. Orthodontic treatment for the removal of these teeth in the dentition in the conditions of the absence of space for the 23rd tooth, a small amount of the abutment teeth, the duration of this treatment, was rejected by the decision of the patient and the doctor immediately. Atypical removal of the dystopic teeth had a risk of injury to the remaining teeth in the front group, formation of ortho-antral anastomosis to the right scared with the severity of the intervention for the patient. Installation of classical cylindrical implants would require the necessary maximum of 30° in relation of the body implant to the axis of the prosthetics. Joint decision of the dentist and the patient was to preserve 2 asymptomatic palatal located dystopic canines, removing the 16th, the 24th and the 25th teeth, endodontic treatment of the 15th, the 11th, the 21st and the 22nd teeth, setting 8 implants in the upper jaw (Fig. 1-1) with immediate loading and cortical integration. 3 of them were installed in a tuberal wedge area. Installation of these implants was conducted according to the principles of the basal implantology which allow you to set implants non-parallel and at an angle greater than 30° to the future prosthesis, setting them in the cortical jaw loading in the first two days after implantation with the two strut designs.
In this work, we used the principles of surgical orthopedics, traumatology. According to them the implants should be fixed in the cortical bone and the areas free of resorption (in their practice, there is no such portion of the bone similar to the alveolar ridge) and avoid installation of parallel implants. Since the non-parallel implants, splinted with a plate, create a high macroretention inside the bone. Such divergence during the installation reduces the risk of loosening of the implants and increases their resistance to loads in various directions .
Immediately after the implant placement the prints were made. Temporary splinting orthopedic constructions were cemented on the following day for a period of up to six months.
Six months later a stage of a permanent prosthesis with zirconium oxide bridges structures was held.
Fig. 1 State of the oral cavity before the surgery in 2011.
Fig. 2 State after a year and a half after the implant placement.
Fig. 3 View of the cemented bridge designs based on zirconium oxide in one and a half year from the date of the implantation and immediate loading.
Risk of damage to the anatomical structures, the duration of treatment or trauma of the interventions can cause the refusal of the patient-doctor from the treatment with classical implants in the presence of dystopic teeth.
Using the trauma principle of immediate loading of plates for osteosynthesis, we established a sufficient number of stable, non-parallel implants and made their splinting with bridges of immediate use. The success of the chosen treatment in conditions of asymptomatic dystopic canines confirms our result after 1 year of functioning.
Thus, we have provided the patient with a possibility to avoid traumatic surgery of removing teeth, the period of rehabilitation, long-term orthodontic treatment giving him a chance to get fixed design with the possibility of immediate functioning.
Being armed with a technique of implant placement with immediate loading and cortical osseointegration a dentist will be able to offer the patients a better job comparing to the majority of others doctors.