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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 3  |  Page : 133-137

Comparative evaluation of clinical and radiographical outcomes of immediate versus delayed dental implant placement: A prospective study


Department of Periodontology and Implantology, Himachal Dental College, Sundernagar, Himachal Pradesh, India

Date of Web Publication3-Jul-2019

Correspondence Address:
Ashish Bali
Depaertment of Periodontics and Implantology, Himachal Dental College, Sundernagar, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_18_18

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  Abstract 


Background: To investigate the crestal bone changes following immediate versus delayed dental implant placement. Aims and Objective: Comparative evaluation of clinical and radiographical outcomes of immediate versus delayed dental implant placement: A prospective study. Methods: A prospective randomized comparative study was conducted in total of ten implant sites in patients within the age group of 20 to 60 years comprising both male and female visiting the Out-Patient Department of Periodontics, Himachal Dental College, Sunder Nagar (H.P.). Clinical parameters were recorded at baseline (1 month), 3 months and 6 months; they included Probing depth (PD), Radiographic Assessment (RA) for crestal bone changes. Results: On intergroup comparison, the mean difference of the probing between Group I and Group II showed that Group I had slightly higher probing depth [Table 1] than Group II during 1st to 3rd month and 3rd to 6th month period and On intergroup comparison, the mean difference of the crestal bone changes [Table 2] between Group I and Group II showed that Group II had slightly higher bone loss than Group I during 1st to 3rd month and 3rd to 6th month period. Conclusion: Within limitations of this study, it can be concluded that there was significant crestal bone loss in Group II (delayed implantation) at both mesial and distal surface during 3rd to 6th month's observation period. Furthermore, a continuous bone resorption was observed over the time in both the groups. Due to small sample size, short duration, and two-dimensional radiographical assessment of crestal bone loss during follow-up in the study, long-term survival of two-piece implants in both the groups cannot be determined; so, further studies are required to be done.

Keywords: Crestal bone loss, dental implant, osseointegration


How to cite this article:
Bali A, Jindal M, Goel A, Gupta V, Dadwal A, Chauhan S. Comparative evaluation of clinical and radiographical outcomes of immediate versus delayed dental implant placement: A prospective study. Indian J Dent Sci 2019;11:133-7

How to cite this URL:
Bali A, Jindal M, Goel A, Gupta V, Dadwal A, Chauhan S. Comparative evaluation of clinical and radiographical outcomes of immediate versus delayed dental implant placement: A prospective study. Indian J Dent Sci [serial online] 2019 [cited 2019 Jul 22];11:133-7. Available from: http://www.ijds.in/text.asp?2019/11/3/133/261941




  Introduction Top


Tooth loss reflects the ultimate outcome of the oral disease over the course of life. A number of techniques are available for the rehabilitation of the single or multiple spaces. The common techniques involved are removable partial dentures, conventional fixed prosthetics, and in some patients, orthodontic treatment. These methods are, however, associated with disadvantages such as loss of tooth substance and a potential loss of tooth vitality, especially in young individuals. In addition, the prognosis for reconstruction can be complicated by carious lesions progression, periodontal disease of abutment teeth, and technical failures such as loss of retention and fracture of bridge components or abutment teeth.[1]

This revolutionary breakthrough was first evolved from the research efforts of the Swedish orthopaedic surgeon P. L. Branemark in late 1960s by pioneering of insertion of machined screw-type commercially pure titanium (cpTi) implants with minimal surgical trauma.[2] To achieve long-term success, rigid fixation of the implants within the host bone site is required. Brånemark et al. (1977)[3] termed the bone bonding ability of implant as “Osseo-integration” and defined it as “a direct structural and functional connection between ordered living bone and the surface of a load carrying implant.”

At a recent consensus workshop 2004,[4] three different protocols were defined: (i) immediate or type 1 when the implant are placed in the same surgical intervention as the dental extraction; (ii) type 2 or early implant placement when implants are placed in the early stages of healing (from 4 to 8 weeks); and (iii) type 3 or delayed implant placement when implants are placed when the ridge has healed (from 3 to 6 months).

Delayed implant placement i.e type-3 implant placement is the gold standard techinque. This technique requires several months of waiting period before implant placement.[5] This method allows ample time for the host tissues to eliminate the infection postextraction, causes good healing of the alveolar bone with greater keratinized mucosal width, less recession, greater mesial and distal papilla height with greater percentage of papilla fill. However, disadvantage is that dentist has to wait for several months after tooth extraction and before placement of the implant.[6]

Immediate implant was first introduced in 1976,[7] and this method involves the implant placement immediately after the tooth extraction, and now, it has become successful, predictable, and alternative treatment modality.[8] There are several advantages which are associated with immediate placement which includes reduced treatment time, maintenance of extraction socket, less crestal bone loss, along with increased patient satisfaction and treatment acceptance.[9] This approach helps to preserve alveolar bone dimension, allowing placement of longer and wider implants and improving the crown-implant ratio. As a result, the bone-implant contact surface area increases, which could decrease the amount of stress due to occlusal load at bone-implant surface and allow better stability and success. There are certain disadvantages that could jeopardize the success of immediate implant procedures, such as lack of soft tissue closure over the extraction site,[10],[11] varying dimensions of implant and empty alveolus, a partially or totally missing bony housing, and periapical and/or periodontal infection.[10],[12],[13]

Several authors have reported promising clinical outcomes with immediate implant placement having survival rate, ranging from 93.9% to 100%,[14] while with the delayed protocols, the survival rate ranged from 96% to 100%.

Moreover, the literature has shown good results with both techniques,[15],[16] but until now, few studies have directly compared numerical data.[17]

Thus, the aim of the present study is to clinically evaluate the periodontal parameters of osseointegrated immediate and delayed dental implants and to radiographically evaluate the difference in the crestal bone height after immediate and delayed placement of dental implant.


  Materials and Methods Top


A prospective randomized comparative study was conducted in total of ten implant sites, in patients within the age group of 20-60 years, comprising both male and female visiting the outpatient Department of Periodontics, Himachal Dental College, Sunder Nagar, Himachal Pradesh. Approval for the study had been obtained from ethical committee. The patients were randomly allocated to the immediate group (n-5) and the delayed group (n-5).

The implants in the immediate group were placed on average immediately following tooth extraction; in the delayed group, implants were placed >12 weeks' postextraction. Each patient was explained in detail about the risk and benefits of participation in this study. Only those patients who signed an informed consent were included in the study and satisfied the following inclusion and exclusion criteria.

Inclusion criteria

Patients within the age group of 20-60 years, willing to comply with all the study requirements, full-mouth bleeding scores of <30%, patients requiring extractions in case of residual and fracture root, carious tooth, periodontally healthy tooth without any periapical or periodontal abscess. Delayed implant case, healed extraction sockets (of >3 months).

Exclusion criteria

Poor oral hygiene with no possibility of improvement, any relevant systemic conditions such as uncontrolled diabetes, osteoporosis, malignancies, and blood dyscrasias, trauma affecting the alveolar bone, lack of interest and cooperation from the patient, drug or alcohol abuse, pathologic changes at the recipient site (cysts, tumors, and osteomyelitis), irradiation in the implant area, pregnant women, and lactating mothers.

Surgical procedure

The patient was scheduled for implant surgery after Phase I therapy. Facial skin all around the oral cavity was scrubbed with povidone iodine solution (5%), and the patient was made to rinse with 0.2% chlorhexidine digluconate mouthrinse for 1 min before surgery. The area of surgery was anesthetized using 2% lidocaine with adrenaline concentration of 1:80000.

Immediate group (Group 1)

Following administration of local anesthesia, a sulcular incision along the buccal aspect of the planned implant site and a vertical beveled releasing incision to spare the adjacent papillae was given. A full-thickness flap was elevated and extended beyond the anticipated apical extension of the preplanned implant length. This method will permit careful evaluation of any pathology present at the periapical region of the tooth to be extracted. The tooth in question was then extracted using a method involving minimal trauma to the bone and surrounding soft tissues. This extraction was accomplished using a periotome taking care to avoid fracturing the buccal plate. A forceps of anatomic design was used to rotate the tooth root in a clockwise-counter clockwise fashion to retrieve the root from alveolus. Following extraction, the socket was then thoroughly degranulated with curettes and to remove all remnants of the periodontal ligament and granulation tissue.

Delayed group (Group II)

After achieving profound anesthesia, the mucoperiosteal flap was elevated with a crestal incision located approximately 2–3 mm toward the lingual aspect and extended to the sulcus of adjacent teeth by an intrasulcular incision. This incision avoids the formation of scar tissue in the midcrestal area.

Following procedure was performed for both the groups:

  • The buccolingual and mesiodistal implant position was partially determined by the morphology of the alveolus, and the site for implant placement was then marked with a surgical round bur. After marking the site, pilot drill (D-2.0 mm) was put to use for creating the osteotomy site of approximate depth for implant placement. It was indexed with various markings (8 mm, 9.5 mm, 11 mm, 14 mm, and 17 mm) corresponding to the desired implant lengths. When approximate depth was reached with the pilot drill, the implant probe was used for tactile perception of intact bony plates and for perforations and for the desired osteotomy depth. Once desired depth was confirmed, paralleling pins were placed to check the proper alignment of the implant with adjacent teeth and opposing occlusion. After confirmation of depth and angulation, the osteotomy site was prepared with Tri-Spade (twist) drills to create the desired osteotomy width. Each Tri-Spade drill is color and letter coded to indicate the osteotomy diameter, red (3.5 mm, “A”), yellow (4.5 mm, “B”), and blue (5.5 mm, “C”). The round drills and the twist drills were operated at maximum 800 rpm (revolutions per minute) as per manufacturer's instructions. The implant site was generously irrigated with sterile saline to remove any residual bone chip/other residue following preparation. The depth of implant osteotomy site was ascertained with implant depth probe. The implant was removed from the sterile vial using insertion tool and delivered into the osteotomy site. The implants were then placed into the prepared site with manual pressure aided by the insertion mount and insertion tools attached to the implant head. Following which, the insertion mount was removed, and hex driver was placed into the implant internal hex and ratcheted with torque-controlled implant ratchet. Care was taken not to allow excessive force application while insertion. Implant was checked for stability by applying gentle pressure to determine if it could be depressed or rotated. Furthermore, primary stability was assessed with the torque controlled ratchet. All implants were placed within the alveoli confines and were clinically stable at the time of insertion. The grafts were placed as per the requirement. And a definitive abutment is placed only at the time of insertion so as to gain the advantage of one abutment one implant concept. Then, the primary closure of the wound was achieved by stabilization of the flap using simple interrupted sutures. The patients in both groups were recalled after 7 days for the suture removal. The patient was then recalled after 1st, 3rd, and 6th month for recording the clinical parameters
  • Clinical parameters assessed: the periodontal status was evaluated at baseline (1st month), 3rd, and 6th month for both groups using University of North Carolina-15 periodontal probe. Probing depth (PD) was measured on mesial, facial/buccal, distal, and lingual surfaces around the implant. The gingival margin was used as a reference line for the location of the mucosal margin
  • Radiographic assessment: standardized intraoral periapical radiograph with Radio Visual Graph attached with X-ray grid was obtained for each implant site at 1st, 3rd, and at 6th month after placement of the implant. The X-ray unit with long cone paralleling device was used. The level of bone was measured on the mesial and distal aspect of each implant. The reference point was taken from implant shoulder to the crest of interproximal alveolar bone. To assess the changes in bone height, the distance between the implant shoulder and the first visible bone-implant contact was determined by measuring the squares on radiograph and expressed in millimeters. After the complete healing the final prosthetic stage was initiated and Final impression was made directly on the abutment, and the definitive porcelain-fused-to-metal splinted restorations were delivered. The data thus collected was subjected to statistical analysis.



  Results Top


On intergroup comparison, the mean difference of the probing between Group I and Group II showed that Group I had slightly higher probing depth [Table 1] than Group II during 1st to 3rd month and 3rd to 6th month period and On intergroup comparison, the mean difference of the crestal bone changes [Table 2] between Group I and Group II showed that Group II had slightly higher bone loss than Group I during 1st to 3rd month and 3rd to 6th month period.
Table 1: Intergroup comparison of probing depth between Group A and Group B

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Table 2: Intergroup comparison of crestal bone between Group A and Group B

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  Discussion Top


Clinical probing is regarded as an important and reliable diagnostic parameter in the continuous monitoring of both periodontal and peri-implant tissues as stated by Niklaus et al.[18] As peri-implant tissue are more sensitive around implant according to Mombelli et al.,[19] so less force is applied during peri-implant probing (0.2–0.3N). On intergroup comparison, the mean difference of the probing depth [Table 1] between Group I and Group II showed that Group I had slightly higher PD than Group II during 1st to 3rd month and 3rd to 6th month period. This could be explained according to the reason mentioned by Mensdorff-Pouilly et al.[20] who reported a tendency of primary Group I to form deeper gingival pockets than the Group II and attributed this to the fact that Group I was marked by occasional losses of attached gingiva. The decrease in the PD till 6th-month follow-up noted in Group II is in agreement with the findings of Abou-Zeid (2014).[21] However, the results were statistically nonsignificant for the both the groups, which was in accordance with the study of Pellicer-Chover et al.[22] who found that PD slightly increase in both groups after loading with nonsignificant differences observed at any of the time points. Pal et al.[1] and Gökçen-Röhlig et al.[23] also found nonsignificant difference (P > 0.05) in mean PD between immediate and delayed group. According to the findings of Ricci et al.,[24] the mean PD was >5 mm in 4.5% of cases, and the survival rate of implants was 100%. In our study, the PD was <3 mm for both groups with 100% survival rate.

Radiographic interpretation of alveolar bone loss has proven to be one of the most valuable means to clarify implant success as stated by Dahlin et al. (1995).[25] On intergroup comparison, the mean difference of the crestal bone loss [Table 2] between Group I and Group II showed that Group II had slightly higher crestal bone loss than Group I during 1st to 3rd month and 3rd to 6th month period. Moreover, this difference was found statistically nonsignificant. The reason for less bone loss in Group I could be due to implant placement in fresh extraction socket, so that the risk of alveolar bone resorption after tooth extraction could be reduced, and the gingival and crestal bone architecture are better maintained. And this was in accordance with the study done by Bilhan et al,[26] in which more bone loss is seen in delayed group due to disuse atrophy. The bone loss was present more in Group II as compared to Group I because the bone defects created in Group I were filled with autogenous bone chips harvested from the surroundings. This was in accordance with the study of Kumar et al.[27] who found less bone loss in implants placed immediately. Tabrizi et al.[28] found similar results as our study, on comparison of bone loss in both groups. They demonstrated that the amount of bone loss is more in Group II than Group I with a significant difference (P > 0.05) observed in Group II. Heinemann et al.[29],[30] on the other hand concluded that there was nonsignificant difference between Group I and Group II in approximal bone level change during 1st year which was in contrast with our study. Strid [31] reported that bone-implant interface decreases during the 1st month following surgical insertion of implants in cases of delayed implantation which supports our study. Sunitha et al.[32] have shown that flap elevation which is required in delayed protocol can lead to increased crestal bone loss during the healing period.

The literature is substantial in support of site preparation for implant therapy, not just in the esthetic zone but throughout the mouth. Clinicians have long known the benefit of preserving the ridge at the time of extraction to reduce the resorptive process and in many cases to avoid an additional surgical procedure to augment a deficient ridge. Dahlin et al.[25] showed that peri-implant dehiscence or any other related bone defect associated with implant placement at healed extraction sites and covered with a mucoperiosteal flap alone did not heal with bone. In the delayed group, grafting was carried out for ethical reasons just after implant placement in cases of dehiscence defects.

When different graft materials are used with or without membrane, it is concluded that biomaterial such as hydroxyapatite when used along with placement promote better healing as given by Wilson et al.[33] In the present study, we have used alloplast (Biograft-HT) in both groups whenever needed, and it has shown good results. This is in accordance with the study done by Viswambaran et al.,[34] Wagenberg and Froum,[35] and Gangar et al.[36] who have also used different types of alloplasts.

The present results also meet the success criteria for implant treatment proposed in the consensus report of the 1st European Workshop on Periodontology: “The criteria of success include average bone loss of <1.5 mm during the 1st year after insertion of the prostheses.” This loss of crestal bone could be attributed to the fact that whenever bone is stripped of its periosteum, its nutrition is affected, which could result in some amount of resorption of the crestal bone. This loss of crestal bone during the 1st year after placement of the implant could also be attributed to the process of wound healing at the bone-implant interface Raja Sunith.


  Conclusion Top


Within limitations of this study, it can be concluded that there was significant crestal bone loss in Group II (delayed implantation) at both mesial and distal surface during 3rd to 6th month's observation period. Furthermore, a continuous bone resorption was observed over the time in both the groups. Due to small sample size, short duration, and two-dimensional radiographical assessment of crestal bone loss during follow-up in the study, long-term survival of two-piece implants in both the groups cannot be determined; so, further studies are required to be done.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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33.
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