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 Table of Contents  
CASE REPORTS
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 56-61

Application of diode laser in immediate implant restoration: A case report


1 Consultant Periodontist and Implantologist, Tooth Priority Family Dental Care, Bangalore, Professor, Department of Periodontology Rajarajeswari Dental College and Hospital, Bangalore, India
2 Department of Periodontology, Rajarajeswari Dental College and Hospital, Bangalore, India
3 Consultant Periodontist and Implantologist, Sri Sai Dental Specialities, Bangalore, India

Date of Web Publication14-Nov-2019

Correspondence Address:
Dr. Shivaprasad Bilichodmath
Consultant Periodontist and implantologist, Tooth Priority Family Dental Care, Bangalore. Professor, Department of Periodontology, RajaRajeswari Dental College & Hospital, No.14, Ramohalli Cross, Mysore Road, Kumbalgodu, Bengaluru 560074, Karnataka.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdl.jdl_9_19

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  Abstract 

Loss of teeth because of trauma in aesthetic zone is a common accident. Tooth loss may lead to bone resorption and collapse of the gingival architecture, which leads to unaesthetic appearance and functional impairment. Replacement of tooth in the anterior region is aesthetically challenging. Immediate implant placement into fresh extraction socket is considered an effective option for restoring missing teeth as it reduces the treatment time, preserves the hard and soft tissues, and reduces the number of surgical interventions. This case report describes application of diode laser in achieving a good emergence profile in a case of immediate implant placement and early implant loading in a 24-year-old boy who was with satisfied aesthetic and functional outcomes.

Keywords: Diode laser, gingival troughing, immediate implant placement


How to cite this article:
Bilichodmath S, Geetha, Bilichodmath R. Application of diode laser in immediate implant restoration: A case report. J Dent Lasers 2019;13:56-61

How to cite this URL:
Bilichodmath S, Geetha, Bilichodmath R. Application of diode laser in immediate implant restoration: A case report. J Dent Lasers [serial online] 2019 [cited 2019 Dec 6];13:56-61. Available from: http://www.jdentlasers.org/text.asp?2019/13/2/56/271016




  Introduction Top


Dental aesthetics has strong influence on psychosocial well-being of an individual. Tooth loss in the aesthetic region may lead to psychological trauma of compromised smile, with or without affecting the phonetics. In such situation, patient desires for immediate rehabilitation of aesthetics and function.

Following tooth extraction, within six months alveolar bone loss of 40% in height and 60% in width is predicted and it continues at a rate of 0.25%–0.5% per year.[1],[2],[3] It can be prevented by immediate replacement of the lost tooth.[4]

Currently, implant is placed immediately following tooth extraction to preserve the hard and soft tissues and to reduce the treatment time.

Traditional protocols recommended a two to three months of healing period for remodeling of the socket after tooth extraction and an additional three to six months of load-free healing, which was essential for osseointegration in the 1980s.[5] Originally, to place the dental implant, patients frequently are required to wait for a period of six to eight months after tooth extraction and further, taking into account the prosthetic treatment they should wait for up to one year for replacement of a lost tooth.[6] The waiting period was the major disadvantage of this therapeutic approach.

Alternative technique such as immediate implant placement in fresh extraction socket and early or immediate loading following implant placement was developed. Schulte and Heimke in 1976 first described the immediate implant placement in an extraction socket.[7]

This technique of immediate implant placement has recently become popular because of various advantages such as decrease soft- and hard-tissue resorption, preservation of the crestal bone, reduction in overall treatment time, reduction in number and complexity of surgical procedure, less trauma, increased patient's satisfaction with better function, and aesthetics.[4],[8]

Davarpanah et al.[9] proposed the emergence profile concept in implant therapy. The emergence profile of a restoration is the shape of the restoration in relation to the gingival tissues. The creation of a proper contoured restoration with a natural emergence profile and gingival architecture that harmonizes with the adjacent teeth is very important for esthetic and functional implant therapy. This case report presents a case of immediate implant placement, early loading, and application of diode laser in achieving good emergence profile in the anterior maxilla.


  Case Report Top


A 24-year-old boy reported to a private dental clinic with the chief complaint of fracture of upper front teeth because of trauma. Medical history was noncontributory. Intraoral examination revealed non-restorable right maxillary lateral incisor with Ellis Class IV fracture [Figure 1] and [Figure 2]. Following clinical and radiographic examination, unfavorable prognosis of the tooth was explained to the patient. The viable therapeutic approaches were discussed with the patient. The patient was highly concerned of his aesthetics and expressed his desire for early rehabilitation. His clinical and radiographic examinations revealed ideal hard- and soft-tissue contour, and immediate implant placement with provisionalization of right maxillary lateral incisor was planned. Following detailed description of the benefits and complications of the proposed treatment, the written consent was obtained from the patient.
Figure 1: Frontal view of fractured maxillary right lateral incisor

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Figure 2: Lateral view of fractured maxillary right lateral incisor

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Following administration of local anesthesia (2% lignocaine with 1:100,000 epinephrine), the fractured tooth was atraumatically extracted [Figure 3] and [Figure 4] using a periotome. The extraction socket was evaluated for osseous defect and thoroughly debrided with 0.9% saline. Following socket debridement, an implant of 4.2 mm × 13 mm was placed [Figure 5] and [Figure 6] according to manufacturer's instructions and with reference to three-dimensional positioning. Implant osteotomy site was prepared by engaging the palatal and basal bone. The implant was inserted with a torque of 35 Ncm, which assured the optimal primary stability. Care was taken not to hamper the existing minimum amount of buccal bone. Provisional restoration was given for up to three weeks for proper healing and adaptation of the gingival soft tissue.
Figure 3: Atraumatic tooth extraction

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Figure 4: Atraumatically extracted teeth

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Figure 5: A 4.2 mm × 13 mm implant placed after sequential osteotomy

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Figure 6: Radiovisiography after implant surgery

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Appropriate antibiotic (amoxicillin 500 mg three times daily for seven days) and analgesic (ibuprofen 800 mg every 4–6h as needed) were prescribed and postoperative instructions were given. Patient was advised to consume soft diet and rinse twice daily with 0.2% chlorhexidinedigluconate for up to two weeks.

After three weeks of healing period, the soft tissue showed a favorable healing pattern and gingival troughing was performed with diode laser [Figure 7] operated in pulse mode with power of 0.5 W for easy placement of crown on the abutment to get good emergence profile. Later, the implant was loaded with porcelain fused to metal crown [Figure 8]. The occlusal adjustment was carried out to clear any occlusal contacts on permanent restoration during centric and eccentric movements. Follow-up was carried out at six months and one year. Patient was satisfied with aesthetic and functional outcome. At one-year follow-up, there was pleasant gingival esthetics and minimum bone loss [Figure 9] and [Figure 10].
Figure 7: Gingival troughing with diode laser

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Figure 8: Frontal view of definitive porcelain fused to metal restoration

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Figure 9: At one-year follow-up

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Figure 10: RVG after one year

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  Discussion Top


Rehabilitation of tooth loss in the aesthetic zone by immediate implants may be good treatment option.[10] In the literature, it has been noted that success rate of immediate implants in maxilla (66%–95.5%) is lower than that of the mandible (90%–100%).[11] Therefore, care must be taken while working in the maxillary anterior region specially to preserve the bone. In this case report while preparing the osteotomy site palatal and basal bone is engaged so as to not hamper the existing minimum amount of buccal bone.

Immediate implant placement is indicated in the case of tooth extraction because of trauma, root resorption, unfavorable crown to root ratio, and root fracture. It is contraindicated in the case of gingival recession, active infection, loss of bone in periapical region, and insufficient bone (<3 mm) beyond the tooth socket apex for primary implant stability. Initially, it was said that immediate placement of implants preserves alveolar bone.[12] However this is considered to be controversial as morphologic hard- and soft-tissue changes of the post-extraction site may occur despite immediate placement. Also, slightly palatal or lingual placement of the implant in the extraction socket is recommended. This avoids exposure of the implant surface because buccal wall of socket is thin. In this case report, the implant is placed by engaging the palatal and basal bone so as to avoid disruption of thin buccal bone.

Immediate implant loading requires primary stability of the implant. The minimum insertion torque has to be equal to or more than 32 Ncm.[11],[13] In this case report, the primary stability was achieved and there was no need for bone augmentation as the dimension of the implant matched with that of the extraction socket.

Immediate or early loading of implants requires knowledge of biology of the recipient tissue, surgical trauma, the wound healing process, and occlusion. Previous research on wound healing has shown that early osteoid formation begins after 7 days and mineralization commences at 21 days; thus, implant loading after two to three weeks may therefore turn into a feasible protocol.[14] In this case report, implant was loaded after three weeks.

In areas of aesthetic concern, the connection of the implant and the prosthetic element is located below the soft-tissue margin. Gingival contouring of the soft tissue is desired or indicated before the preparation or impression; then, a laser is the instrument of choice to accomplish this procedure.[15] Laser technology is an attractive and increasingly popular alternative to traditional methods (cord and electrosurgery) for the management of soft tissue. When crown troughing with the diode laser is compared with the traditional techniques, many clinicians find the laser to be easier and quicker than “packing cord.” The electrosurgery units cannot be used safely around metals intraorally[16],[17],[18] and have discovered that the diode laser can be used safely around adjacent restorations that are metal (amalgam and gold), as well as for dental implants.[19],[20],[21] The safety of using lasers for tissue retraction has been documented by Gherlone et al., who found lasers (diode and Nd:YAG) to yield less bleeding and less recession than either double cord or electrosurgery techniques. Their conclusion was that the laser techniques were in fact less traumatic to the periodontal tissues.[22] When considering using the diode laser for anterior restorations, Goharkhay et al.[23] concluded that the diode laser has a remarkable cutting ability and the tolerable damage zone, and because of its excellent coagulation ability.

Height or shape discrepancies can be easily corrected, and the gingival contours are maintained and the field can remain dry and clean, ready for impressions. The negligible tissue shrinkage after laser therapy is an advantage. Minor surgical correction of the gingival margin can be carried out to assist adequate implant exposure or establish the correct emergence profile.[14] In this case, gingival troughing was performed with the diode laser, which resulted in wider gingival sulci that enabled easy insertion of prosthesis on the abutment without violation of the biologic width with the establishment of good emergence profile, less inflammation, and more patient comfort.

Immediate implants with immediate or early loading into carefully selected extraction socket have higher survival rates as compared with implant placed in healed site.[4] In this case report, during one-year follow-up there was minimal bone loss and pleasant gingival aesthetics.

Immediate implant placement has various advantages such as preservation of the bone at the extraction site, optimal gingival aesthetics, and reduction in the number of surgical procedures and early rehabilitation of aesthetics.

In this case report, immediate implant placement approach to replace the fractured lateral incisor provided satisfied aesthetic and functional outcome to the patient.


  Conclusion Top


Immediate implant placement post-extraction is a reliable treatment approach in terms of aesthetic and functional outcome. Although it is a technique, sensitive careful case selection and treatment planning will result in good success rate. This case report also shows how the diode laser can act as a wonderful alternative to traditional methodologies of tissue retraction and soft-tissue contouring, which added benefits for aesthetics and function.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Iabella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA, et al. Ridge preservation with freeze‑dried bone allograft and a collagen membrane compared to extraction alone for implant site development: A clinical histologic study in humans. J Periodontol 2003;74:990‑9.  Back to cited text no. 1
    
2.
C Pinho MN, Roriz VL, Novaes AB Jr, Taba M Jr, de Souza SL, Palioto DB . Titanium membranes in prevention of alveolar collapse after tooth extraction. Implant Dent 2006;15:53-61.  Back to cited text no. 2
    
3.
Schropp L, Wenzel A, Kostopoulos L, Karring T . Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restor Dent 2003;23:313-23.  Back to cited text no. 3
    
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Schropp L, Kostopoulos, L, Wenzel A. Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: A prospective clinical study. Int J Oral Maxillofacial Implants 2003;18:189-99.  Back to cited text no. 4
    
5.
Albrektsson T, Branemark PI, Hansson HA, Lindstrom J. Osseointegrated titanium implants: Requirements for ensuring a long‑lasting, direct bone‑to‑implant anchorage in man. Acta Orthop Scand 1981;52:155‑70.  Back to cited text no. 5
    
6.
Branemark PL, Adell R, Breine U, Hansson BO, Lindstrom J, Ohlsson A. Intra-osseous anchorage of dental prostheses, I: Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100.  Back to cited text no. 6
    
7.
Esposito MA, Koukoulopoulou A, Coulthard P, Worthington HV. Interventions for replacing missing teeth: Dental implants. Int J Sci Res Publ 2015;5:1019-20.  Back to cited text no. 7
    
8.
Quirynen M, Van Assche N, Botticelli D, Berglundh T. How does the timing of implant placement to extraction affect outcome? Int J Oral Maxillofac Implants 2007;22:203-23.  Back to cited text no. 8
    
9.
Davarpanah M, Martinez H, Celletti R, Tecucianu JF. Three‑stage approach to aesthetic implant restoration: Emergence profile concept. Pract Proced Aesthet Dent 2001;13:761‑7.  Back to cited text no. 9
    
10.
Ataullah K, Chee LF, Peng LL, Tho C, Wei WC, Baig MR. Implant placement in extraction sockets: A short review of the literature and presentation of a series of three cases. J Oral Implantol 2008;34:97-100.  Back to cited text no. 10
    
11.
Uribe R, Penarrocha M, Balaguer J, Fulguerias N. Immediate loading in oral implants: Present situation. Med Oral Patol Oral Cir Bucal 2005;10:143-53.  Back to cited text no. 11
    
12.
Schwartz AD, Chashu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: A literature review. J Periodontol 1997;68:915-23.  Back to cited text no. 12
    
13.
McNutt MD, Chou CH. Current trends in immediate osseous dental implant case selection criteria. J Dent Edu 2003;67:850-9.  Back to cited text no. 13
    
14.
Schwartz Z, Boyan BD. Underlying mechanism of the bone-biomaterial interface. J Cell Biochem 1994;56:340-7.  Back to cited text no. 14
    
15.
Francis L, Pillai SB. Lasers in implant dentistry. J Dent Implant 2017;7:41-5.  Back to cited text no. 15
  [Full text]  
16.
Robertson PB, Luscher B, Spangberg LS, Levy BM. Pulpal and periodontal effects of electrosurgery involving cervical metallic restorations. Oral Surg Oral Med Oral Pathol 1978;46;702-20.  Back to cited text no. 16
    
17.
Skaria AM. Electrocoagulation and hazardous damage to a dental prosthesis. J Am Acad Dermatol 2006;54:543-4.  Back to cited text no. 17
    
18.
Wilcox CW, Wilwerding TM, Watson P, Morris JT. Use of electrosurgery and lasers in the presence of dental implants. Int J Oral Maxillofac Implants 2001;16:578-82.  Back to cited text no. 18
    
19.
Yeh S, Jain K, Andreana S. Using a diode laser to uncover dental implants in second-stage surgery. Gen Dent 2005;53:414-7.  Back to cited text no. 19
    
20.
Romanos GE, Everts H, Nentwig GH. Effects of diode and Nd:YAG laser irradiation on titanium discs: A scanning electron microscope examination. J Periodontol 2000;71: 810-5.  Back to cited text no. 20
    
21.
Park CY, Kim SG, Kim MD, Eom TG, Yoon JH, Ahn SG. Surface properties of endosseous dental implants after NdYAG and CO2 laser treatment at various energies. J Oral Maxillofac Surg 2005;63:1522-7.  Back to cited text no. 21
    
22.
Gherlone EF, Maiorana C, Grassi RF, Ciacaglini R, Cattoni F. The use of 980- nm diode and 1064-nm Nd:YAG laser for gingival retraction in fixed prostheses. J Oral Laser Appl 2004;4:183-90.  Back to cited text no. 22
    
23.
Goharkhay K, Moritz A, Wilder-Smith P, Schoop U, Kluger W, Jakolitsch S, et al. Effects on oral soft tissue produced by a diode laser in vitro. Lasers Surg Med 1999;25:401-6.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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