Clinical Advances in Periodontics Vol. 7, No. 4, November 2017 : Page-175

CASE REPORT Management of an Immediate Implant Horizontal Defect Using Freeze-Dried Bone Allograft and a Neodymium:Yttrium-Aluminum-Garnet Laser Thomas M. Johnson* and Miguel A. Jusino † Introduction: A contemporary protocol for managing horizontal alveolar defects adjacent to immediate implants in-cludes placement of a well-designed provisional restoration to contain graft material and seal the socket. However, imme-diate provisionalization is not always possible or practical. Case Presentation: A 39-year-old male presented with a non-restorable tooth #29, which was extracted. An immediate implant was placed in the tooth #29 position, and a freeze-dried bone allograft was placed in the horizontal defect between the implant platform and osseous walls. A neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was used to create a stable fibrin clot over the graft material. After 31 months, favorable radiographic bone levels and complete papilla fill were noted. Conclusion: The present case illustrates use of an Nd:YAG laser in the management of an immediate implant horizon-tal defect in lieu of an immediate provisional restoration. Clin Adv Periodontics 2017;7:175-181. Key Words : Allografts; bone regeneration; dental implants; lasers; treatment outcome; wound healing. Background When a dental implant is placed into a fresh extraction socket, a defect exists between the socket walls and the implant surface. Immediate implant insertion per se does not appear capable of preventing physiologic postextraction modeling of alveolar bone and establishment of unfavorable soft tissue contours. 1 Use of a biomaterial, such as bovine bone combined with collagen, in the peri-implant gap may mitigate such untoward ridge dimensional changes. 2 How-ever, some evidence suggests bone augmentation may be unnecessary when the horizontal defect dimension is sufficiently small. 3 In addition to a positive influence on ridge dimensions, favorable peri-implant mucosal stability * United States Army Advanced Education Program in Periodontics, Fort Gordon, GA. † has been reported when a mineralized biomaterial was placed in the postextraction peri-implant gap and a non-submerged healing abutment supported the peri-implant mucosa during healing. 4 A recent protocol involving graft placement within and coronal to the peri-implant osseous defect along with a prosthetic socket seal using an immediate provisional restoration has received clinical interest. 5 This protocol seeks to enhance both the alveolar ridge contour and the peri-implant mucosa thickness by incorporating a biomaterial from the apical extent of the defect to the free gingival margin. 5 The present case illustrates a means of achieving graft containment and healing around an immediate dental implant when socket seal using an immediate provisional restoration is not practicable. United States Army Dental Health Activity, Fort Hood, TX. Clinical Presentation A male patient (aged 39 years) with non-restorable tooth #29 (Fig. 1) presented to Tingay Dental Clinic, Fort Gordon, Georgia in May 2015. The chief resident (MAJ) fully Clinical Advances in Periodontics, Vol. 7, No. 4, November 2017 Submitted December 29, 2016; accepted for publication March 14, 2017 doi: 10.1902/cap.2017.160093 175

Management Of An Immediate Implant Horizontal Defect Using Freeze-Dried Bone Allograft And A Neodymium:Yttrium-Aluminum-Garnet Laser

Thomas M. Johnson, and Miguel A. Jusino

Introduction: A contemporary protocol for managing horizontal alveolar defects adjacent to immediate implants includes placement of a well-designed provisional restoration to contain graft material and seal the socket. However, immediate provisionalization is not always possible or practical.

Case Presentation: A 39-year-old male presented with a non-restorable tooth #29,which was extracted. An immediate implant was placed in the tooth #29 position, and a freeze-dried bone allograft was placed in the horizontal defect between the implant platform and osseous walls. A neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was used to create a stable fibrin clot over the graft material. After 31 months, favorable radiographic bone levels and complete papilla fill were noted.

Conclusion: The present case illustrates use of an Nd:YAG laser in the management of an immediate implant horizontal defect in lieu of an immediate provisional restoration. Clin Adv Periodontics 2017;7:175-181.

Key Words: Allografts; bone regeneration; dental implants; lasers; treatment outcome; wound healing.

Background

When a dental implant is placed into a fresh extraction socket, a defect exists between the socket walls and the implant surface. Immediate implant insertion per se does not appear capable of preventing physiologic postextraction modeling of alveolar bone and establishment of unfavorable soft tissue contours.1 Use of a biomaterial, such as bovine bone combined with collagen, in the peri-implant gap may mitigate such untoward ridge dimensional changes.2 However, some evidence suggests bone augmentation may be unnecessary when the horizontal defect dimension is sufficiently small.3 In addition to a positive influence on ridge dimensions, favorable peri-implant mucosal stability has been reported when a mineralized biomaterial was placed in the postextraction peri-implant gap and a non submerged healing abutment supported the peri-implant mucosa during healing.4 A recent protocol involving graft placement within and coronal to the peri-implant osseous defect along with a prosthetic socket seal using an immediate provisional restoration has received clinical interest.5 This protocol seeks to enhance both the alveolar ridge contour and the peri-implant mucosa thickness by incorporating a biomaterial from the apical extent of the defect to the free gingival margin.5 The present case illustrates a means of achieving graft containment and healing around an immediate dental implant when socket seal using an immediate provisional restoration is not practicable.

Clinical Presentation

A male patient (aged 39 years) with non-restorable tooth #29 (Fig. 1) presented to Tingay Dental Clinic, FortGordon, Georgia in May 2015. The chief resident (MAJ) fully explained alternative therapies, and the patient selected extraction of tooth #29 with immediate implant placement.

Case Management

Tooth #29 was removed (Fig. 2), and an implant osteotomy was created according to the surgical protocol of the manufacturer. The osteotomy was undersized to enhance primary stability (Fig. 3). A 4.3 13 mm implant‡ was placed with 50-Ncm insertion torque (Fig. 4). A 4.3 3 3 mm healing abutmentx was applied with firm digital pressure, and a freeze-dried bone allograft (FDBA)|| was placed into the peri-implant osseous defect. Additional biomaterial was placed between the healing abutment and gingiva to stabilize the gingivalmargin (Fig. 5). Blood was allowed to pool over the FDBA particles, and a neodymium:yttrium-aluminumgarnet (Nd:YAG) laser{ (3.6W, 550 ms, 20 Hz) was used to support formation of a fibrin clot within and over the graft (Figs. 6 through 8). A 360-mm optical fiber# was inserted z2 mm into the graft material, and the laser was activated as the operator withdrew the fiber above the pooled blood surface. Fiber insertion, activation, and withdrawal proceeded at six points around the implant circumference. The fiber orientation was parallel to the implant surface, and a total of 47 J was applied. The patient received postoperative analgesics as well as a 1-week course of amoxicillin (500 mg three times daily). Toothbrushing in the tooth #29 area was with held for 2weeks, and the patient used chlorhexidine plaque control until normal oral hygiene measures could be reinstated.

Clinical Outcomes

The patient exhibited favorable healing in the immediate postoperative period and reported minimal postoperative pain, obviating the need for narcotic analgesics. Treatment was prolonged due to military duties of the patient. At 21 months post-surgery, a provisional restoration was placed (Fig. 9), and a periapical radiograph demonstrated stable interproximal bone levels (Fig. 10). After definitive restoration at 31 months, maintenance of normal gingival architecture was observed (Fig. 11).

Discussion

Immediate implants have a long track record of success, and in cases involving peri-implant defects as diminutive as the one shown in this case, positive outcomes are achievable without laser use or placement of biomaterials. Moreover, in this circumstance, the patient underwent to two distinct treatment variables beyond immediate implant placement alone: FDBA and Nd:YAG laser use. Insertion of biomaterials in the postextraction peri-implant gap has been shown to enhance stability of peri-implant hard and soft tissues.2,4 Biomaterials are commonly used to diminish the clinical impact of alveolar bone modeling accompanying tooth extraction, and the favorable outcome observed in this case could be attributable to the allograft rather than the laser. However, documented characteristics of Nd:YAG laser output suggest this laser could provide benefit in the context of immediate implant placement, and this technique should be studied to establish efficacy, predictability, and histologic effects in periimplant tissue.

The Nd:YAG laser is known to support hemostasis.6 The laser-generated fibrin clot in the present case exhibited immediate mechanical stability and graft containment. This clot presumably provides a favorable matrix over which cells may migrate during wound healing, although, to the best of the authors’ knowledge, there are apparently no studies to directly confirm this assumption. Use of the Nd:YAG laser with the described settings in contact with pooled blood on the surface of graft material is considered high-level laser therapy; the subjacent tissue is concomitantly exposed to low-level laser energy and therefore possible photobiomodulation effects (also known as biostimulation). 6 Photobiomodulation mechanisms are often discussed in general terms,without attributing specific cellular responses to particular laser types.6 However, the effect of laser energy on cellular events in wound healing is likely dependent upon details of the experimental conditions (e.g., wavelength, average power, pulse duration, energy density, target tissue, and other parameters). Thus, interpreting photobiomodulation literature is challenging. In in vitro studies Nd:YAG laser energy has been found to induce preosteoblast bone morphogenetic protein-2 expression, 7 stimulate osteoblast proliferation and differentiation, 8 increase osteoblast intracellular calcium,9 and stimulate fibroblast proliferation and epidermal growth factor secretion.10 In animal models, Nd:YAG laser energy markedly enhanced collagen III biosynthesis11 and accelerated bone formation compared with controls.12

Additionally, low-level Nd:YAG irradiation may modulate the inflammatory response and thus affect wound healing.13

Separate from possible stimulatory effects on wound healing, Nd:YAG laser energy may have positive antibacterial effects.14 Nd:YAG laser use in immediate implant sites has potential benefit since perioperative contamination at implant insertion has been cited as a cause of early failure.15 The technique presented produces a robust clot that seals the defect established when an implant is placed into a fresh extraction socket and possibly provides stimulatory influences on wound healing as well as positive antiseptic effects. This protocol appears capable of maintaining favorable radiographic bone levels and soft tissue contours adjacent to an immediate implant. Further controlled clinical and confirmative biologic study is warranted to establish benefit beyond the same therapy without laser use.

Summary

Why is this case new information?

■ To the best of the authors’ knowledge, this is the first report in the literature demonstrating long-term follow-up of Nd:YAG laser use to treat the horizontal defect around an immediate implant.

What are the keys to successful management of this case?

■ The preoperative position of the gingival margin must remain supported postoperatively. Thus, graft material must be placed within the osseous horizontal defect but also between the gingival margin and the healing abutment.

What are the primary limitations to success in this case?

■ Implants can easily become overheated if exposed to excessive laser energy. A typical light dose for this procedure would be 30 to 50 J.

Acknowledgments

The authors thank their friend Professor Ulf M.E. Wikesjo¨ , Department of Periodontics, Oral Biology Laboratory for Applied Periodontal & Cranio facial Regeneration, Augusta University,The Dental College of Georgia,Augusta, Georgia, for his assistance in editing this manuscript.The authors would also like to thank CPT Steven Handel, US Army Dental Health Activity, Bavaria,Grafenwoehr,Germany, for providing the restorative treatment in this case. The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy of the Department of Defense, Department of Army, US Army Medical Department, or the US Government. The authors report no conflicts of interest related to this case report.

CORRESPONDENCE:

Dr. Thomas M. Johnson, United States Army Advanced Education Program in Periodontics, 320 East Hospital Rd., Fort Gordon, GA 30905. E-mail: thomas.m.johnson34.mil@mail.mil.

References

1.Arau´ jo MG, Sukekava F, Wennstro¨m JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: An experimental study in the dog. J Clin Periodontol 2005;32:645-652.

2.Arau´ jo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at immediate implants: A 6-month study in the dog. Clin Oral Implants Res 2011;22:1-8.

3.Botticelli D, Berglundh T, Buser D, Lindhe J. The jumping distance revisited: An experimental study in the dog. Clin Oral Implants Res 2003;14:35-42.

4.Ramaglia L, Sbordone C, Saviano R, Martuscelli R, Sbordone L. Marginal masticatory mucosa dimensional changes in immediate postextractive implants: A 2 year prospective cohort study. Clin Oral Implants Res 2015;26:1495-1502.

5.Chu SJ, Salama MA, Salama H, et al. The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent 2012;33:524-532, 534.

6.Aoki A, Mizutani K, Schwarz F, et al. Periodontal and peri-implant wound healing following laser therapy. Periodontol 2000 2015;68:217-269.

7.Kim IS, Cho TH, Kim K, Weber FE, Hwang SJ. High power-pulsed Nd: YAG laser as a new stimulus to induce BMP-2 expression in MC3T3-E1 osteoblasts. Lasers Surg Med 2010;42:510-518.

8.Karoussis IK, Kyriakidou K, Psarros C, Lang NP, Vrotsos IA. Nd:YAG laser radiation (1.064 nm) accelerates differentiation of osteoblasts to osteocytes on smooth and rough titanium surfaces in vitro. Clin Oral Implants Res 2017;28:785-790.

9.Chellini F, Sassoli C, Nosi D, et al. Low pulse energy Nd:YAG laser irradiation exerts a biostimulative effect on different cells of the oral microenvironment: “An in vitro study.” Lasers Surg Med 2010;42:527- 539.

10.Gkogkos AS, Karoussis IK, Prevezanos ID, Marcopoulou KE, Kyriakidou K, Vrotsos IA. Effect of Nd:YAG low level laser therapy on human gingival fibroblasts. Int J Dent 2015;2015:258941 10.1155/ 2015/258941.

11.Dang YY, Ren QS, Liu HX, Ma JB, Zhang JS. Comparison of histologic, biochemical, and mechanical properties of murine skin treated with the 1064-nm and 1320-nm Nd:YAG lasers. Exp Dermatol 2005;14:876-882.

12.Kim K, Kim IS, Cho TH, Seo YK, Hwang SJ. High-intensity Nd:YAG laser accelerates bone regeneration in calvarial defect models. J Tissue Eng Regen Med 2015;9:943-951.

13.Giannelli M, Bani D, Tani A, et al. In vitro evaluation of the effects of low-intensity Nd:YAG laser irradiation on the inflammatory reaction elicited by bacterial lipopolysaccharide adherent to titanium dental implants. J Periodontol 2009;80:977-984.

14.Harris DM, Reinisch L. Selective photoantisepsis. Lasers Surg Med 2016;48:763-773.

15.Tonetti MS, Schmid J. Pathogenesis of implant failures. Periodontol 2000 1994;4:127-138.

indicates key references.


United States Army Advanced Education Program in Periodontics, Fort Gordon, GA.

† United States Army Dental Health Activity, Fort Hood, TX.

Submitted December 29, 2016; accepted for publication March 14, 2017

doi: 10.1902/cap.2017.160093

Read the full article at http://onlinedigeditions.com/article/Management+Of+An+Immediate+Implant+Horizontal+Defect+Using+Freeze-Dried+Bone+Allograft+And+A+Neodymium%3AYttrium-Aluminum-Garnet+Laser/2908822/445120/article.html.

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