8 Trends & Applications DENTAL TRIBUNE Middle East & Africa Edition Emergency dental implant procedures Drs. Nicholas Caplanis and Jaime Lozada Patients often present to the office with unscheduled emergency conditions that require immediate tooth removal. These situations have become increasingly complex to deal with given the myriad available treatment options, which impact the treatment approach and methodology of both tooth extraction as well as provisionalization.1 therapy was performed, specifically, endodontic treatment, post and core buildup and a toothsupported crown.2 Immediate implant placement following an emergency extraction should therefore be an integral part of emergency treatment. A oneyear prospective study reported a 100 percent implant success rate and also suggested improved esthetic outcomes are achieved following this approach when compared to extraction alone without implant placement.5 The ability to quickly and effectively treat Unrestorable crown and root these emergency scenarios imfractures are often ideal clinical proves patient satisfaction, facilscenarios for immediate implant itates patient management and is placement given the frequent a tremendous clinical service. lack of overt infection and alveoTherefore, the dental office lar bone damage, which is often and team should be welleassociated with other emergency quipped, or referral guidelines conditions such as endodontic be effectively established, to allow for efficient and predictable dental implant placement during these types of emergency appointments. The following two clinical case reports describe a simple and efFig. 1a: Emergency presentation of unrestorable crown fective process and root fracture of tooth #8. to treat hopelessly fractured teeth using dental implants and periodontal abscesses. Failand either a bonded restoration ure to perform immediate imas a provisional or a provisional plant placement or site preservaplaced immediately on the imtion during the emergency visit plant. often leads to a loss of alveolar bone, which greatly impacts dental implant treatment success. Patient 1 When comparing the excellent longterm success rates of imA 65yearold Asian female plants with the guarded presents for a new patient emerlongterm prognosis of a badly gency exam, with an oblique fractured tooth requiring encrown and root fracture affecting dodontic treatment, crown her maxillary right central incilengthening surgery, and a post sor. The fracture occurred sponand core buildup, extraction and taneously while eating, involved site preservation or immediate the entire facial surface of the implant placement is frequently tooth and extended the ideal treatment approach. to the alveolar crest A clinical study of 534 frac(Figs.1a,1b). The clinical crown tured teeth reported a 20 percent exhibited severe mobility and failure rate when conventional Fig.1b:Radiographofobliquecrownandrootfracturetooth#8. Fig.1e:Radiographofimmediateimplantinplacewithbondedprovisional. was painful upon palpation and percussion. The prognosis was poor and extraction was advised. Treatment options to replace the tooth were discussed and included a fixed partial denture as well Fig.1c:Intactclinicalcrowntobeusedas- Fig.1d:Fracturedcrownbondedtoadjacentdentitionservingasprimaryprovisional. as an implant sup- bondedprovisional. ported crown. Given the excellent condition of the adjacent teeth as central incisor was well as the patient’s prior history partially fractured at of having successful dental immid root and exhibplantsupported restorations, she ited grade III mobility elected to have an implant (Fig. 2a). The left latplaced. eral incisor was tenThe crown portion of the der to percussion and tooth was easily removed and, exhibited grade 1 given its excellent condition, was mobility, but it retained to be used as a bonded recorded a negative provisional (Fig. 1c). The tooth response with ethyl root was extracted atraumatichloride and elecFig.2a:Traumatothemaxillaryleftcentralincisorcally without flap elevation and tronic pulp testing. withhorizontalrootfracture. the socket debrided, irrigated The patient was and evaluated with a periodontal then scheduled to unprobe. The extraction defect had dergo an emergency minor horizontal bone loss assoprocedure at the ciated with a reduced periodonclinic consisting of tium secondary to a prior history atraumatic extracof periodontitis, but the adjacent tion of the affected socket walls including the buccal tooth and immediate crest were otherwise intact. implant placement Therefore the defect appeared with immediate proamenable for immediate implant visionalization. The placement. A 4.3 x 16 mm Refractured tooth was place® Select implant (Nobel extracted and the reBiocare™) was placed and utimaining root fraclized the entire length of the alveture was removed olus and engaged the nasal floor, utilizing a periotome Fig.2b:Periotomeandforceptextractionoffracturedroot. in order to achieve effective priinstrument (Fig. 2b). mary stability (Fig. 1e). After imThe alveolus was plant placement, the residual curetted and no bone socket defect was grafted with a fenestration was composite anorganic bovine noted. A Nobel Active bone matrix (BioOss® Osteodental implant was health®) and a demineralized used to replace the cortical bone allograft (Oraextracted tooth (Fig. Graft® LifeNet®). Composite 2c). The osteotomy was bonded to the fractured surwas performed face of the clinical crown in order palatal to the alveoto develop an ovate surface to lus in order to obtain maintain soft tissue esthetics. maximum stabilizaThe modified clinical crown was tion for the implant. then bonded to the adjacent teeth The implant was and served as a primary proviseated at 35 nc stabil- Fig.2c:Immediateimplantisplacedachievingexcelsional restoration (Fig. 1d). The ity, which made the lentprimarystability. patient was then referred back to clinical situation viher restorative dentist the next able for immediate day to fabricate an immediate provisionalization. A provisional supported by the prefabricated abutimplant. The emergency apment was placed and pointment including the exhand torqued to protraction, placement of the imvide the support for plant, grafting of the residual the acrylic resin socket defect and bonding of restoration. The prothe primary provisional visional crown was restoration took approxithen relieved from all mately one hour of clinical occlusal contacts time. (Fig. 2d). Intraoperative radiographs rePatient 2 vealed adequate po- Fig.2d:Animmediateacrylicrestorationisusedasaprovisional. sition of the implant A 35yearold female prein relation to the adjasented at the emergency tion or bonding of the fractured cent dentition and bone implant clinic of Loma Linda Univercrown can be used as a provilevel. sity School of Dentistry and sional restoration. The emergency dental imwas immediately referred to plant procedure should be conthe Center for Implant DenReferences sidered a viable and often prefertistry. She complained of 1 Iasella JM et.al. Ridge preservaable treatment approach to treat trauma to her maxillary antetion with freezedried bone alloemergency situations that ultirior dentition after an alleged graft and a collagen membrane mately lead to tooth loss such as assault, a “blow to the face,” compared to extraction alone for implant site development: A clinroot fractures. When appropritwo days previously. Upon exical and histologic study in huate, immediate provisionalizaamination, the maxillary left