Feline Alveolar Osteitis Osseodensification with Implant

Open Access Journal of Veterinary Science & Research ISSN: 2474-9222 MEDWIN PUBLISHERS Committed to Create Value for Researchers

Feline Alveolar Osteitis: Osseodensification with Implant Placement Protocol

Rocco E Mele1 and Gregori M Kurtzman2* Case Report 1VCA Valley Animal Hospital and Emergency Center, Tucson, AZ, USA Volume 6 Issue 2 2Silver Spring, MD, USA Received Date: April 05, 2021

Published Date: May 04, 2021 *Corresponding author: Gregori M Kurtzman, General practitioner, International dental DOI: 10.23880/oajvsr-16000212 author and lecturer, Leisure World Plaza Professional Building, 3801 International Drive, Suite 102, Silver Spring, MD 20906, USA, Tel: 301-598-3500; Email: [email protected]

Abstract

Feline dental implants are becoming a predictable and viable treatment option for the replacement of lost canines due to maxillary alveolar osteitis (AO) a painful condition, commonly experienced by felines. Surgical extraction and debridement

remains the treatment of choice for this complex inflammatory process. Future complications however can be a common sequela of maxillary canine loss. The case presented demonstrates successful surgical extraction of a maxillary canine with implant placement following the osseodensification protocol and utilizing the sockets osteitis buttressing bone formation to

promote a positive result with final restoration of the implant with a crown 13 weeks post implant placement. Keywords:

Alveolar Osteitis; Osseodensification; Implant; Tooth Resorption

Introduction (Figure 2 blue) and a mottled osseous appearance mimicking rough, large trabeculae (Figure 2 yellow). felineAlveolar patient. osteitis The clinical (AO) is presentation a chronic inflammatory of AO may processinclude more frequently diagnosed in maxillary canine sockets of the and alveolar buccal bone changes [1-5]. oral pain, bleeding, periodontitis, tooth resorption (ORL), A presumptive diagnosis clinically of AO is made on

erythema,the awake buccal patient, bone documenting expansion, and clinical coronal features extrusion such as; gingivitis with soft tissue swelling, gingival mucosal general anesthesia. Those bony changes and pathology may Figure 1: include;(Figure 1).deep Radiographically, palatal probing changes(Figure 2 are red), identified alveolar under bone maxillary left canine. expansion (Figure 2 green), buttressing condensing bone Alveolar Osteitis (AO) associated with the

Feline Alveolar Osteitis: Osseodensification with Implant Placement Protocol J Vet Sci Res 2 Open Access Journal of Veterinary Science & Research

Figure 2:

Deep probing (red) with osseous expansion of the socket wall (green) and condensing bone (blue) demonstrating a mottledOsseodensification trabeculae pattern in the radiograph (yellow). diagnostic profile to evaluate the patient’s general health. preparation technique for dental implant placement to Results were all in the normal range. improveOsseodensificaiton bone quality by is increasing a novel biomechanicalits density utilizing bone Veterinary Supply, Boise, Idaho) 0.01 (SQ)Patient and Acepromazine was premedicated Maleate with (MWI atropine Veterinary sulphate Supply) (MWI 0.02 mg/kg subcutaneously rpm.Densah While burs standard (Versah, osteotomy Jackson, MI). drills The remove burs are and rotated excavate in a counterclockwise direction (reverse mode) at 800 - 1500 mg/kg SQ. An intravenous catheter was placed and bone preservation by condensation through compaction. lactated ringers solution was started at a rate of 3 ml/kg/h. Thisbone resultsduring implantin autografting site preparation, during osteotomy the Densah preparation burs allow General anesthesia was induced by mask with Sevoflurane set at #7 and O2 thereby increasing the peri-implant bone density (% BV) and (Sevo) (MWI Veterinary Supply). The Sevo Vaporizer was the resulting implants mechanical stability [6]. flow was set at 1L. Intubation with a cuﬀed 2 endotracheal tube was completed, and the anesthetic agent was maintained at the vaporizer setting of 3%. O flow rate the percentage of bone at the implant surface by increasing Dental,was set Tucson,at 1L/M. AZ) A unilateral at 0.1ml leftat themaxillary site and infraorbital Buprenorphine nerve the boneOsseous mineral densification density inhas the demonstrated peri-implant an region. increase Bone in block was administered with 0.5% Bupivacaine (Benco compaction has been reported in numerous studies to General Anesthetic Protocol (MWI Veterinary Supply) at 0.01 mg/kg IV following the through increased bone density at the bone implant interface A complete oral examination and digital PA radiographs [7-9].improve early implant fixation and better load handling

Case Presentation were obtained and a final diagnosis of alveolar osteitis was made. The owner was notified of the results and the treatment options available which included: 1) Surgical extraction (XSS) with socket debridement. 2) XSS with particulate allograft. 3) A 9 year old neutered male DLH feline weighing 5 kg XSS with possible immediate implant placement. The feline’s presented for evaluation of “swollen gums”. Initial oral owner chose to place an immediate implant, if possible and a mobilityexamination (M1) noted:(Figure alveolar1). A preliminary bone expansion diagnosis with of alveolar tooth future restoration following implant healing. extrusion (#204) with gingival erythema and mild tooth A sulcular incision was made to create an envelope flap osteitis was made with a final diagnosis and treatment plan removalwith a distal of the vertical affected releasing canine incision (#204) for aand full maximize thickness to be presented to the owner at the time of general anesthesia maintenanceflap to expose of the the underlying surrounding bone bone and and to tissueallow vascularityatraumatic followingSurgical a complete Phase oral exam.

ofmaking the affected future implant/restoration canine utilizing small more curettes predictable and copious(Figure surgical procedure for a complete blood count (CBC) and 3). Socket debridement was performed following extraction Blood was drawn the morning of the scheduled oral sterile saline lavage with removal of any connective tissue,

introduced into the condensed site to a depth of 4/5mm was set at 45 Ncm with a speed of 20 rpm. The implant was 45 Ncm (Figure 5). The evolution of Implant Stability Quotientsubcrestal (ISQ) at whichvalues pointto access the implant handpiece secondary torqued stability out at

demonstrated statistically significant correlation with implant outcome. In fact, no implant with > 60 failed, while (Osstell19% of implants USA, Baltimore, ISQ < 60 MD) failed read [14]. 65. The implant was tested Figure 3: for Implant Stability Quotient (ISQ) using the Osstell IDX unit

Following extraction of the affected canine a full thickness envelop flap is elevated to expose the buccal aspect of the extraction socket. auto-graftingSocket osteotomyutilizing Densah was Burs. accomplished The burs and technique with an compressosseodensification the osteotomized drilling protocol alveolar referred bone to asincreasing compaction its density to yield better primary stability and superior bone- to-implant contact when the implant is inserted (Figure Figure 5: Implant placement is performed utilizing the 4). The bur geometry rotating counter-clockwise (reverse surgical handpiece into the prepared osteotomy. compactionmode) at a rotaryof the bone speed along of 800 the innerto 1500 surface rpm ofwith the implantprofuse saline irrigation prevents bone over-heating, while allowing motion (in and out movement) is helpful to create a rate- dependentosteotomy stress without to osseousproduce a cutting. rate-dependent A gentle strain bouncing and graft material from entering the implants connection at A cover screw was inserted into the implant to prevent (Veterinary Transplant Service (VTS), Kent, WA) into the gap plasticityallowing salineand resulting solution bone pumping expansion to gently [10-13]. pressurize the the platform. A condenser was utilized to pack an allograft boney walls. This combination facilitates an increased bone andbetween bone thebut implantoccupies and the sockettissue zonewalls to at the the height crest. of The the graft free gingivalmaterial marginnot only (FGM). fills the The “jump graft gap” material between is incorporated the implant

(Figure 6). The into the tissue zone, acting as a scaﬀold to support the ridge contour profile and peri-implant tissue [15] cover screw is carefully removed, so as not to disturb the thegraft soft and tissue replaced so that with a asingle 4/5mm stage flat surgical healing approachabutment could(OCO beBiomedical) utilized. Thiswith actsa height as a slightly prosthetic taller seal than and the isthickness tightened of

with finger pressure utlizing a hand held hex driver. The flap margins were reapproximated around the healing abutment and fixated with Securocryl, a 5/0 synthetic suture material implant/abutment(Securos Surgical, Fiskdale,interface MA)and graft in an placement interrupted (Figure manner 8) (Figure 7). Post-Op radiographs were taken to evaluate the Figure 4: to condense the osteotomy improving the bone density Recovery was uneventful and the patient was discharged Densah bur is utilized in the extraction socket SQwith at post-surgical a dose of 0.045 instructions ml/lb (Zoetis, to the Inc., animal’s Kalamazoo, owner MI) on andthe same day as surgery. Cefovecin Sodium was administered (quality) that will house the implant.

Buprenorphine (MWI Veterinary Supply, Boise, ID) at a dose of mucositis and/or peri implantitis. continued to display minimal inflammation with no evidence of 0.01mg/kg orally every 12 hours for 5 days.

Figure 6: Osseous graft material is placed into the gap

Figure 9: between the implant and wall of the extraction socket prior to flap closure. Clinical appearance at 8 week post-surgical demonstrating non-inflamed gingival tissue.

QuotientAt 10 (ISQ)weeks value post implant (Osstell placement, USA, Columbia, the patient Maryland) returned to assessfor intra-oral osseointegration dental radiographs for a possible and earlya final restoration Implant Stability phase. The same feline general anesthetic protocol (GAP) for the

surgical phase was repeated for the restorative phase. Dental Figure 7: radiographs were taken demonstrating excellent stability primary closure around the healing abutment and secured stability.and osseointegration with an ISQ value of 74 recorded. ISQ The soft tissue flap is approximated to achieve value is an objective world standard for measuring implants

with interrupted sutures. The healing abutment (HA) was removed and a 5mm diameter impression coping (OCO Biomedical) was attached Polysiloxaneto the implant (VPS) (Figure (Benco 10). Rostral Dental) maxillary The impression and mandibular coping impressions and bite registration were obtained with Vinyl diameter HA repositioned into the implant to maintain the was then detached intraorally and replaced with a new 5mm

tissue emergence profile (Figure 11) and a final radiograph was taken (Figure12).

Figure 8:

placement (right)Radiograph at the surgical at immediate appointment. placement (left) and following healing abutment placement with graft

Restorative Phase Figure 10: Impression coping placed into the implant at

abutment. Because of the owner’s busy schedule, re-evaluation the restorative phase following removal of the healing was limited to e-mail photos of the surgical site at 3 weeks and 8 weeks post-operatively (Figure 9). The implant site

Figure 13:

Figure 11: Cad/Cam milled wax crown on the mounted models to verify relationship with the opposing arch. around the healingClinical abutment.appearance at 10 weeks post-surgical demonstrating healthy non-inflamed gingival tissue

Figure 14:

verify complete Radiograph mating atof 13 the weeks restoration post-surgery and implant with the at Figure 12: thescrew platform. retained restoration fixated to the implant taken to

Radiograph at 10 weeks post-surgical demonstrating incorporation of the graft placed with the patients bone and lack of radiolucency between the implant and socket walls. around the implant is crucial for long term implant and bone Maintenance of healthy thick keratinized tissue (KT) around the prosthetics under function [17,18]. stability. KT minimizes bone resorption and inflammation Customized Digital Workflow for Veterinary Prosthetics Figure 15: restoration to The the implant. screw retained restoration intraorally following torque of the fixation screw to secure the The impressions were sent to the dental lab (Dental 3Prosthetics, Shape D2000 Tucson, scanner AZ) (3 and Shape a stone Inc., model Warren, was NJ) created to create with a an implant analog within the model and scanned utilizing a Three weeks after dental impressions were taken, virtual model. Final components were designed incorporating the patient returned for delivery of the final prosthetic 3 Shape software and CAD CAM milled (Figures 13). components, a screw-retained zirconia crown on a custom

Placement Protocol. J Vet Sci Res 2021, 6(2): 000212. Rocco E Mele and Gregori M Kurtzman. Feline Alveolar Osteitis: Osseodensification with Implant Copyright© Rocco E Mele and Gregori M Kurtzman. 6 Open Access Journal of Veterinary Science & Research titanium abutment. The restoration arrived from the laboratory as a one piece restoration with the zirconia crown luted to the titanium abutment that would be screw retained to the implant intraorally. The patient was again anesthetized following the general anesthetic protocol followed in the tissuetwo previous and the quality procedures. of the Anbone oral surrounding exam and the intra implant oral radiographs were obtained to evaluate the peri-implant soft % Chlorhexidine Gluconate rinse ZN,(Figure MWI 14). Veterinary The screw Products) retained crownfor 2 wasminutes soaked to inprevent a 0.12 introduction of oral bacteria into (Deltathe implant Hex Oral connection Rinse w during restoration insertion. The restorations external hex Figure 17: Clinical appearance 9 days post insertion of the hex connector to get the correct rotational position and connector was lined up with the implant platforms internal tissue. implant restoration demonstrating non-inflamed gingival seated into the implant. The restorative fixation screw was inserted into the screw access channel and tightened to 25 At a four-year routine appointment, the maxillary canine Ncm following the manufactures recommendations and implant/restoration demonstrated excellent tissue and bone verified with a calibrated torque wrench (Figure 15). A piece of Teflon tape was placed into the crowns screw access PermaFlochannel and (Ultradent then the area Products,Inc. over the tape South was filled Jordan, with UT) a light- to doesstability not maintain (Figure 18). daily Minimal oral hygiene gingival that inflammationthe human patient was cured radiopaque, methacrylate-based flowable composite, noted with a lack of bone loss even though the feline patient restorations contours (Figures 16). seal trhe screw access channel and match the surrounding would practice.

Figure 16: Composite has been placed to seal the

appearancerestoration of screw the restoration. access following placement of teflon Figure 18: tape over the fixation screw to complete the esthetic gingival health surrounding the implant and its restoration Four year routine follow-up demonstrating

andDiscussion an absence of gingival inflammation. The nine day and six week re-call appointments presented with minimal inflammation and good implant asstability it relates related to the to adjacentthe emergence soft tissue, profile as aof good the restoration. emergence under no circumstances, should ever be placed in dogs and The axial contour of the natural tooth or prosthetic crown Dental implants in the view of many veterinarians, hygiene near the gingival sulcus limiting potential for soft programs [20]. profile has been shown improve the effectiveness of oral rigorousfelines for training many reasonsis necessary including to develop lack of acceptable formal training and impaction during mastication is eliminated [19] (Figures predictable outcomes.The authors In contrast would other agree disciplines that formal that andare tissue recession and marginal inflammation related to food universally accepted, such as, endodontics, orthodontics, and periodontics, are continually utilized to save, not extract, 17). Design of the restoration allows long-term maintenance functional teeth in our pets. Ironically, the favored argument of the gingival health without inflammation.

Conclusion is that pets do very well without their teeth. predictableMany years option ago for companion there was animals. very little Yet, evidenceover the years that Utilizing AO inflammatory socket modifications endodontic and orthodontic treatment was a viable and maintenancecombined with of the an surrounding innovative bone osteotomy and its quality technique and accepted as a predictable valuable service that can be offered implant(osseodensification) stability thus thepreventing surgical future site cancollapse be optimized of the buccal by and with a number of Until published recently case there reports, has been it has minimal been plate. Immediate implant /restoration can be a manageable evidence in the literature that dental implants have ever been approach to restore the feline patient to full function and toapplied pet owners in specialized [21-25]. treatment planning in canine and feline preclude the serious common complication of feline maxillary dentistry. Because clinical case documentation and short canine extraction, lip-entrapment. Extraction and immediate and long term follow up is lacking, many would consider this treatmentimplant placement for this common with early feline loadingdental condition. utilizing the new discipline experimental. However, the principal author has osteotomy protocol with Densah burs provides a predictable manyplaced appearing 60 implants in inmultiple 40 feline publications patients with in Veterinarymore than halfand References Humanbeing restored. dental journals All cases [26-28]. have complete documentation with 1. Feline Alveolar Osteitis is a common presenting problem that the veterinary dental clinician has to deal extrusionLewis JR, and Okuda tooth A, resorption Shofer FS, in Pachtinger domestic G,cats. Harvey J Vet DentCE, et 25 al. (2): (2008) 86-95. Significant association between tooth the affected tooth, buccal bone osteoplasty, and extensive with routinely. Most cases require surgical extraction of 2. Clinical Periodontology, 12th (Edn.), St. Louis Missouri: Newman MG, Takei HH, Klokkevold PR (2015) Carranza’s debridement before a tension free gingival flap is closed. Sanders pp: 875. In this case presentation we explore a paradigm shift in 3. the treatment of AO with surgical extraction, utilizing the augment treatment of chronic periodontitis of canine alveolar inflammatory changes (bone buttressing) and a an ideal site for immediate implant placement, excellent teethBeebe in DE,a cat. Gengler J Vet Dent WR 24(1): (2007) 30-38. Osseous surgery to osteotomy drilling protocol (osseodensification) to develop 4. protocolprimary has stability proven and effective a prosthetic and predictable crown restorationin over 40 plus 13 alveolar bone expansion. Can Vet J Mar 56(3): 295-300. weeks following implant placement. This new treatment D’Astous J (2015) Periodontology: An overview of 5. cases. Although, implants may be viewed as being an esthetic lipsolution, support. quality The implantof life is and important restoration and nothas onlybeen provides shown to a Bell CM, Soukup JW (2015) Histological, Clinical, and normalimprove functioning the feline’s maxillary lifespan by canine improved yet prevents eating abilitya common and 52(5):Radiographic 910-918. Findings of Alveolar bone expansion and complication, lip entrapment, especially in the feline patient. osteomyelitis in the jaws of cats. Veterinary Pathology 6. approach in Implant Osteotomy Preparation to increase BiomechanicalHuwais S, Meyer Primary EG (2016) Stability, A Novel Bone Osseous Mineral Densification Density, Customized digital planning is now being utilized in and Bone-to- Implant contact. J Oral Maxillofac Implants 32(1): 27-36. dentalall our laboratoryimplant crown creates restoration a soft tissue cases model compared and subsequent to older techniques utlizing direct wax-ups. With digital planning, the castings employing advanced computer-aided design. The 7. computer aided process produces more precise restorative surgery: The osteotome technique. Compendium 15(2): results than the traditional methods of the past. 152-162.Summers KB (1994) A New concept in Maxillary implant

Detailed post-op instructions for the long-term survival 8. (1994) The eﬀect of bone composition on early fixation ofGreen porous-coated JR, Nemzek implants.JA, Arnoczky J Arthroplasty SP, Johnson 14(1): LL, Balas 91-97. MS foodof the only implant/crown (no dry food), restoration no toys and are gentle discussed cleaning and of sent the home with the owner in the departing instructions. Softer 9. implant placement. Pain medication and antibiotics are dispensedprosthesis onwith case soft by moist case swabs basis. daily for 2-4 weeks following Kold S, Rihbek O, Vester M, Overgaard S, Soballe K (2005) Bone compaction enhances fixation of weight bearing titanium implants. Clin orthop Relat Res 431: 138-144.

10. dentistry for the improved aesthetics and function. Pract Periodontics Aesthetics Dent 10 (2): 177-186. Trisi P, Bernardini M, Falco A, Podaliri M (2016) New evaluationOsseodensification in sheep. Implant implant Dentistry site preparation 25(1): 24-31. method 19. to increase bone density in low-density bone. In Vitro contour. Part II: Clinical Considerations. J Prosthet Dent 11. 63(4):Croll BM 374-379. (1990) Emergence profile in natural tooth reaction of cortical bone to compression. ACTA Orthop ScandPerren Suppl SM, 125: Huggler 19-29 A,. Russenberger M (1969) The 20. the use of dental Implants in dogs and cats. J AM Vet Med 12. Trisi P, Todisco M, Comsolo U, Travaglini D (2011) AssocTannenbaum 243(12): J, Arzi 1680- B, Reiter1685. AM (2013) The case against

morphometric, and bio medical study in sheep mandible. 21. Visser C (1990) Endodontology: Chronic Maxillary Sinus IntHigh J Oral versus Maxillofac low implant Implants torque: 26(4): A 837-849. histological, histo- abcessation in the Canine. J Vet Dent 7(2): 12-13.

13. 22. Eisner E (1990) Transcoronal approach for endodontic approaching implant osteotomy preparation to increase access to the fourth maxillary premolar in dogs. J Vet bioHuwais mechanical S, Meyer primaryEG (2017) stability, A Novel bone osseous mineral densification density Dent 7(4): 22-23. and bone-to- implant contact. Int J Oral Max-illofac 23. Willams C (1986) Endodontics. Vet Clin North Am Small Implants 32(1): 27-36. Anim Pract 16(5): 875-893. 14. 24. Visser C (1991) Coronal access of the canine dentition. J implant stability and its impact on implant survival : A Rodrigo D, Aracil L, Martin C, Sans M (2010) Diagnosis of Vet Dent 8(4): 12-16. 255-261. 25. prospective case series study. Clin Oral Impl Res 21(3): of root canal treatment in dogs 127cases (1995-2000). J 15. Chu SJ, Salama MA, Salama H, Garber D, Saito H, et AmKuntsi-Vaattovaara Vet Med Assoc 220(6): H, Verstraete 775-780. F, Kass P (2002) Results al. (2012) The dual-zone thera-peutic concept of managing immediate implant placement and provisional 26. restoration in anterior extractionug. 33(7). Feline Dental Implants in Maxillary Alveolar Osteitis Mele RE, Kurtzman GM (2019) New paradigm shift in 16. Baltayan S, Anfruns JP, Aghaloo T, Moy P (2016) The Spring 11(3): 1-8. predictive value of resonance frequency analysis in treatment with osseodensification. Spectrum Implants – surgical placement and loading endosseous implants. J 27. Oral Maxillofac Surgery 74(6): 1145-1152. 34Mele (4): RE, 249-258. Caiafa A, Kurtzman GM (2017) Feline Dental 17. Implants: Long term follow - up of two cases. J Vet Dent to achieve biologic mechanical and esthetic objectives. 28. Rieder C (1996) Customized implant abutment copings and Incisor Bridge Placement in a Dog. J Vet Dent 33(4): 249-258.Mele RE, Caiafa A, Kurtzman GM (2016) Dental Implants 18. ChicheInt J Periodont FA, Leriche Restorative MA (1998) Dent Multi-diciplinary 16(1): 20-29. implant