A Minimally Invasive Approach Using a 4-Mm Implant Without Extraction of Impacted Maxillary Canine: Four-Year Postloading Results

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A Minimally Invasive Approach Using a 4-mm Implant Without Extraction of Impacted Maxillary Canine: Four-Year Postloading Results

Pietro Felice, MD, DDS, PhD1 The maxillary canines are the most Carlo Barausse, DDS2 commonly impacted permanent Martina Stefanini, DDS, PhD3 teeth after the third molars.1 Be- Roberto Pistilli, MD4 tween 25% and 50% of the general 5 Giovanni Zucchelli, DDS, PhD population are affected by impacted teeth,2 with the prevalence of The aim of this case report was to suggest an alternative minimally invasive maxillary canine impaction ranging surgical approach to an impacted maxillary canine using a 4-mm-long implant from 1% to 3%.3–5 Impactions are for a fixed prosthetic rehabilitation, avoiding tooth extraction or surgically twice as common in females (1.17%) forced extrusion and exploiting the 6 mm of coronal bone availability. At 4 as in males (0.51%); of all patients years postloading, the implant was healthy and well integrated with stable marginal bone levels. The 4-mm length of the implant reduced operative with maxillary impacted canines, it times, postsurgical morbidity, possible complications, and costs. Short implants is estimated that 8% have bilateral might be an alternative to traditional, more invasive surgical procedures impactions.4 The most common used in the rehabilitative treatment of impacted maxillary canines. Int J causes for canine impactions are Periodontics Restorative Dent 2017;37:819–824. doi: 10.11607/prd.3334 the result of any one or a combina- tion of the following factors: tooth size–arch length discrepancies, prolonged retention or early loss of the deciduous canine, ankylosis, cys- tic or neoplastic formations, dilac- erations of the root, and idiopathic conditions with no apparent cause.4 Another important etiologic factor associated with canine impaction is the absence of the maxillary permanent lateral incisor, as proposed by 1Researcher, Department of Biomedical and Neuromotor Sciences, Unit of Periodontology the guidance theory.6 About one- and Implantology, University of Bologna, Bologna, Italy. third of impacted maxillary canines 2 Resident, Department of Biomedical and Neuromotor Sciences, Unit of Periodontology and are positioned labially or centrally, Implantology, University of Bologna, Bologna, Italy. 3Resident, Department of Biomedical and Neuromotor Sciences, University of Bologna, and two-thirds are located pala- Bologna, Italy. tally.7 While ectopic labially posi- 4Resident, Oral and Maxillofacial Unit, San Camillo Hospital, Rome, Italy. tioned canines may erupt without 5Professor, Department of Biomedical and Neuromotor Sciences, University of Bologna, surgical or orthodontic treatment, Bologna, Italy. palatally impacted canines seldom Correspondence to: Prof Giovanni Zucchelli, Department of Biomedical and Neuromotor erupt on their own.2 It is believed Sciences, University of Bologna, Via San Vitale 59, 40125 Bologna (BO), Italy. that this impeded eruption is due Fax: +39 051 225208. Email: [email protected] to the thickness of the palatal cor- ©2017 by Quintessence Publishing Co Inc. tical bone as well as the thick and

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© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 820 resistant palatal keratinized tissue.4 most desirable approach.4 Unfor- deciduous canine had been lost The possible consequences of ca- tunately, a high frequency of failure about 30 years earlier and that the nine impaction include migration of of the orthodontic treatment has permanent tooth never erupted. A the neighboring teeth, dentigerous been demonstrated in adult pa- cone beam computed tomography cyst formation, external root resorp- tients.12 As a consequence, surgi- (CBCT) scan was obtained to evalu- tions, infection (particularly with par- cal extraction followed by implant ate the canine position and its rela- tial eruption), and referred pain.8 therapy could be an alternative for tionship to neighboring teeth. The The preferred management of adults.6,11,12 However, this procedure CBCT scans showed a palatal loca- an ectopic permanent canine in a usually requires bone augmentation tion of the impacted canine without young patient is early diagnosis and and might cause additional morbid- root resorption of the lateral incisor. interceptive treatment.3–5 The diag- ity and complications.11,13 –15 Mazor The mean residual bone under the nosis of canine impaction is based et al16 suggested an alternative ap- impacted tooth was 6 mm in height on clinical and radiographic exami- proach to avoid impacted canine ex- and 7 mm in width (Fig 2). nations.8 It has been suggested that traction by using computer-guided The more traditional surgical the following clinical signs might in- implant placement to provide an options (extraction of the impact- dicate canine impaction: prolonged implant adjacent to the impacted ed canine, grafting the atrophic retention of the deciduous canine canine without contacting it. These site, and implant placement after beyond 14 to 15 years of age, ab- authors concluded that this proce- 6 months of healing; immediate sence of a normal labial canine bulge dure could provide a short treat- implant placement and grafting of or its palatal presence during intra- ment time and fewer complications the impacted canine extraction site; oral palpation, and migration of the compared to the extraction. and exposure of the tooth and orth- lateral incisor.8,9 A radiographic sign The present case report evaluat- odontic treatment) were explained that might be indicative of canine ed the 4-year postloading outcome to the patient, but she declined impaction is the inclination of the ca- of an alternative minimally invasive these in favor of a faster and less in- nine from the midline observed on a approach to an impacted maxillary vasive solution. To meet her needs, panoramic radiograph: if the angle canine using a 4-mm-long implant, a less invasive fixed prosthetic so- between the tooth and the midline is exploiting the 6 mm of coronal bone lution was adopted using a 4-mm greater than 25 degrees, the canine available and avoiding contact with implant. The patient underwent full- is at risk of inclusion.10 the impacted tooth. mouth professional oral hygiene 2 However, the diagnosis of an weeks before the planned surgery impacted canine is frequently de- and gave informed consent for all layed and the patient often requires Materials and Methods surgical procedures. The guidelines surgical intervention as a part of the of the Declaration of Helsinki were treatment.11 When the patient is an A 54-year-old systemically healthy observed. Amoxicillin (2 g) was ad- adult, the clinician should consider woman was referred for a fixed ministered 1 hour prior to implant the following treatment options: no prosthetic rehabilitation of her placement, and the patient rinsed treatment if the patient does not edentulous maxillary left canine site. for 1 minute with 0.2% chlorhexi- desire it (in this case, the clinician Preliminary clinical and radiographic dine. The surgical procedure was should periodically evaluate the (orthopantomogram) evaluations performed under local anesthesia impacted tooth for any pathologic showed an edentulous left canine (4% articaine, 1:100,000 adrena- changes), extraction of the impact- space due to the impaction of the line; Citocartin, L. Molteni & C. dei ed canine, and surgical exposure of left permanent canine, treated with Fratelli Alitti). A crestal incision was the canine and orthodontic treat- a provisional prosthesis solution made, a full-thickness flap was ele- ment to bring the tooth into the that did not suit the patient’s needs vated, and a 4 × 4-mm transmuco- line of occlusion. The latter is the (Fig 1). The patient stated that the sal short implant (twinkon 4, Global

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Fig 1 Preoperative panoramic radiograph (orthopanto- Fig 2 Presurgical CBCT scan showing the mean residual bone under the mogram) showing the maxillary left canine impaction. impacted tooth (approximately 6 mm height and 7 mm width).

Fig 3 Short (4 mm long and 4 mm in diameter) implant. Fig 4 4 × 4 mm short implant. Note the Fig 5 Postsurgical periapical presence of the stop in the dedicated drill. radiograph showing the 4-mm implant position in the maxillary left canine site.

D) was placed, using dedicated drills with stops, in the maxillary left canine site (Figs 3 and 4). Flaps were carefully sutured with Vicryl 4-0 (Ethicon FS-2, Ethicon). Postsurgical radiographs (periapical radiograph and CBCT scan) were taken after implant placement to verify the correct implant position and the absence of contact with the impacted tooth (Figs 5 and 6). The patient was prescribed 1 g amoxicillin with clavulanic acid twice a day for 6 days and 400 mg ibuprofen twice a day with meals, in the presence of pain, as long as required. The patient was instructed to place 1% chlorhexi- Fig 6 Postsurgical CBCT scan showing implant position and the absence of dine gel on the wound twice a day for 2 weeks contact with the impacted canine. and to avoid brushing and trauma on the surgical site, and a soft and cold diet was advised for 1 week.

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a b Fig 7 Periapical radiographs taken (a) 4 and (b) 6 months after Fig 8 Panoramic radiograph (orthopantomogram) implant placement: no radiologic problems detected. after definitive prosthesis delivery 6 months and 2 weeks after implant surgery.

Fig 9 Periapical radiographs at (a) 2, (b) 3, and (c) 4 years postloading, showing the radiologic stability over time.

a b c

Results ful. At 6 months after implant placement, the healing abutment was Sutures were removed after 7 days, connected; 2 weeks later a definitive and the patient was examined clini- screw-retained prosthesis was deliv- cally each week in the first month ered, avoiding cuspid guidance and after surgery and twice in the sub- lateral loading (Fig 8). sequent month. The patient was At 1, 2, 3, and 4 years after pros- also enrolled in an oral hygiene thetic loading, the implant and the

Fig 10 Clinical image of the definitive program with recall visits every 6 impacted tooth showed no clinical prosthesis 4 years after loading; the patient months. Clinical and periapical ra- or radiologic signs of failure or com- is fully satisfied from both the functional diographic checks were made at 4 plication. No bone loss around the and esthetic points of view. and 6 months after the surgery, and implant was observed, and the pa- no complications were detected tient was fully satisfied from a func- (Fig 7). The healing process and the tional and an esthetic point of view postoperative course were unevent- (Figs 9 and 10).

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Discussion all other factors seems to be favor- by selecting short implants as an able.18 This indicates that the prog- alternative treatment. Furthermore, According to Dewel,17 maxillary ca- nosis for a successful orthodontic a short-term (4 months and 1 year nines have the longest period of resolution of an impacted canine in after loading) randomized clinical development and the longest and adults is by no means certain and trial (RCT) showed that 4 × 4-mm most tortuous course to travel from that it worsens with age.12 This is implants placed in native bone in the point of formation, lateral to the presumably due to ankylosis of the the presence of adequate bone piriform fossa, to their final desti- impacted tooth to the surrounding volume achieved similar results to nation in full occlusion. The most bone.12,18 As a consequence, the longer implants.23,24 Two other RCTs common impaction encountered by patient should be informed of the seem to confirm these good results, orthodontists is palatal impaction of possibility of failure, a factor that, to- with 4- and 5-mm-long implants maxillary canines.7 Because palatally gether with the increased treatment achieving similar, if not better, out- impacted canines are frequently as- time, must be taken into consider- comes with fewer complications25,26 sociated with minor malocclusions,2 ation in the decision-making process than longer implants in augment- occasionally the impaction eludes from the outset. To avoid surgical ed jaws. Regarding the debated diagnosis until a much older age, removal of the canine, Davarpahah crown-to-implant ratio, the literature when exfoliation of the deciduous and Szmukler-Moncler19 described indicates that high ratios are not canine occurs or a routine radio- several cases of implants placed associated with more peri-implant graphic examination by a general through the impacted teeth; all the bone loss or implant failure.27–30 dentist shows the impacted tooth.12 implants healed uneventfully except However, some literature shows Adults need to know what level for an 8.5-mm-long implant that be- more prosthetic complications relat- of success can be expected in treat- came mobile after 4 months. The ed to a high crown-to-implant ratio. ing the impacted tooth and the authors suggested that placement To avoid this kind of problem, the duration of the treatment.12 When through an impacted tooth might occlusal scheme in the prosthetic re- impacted teeth are asymptomatic not interfere with implant integra- habilitation of short implants should and do not undergo any pathologic tion, but further studies and longer be carefully planned, for instance in changes, surgical removal might not follow-ups are necessary to consider the present case, by avoiding cuspid be necessary.4 Sometimes, as in the this procedure a predictable clinical guidance and lateral loading. present case, patients ask for reha- treatment. On the other hand, this less in- bilitation of the site after the loss of The use of short implants rep- vasive implant solution to manage the deciduous canine. Regarding resents a simplified approach that canine impaction cannot be ad- surgical extraction followed by im- could reduce operative times and opted in young growing patients plant therapy, it should be explained costs as well as intraoperative and because of the problem of infraoc- to the patient that impacted tooth postoperative patient discomfort.20 clusion of the adjacent natural teeth. removal might be complex and in- This is even more true if one consid- vasive. Moreover, after extraction, ers that postoperative pain is greater bone augmentation procedures after surgery on impacted maxillary Conclusions are often required before implant canines than on other impacted placement. An alternative solution teeth.21 Moreover, when the canine Within the limitations of this case is surgical exposure of the tooth fol- is located near the neurovascular report, 4-mm-long implants could lowed by forced orthodontic extru- bundle, paresthesia may occur after reduce operative time and costs, sion. It has been demonstrated that the surgery.21 Other problems as- complications, and postsurgical canines impacted for many years sociated with orthodontic traction, morbidity with respect to more frequently undergo changes that such as failure to erupt, bond failure, conventional surgical or surgical- prevent their eruption even when and ankylosis,22 could be avoided orthodontic procedures currently

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adopted for the management of im- 7. Johnston WD. Treatment of palatally im- 21. Alberto PL. Management of the impact- pacted maxillary canines in adults. pacted canine teeth. Am J Orthod 1969; ed canine and second molar. Oral Maxil- 56:589–596. lofac Surg Clin North Am 2007;19:59–68. As always in implant therapy, accu- 8. Bishara SE. Clinical management of im- 22. Kokich VG. Surgical and orthodontic rate case selection combined with pacted maxillary canines. Semin Orthod management of impacted maxillary ca- 1998:4:87–98. nines. Am J Orthod Dentofacial Orthop precise surgical procedures, fol- 9. Williams BH. Diagnosis and prevention 2004;126:278–283. lowed by appropriate oral hygiene of maxillary cuspid impaction. Angle Or- 23. Esposito M, Barausse C, Pistilli R, et al. and maintenance programs, are cru- thod 1981;51:30–40. Posterior jaws rehabilitated with partial 10. Incerti Parenti S, Marini I, Ippolito DR, prostheses supported by 4.0 × 4.0 mm cial for long-term success. 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