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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 104-108

Management of long-standing edentulous space with dental implants: An interdisciplinary approach


Dent-Align, Orthodontic, Multispeciality Dental and Implant Clinic, Mumbai, Maharashtra, India

Date of Submission20-May-2021
Date of Acceptance11-Oct-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Dr. Monish Shashikumar Naidu
B-102, Chancellors Court, Jeevan Bima Nagar, Borivali West, Mumbai - 400 103, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_8_21

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   Abstract 

Long-standing edentulous cases due to missing permanent mandibular first molars commonly result in mesial tipping and migration of second molars in the edentulous space. In order to place an optimum-sized dental implant and crown for replacement of the missing tooth space regaining by uprighting and distalization of the second molar is essential. Various orthodontic techniques using fully bonded fixed appliances and segmental orthodontics with coil springs, loops, and miniscrew orthodontic implants have been used for space regaining. Obtaining three-dimensional control during tooth movement in segmental orthodontics is challenging as all the forces are applied to the teeth buccally. This case report shows a method to regain space using a long head miniscrew orthodontic implant placed at the retromolar pad area with three-dimensional control during second molar uprighting and distalization followed by restoration with a dental implant.

Keywords: Dental implant, distalization, miniscrew implant, retromolar


How to cite this article:
Naidu A, Naidu MS. Management of long-standing edentulous space with dental implants: An interdisciplinary approach. J Dent Implant 2021;11:104-8

How to cite this URL:
Naidu A, Naidu MS. Management of long-standing edentulous space with dental implants: An interdisciplinary approach. J Dent Implant [serial online] 2021 [cited 2022 Aug 7];11:104-8. Available from: https://www.jdionline.org/text.asp?2021/11/2/104/332477




   Introduction Top


A premature loss of a permanent mandibular first molar due to caries or periodontal disease can lead to mesial tipping and translation of the adjoining second molar.[1] The results of long-standing cases of molar tipping are (1) elongations of opposing teeth, (2) balance interferences and symptoms from temporomandibular joints and muscles, (3) paralleling and space problems in conjunction with prosthetic rehabilitation, (4) traumatic occlusion, and (5) bone defects on the mesial surface of the tipped molar.[2],[3]

Uprighting the tipped second molar and additional distalization will help regain the space for replacement of the missing permanent first molar. This space can then be restored prosthetically with a dental implant or fixed partial denture. Uprighting and distalization for space regaining can be achieved with many conventional orthodontic techniques, but they involve multibracket comprehensive treatment. Whereas the use of skeletal anchorage, i.e., miniscrew implants (MI), allows direct application of precise force systems to the target tooth or segment without involving other teeth or using inter-arch mechanics. This eliminates the reaction forces usually applied on the anchor teeth, thus preventing unwanted tooth movement and anchorage loss.[4]

The purpose of this case report is to showcase an interdisciplinary approach for replacement of a missing tooth with a dental implant using orthodontic miniscrew implant at the retromolar pad area for space regaining.


   Case Report Top


We report a case of a missing lower left permanent first molar in a 46-year-old male patient who desired replacement of tooth no. #36 with dental implants. The tooth was extracted 5 years ago due to caries. On examination intraorally, the patient had a complete dentition in all four quadrants except missing #36 and #38. Orthopantomogram (OPG) examination showed that #16 has been replaced by dental implants and #24 and #46 were endodontically treated. #37 was tipped mesially and had drifted into the edentulous space of #36 [Figure 1]. Although mesially tipped molars adjacent to edentulous spaces exhibit varying degrees of lingual rolling, intraorally #37 showed minimum lingual rolling and good occlusal interlocking. The mesiodistal width between #35 and #37 was 5 mm, an amount of space inadequate to place a dental implant. Hence, uprighting and distalization of #37 was planned.
Figure 1: Pretreatment radiograph shows mesially tipped lower left second molar

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Orthodontic phase

A 1.4 mm × 10 mm (LH 14–10, AbsoAnchor, Dentos, Korea) long head (LH)-type miniscrew implant was selected [Figure 2]. The retromolar pad was chosen because the tooth was positioned in the line of the arch and exhibited minimum lingual rolling. The implant was placed using a long handle driver (Dentos, Korea) and was self-drilled at the retromolar area 10 mm from the distal surface of #37 [Figure 3] and [Figure 4]. The biomechanical objectives were distalization of #37 which included uprighting, translation, and rotation control.
Figure 2: Long head miniscrew implant (AbsoAnchor, Dentos Inc., Korea)

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Figure 3: Miniscrew implant placed at the retromolar pad area

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Figure 4: Intraoral radiograph: Implant site

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After 4 weeks of implant placement (MI), a button was bonded on the mesial surface of #37 and a continuous power chain was run from the button to the implant head [Figure 5]. This was done to achieve primary uprighting and mild translation. Canine bite ramps made with Glass ionomer cement Type IX (GC Gold label, GC Corporation, Japan) restorative cement were placed lingual to #13 and #23 to jump the bite and provide clearance for uprighting [Figure 6]. After 4 weeks, additional attachments were bonded to the buccal and the lingual surface of #37. Buccally, a #47 molar tube was bonded to #37 in order to reverse the direction of the hook, and lingually, a button was bonded. Care was taken to bond both the attachments at the same height to minimize rotation and rolling. Power chains were run additionally from these attachments to increase the intensity of translation [Figure 7]. Although some soft-tissue growth was observed at the implant site, the LH implant did not submerge.
Figure 5: Power chain for uprighting molar

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Figure 6: Canine bite ramps

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Figure 7: Power chains for uprighting and distalization

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Every 4 weeks the power chains were replaced. At the end of 12 weeks, uprighting power chain was stopped and only translation power chains were continued. At the end of 20 weeks, the distalization achieved was 5 mm [Figure 8]. The tooth was tied to the implant by 0.010'' stainless steel ligature wire (Ortho Organizers, USA) and held passively till the implant prosthesis with crown was restored [Figure 9] and [Figure 10]. The GIC canine bite ramps were removed and the occlusion was allowed to settle. The total treatment duration was 20 weeks.
Figure 8: Molar distalization achieved after 20 weeks

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Figure 9: Second molar secured to the miniscrew implant post distalization

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Figure 10: Post distalization radiograph

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Dental implant placement

After stabilizing #37 with the microimplant, treatment planning for the replacement of #36 began. Post distalization OPG revealed abundant bone axially as well as mesiodistally. Clinically, adequate arch width was observed buccolingually. No relevant medical history was revealed, and routine blood investigations were carried out. Full-thickness buccal and lingual flaps were raised at the implant site. Immature bone was visible against the mesial surface of #37, and abundant bone was noted buccolingually for implant placement.

With the help of surgical measurement tools, the purchase point was decided and osteotomy was initiated using a 2-mm pilot drill (TSD 2020, BioHorizons, Alabama, USA) using a surgical contra-angle handpiece (W and H GmbH, Austria). After completing the osteotomy, a 4.6 mm × 10.5 mm tapered internal implant ((BioHorizons, Alabama, USA) was placed at 35 Ncm and final turns were hand torqued using a surgical torque wrench (EL-12374, BioHorizons, Alabama, USA). Implant position was verified radiographically, cover screw was placed, and using nonabsorbable silk sutures (4-0 Mersilk), wound closure was achieved by giving intermittent sutures. Suture removal was done after 10 days post surgery. Stage II surgery was done after 3 months. The cover screw was removed and a healing abutment with regular emergence collar and 5 mm height was placed with the help of a 1.25mm hex driver (135–351, BioHorizons, Alabama, USA).

Prosthetic phase

Two weeks post Stage II surgery, the prosthetic phase of treatment was started. After confirming adequate soft-tissue healing, the depth of soft-tissue collar was measured using a graduated periodontal probe and was found to be just above 5 mm at the distal-most part. Hence, a screw-retained crown was the choice of implant prosthesis.

The lower impression was made using a “snap coping,” with addition silicone impression material, i.e., putty and light body (Silagum, DMG, Germany) and the closed tray technique. Opposing arch impression was made using alginate impression material (Hydrogum, Zhermack, Italy) followed by a wax bite record and shade selection. Laboratory instructions for a screw-retained porcelain-fused-to-metal (PFM) crown were given. The screw-retained PFM crown was fabricated using University of California at Los Angeles (UCLA) abutment, and the crown was fitted onto the implant, with prosthetic screw being hand tightened with the help of the hex driver. The fit of the crown was checked radiographically, and the prosthetic screw was torqued at 35 Ncm. Occlusal equilibration using 40-μ articulating paper (Bausch, USA) was carried out. Standard protocols of fine occlusal reductions were carried out. The crown access hole was sealed with light-cured composite material (P60, 3M ESPE Filtek, USA). Occlusal contacts were rechecked again and the occlusal surface of the crown was finished and polished [Figure 11], [Figure 12], [Figure 13].
Figure 11: Dental implant with occlusal crown placement

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Figure 12: Posttreatment dental implant intraoral radiograph

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Figure 13: Posttreatment occlusion

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Retention

Retention of the distalization was achieved by the restoration of #36 with the implant prosthesis. The ligature wire and the attachments on #37 were debonded. The miniscrew implant was then removed with the implant hand driver, and the case was complete.


   Discussion Top


Long-standing edentulous spaces due to premature loss of mandibular permanent first molars commonly lead to mesial tipping and migration of the lower second molars. This limits the bone available to place an optimally sized implant and not an ideal contact with the tipped second molar. Multiple treatment options are available for uprighting and distalization of the second molars for space regaining, but it involves sound anchorage preparation and control of reactionary forces like extrusion.[5]

In the present case, a segmental treatment approach was planned by using a LH miniscrew implant in the retromolar pad region as a direct anchorage technique. The elastomeric chain attached occlusally provided an uprighting, distalizing, and an intrusive force to the second molar which was desirable followed by uprighting and distalization. This appliance system biomechanically had good rotational control during the distalization phase which is difficult to achieve when forces are applied only on the buccal surface of the molar using coil springs and uprighting loops. The use of the retromolar miniscrew implant eliminates any reactionary forces on neighboring teeth as it is the source of absolute anchorage. The location of the implant, i.e., distal to the tooth moved, also is favorable to act as an anchor to retain the distalized tooth till the permanent first molar is replaced.

The restoration of the edentulous space with the use of dental implants with good surgical technique maintains the bone height, and the restored crown acts as a fixed space maintainer. The time taken for the dental implant to osseointegrate allows settling of the occlusion. This interdisciplinary line of treatment achieved the treatment goal of obtaining adequate mesiodistal space to place an optimum-sized implant with orthodontic attachments placed only on the tooth involved.


   Conclusion Top


Mandibular second molar uprighting and space regaining can be carried out efficiently with the use of miniscrew implants with a LH at the retromolar pad area. This technique works best when the second molar is the most distal tooth and is centrally positioned on the ridge with minimum rolling. The combination use of miniscrew implant for space regaining and dental implant for restoration provides a conservative and efficient modality of treatment for similar cases.

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.
Gracco A, Lombardo L, Cozzani M, Siciliani G. Uprighting mesially inclined mandibular second molars with a modified Uprighter Jet. J Clin Orthod 2007;41:281-4.  Back to cited text no. 1
    
2.
Lundgren D, Kurol J, Thorstensson B, Hugoson A. Periodontal conditions around tipped and upright molars in adults. An intra-individual retrospective study. Eur J Orthod 1992;14:449-55.  Back to cited text no. 2
    
3.
Melo AC, Duarte da Silva R, Shimizu RH, Campos D, Andrighetto AR. Lower molar uprighting with miniscrew anchorage: Direct and indirect anchorage. Int J Orthod Milwaukee 2013;24:9-14.  Back to cited text no. 3
    
4.
Lee KJ, Park YC, Hwang WS, Seong EH. Uprighting mandibular second molars with direct miniscrew anchorage. J Clin Orthod 2007;41:627-35.  Back to cited text no. 4
    
5.
Magkavali-Trikka P, Emmanouilidis G, Papadopoulos MA. Mandibular molar uprighting using orthodontic miniscrew implants: A systematic review. Prog Orthod 2018;19:1.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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