Assessment of Implant Stability in Immediate Implant Placement using Different Bone Grafting materials: A Clinical Study.

AIM: The aim of the present study was to assess the implant stability in immediate implant placement using different bone grafting materials.
MATERIALS AND METHODS: Twelve patients (5 males, 7 females, range of 40-58 years) were included in the study. All patients were divided into two groups based on the graft material used. For Group 1, Xenograft bone grafting material was used, and for Group 2, Freeze-dried bone allograft was used. The patients were suggested to rinse with 0.2% chlorhexidine mouth wash for 1 min. Periotome was used for atraumatic tooth extraction, and necessary care was taken to avoid fracture of socket wall. The implant was placed with respective bone grafting materials. An Orthopantomogram (OPG) radiograph is taken at the day of the operation to serve as baseline data for the marginal bone level. Clinical and radiological parameters were evaluated at baseline, 3 months, 6 months, and 12 months to assess the mean marginal bone level changes. Periotest was used for the measurement of implant stability.
RESULTS: The mean marginal bone level in Group 1 at baseline (13.58 ± 1.09), 3 months (12.64 ± 0.88), 6 months (12.02 ± 1.42), and 12 months (11.20 ± 1.26), respectively. In Group 2, the marginal bone level was at baseline (14.22 ± 0.26), 3 months (13.52 ± 1.28), 6 months (13.10 ± 0.32), and 12 months (12.12 ± 1.26), respectively. There was a statistically significant difference found in both the groups. Moreover, there was no statistically significant differences found between the groups at all the duration on intergroup comparison of the mean marginal bone level. The mean difference of implant stability in Group 1 the implant stability was 188.6 ± 22.5 and in Group 2 was 191.5 ± 18.2, and there was no statistically significant difference found between the groups.
CONCLUSION: Both bone grafting materials used in the study showed improvement in implant stability and marginal bone levels after immediate placement of implant. Copyright:

INTRODUCTION

A highly reliable treatment modality for replacing a failing tooth is single-tooth immediate implant placement and provisionalization, within the esthetic zone. Research interest has been shifted from implant survival toward optimal preservation of sentimental and hard tissue due to reduced treatment time and improved esthetics and luxury, resulting in increasing patient expectations. Immediate placement and restoration of implants are strongly recommended whenever feasible. The ultimate esthetic outcome may be influenced by a couple of factors,[1] one among the foremost significant is recession of the marginal peri-implant mucosa. Of utmost importance is maintaining the soft tissue and underlying bone as it is clearly associated with the bone levels surrounding the implant.[2]

To reduce the bone resorption and damage, atraumatic extraction method is used which utilizes instruments such as periotomes. The ultimate outcome of bone remodeling phase is difficult to predict because of individual variability which complicates the esthetic outcome, despite the residual buccal bone postextraction.[3]

Only half of implantation sites depict bone deficiency. There are half immediate implant placement in anterior teeth zone need bone enhancement. Due to the defect of buccal wall in the anterior, half of the immediate implant placement occurs in the anterior teeth zone; otherwise this can lead to trauma, apical periodontitis, and periodontitis.[4] To revive functional, bridges, and esthetic deficit occurring due to missing teeth, dental implants are considered as an alternative for denture. An alternate treatment for traditional dental implants which reduce physiological resorption of the alveolar ridge is immediate implants placed in freshly extracted sockets.[5] Hence, the present study was conducted to assess the implant stability in immediate implant placement using different bone grafting materials.

MATERIALS AND METHODS

Twelve patients (five males and seven females, range of 40–58 years) were involved in the study. Patients at least 18 years old. Indication of single tooth extraction in the anterior maxilla, presence of teeth adjacent mesial and distal to the extraction site. At least 5 mm of solid bone in the alveolar process and apical to the alveolus of the failing tooth to ensure initial implant stability were included in the study.

Patient who had not committed to a smoking cessation protocol, heavy smokers, lack of oral hygiene compliance or poor plaque control, parafunctional habits such as bruxism, uncontrolled periodontal disease, and uncontrolled diabetes were excluded from the study.

Surgical procedure

Based on the graft material used, all patients were divided into two groups. For Group 1, xenograft bone grafting material was used, and for Group 2, freeze-dried bone allograft was used. The patients were suggested to rinse with 0.2% chlorhexidine mouth wash for 1 min. Periotome was used for atraumatic tooth extraction, and necessary care was taken to avoid fracture of socket wall. The sockets postextraction was cautiously cleaned of any remains of granulation tissue, the integrity of the labial bone assessed and whenever apt, to visualize the crestal bone margin on the labial aspect, minimally invasive crestal flap was used. To prepare the socket for the implant, drills were used. The axis of the implant was allied with the incisal edges of the contiguous teeth or be slightly palatal to this landmark. A minimum of 2 mm apical to the interproximal and crestal bone is where the implant head was placed. A collagen membrane was tucked in palatal attached mucosa and bone graft particles after preparation were condensed into the gap and the socket is then covered with collagen membrane; this was followed by approximation of the flap and primary closure utilizing interrupted 3/0 braided black silk sutures. An OPG radiograph is taken at the day of the operation to serve as baseline data for the marginal bone level.

With the following clinical and radiological parameters, patients were evaluated at baseline, 3 months, 6 months, and 12 months to assess the mean marginal bone level changes. All the above parameters were considered for the implant site. For measurement of implant, secondary stability periotest (PeriotestS3218, Medizntechnik, Gulden) was used.

Statistical analysis

SPSS 20® (statistical Package for Social Science, IBM, USA) was used for statistical analysis. Data presented as means and standard deviation values. Paired t-test was used to analyze the difference between the two bone grafting materials. The P < 0.05 was considered statistically significant.

RESULTS

Table 1 shows that the intragroup comparison of the mean marginal bone level. In Group 1, the marginal bone level was at baseline (13.58 ± 1.09), 3 months (12.64 ± 0.88), 6 months (12.02 ± 1.42), and 12 months (11.20 ± 1.26), respectively. In Group 2, the marginal bone level was at baseline (14.22 ± 0.26), 3 months (13.52 ± 1.28), 6 months (13.10 ± 0.32), and 12 months (12.12 ± 1.26), respectively. There was a statistically significant difference found in both groups.

Table 1

Intragroup comparison of mean marginal bone level

Groups	Mean±SD	t	P
Group 1: Xenograft
Baseline	13.58±1.09	9.226	0.001
3 months	12.64±0.88
6 months	12.02±1.42
12 months	11.20±1.26
Group 2: Freeze-dried bone allograft
Baseline	14.22±0.26	6.020	0.001
3 months	13.52±1.28
6 months	13.10±0.32
12 months	12.12±1.26

SD: Standard deviation

Table 2 shows that the intergroup comparison of mean marginal bone level, and there was no statistically significant difference found between the groups at all the duration.

Table 2

Intergroup comparison of mean marginal bone level

	Group 1: Xenograft	Group 2: Freeze-dried bone allograft	P
Baseline	13.58±1.09	14.22±0.26	0.862
3 months	12.64±0.88	13.52±1.28	0.911
6 months	12.02±1.42	13.10±0.32	0.659
12 months	11.20±1.26	12.12±1.26	0.821

Table 3 shows that the mean difference in implant stability. In Group 1, the implant stability was 188.6 ± 22.5 and in Group 2 was 191.5 ± 18.2, and there was no statistically significant difference found between the groups.

Table 3

Mean difference of implant stability

Groups	Changes in implant stability (mean±SD)	P
Group 1: Xenograft	188.6±22.5	0.926
Group 2: Freeze-dried bone allograft	191.5±18.2

SD: Standard deviation

DISCUSSION

After tooth extraction, catabolic changes start with bundle bone resorption, which lines the extraction socket as a part of bone remodeling, and this is a tooth-dependent structure. The bundle bone represents about 0.2–0.3 mm width at the palatal bone plate, while it is usually ≥2 mm at the buccal bone plates, which appears to cover the entire width of the buccal bone in the coronal part of the tooth socket. Lack of both mechanical stimulus and vascular blood supply due to loss of periodontal ligament are the factors that affect the degree of vertical and horizontal bone alterations after tooth extraction. In the course of time, with decreased blood supply, the bundle bone becomes nonviable and finally undergoes complete resorption.[6]

The current study applied two bone substitutes that are most frequently used in bone augmentation procedure. Implant stability measurements have shown improved secondary stability with both types of grafts; this is attributed to qualities of the applied bone grafts, leading to stabilization and bone formation around the implant, thus increasing in the bone implant contact which coincide with the results stating values of periotest are decreased when surface area connection is increased.[7]

It is not easy to select an implant perfectly matching the dimensions of the extracted socket even though the immediate implant placement is very reliable and predictable. For primary stability and better osseointegration, the horizontal defect dimensions or so-called “jumping distance” hae to be filled with a graft material, despite the advances in the design technologies and clinical expertise. A tissue or material utilized to restore a defect or deficiency in silhouette and/or volume is defined as a bone graft. The rationale for using different graft materials for different clinical applications or the basis for using combinations of materials, and their percentages in combination are not very clear as there is a diversity of opinions regarding the same. Before implant placement, different types of biocompatible graft materials were widely used in bone regeneration procedures.[8]

The reduced vertical and horizontal dimensions of the ridge are due to bone remodeling as a consequence to tooth extraction. Postextraction alveolar bone changes analysis using standardized radiographs and study casts was done by Schropp et al.[9] Implants inserted in healed bone and implants placed in postextraction sockets have similar predictability. The physiologic resorption of the buccal bone plate is not influenced by the placement of implants in fresh extraction sockets, as it is mainly composed of bundle bone, which is proved by many studies.[10]

There is a need of more randomized clinical trials to compare both treatment approaches with longer follow-up. In further studies, the evaluation of soft-tissue dimensional changes and clinical primary outcomes such as bone density and quality of life after immediate implant placement.

CONCLUSION

The present study concluded that both bone grafting materials used in the study showed improvement in implant stability and marginal bone levels after immediate placement of the implant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.