The Tamil Nadu Dr.M.G.R. Medical University In partial fulfilment of the degree of

Dissertation submitted to

The Tamil Nadu Dr.M.G.R. Medical University In partial fulfilment of the degree of

MASTER OF DENTAL SURGERY

BRANCH I

PROSTHODONTICS AND CROWN & BRIDGE 2017-2020

“A COMPARATIVE RADIOGRAPHIC EVALUATION OF CRESTAL BONE LEVELS FOLLOWING IMMEDIATE

LOADING OF SINGLE PIECE AND TWO PIECE

IMPLANT- AN IN VIVO STUDY”

This is to certify that the dissertation entitled “A comparative radiographic evaluation of crestal bone levels following immediate loading of single piece and two piece implant- An in vivo study” is a bonafide record of the work done by Dr.Ponjayanthi.V. A Post graduate student during the period 2017- 2020 under my guidance and supervision. This dissertation is submitted in partial fulfilment of the requirements for the award of MASTER OF DENTAL SURGERY IN BRANCH I (PROSTHODONTICS AND CROWN & BRIDGE) under THE TAMIL NADU Dr. M.G.R MEDICAL UNIVERSITY, GUINDY, CHENNAI. It has not been submitted (partial or full) for the award of any other degree or diploma.

GUIDE

Dr.T.SREELAL, M.D.S Professor and Head,

Department of Prosthodontics,

Sree Mookambika Institute of Dental Sciences, Kulasekharam,

Kanyakumari Dist.

CO-GUIDE

Dr.APARNA MOHAN M.D.S Reader,

Department of Prosthodontics,

Sree Mookambika Institute of Dental Sciences, Kulasekharam,

Kanyakumari Dist.

CERTIFICATE - II

This is to certify that this dissertation titled “A comparative radiographic evaluation of crestal bone levels following immediate loading of single piece and two piece implant- An in vivo study” of the candidate Dr.Ponjayanthi V with registration number 241711302 for the award of MASTER OF DENTAL SURGERY in the branch of PROSTHODONTICS AND CROWN & BRIDGE (BRANCH I). I personally verified the urkund.com website for the purpose of plagiarism check. I found the uploaded thesis file contains from introduction to conclusion pages and result shows 7% of plagiarism in the dissertation.

GUIDE & SUPERVISOR Dr.T.SREELAL, M.D.S

Professor and Head, Department of Prosthodontics, Sree Mookambika Institute of Dental Sciences, Kulasekharam, Kanyakumari Dist, Tamil Nadu.

DECLARATION

I hereby declare that this dissertation “A comparative radiographic evaluation of crestal bone levels following immediate loading of single piece and two piece implant- An in vivo study” is a bonafide record of work undertaken by me during the period 2017-2020 as a part of post graduate study.

This dissertation, either in partial or in full, has not been submitted earlier for the award of any degree, diploma, fellowship or similar title of recognition.

Dr.Ponjayanthi V, MDS Student,

Department of Prosthodontics,

Sree Mookambika Institute of Dental Sciences,

Kulasekharam, Kanyakumari Dist,

Tamil Nadu.

SREE MOOKAMBIKA INSTITUTE OF DENTAL SCIENCES, KULASEKHARAM

ENDORSEMENT BY THE PRINCIPAL / HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “A comparative radiographic evaluation of crestal bone levels following immediate loading of single piece and two piece implant- An in vivo study” is a bonafide research work done by Dr.Ponjayanthi V under the guidance of Dr.T.Sreelal, M.D.S, Professor and Head, Department of Prosthodontics and Crown & Bridge, Sree Mookambika Institute of Dental Sciences, Kulasekharam, Kanyakumari Dist, Tamil Nadu.

Date:

Dr.Elizabeth Koshi, MDS, Principal,

Sree Mookambika Institute of Dental Sciences,

V.P.M Hospital Complex, Padanilam, Kulasekharam, Kanyakumari District, Tamil Nadu - 629161

E l i z a b e t h K o s

“Gratitude is the fairest blossom which springs from the soul.

Successful completion of a task and ecstasy behind that won’t be complete without mentioning the people who supported and made it possible in every stage as a constant source of encouragement and guidance.

“Always trust God, He will clear the road and lead you to the right path.”

Primarily I would like to thank God Almighty for giving me the strength, knowledge, ability and opportunity to undertake this research study and able to complete this dissertation with success. Without His blessings, this achievement would not have been possible. I also thank the Almighty for His support, unparalleled grace, superior protection and guidance throughout the systole and diastole of my post graduate journey, especially to overcome the adversities in challenging situations.

I would like to express my immense gratitude and thanks to my guide and mentor Dr.T.Sreelal MDS, Professor and Head of the Department of Prosthodontics, Sree Mookambika Institute of Dental Sciences, Kulasekharam, who gave constant encouragement and enlightenment in every stage of my thesis.

Because of his guidance with constant support, inspiration and confidence, it was possible for me to place my first step in implantology and pursue my ambition. I

hereby extend my deepest gratitude to; who gave me the greatest faith and guidance, in every challenging case and lead me to complete it in innovative and ethical way. I have been amazingly fortunate to have the opportunity to study under his guidance. I also thank him in particular with whom I started this thesis work and many rounds of discussions on my project with him, helped me a lot and provided me with vast knowledge. The confidence begins, most of the time, with a mentor who believes in you, who tugs and pushes and leads you on to the next plateau. I thank him from the bottom of my heart for his time, patience and unyielding faith in me for promoting my confidence. It is because of sir’s motivation and encouragement; I was able to improve my skills and did my thesis with confidence. Sir, you are the best person, guide and mentor in this world. I have been amazingly fortunate to get the opportunity to study under his guidance.

With his seeds of wisdom, he made the subject interesting and understandable for our budding minds. I take pride in acknowledging the insightful guidance by promoting my confidence level and being there at times when I required motivation and propelling me on the course of this thesis. With all the gratitude that I feel and warm regards that I can muster, I thank you sir for proffering me with your vast knowledge and for planting a seed of curiosity and igniting my imagination for me to be able to flourish and succeed.

I am extremely grateful to Dr.Aparna Mohan MDS, Reader, my co-guide, for her everlasting support, source of love, affection and care. I also extend my

with articles needed for my dissertation. She is a strong pillar of support who inspite of her own hectic schedule found time in correcting this dissertation. She always guided me to the light of knowledge with her valuable guidance, suggestions and tireless pursuit for perfection. She has a strong personality and a heart full of affection which helped me to pass the tough times during my post graduate programme.

I am deeply indebted to Dr.Giri Chandramohan, MDS, Reader, who with his vast knowledge helped me in my work theoretically as well as clinically. He is a person with lots of clinical and laboratory knowledge and at the same time he is very helpful and trustful person. He guided me with direction and technical support and provided knowledge about many innovative approaches in prosthodontics. Being nice and friendly he has persuaded me to develop my presentation skill and to perform better in a large podium.

I also extend my gratitude to Dr.Allen Jim Hines MDS, Reader, who is always approachable for any help and he is the one who taught me how to manage anxious and apprehensive patients with his unique style and getting us out of trouble.

I express my heartfelt and sincere thanks to Dr.James Rex (Reader) for his valuable help and guidance.

I express my sincere gratitude to Dr.Vivek B Chandran MDS, Dr.Soumya Mohan MDS and Dr. Eshona Pearl MDS Senior Lecturer, for their valuable help and guidance throughout my postgraduate journey.

Dr.Vivek B Chandran MDS and Dr.Soumya Mohan MDS earlier as my seniors and as good friends and now as a staff, they provided me moral support and became a friend for exchanging their knowledge, support and skills during my post graduate programme, which helped me to enrich my skills.

I express my sincere thanks to Dr.Elizabeth Koshi MDS, Principal, Sree Mookambika Institute of Dental Sciences, Kulashekaram for allowing me to utilize the clinical material and facilities for the completion of this dissertation.

I extend my profound gratitude to Dr.Jossy for determining the sample size for my study and to Mr.Porchelvan, Statistician, for helping me in untying various knots of statistics and solving the riddles in it, thereby working out proper results that made my thesis an unadulterated one.

This endeavour would have been impossible without the help and guidance of Dr.Tatu Joy, Dr. Farakath Khan, Dr. Redwin Manchil, Dr. Rahul and Dr.Lakshmi Department of Oral Medicine and Radiology, Sree Mookambika Institute of Dental Sciences, Kulasekharam for their support and guidance in measuring the CBCT images to calibrate the crestal bone level changes.

who has been with me throughout my postgraduate life as a best friend and for encouraging me during the happy and hard moments making this journey a memorable one. Thank you for being with me all the times and support me as a good friend.

This acknowledgement seems lacking without the mention of my dear seniors Dr. Amalorpavam V, Dr.Jithin G N, Dr. Rajkumar, Dr.Ebinu A and my dear fellow Post graduates Dr.Claudia Peter, Dr.Harshini A K, Dr.Shyju Prasad and Dr.Inita for their constant support, motivation and encouragement when I slow down in my daily work, I have been blessed with a friendly and cheerful group of fellow postgraduates. Not only as seniors, but also as sisters and brothers, they gave me a homely environment in and out of the department, which gave me the strength to progress.

I am also thankful to Mr.Bibin Sekhar, Mr. Allen technician and ceramist SMIDS and to Mrs.Anitha, Mrs.Sunitha , Mrs.Jayalekshmi , Mrs.Mallika and Mrs.Suja Y Assistants, Department of Prosthodontics, SMIDS a lot, for being there all through my three years of Post Graduate life.

I am thankful to Mr.Srinivasan, Mrs.Jeyalakshmi Srinivasan, Ms. Priya and Mrs. Sreeja Office staffs, SMIDS for their sincere work throughout my three years of postgraduate life.

The success of this study required the help of various individuals, but without the support and love of my family, I could not have met their objectives in doing this study. A wave of fond emotions sweep over me as I struggle to gather the appropriate words, to express the insurmontable respect and warm gratitude I feel for my father Mr.C.Velusamy, my mother Mrs. K. Dhanalakshmi for their confidence in me and their sacrifices, strength, support and encouragement at all the difficult times. They are always my inspiration and is solely responsible for refurbishing my life and profession.

Finally, my heartfelt thank you to everyone who has been a part of my life, directly or indirectly supported me along the way.

Thank you everyone for helping me in selecting the best fitting pieces for completing the puzzle. Thank you God, for your blessings and leading my way at every situations and gifting me with wonderful people who supported, encouraged and rekindled the spark in me, to reach the glory throughout my journey.

- Dr. Ponjayanthi V

SPECIAL ACKNOWLEDGEMENT

I take this opportunity to thank specially our Chairman Dr.C.K.VELAYUTHAN NAIR MS, Sree Mookambika Institute of Dental Sciences, our Director Dr.REMA V NAIR MD, Sree Mookambika Institute of Dental Sciences and our Trustees Dr.R.V.MOOKAMBIKA MD,DM, Dr.VINU GOPINATH MS,MCH and Administrative Officer Mr.J.S.PRASAD for giving me the opportunity to utilize the facilities available in this institution for conducting this study.

CONTENTS IN CONCISE

Sl.No INDEX 1 LIST OF ABBREVIATIONS 2 LIST OF FIGURES

3 LIST OF TABLES

4 LIST OF GRAPHIC DIAGRAMS

5 ABSTRACT

6 INTRODUCTION

7 AIMS AND OBJECTIVES 8 REVIEW OF LITERATURE

9 MATERIALS AND METHODOLOGY

10 RESULTS AND OBSERVATIONS 13 DISCUSSION

14 SUMMARY AND CONCLUSION 15 BIBLIOGRAPHY

SL.No INDEX PAGE

1 ABSTRACT 1-4

2 INTRODUCTION 5-11

3 AIMS AND OBJECTIVES 12

4 REVIEW OF LITERATURE 13-26

5 MATERIALS AND METHODOLOGY 27-34

6 RESULTS AND OBSERVATIONS 35-47

9 DISCUSSION 48-55

10 SUMMARY AND CONCLUSION 56-58

LIST OF ABBREVIATIONS

1P Single piece implants

2P Two piece implants

LA Local Anaesthesia

CBCT Cone Beam Computed

Tomography

OPG Orthopantomogram

IOPA Intraoral periapical

FIGURE 1 IMPLANT SURGICAL KIT FIGURE 2 INSTRUMENT KIT

FIGURE 3 PHYSIODISPENSER FIGURE 4 OPG MACHINE FIGURE 5 CBCT MACHINE

FIGURE 6 SINGLE PIECE AND TWO PIECE IMPLANTS FIGURE 7 DIAGNOSTIC CAST

FIGURE 8 PRE OPERATIVE OPG IMAGE

FIGURE 9 PRE OPERATIVE CBCT IMAGE OF SINGLE PIECE IMPLANT PLACEMENT SITE

FIGURE 10 PRE OPERATIVE CBCT IMAGE OF TWO PIECE IMPLANT PLACEMENT SITE

FIGURE 11 LOCAL ANAESTHESIA INJECTION

FIGURE 12 FLAP REMOVAL WITH CIRCULAR TISSUE PUNCH – LEFT SIDE – FOR SINGLE PIECE IMPLANT

FIGURE 13 OSTEOTOMY PREPARATION WITH INITIAL DRILL – LEFT SIDE

FIGURE 14 OSTEOTOMY PREPARATION WITH SUBSEQUENT DRILLS – LEFT SIDE

FIGURE 15 SINGLE PIECE IMPLANT WITH 3.65 × 11.5 MM DIMENSION

FIGURE 16 SINGLE PIECE IMPLANT PLACEMENT ON LEFT SIDE FIGURE 17 INTRA ORAL SINGLE PIECE IMPLANT POSITION-

PROXIMAL VIEW

FIGURE 18 FLAP REMOVAL WITH CIRCULAR TISSUE PUNCH – RIGHT SIDE – TWO PIECE IMPLANTS

FIGURE 19 OSTEOTOMY PREPARATION WITH INITIAL DRILL – RIGHT SIDE

FIGURE 20 OSTEOTOMY PREPARATION WITH SUBSEQUENT DRILLS – RIGHT SIDE

FIGURE 21 TWO PIECE IMPLANT WITH 3.75 × 11.5 MM DIMENSION FIGURE 22 TWO PIECE IMPLANT PLACEMENT ON RIGHT SIDE FIGURE 23 POST OPERATIVE INTRA ORAL IMAGE SHOWING

SINGLE PIECE AND TWO PIECE IMPLANT

FIGURE 24 INTRA ORAL POST OPERATIVE IMAGE AFTER IMPLANT AND ABUTMENT FIXATION – BILATERAL

PROXIMAL VIEW

FIGURE 26 TEMPORARY CROWN OVER TWO PIECE IMPLANT – PROXIMAL VIEW

FIGURE 27 CEMENTED TEMPORARY CROWNS

FIGURE 28 CBCT IMAGE SHOWING BONE LOSS – 4^TH WEEK AFTER IMPLANT PLACEMENT – SINGLE PIECE IMPLANT

FIGURE 29 CBCT IMAGE SHOWING BONE LOSS – 4^TH WEEK AFTER IMPLANT PLACEMENT – TWO PIECE IMPLANT

FIGURE 30 CBCT IMAGE SHOWING BONE LOSS – 8^TH WEEK AFTER IMPLANT PLACEMENT - SINGLE PIECE IMPLANT

FIGURE 31 CBCT IMAGE SHOWING BONE LOSS – 8^TH WEEK AFTER IMPLANT PLACEMENT - TWO PIECE IMPLANT

FIGURE 32 CBCT IMAGE SHOWING BONE LOSS – 12^TH WEEK AFTER IMPLANT PLACEMENT - SINGLE PIECE IMPLANT

FIGURE 33 CBCT IMAGE SHOWING BONE LOSS – 12^TH WEEK AFTER IMPLANT PLACEMENT - TWO PIECE IMPLANT

LIST OF TABLES

TABLE 1 TOTAL NUMBER OF SAMPLES IN EACH GROUP

TABLE 2 MEAN BONE LOSS ON BUCCAL ASPECT OF GROUP I

TABLE 3 MEAN BONE LOSS ON BUCCAL ASPECT OF GROUP II

TABLE 4 COMPARISON OF MEAN BONE LOSS BETWEEN GROUP 1 AND GROUP 2 ON BUCCAL ASPECT

TABLE 5 MEAN BONE LOSS ON LINGUAL ASPECT OF GROUP I

TABLE 6 MEAN BONE LOSS ON LINGUAL ASPECT OF GROUP II

TABLE 7 COMPARISON OF MEAN BONE LOSS BETWEEN GROUP 1 AND GROUP 2 ON LINGUAL ASPECT

TABLE 8 MEAN BONE LOSS ON MESIAL ASPECT OF GROUP I

TABLE 9 MEAN BONE LOSS ON MESIAL ASPECT OF GROUP II

1 AND GROUP 2 ON MESIAL ASPECT

TABLE 11 MEAN BONE LOSS ON DISTAL ASPECT OF GROUP I

TABLE 12 MEAN BONE LOSS ON DISTAL ASPECT OF GROUP II

TABLE 13

COMPARISON OF MEAN BONE LOSS BETWEEN GROUP 1 AND GROUP 2 ON DISTAL ASPECT

TABLE 14

TOTAL MEAN BONE LOSS ON MESIAL, BUCCAL, DISTAL AND LINGUAL ASPECTS OF GROUP 1 AND GROUP 2

LIST OF GRAPHIC DIAGRAMS

GRAPH NO:1

COMPARISON OF MEAN BONE LOSS BETWEEN

GROUP 1 AND GROUP 2 ON BUCCAL ASPECT DURING 4^TH , 8^TH AND 12^TH WEEK.

GRAPH NO:2

COMPARISON OF MEAN BONE LOSS BETWEEN

GROUP 1 AND GROUP 2 ON LINGUAL ASPECT 4^TH , 8^TH AND 12^TH WEEK.

GRAPH NO:3

COMPARISON OF MEAN BONE LOSS BETWEEN GROUP 1 AND GROUP 2 ON MESIAL ASPECT 4^TH , 8^TH AND 12^TH WEEK.

GRAPH NO:4

COMPARISON OF MEAN BONE LOSS BETWEEN GROUP 1 AND GROUP 2 ON DISTAL ASPECT 4^TH , 8^TH AND 12^TH WEEK.

GRAPH NO:5

TOTAL MEAN BONE LOSS ON BUCCAL, LINGUAL, MESIAL AND DISTAL ASPECTS OF GROUP 1 AND GROUP 2

ABSTRACT

Abstract

1

INTRODUCTION:

Over the last few decades, implant supported prosthesis has become one of the best options for the rehabilitation of edentulous and partially edentulous arches. The former protocol for dental implant treatment proposed by Branemark was based on delayed loading protocol where two piece implants with submerged healing period of 4 to 6 months prior to loading was followed.

Now a days, in this rapidly evolving field of dentistry, researches had been made and results supporting immediate loading of dental implants were obtained. For patients, immediate occlusal loading will provide esthetic restorations, soon after the implant placement and is also associated with reductions in patient pain, chair time, and eliminates the need for second surgery. The immediate occlusal loading concept is a pragmatic alternative to conventional two stage approach.

Immediate loading of oral implants has been defined as a situation where the superstructure is attached to the implants no later than 72 hrs after surgery (Aparicio et al. 2003; Cochran et al. 2004). Two piece implants which are originally designed for submerged technique can also be used for this non submerged procedure by providing provisional restoration to implant abutment connection immediately after implant placement. Abutment screw loosening and screw fracture are some of the complications anticipated with this two

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piece implant system. To overcome these complications one piece root form implants were introduced.

One Piece implant (OPI) which actually mimics the natural tooth in its construction , also offers many advantages viz strong unibody design, no split parts and single stage surgery.

The purpose of the current study is to compare the amount of crestal bone loss around one piece and two piece implants placed by immediate loading procedure. The goal is to determine whether implant prognosis was more favorable with one piece or two piece implant on immediate loading.

AIMS:

1. To identify the best implant design for immediate loading procedure.

2. By measuring the crestal bone levels in all four aspects around both the implant design.

OBJECTIVES:

1. To evaluate the change in crestal bone height on mesial, distal, buccal and lingual aspects following immediate loading of one piece implants during 0, 4,8,12 weeks.

2. To evaluate the change in crestal bone height on mesial, distal, buccal and lingual aspects following immediate loading of two piece implants during 0, 4,8,12 weeks.

Abstract

3

3. To compare the crestal bone heights on mesial, distal, buccal and lingual aspects following immediate loading of single piece and two piece implants.

METHODOLOGY:

The present study was an in vivo study planned to check the best implant design for immediate loading. Totally 16 implants were placed in 8 patients. Patients with bilateral missing teeth were selected for this study. The two basic implant designs: two piece and one piece implants were placed contalaterally in selected patients following split mouth technique and evaluated for the changes in marginal bone loss in all 4 proximal surfaces of loaded implants.

Flapless surgery using circular tissue punch was performed and osteotomy preparation was done using drills of incremental sizes. Followed by that implants of same dimension were placed. Single piece implants were placed on the left side and two piece implants on the right side. Immediately after implant placement, impression is made for temporary crown using alginate impression material. Then cast was poured and provisional restoration using heat cure acrylic resin was fabricated. Then the restoration was cemented in patient’s mouth using non eugenol cement, after checking for high points.

Patients were recalled after a week, 4, 8 and 12 weeks for review.

Occlusion was evaluated in each appointments and CBCT was taken on 4^th, 8^th and 12^th week to measure the changes in crestal bone around implants. Bone loss was measured on the mesial, distal, buccal and lingual aspects.

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Caliberation was done from implant abutment junction till the point where the crestal bone makes contact with the implant.

RESULTS:

In the present study, when assessing the change in the crestal bone levels between two implant groups, having single piece implants as group 1 and two piece implants as group 2, the cumulative mean bone loss for group 1 and group 2 respectively was, 0.78 mm & 0.60 mm buccally, 0.26 mm & 0.38 mm lingually, 0.54 mm & 0.69 mm mesially and 0.76 mm & 0.52 mm distally.

According to the observations in this study, single piece implants had more loss on buccal and distal aspect, when compared with two piece implants and two piece implants showed more bone loss on lingual and mesial proximal surfaces of single piece implants. But the difference in bone loss was not statistically significant, when subjected to t-test and in clinically acceptable range.

SUMMARY AND CONCLUSION:

According to the observations in this study both single piece and two piece implants showed crestal bone levels in clinically acceptable range and the mean change in crestal bone level is not statistically significant. The primary change in implant design does not have significant effect on crestal bone levels.

Hence both the implant designs can be successfully used for immediate loading depending on specific clinical conditions.

INTRODUCTION

5

Implant dentistry has become a vital part of prosthodontics. Implant supported prosthesis has become a successful treatment modality for the restoration of partial and completely edentulous arches since 1980s with a high success rate of 90% - 95%¹. Dental implants by providing a strong foundation for permanent or removable prosthesis, improves appearance, speech and comfort to patients which discursively improves the patient’s psychology.

Implant dentistry has undergone drastic variations in the past few decades. Considerable changes in the methods, principles and hypothesis have occurred. According to Branemark, the pioneer in the field of implant dentistry, a minimum of 6 months healing period and submerging of implant is considered as an absolute requirement². However recent researches in this field have transcended the delayed loading protocol. Nowadays implants are often placed in single stage surgical procedure, provided with prosthetic restorations placed immediately after implant placement with high success rate¹. Immediate loading of implants is an eminent and acknowledged treatment strategy which is extensively being used in demanding situations.

IMMEDIATE LOADING:

Immediate loading of dental implants has been defined as a condition where the crown or suprastructure is attached to implants no later than 72 hours after surgery³. It consists of non submerged single stage

Introduction

6

surgery in which loading of the implant done with a provisional restoration at the same appointment or shortly thereafter. Though this technique is commonly used recently, successful immediate loading of screw type dental implant has been reported as early as 1979 (Ledermann 1979)⁴. Immediate loading of dental implants render many advantages for the patients that, it reduces chair side time, pain and the need for second surgery⁵. Patients are able to obtain acceptable esthetic results during the entire treatment period and functional rehabilitation is improved. Hence immediate loading concept is a pragmatic treatment alternative for conventional delayed loading concept or two stage approach.

FLAPLESS TECHNIQUE:

Flapless surgical technique is being used as an alternative to conventional flap technique which increase the patients comfort and maintains proper blood supply over the surgical site. It is commonly used for single stage procedure. One of the pre-requisites for osseointegration is atraumatic surgery that comprises pertinent flap management and sequential drilling under ample irrigation at a recommended speed. Nonetheless, no matter how carefully performed, elevation of a full thickness muco-periosteal flap compromises the blood supply to the underlying bone with resultant marginal bone loss. In the flapless surgical technique, a round tissue punch is commonly used to remove the soft tissue over crestal region at the implant

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site^6,7,8,9. Roman had documented that flapless procedure is recommended to minimize crestal bone loss and loss of papilla interproximally¹⁰.

Other advantages of flapless design are, reduction in surgical trauma and patient morbidity, it reduces the surgical time and intra- operative bleeding¹¹. Generally suturing is not required for this technique. It permits the patient to recommence routine oral hygiene procedures promptly after the procedure. Thus the use of flapless surgical technique with immediate loading is an effective alternative for conventional approach and is amiable to the patient.

The two basic designs of implants available for immediate loading or single stage technique includes, single piece or one piece implant (OPI) system and two piece implant (TPI) system.

SINGLE PIECE IMPLANTS:

One piece implant design consists of the implant fixture and the abutment fabricated as a single unit, that is, it assimilates transmucosal abutment as an intrinsic part of implant. This system literally mimic the natural tooth in its structure and afford several advantages including, strong unibody design without any split parts, eliminates any structural weakness and can be placed with single stage surgery with either flap or flapless technique. Use of single piece system reduces the surgical and prosthetic time¹¹.

Introduction

8

As this design eliminates the necessity for screw to affix the implant with abutment, there is no vacant space in implant; hence it acquires more mechanical strength. No loosening or fracture of the abutment screw is anticipated. It also excludes the need for secondary component placement; improves soft tissue apposition and saves time.

Several clinical studies have confirmed that one piece system has favourable success rate. The highest value is documented as 100%

by Sohn D et al¹² and Siepenkothen T¹³, whereas Ostman et al in their study reported that one piece implant system had a success rate of 94.8%¹⁴. Hence a cumulative success rate of about 98-100% is obtained which is comparable with the two piece implant system.

The single piece implant design is best suited for situations, where the implant and supra structure or prosthesis share a similar angulations, also bone quality and quantity enables immediate loading.

TWO PIECE IMPLANTS:

Two piece implant system comprises of two components, a surgical fixture or implant and a prosthetic abutment. Here the abutment is fastened with the implant with the help of abutment screw. It can be used both in submerged or two phase technique and in single stage technique. Although both the one piece and two piece implant systems show good success rates, an additional benefit of two piece system is, it is possible

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to modify the angulation of the abutment, according to the need for individual patients.

The abutment types available for two piece system can either be a standard abutment or customized abutment. The application of straight standard abutment is desirable if the fixture is positioned in an ideal prosthetic position, usually possible in replacement of posterior teeth.

Standard angled abutment is advisable, when correction of divergence amid of implant supported multi-unit prosthesis is required, especially in full mouth rehabilitation with implants and in anterior maxilla.

Customized abutments are desired especially in anterior esthetic zone, specifically in situations which necessitate alteration in the collar height and in patients with thin gingival biotype. In these circumstances customizing the abutment, allows prosthodontist, the freedom to individualize its angulation and position. It is also feasible to characterize the future crown margin position and emergence profile for final prosthesis. It also affords optimal support for the veneering ceramic material, mainly for screw retained reconstructions.

PROVISIONAL RESTORATIONS:

After abutment placement immediate loading is done by provisionalization on the implant. Selecting the crown material for temporization plays a vital role¹⁵. Soliman et al reported that using crown

Introduction

10

materials with high modulus of elasticity transmits higher amount of applied load to the crestal bone beneath implant, while materials with low modulus of elasticity such as acrylic and composite resins, absorbs more energy from applied load and reduces force to the underlying system, that is, to the implant abutment complex and bone, by about 94%¹⁶. Hence provisionalization with acrylic crowns, which have low Young’s modulus can be provided, that helps in reducing stress distribution to the underlying system during the healing period without compromising the functional and esthetic requirement of the patient.

In the last three decades, implant dentistry has emerged as a fully accepted discipline in dentistry. Several favourable changes have been occurred which not only reduces the treatment time but also provides good prognosis and patient acceptance. Immediate loading is one among those evolutions that fulfil the patient’s demands for early treatment results and have improved patient’s acceptance. The introduction of single piece implant design which assists in immediate loading made a shooting change in the field of implantology. As Single piece implants have a strong unibody design, there is no micro motion between the implant and fixture, which will provide it with good mechanical strength and reduces crestal bone loss.

The purpose of current study is to compare the changes in crestal bone levels, around single piece and two piece implants placed by flapless surgical technique. 16 implants were placed in 8 patients:

contralaterally in posterior mandible for each patient (to eliminate the

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selection bias) and loaded immediately with temporary restoration (acrylic crown). CBCT is used to determine the changes in crestal bone levels during 4^th, 8^th and 12^th week following implant placement, which is considered as a critical period for osseintegration and wound healing.

AIMS AND OBJECTIVES

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AIM:

➢ The aim of this study is to evaluate and compare the changes in crestal bone levels around immediately loaded one piece and two piece implants.

OBJECTIVES:

➢ To evaluate the change in crestal bone height on mesial, distal, buccal and lingual aspects following immediate loading of one piece implants during 0, 4,8,12 weeks.

➢ To evaluate the change in crestal bone height on mesial, distal, buccal and lingual aspects following immediate loading of two piece implants during 0, 4,8,12 weeks.

➢ To compare the crestal bone heights on mesial, distal, buccal and lingual aspects following immediate loading of single piece and two piece implants.

REVIEW OF LITERATURE

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Tarnow et al (1997)¹⁷ studied the outcome of immediate loading of threaded implants at stage 1 surgery in edentulous arches and concluded that immediate loading of implants can be a viable treatment modality in replacing edentulous arches.

Randow et al (1999)¹⁸ evaluated the radiographic and clinical outcome of titanium implants placed nonsubmerged with immediate loading and implants placed according to two stage protocol in edentulous mandible for a period of 18 months and summarized that bone resorption observed between both the groups showed no significant difference and two piece implants designed for two stage submerged technique can also be used for immediate loading with predictable success rate.

Ericsson et al (2000)⁵ clinically as well as radiographically evaluated

and studied the outcome of single missing tooth replaced with implant supported crowns retained by, dental implants installed using non submerged surgical technique and immediate loading along with its comparison to dental implants placed by two stage concept or submerging technique and concluded that, both the non submerged and submerged groups showed insignificant changes in the final outcome both clinically and also radiographically and with minimal change in crestal bone support, whinch was around 0.1 mm on either of the groups.

Review of literature

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Jaffin et al (2000)¹⁹ deliberated the effect of immediately loaded implants in completely edentulous and partial jaws and culminated that, both the jaws groups may preferably be restored with implant prosthesis in a fixed manner and success rate is much similar without any statistical significance to those in delayed loaded cases.

Glauser et al (2001)² studied and evaluated the success rate of immediately loaded implants in various jaw bones and concluded that the immediate loading concept shows good clinical outcome and is a realistic treatment alternative in various jaw bone regions except in posterior part of maxilla.

Hermann et al (2001)²⁰ compared the biological width around one and two piece titanium implants and concluded that , the change in biological width and crestal bone loss between both the implants groups were insignificant and within clinically allowable range.

King et al (2002)²¹ radiographically estimated the effect of the microgap on marginal bone levels in non-submerged implants and summarized that the two piece implants revealed significantly greater crestal bone loss in contrast with one piece implants propounding that the stability of

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the implant and abutment annexation may have an important role to play in modifying crestal bone levels.

Heydenrijk et al (2002)²² studied the clinical and radiographic interpretation of two piece implants placed in single-stage procedure and concluded that implants constructed for a submerged implantation technique can be used in non submerged procedure and the results are as predictable as when the dental implants used in two stage procedure or similar to 1-stage implants.

Glauser et al (2003)²³ studied immediate loading of Branemark Implants placed predominantly in soft bone and summarized that a cumulative success rate of 97.1% after 1 year of immediate occlusal loading was comparable to what was reported using the original, submerged technique.

Calandriello et al (2003)²⁴ studied the outcome of immediately loaded Branemark TiUnite implants and summarized that, as these implants showed marginal bone levels in accordance with normal biologic width requirements and resonance frequency analysis showed high and consistent implant stability, they can be placed in molar regions of lower jaw with high success rate on immediate loading.

Rocci et al (2003)²⁵ studied the feasibility of immediate loading protocol of two piece implants using flapless surgery in maxilla and concluded

Review of literature

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that immediate loading of implants has an unchanged survival rate and good long term prognosis as compared to delayed loading.

Cehreli et al (2004)²⁶ analyzed the force transmission of one piece and two piece taper oral implants, in a nonlinear finite element analysis and concluded that, two piece implants experience higher mechanical stress under oblique load.

Schiroli et al (2004)²⁷ evaluated the clinical outcome of single missing tooth replaced with implant supported fixed prosthesis with ceramic crowns in esthetic zone and concluded that, fixed restoration supported by single implants showed good success rate and can be used as a better option for replacement of missing tooth.

Parel et al (2005)²⁸ evaluated the efficacy of one piece implants clinically in single tooth sites and concluded that, one piece implant can be used with immediate loading procedure in both anterior and posterior single edentulous sites with a high level of implant success.

Engquist et al (2005)²⁹ studied and evaluated the clinical outcome of single stage surgery versus two stage surgery and early loading concept and concluded that, early loading protocol seemed to give better results in anterior part of mandible and that survival rate of early loaded dental implants did not

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differ significantly from that of dental implants placed with the conventional or two-stage procedure.

Hahn et al (2005)³⁰ studied the clinical outcome of immediately loaded

single piece implants by flapless procedure and concluded that single piece implants placed by the minimally invasive procedure showed excellent esthetic results and significantly shortened treatment time.

Koeck et al (2005)³¹ clinically evaluated the outcome of immediately loaded single piece implants placed in posterior region of maxilla and mandible and concluded that the immediate loading of unsplinted single-tooth implants in the posterior region may be a viable treatment option with an esthetic outcome.

Degidi et al (2005)³² clinically and radiographically evaluated the outcome of 93 immediately loaded titanium implant for seven years and concluded that the cumulative success rate was 93.5%, and the prostheses survival rate was 98.5% were obtained with the mean marginal bone loss of 0.6 mm after the first year and 1.1 mm after 7-year evaluation implying that immediate loading is a best treatment option if sufficient primary stability is achieved.

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Nkenke et al (2006)³ studied the success rate of immediately loaded implants and concluded that immediate loading can lead to survival rates comparable with those of conventional loaded implants which was true for both edentulous and partially dentate situations.

Lindeboom et al (2006)³³ compared and evaluated the outcome of solid plasma sprayed BioComp dental implants loaded immediately versus nonloaded BioComp immediately provisionalized implants in the premolar and anterior regions of maxilla and concluded that there has been no significant differences in mean ISQ values in bone loss radiographically and gingival esthetics were found between immediate but nonloaded provisionalization and immediate loaded BioComp dental implants in the maxilla.

Ghanavati et al (2006)³⁴ studied the effects of Loading Time on Osseointegration and New Bone Formation Around Dental Implants and concluded that the overall implant survival rate of immediately loaded implants is similar to long term results achieved with conventional two stage implant protocol, hence loading time did not significantly affected the degree of osseointegration and bone-to-implant contact and the composition of newly formed bone around dental implants.

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Hahn et al (2007)³⁵ examined the clinical and radiographic outcome of

single piece implants, that was used for immediate loading and concluded that the one-piece implant design resulted in a high cumulative implant survival rate and beneficial marginal bone levels and also this implant design offered an attractive and easy alternative to two piece implants for treatment with immediate provisional restorations.

Zamani et al (2008)³⁶ compared the level of stresses generated by two

piece and one piece implant designs in simulated homogenous bone and concluded that, one piece implants generated similar stresses to two-piece implants in the same length and diameter.

Romanis et al (2010)³⁷ studied the survival rate of immediately loaded

and delayed loaded implants in different bone quality and concluded that the overall implant survival rate of immediately loaded implants was similar to long term results achieved with conventional two stage implant protocol and proved that the histologic evidence based on human and animal studies reinforces the idea of successful osseointegration with implants under immediate functional occlusal loading.

Fanali et al (2011)³⁸ evaluated the radiographical effect of one piece implants over the quantity of crestal bone resorption and concluded that,

Review of literature

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single piece implants were better devices for oral rehabilitation for both complete and partially edentulous conditions.

Broweays et al (2011)³⁹ analysed the success rate of 749 early and immediately loaded Osseotite implants in cross-arch rehabilitations in edentulous maxillas and mandibles up to 7 years and concluded that the Osseotite implants offered a predictable long-term outcome in terms of implant survival and stable periimplant bone under immediate loading even in grafted bone.

Zorzano et al (2011)¹⁵ evaluated the effect of immediate temporary restorations on single tooth implants and concluded that immediate restoration of single-tooth implants with provisional crowns can be considered as a predictable technique with a success rate similar to that of delayed loading.

Lata et al (2012)⁴⁰ studied the clinical outcome of single tooth implants positioned in completly, healed socket with immediate temporization and finally evaluated the result in terms of gingival health, stability, marginal bone loss, esthetics, and patient’s psychological attitude and concluded that, immediate temporization is a successful method which showed good clinical results, providing favourable psychological benefits to the patients and also eliminats the need for second surgery.

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Raviv et al (2013)⁴¹ evaluated the clinical outcome of immediately loaded one piece implants for the restoration of single posterior tooth with fixed prosthesis and concluded that, single piece implants could be used successfully for immediate loading, when the implant fixture and final prosthesis shared similar angulation.

Gumeniuc et al (2014)⁴² clinically studied and summarized the outcome of prosthetic treatment with one piece and two piece dental implants and concluded that prosthetic treatment with implants can be successfully and efficiently performed both on one- piece implants and two- piece dental implants.

Beriberi et al (2014)⁴³ compared the change in marginal bone levels following immediately loaded single tooth implant in healed and freshly extracted socket and concluded that, local bone response to immediately loaded implants is similar in both the conditions and using prefabricated abutment for functional loading technique maintains marginal bone around implants in healed and extracted socket.

Soliman et al (2015)¹⁶ assessed stress distribution around implant fixture with acrylic, porcelain fused to metal and in ceram materials and concluded that acrylic crown reduced the stresses generated on the jaw bone including cortical and spongy bone, that it absorbed more energy from the

Review of literature

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applied load, and transfered less energy to the following parts of the system including implant abutment complex and bones.

Minichetti et al (2015)⁴⁴ studied the survival and prognosis of immediately loaded single piece implant and concluded that when provided with adequate bone quality and stabilization tapered single piece implants are best substitute for conventional implants with long term survival rate.

Siadat et al (2015)⁴⁵ evaluated the effect of interim prosthetic option for implants and concluded that, interim prosthesis not only helped to enhance esthetics by providing a good emergence profile but also maintained the marginal bone level.

Grassi et al (2015)⁴⁶ evaluated the radiographic and clinical outcome of one piece implants loaded immediately and concluded that after 5 years of function the implants showed acceptable soft tissue health and satisfactory amount of marginal bone level and were the better option for replacement of missing teeth.

Ormianere et al (2016)⁴⁷ compared the clinical and radiographic outcome of one piece and two piece implants placed in same patients and concluded that both one piece and two piece implants exhibited good clinical outcome and appeared equally effective after 5 years of function.

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Patil et al (2016)¹¹ studied the clinical outcome of one piece implants and concluded that one-piece implant design resulted in a high cumulative implant survival rate and beneficial marginal bone levels.

Duda et al (2016)⁴⁸ compared the marginal bone loss around immediately loaded single piece implants and delayed loaded single piece and two piece implants and concluded that statistically insignificant bone loss occurred between immediate and delayed loaded single piece implants in three years of function and one piece implants can be used for both the single stage and two stage technique.

Gammal et al (2016)⁴⁹ evaluated the clinical as well as radiographic outcome of conventionally placed single piece implant and the ones placed along with melatonin and concluded that, single piece implants that are used extensively for immediate loading can be placed along with biomimetic agents which reduce the marginal bone loss especially in regions with less bone density.

Damarisy et al (2017)⁵⁰ evaluated the effect of one piece versus two piece mini implants on bone height of implant retained mandibular overdenture and concluded that both the groups showed insignificant

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difference in bone loss during the follow up period and the choice between one and two-piece mini-implants narrowed down to the surgical protocol.

Gheisari et al (2017)⁵¹ evaluated and compared the crestal bone loss in two stage and single stage implant surgery and culminated that the difference in mean bone loss on the distal and mesital aspects of implants positioned through one stage and two stage procedure was 0.76±0.04 and 0.842±0.04 mm respectively, representing no significant change between two procedures concerning the crestal bone loss.

Peter (2017)⁵² evaluated the treatment outcome of immediately loaded titanium and zirconia two piece implants and concluded that both the two piece implant types can be used for immediate and early loading, with bone loss similar to that of delayed loading and with predictable success rates.

Bilichodmath et al (2018)⁵³ clinically evaluated the outcome of immediately loaded one piece root form implants over a period of 3 years and concluded that a single stage, one piece implant placement with immediate loading provides a good soft tissue healing and minimal postoperative discomfort to the patient.

Alfada et al (2018)⁵⁴ assessed the clinical outcome of immediately loaded implant-supported over dentures over a period of 14 years and

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concluded that immediate loading of implant supported dentures have a predictable success rate as compared to delayed loading technique.

Pera et al (2018)⁵⁵ clinically and radiographically compared the outcome of full arch fixed implant supported prosthesis loaded immediately and after 3 months and concluded that, treatment outcome of immediately loaded implants shows no significance with delayed loaded implants over a period of 10 years and this single stage protocol can be used clinically with better results.

Schiegnitz et al (2018)⁵⁶ evaluated the treatment outcome of narrow diameter implants and concluded that, no loss of implant or prosthesis was experienced and the use of narrow diameter implant is a good treatment option for replacement of missing tooth.

Ma et al (2018)⁵⁷ studied the clinical outcome of maxillary anteriors replaced with implants and loaded immediately and concluded that, replacing single missing tooth with titanium implants and loading immediately shows good results similar to delayed loading.

Singla et al (2018)⁵⁸ compared the clinical and radiographic outcome of immediately loaded single piece implants placed by flap and flapless technique and summarized that at the end of three months implants placed by

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flapless technique showed lesser bone loss when compared to implants placed by conventional flap technique, patients also experienced less pain post operatively following flapless technique.

Lazarov A (2019)⁵⁹ evaluated the concept of immediate functional loading with single piece implant and summarized that single piece implants because of their unibody design showed less bacterial colonization and peri- implantitis and is an effective alternative that can be used for immediate loading with better results compared to two piece implant system.

Kadkhodazadeh et al (2019)⁶⁰ analyzed the success rate of immediate nonfunctional loaded single piece implants for 10 years by measuring the marginal bone loss around the implants both bucally and lingually and concluded that, only moderate amount of bone loss was occurred around single piece implants and this design can be used for immediate non functional loading with good success rate.

MATERIALS AND METHODOLOGY

Materials and Methodology

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In the present study, an effort was made to evaluate the best implant design for immediate loading. The two piece implant design, having the implant and abutment as separate component, which is originally prepared for delayed loading or submerged technique and single piece implant design which has both the implant fixture and abutment as single unit are compared in the study in two groups, by split mouth technique. Conclusion was obtained on the basis of changes in crestal bone levels on mesial, distal, buccal and lingual aspects around immediately loaded one piece and two piece implants through CBCT study.

MATERIALS:

1) Patient drape

2) Irreversible hydrocolloid impression material (DPI – Algitex, India) 3) Polyvinyl siloxane (Flexeed, GC India)

4) Type IV gypsum ( Pearlstone, India)

5) Local anaesthesia - Lignocaine 2% 1:80,000 adrenaline (Lignox 2% A, India)

6) Betadine solution ( Betadine, India) 7) Heat cure acrylic resin (DPI, India) 8) Saline ( Baxter, India)

9) Disposable cups

10) Single piece implants (ADIN, Israel)

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11) Two piece implants (ADIN, Israel)

12) Temporary luting cement (Templute Eugenol free, India) INSTRUMENTS:

1) Perforated stock impression tray 2) 2 ml disposable syringe with needle

3) Tissue punch -4 mm diameter (Plunger biopsy punch).

4) Gauze 5) Surgical kit

Mouth mirror, Explorer, Straight probe, Tweezers, Cheek retractor, Artery forceps, Suction tips

6) Implant kit (ADIN, Israel)

Pilot drill (2 mm diameter), Osteotomy drills (2mm,2.8 mm,3.2mm,3.65mm in diameter), Paralleling pins, Depth probe, Drill extender, Hex drive, Implant drive (Single piece implant drive ,Two piece implant drive), Torque ratchet.

EQUIPMENTS:

1) Physiodispenser (W & H, Austria)

2) Contra –angle micro motor handpiece (W & H, Austria) 3) X- ray machine for OPG ( Planmeca Proline XC)

4) IOPA machine (Alerio DC Optima, India) 5) CBCT (Planmeca ProMax 3D Mid) 6) Autoclave ( Confident, India)

Materials and Methodology

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7) X ray viewer ( Jupiter, India) DRUGS:

1) Cap Amoxicillin 500 mg 2) Tab Aceclofenac 100 mg 3) Tab Pantoprazole 40 mg SAMPLES:

In the present study, 16 implants were placed in 8 patients using split mouth technique (in this design, mouth is divided into two or multiple groups, when performing clinical study, involving multiple groups, to eliminate inter subject variability). According to this technique 8 two piece implants (fixture and abutment as separate component) were placed on one side and 8 one piece implants (fixture and abutment as a single unit) were placed on other side. Thus the 16 implants were divided in two groups,

Group 1– Immediate loading of one piece implants on left side Group 2 – Immediate loading of two piece implants on right side

INCLUSION CRITERIA:

• One piece and two piece implants from the same manufacturer

• Partially edentulous patients with bilateral missing teeth

• Both one piece and two piece implants placed contra laterally in same patients

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• Patients with sufficient bone height of at least 14 mm from ridge crest till inferior alveolar canal

• Patients with healthy and stable soft tissue architecture.

• Physically able to tolerate surgical and restorative procedures.

• All subjects had to be > 20 years of age

• Minimum buccolingual crestal bone width of at least 4.5 mm without undercuts of >15 degree(based on clinical measurements and bone sounding under anesthesia)

• Implants were placed in extraction sites after at least 3 months of post extraction healing

• Keratinized tissue of at least 5 mm.

EXCLUSION CRITERIA:

• Patients with complicated medical history such as uncontrolled diabetes, bleeding disorders, osteoporosis, radiation therapy, immune compromised state.

• Untreated periodontitis

• Smoking

• Patients with history of bruxism were omitted from the study.

• Pregnant or lactating women

• Patients requiring guided bone regeneration for implant placement

Materials and Methodology

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METHODOLOGY:

Patient selection:

Patients with bilateral posterior teeth missing, who requested for immediate esthetic restorations were selected to participate in the study. All treatment options were explained to the patients. Patients were thoroughly evaluated for eligibility, based on inclusion and exclusion criteria and by evaluating the amount of bone availability and presence or absence of any pathology by using panoramic radiograph and CBCT.

Diagnostic investigations:

A detailed case history was taken and evaluated. Laboratory investigation for blood levels of vitamin D3, HbA1c and serum calcium were done to assess the health status of the patient. Followed by this, diagnostic impression of both the concerned arch (mandibular arch in this study) and opposing arch was made and cast was obtained, in which measurements were taken to check the availability of bone and its feasibility for implant placement. Once the implant treatment was found possible, the procedures, advantages, precautions, maintenance and care were explained to the patient and the patient’s informed consent for the treatment was obtained on paper. A total of sixteen implants were placed in eight patients- eight one piece implants and eight two piece implants.

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Implant surgery:

Sterilization protocol was strictly adhered during the entire process of surgery. The areas of implant placement were anaesthetized using 2%

lignocaine with 1:80,000 Adrenaline. Circular tissue punch was done for the entry of osteotomy burs and implants through the soft tissues and the bone (flapless surgery was done in all patients). Initial penetration through bone was achieved with Pilot drill. The osteotomy preparation was then be completed by using drills of incremental sizes. Once the required depth and width has been achieved, implant of size 3.7 mm in diameter and 11.5 mm in height was placed in the osteotomy site.

CBCT was taken to confirm the complete placement of the implants and to check its parallelism with adjacent tooth. Both the single and two piece implants of same dimensions were used for the study and were placed in successive days contralaterally in each patients to avert complications that occur due to bilateral lingual nerve block. Abutment was attached to two piece implant on the day of implant placement.

Prosthodontic protocol:

Impressions were made using irreversible hydrocolloid and casts were poured with die stone. Temporary restorations were fabricated using heat cure acrylic resin (crown material with low modulus of elasticity to absorb more amount of applied load and transmit only less stress to the underlying component) and were trimmed and polished to try in patients. Crown was

Materials and Methodology

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then placed over implants and checked for high points. Followed by this crown was luted with non eugenol cement, the day after implant placement (within 48 hours of implant placement).

Follow up:

Patients were prescribed with antibiotics and analgesics for 3 days post operatively. Patients were advised to continue routine oral hygiene procedures and advised to eat soft diet and avoid having hard food in the region of provisional restoration for 12 weeks. Initially patients were recalled after 1 week for review and followed by monthly recall for 3 months. In every appointment occlusion was verified and corrected.

Radiographic evaluation of crestal bone level:

After the implants were placed, a series of CBCT were obtained at 0, 4, 8, 12 weeks duration to study the changes in the amount of crestal bone level.

Values were calibrated by measuring the distance from the implant abutment junction to the crest of the bone where it contacted with the implant, on buccal, lingual, mesial and distal aspects and the difference in the mean values were calculated. Planmeca Romexis software was used for the analysis.

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STATISTICAL ANALYSIS:

The values obtained from observation were subjected to statistical analysis. Analysis was carried out with t-test to identify statistical significance between group 1 and group 2.

FIGURES

FIG 1: IMPLANT SURGICAL KIT

FIG 2: INSTRUMENT KIT

Figures

FIG 3: PHYSIODISPENSER

FIG 4: OPG MACHINE

FIG 5: CBCT MACHINE

FIG 6: SINGLE PIECE AND TWO PIECE IMPLANTS

Figures

FIG 7: DIAGNOSTIC CAST

FIG 8: PRE OPERATIVE OPG IMAGE

FIG 9: PRE OPERATIVE CBCT IMAGE OF SINGLE PIECE IMPLANT PLACEMENT SITE

FIG 10: PRE OPERATIVE CBCT IMAGE OF TWO PIECE IMPLANT PLACEMENT SITE

Figures

FIG 11: INJECTION OF LOCAL ANAESTHESIA

FIG 12: FLAP REMOVAL WITH CIRCULAR TISSUE PUNCH – LEFT SIDE – FOR SINGLE PIECE IMPLANT

FIG 13: OSTEOTOMY PREPARATION WITH INITIAL DRILL – LEFT SIDE

FIG 14: OSTEOTOMY PREPARATION WITH SUBSEQUENT DRILLS – LEFT SIDE

Figures

FIG 15: SINGLE PIECE IMPLANT WITH 3.65 × 11.5 MM DIMENSION

FIG 16: SINGLE PIECE IMPLANT PLACEMENT ON LEFT SIDE

FIG 17: INTRAORAL SINGLE PIECE IMPLANT POSITION- PROXIMAL VIEW

Fig 18: FLAP REMOVAL WITH CIRCULAR TISSUE PUNCH – RIGHT SIDE – TWO PIECE IMPLANTS

Figures

FIG 19: OSTEOTOMY PREPARATION WITH INITIAL DRILL – RIGHT SIDE

FIG 20: OSTEOTOMY PREPARATION WITH SUBSEQUENT DRILLS – RIGHT SIDE

FIG 21: TWO PIECE IMPLANT WITH 3.75 × 11.5 MM DIMENSION

FIG 22: TWO PIECE IMPLANT PLACEMENT ON RIGHT SIDE

Figures

FIG 23: POST OPERATIVE INTRA ORAL IMAGE SHOWING SINGLE PIECE AND TWO PIECE IMPLANTS

FIG 24: INTRA ORAL POST OPERATIVE IMAGE AFTER IMPLANT AND ABUTMENT FIXATION – BILATERAL