Case Report Tall And Tilted Pin Hole Immediately Loaded .

International Journal of Research and Reviewwww.ijrrjournal.comE-ISSN: 2349-9788; P-ISSN: 2454-2237Case ReportTall and Tilted Pin Hole Immediately LoadedImplants (TTPHIL) Technique for Maxillary ArchRehabilitationDr. P. Venkat Ratna Nag1, Dr. P. Sarika2, Dr. Ruheena Khan3,Dr. Tejashree Bhagwatkar41Reader, Department of Prosthodontics, S.B. Patil Dental College and Hospital, Bidar& Director, Institute for Dental Implantology Hyderabad2Reader, Department of Pedodontics and Preventive Dentistry, S.B. Patil Dental College, Bidar3Oral Medicine and Radiologist, Institute for Dental Implantology, Hyderabad4Oral Pathologist, Institute for Dental Implantology, HyderabadCorresponding Author: Dr. P. Venkat Ratna NagABSTRACTAlthough dental implantology has evolved over the years with different techniques such asconventional and basal implants through immediate and delayed loading, there exists still a dilemmaamong modern clinicians regarding the concept of immediate implantation along with prostheticloading. The aim of this article is to provide an overview of newer technique called Tall and TiltedPin Hole Immediately Loaded implants (TTPHIL).This article describes a case report of immediateloading with bicortical longer implant engaging nasal bone.Key words- Dental Implant, Immediate implantation, TTPHIL technique, Basal implant, Immediateloading, Bicortical implantINTRODUCTIONAs skin is considered as the bestdressing for the wound, tooth is the beststimulant for the jaw, in their absence,definitely a dental implant. [1]Complete tooth loss can be the resultof many conditions like severe periodontitis,trauma, dental caries and rapy in oral carcinoma, etc. Theaffordable option, which has been advisedby the most of the dentists, is the completedenture. But, the complete dentures are notvery much comfortable for most the patientsbecause of inadequate retention andstability, soft tissue erosions, gagging,improper speech etc. [1]In recent times, dental implantsupported prosthesis (implant over dentures)has offered many advantages such asimproved retention and support, reducedsize prosthesis, better speech, and enhancedmastication ability when compared to theconventional methods. [2,3]Full mouth implantation is aconventional technique which works on theplacement of implants and keeps themundisturbed for subgingival healing tillosseointegration of bone takes place. Theseimplants are uncovered only after thesubgingival healing which takes forapproximately 3 to 6 months basicallydepends on various factors like bonedensity, occlusal load, implant dimensionsetc. and restored in function once the softtissue get heal in next 3 to 4 weeks. [4,5]The full mouth rehabilitation isdifficult in many cases because theInternational Journal of Research & Review (www.ijrrjournal.com)Vol.5; Issue: 6; June 2018104

P. Venkat Ratna Nag et al. Tall and Tilted Pin Hole Immediately Loaded Implants (TTPHIL) Technique forMaxillary Arch Rehabilitationedentulous patients usually do not haveadequate bone dimensions for the placementof implants. [6] Conventional method for fullmouth implant supported fixed prosthesisrequires placement of multiple number ofimplants,bonegrafting/augmentationprocedures, increased treatment durationand multiple number of surgical steps, notalways comfortable and affordable. [7]The concept of tilted implantdemonstrates that the back implants areslanted distally to place implant head at thesecond premolar or first molar region. It isconsidered as a graft less implant placementprocedure for restoring the edentulous jawsby tilting posterior implants so thatmaximum amount of bone can get utilizedand stabilized them into highest possiblebone density and avoiding sinus liftprocedures. [7,8]Advancement in implant dentistryallowed a shift from the early paradigmsestablished by the work of Branemark andcoworkers. While initial healing of 6months in the maxilla and 3 months in themandible was recommended. [9]This case report aims to explain thegraft less approach for full arch immediaterehabilitation by placing six implants inmaxillary arch by smartly tilting all theimplants to avoid vital structures, such asmaxillary sinus and stabilizing into the highdensity bone taking bicortical anchorage.CONCEPT OF TTPHILTECHNIQUEThe concept of tilted implants wasdescribed by Paulo Malo, Lisbon, Portugalin his state of art All-on-4TMConcept. In thistechnique, the back implants are slanteddistally to place the implant head at thesecond premolar or first molar positionwhich helps to place longer implants,stabilizing their apices into the anteriorhigher bicortical bone, and reducing thedistal cantilever of the prosthesis.In this technique four implants areused two straight implants are placed closeto the midline and other two implants areplaced anterior to the maxillary sinus (inmaxilla) or mental foramen (in mandible)which are slanted distally to reach thesecond premolar or first molar position. A10 to 12 unit screw-retained metal to acrylic(hybrid) splinted prosthesis is placed overthe implants. [10] But in few patients 10 to 12unit prosthesis is inadequate due toreduction in mastication and cantilever ismore. In such patients, two additionalimplants are placed posterior to the sinusinto the tuberopterygoid bone in the maxillato support 14 to 16 unit prosthesis. [8] Thiswill help facilitate a proper support for anacrylic prosthesis which can be immediatelyfixed over the implants to restore theesthetics and functions within few hoursafter the implant insertion. [11]TTPHILTM concept is the newertechnique which not only overcomeslimitations of axial implants but alsodisadvantages of All-on-4 concept. Tall(18mm-25mm), Tilted (TT) implants (30ᴏ45ᴏ) are placed. Tall implants consideredgood for osseointegration as it provide moresurface area and also engaged to the corticalbone i.e. bicortical anchorage. The implantsare placed in Pinhole (PH) manner i.e.flapless. All implants are immediatelyloaded (IL) within 48 hours after extraction.[12,13]CASE REPORTDiagnosis and treatment planningA 50 year old male patient reportedwith a chief complaint of mobility in theback teeth region and food lodgment, painin his anterior bridge and wants fixed teethimmediately and permanent solution for hisfull maxillary arch (fig. 1). A complete casehistory was recorded followed by thoroughintraoral examination. On intra oralexamination, maxillary anterior bridge andmaxillaryposteriorteethweremobile.Computed tomography (CT) andOrthopantomogram(OPG)(fig.2)demonstrated very little bone was present inthe maxillary sinus region. CT scans werecarefully studied for the thickness andheight of bone in the tuberosity region. Themouth opening was assessed and found tobe adequate for placing implants in theInternational Journal of Research & Review (www.ijrrjournal.com)Vol.5; Issue: 6; June 2018105

P. Venkat Ratna Nag et al. Tall and Tilted Pin Hole Immediately Loaded Implants (TTPHIL) Technique forMaxillary Arch Rehabilitationtuberosity region. Considering the amountof residual bone and request of immediateteeth, it was decided that placing implantsusing TTPHIL technique was the bestalternative. Routine blood investigationswere done and fitness obtained for surgicalprocedure.Figure 1: Clinically, maxillary falling fixed anterior bridgeand mobile posterior teethFigure 2: OPG showing bone loss in the maxillary posteriorregionSurgical protocolMedicationPatient consent was taken prior tosurgical procedure. Surgical protocolemphasized complete asepsis and infectioncontrol. Amoxicillin 1 g for 1 h beforesurgery then 500 mg for 3 times daily forthe next 3 days. Before the surgicalprocedure, the patient was instructed torinse with 0.2% chlorhexidine gluconate for1 min.AnaesthesiaAll implants are placed under localanaesthesia. 2% lignocaine hydrochloridewith adrenaline (1:200000) was used.Implantation surgeryExtractions of the teeth were doneatraumatic with the luxators and forceps,deep curettage and socket debridement wasdone with the ultrasonic scaler. Lancet drill(1.2mm up to 6 mm) on pterygoid regionacts as guidance point for implantplacement, proper mesio distal and buccolingual tilt. It help check whether it isperforatingmaxillarysinus(fig.3).Therefore, RVG was taken. Pilot drills wereused 2.5 mm drill for 3.25/3.5 implant,2.75mm drill for 3.75 mm implant underpreparation of the sound bone. Bioline Ispiral implant 3.75x20mm diameter andlength of implants were planned and twoplaced in the canine region, two implants inthe 2nd premolar region and two implants inthe pterygoid region (fig.4). Multi unitabutments is placed for canine- 30 degrees,2nd premolar- 45 degree, while in 2 nd molarpterygoid region 45 degree.MultiunitImplant parallelism was obtained (fig.5). AnInjection NSAIDs intramuscular was givento the patient just after surgery to reducepostoperative pain and swelling. OPGshowed tall and tilted implants afterplacement (fig.6). Patient was recalled afterone week. Temporary abutment was placedon these multi units abutments andprovisional bridge was fixed for 3 monthsand wait for healing. Occlusion waschecked properly with no excursivecontacts.Figure 3: Atraumatic extraction and Lancet drill (1.2mm, 500rpm) is usedInternational Journal of Research & Review (www.ijrrjournal.com)Vol.5; Issue: 6; June 2018106

P. Venkat Ratna Nag et al. Tall and Tilted Pin Hole Immediately Loaded Implants (TTPHIL) Technique forMaxillary Arch RehabilitationFigure 4: Atraumatic extraction and Pilot drill (1.2mm, 500rpm) is used and immediate placement of six implantsFigure 5: Implant Parallelism was obtainedProsthetic reconstruction- PermanentAfter 3 months patient visited to usand the temporary were removed and showswith good healing (fig. 7). Plastic tray wasselectedforfullmaxillaryarchimpressionfor which distance minimum of5-10 mm between the tray and theimpression (fig. 8). Two step open trayimpression were taken with putty and lightbody (fig. 9). Multi-unit implant analogueswere placed and tighten (fig. 10) after whicha jaw relation was recorded (fig. 11) andsent for laboratory for CAD CAM designingscrew retained fixed prosthesis. DirectMetal Laser Sintered Cobalt ChromiumCopings were printed. After two days thepatient was rehabilitated with immediatelyplaced and loaded all ceramic screwretained fixed prosthesis (fig. 12). Implantocclusion was group function (fig. 13). Postoperative OPG was taken (fig. 14). Patientwas happy and satisfied with the prostheses(fig.15). A follow-up of implant survivalwas done up to 1 year. OPG taken after 3year follow up (fig.16).Figure 6: OPG showing tall and tilted implants afterplacementProsthetic replacement- TemporaryAftersurgicalintervention,temporary abutments were placed to thepatient multiunits which were made parallelto each other to compensate the implantangulation on the same day of surgery.Alginate impressions were taken and bitewas recorded in centric relation. Immediateprovisionalization was done with self cureacrylic and cemented it with provisionalcement (IRM). Occlusion was checked andseen to it that bilateral contact and groupfunction was gained without any excursivecontactsFigure 7: Six implants in the maxilla with good tissue healingFigure 8: Open plastic tray is selected and modified for fullmaxillary arch impressionInternational Journal of Research & Review (www.ijrrjournal.com)Vol.5; Issue: 6; June 2018107