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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 87-90

Use of pterygium sutures and diode laser in second-stage implant exposure procedure for single implant-retained overdenture


Department of Periodontics and Oral Implantology, Faculty of Dental Science, DDU, Nadiad, Gujarat, India

Date of Submission22-Sep-2021
Date of Acceptance14-Oct-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Anal Rutvik Trivedi
3, Lakshya La Villa, Opp. Lambhavel Hanumann Tample, Anand-Lambhavel Road, Anand - 388 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_25_21

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  Abstract 


Nowadays, single implant-retained overdenture (SIROD) has gained popularity over two/multi-implant-supported overdenture. Prosthetic success of SIROD depends on second-stage surgical procedure for implant exposure with surrounding tissue manipulation. The anatomy and soft-tissue support around implants are different than that around teeth. Unlike the supportive periodontal ligament around teeth, a direct anchorage of connective tissue to the surface of the implant is not possible, and the mechanical quality of this attachment is low. This is especially important because the implant-supported restoration is located beneath the oral mucosa. These differences are important to understand the susceptibility of implant for infection in case of implant-supported overdenture with inadequate width of keratinized gingiva and shallow vestibule. In the present case report with the use of pterygium sutures and diode laser, successful implant exposure without hindrance of surrounding mucosal or muscle pull could be achieved.

Keywords: Diode laser, pterygium sutures, single implant-retained overdenture


How to cite this article:
Trivedi AR, Patel VI, Gupta SS, Purani HJ. Use of pterygium sutures and diode laser in second-stage implant exposure procedure for single implant-retained overdenture. Indian J Oral Health Res 2021;7:87-90

How to cite this URL:
Trivedi AR, Patel VI, Gupta SS, Purani HJ. Use of pterygium sutures and diode laser in second-stage implant exposure procedure for single implant-retained overdenture. Indian J Oral Health Res [serial online] 2021 [cited 2022 Nov 29];7:87-90. Available from: https://www.ijohr.org/text.asp?2021/7/2/87/333380


  Introduction Top


Mandibular single implant-retained overdenture (SIROD) has gained popularity over two/multi-implant-supported overdenture (TISOD). SIROD requires less clinical expertise, less cost, less time, and less invasive procedure and has less risk of mental nerve paresthesia compared to TISOD.[1] As the single implant is placed in very poor alveolar ridge, the only requisite for SIROD is the management of surrounding mucosal and muscle pull which may lead to poor oral hygiene maintenance. Pterygium sutures followed by the use of diode laser had been proved to be effective at different stages of implant exposure surgical procedure in the present SIROD case report.


  Case Report Top


A 65-year-old male was referred from the department of prosthodontics and oral implantology to the department of periodontics and oral implantology for the second-stage implant exposure surgical procedure. The single implant was placed in mandibular symphyseal region for mandibular SIROD before 6 months. On examination, poor mandibular alveolar ridge and shallow lower anterior vestibular region with blanching of tissue were detected [Figure 1] and [Figure 2]. After taking patient's consent, second-stage implant exposure procedure and ball abutment placement were planned. After achieving adequate local anesthesia (1:100,000 epinephrine), a horizontal incision was placed over the most blanched and bulged region of lower anterior alveolar ridge [Figure 3] to expose the cover screw over implant, further deepening of peri-implant vestibular region was done by incising muscle fibers [Figure 4]. Cover screw was removed, and ball abutment was tightened at 32Ncm with torque wrench [Figure 5]. Pterygium sutures (with resorbable 4-0 polyglactin, ½ circle round-bodied needle) (Vicryl 4-0 polyglactin 910, ½ circle round-bodied needle) [Figure 6] were taken on both the labial and lingual sides of ball abutment. Postoperative instructions were explained. Postoperative antibiotics, analgesics, and mouth rinses were prescribed. The patient was recalled for follow-up after 2 weeks. However, the patient failed to come for follow-up visit, and he did not visit the department of prosthodontics also for 3 months. After 3 months, the patient was reported back, and it was found that the ball abutment was almost covered with the peri-implant mucosal tissue [Figure 7]. At this time, after taking patient's consent, ball abutment exposure was done with 808 ± 5 nm diode laser (DenMat Sapphire® Portable Diode Laser, DenMat Holdings, LLC, Lompoc, CA, USA) [Figure 8], and metal housing of final prosthesis was attached over the ball abutment [Figure 9] on the same day. After 2 weeks of follow-up, the patient was referred back to the department of prosthodontics and oral implantology for final prosthesis impression taking. Single implant-retained overdenture was delivered with patient's satisfaction from the department of prosthodontics in the subsequent visits. Excellent oral hygiene maintenance had been demonstrated without any signs of peri-implant mucositis after 1 year in the follow-up visit [Figure 10].
Figure 1: Poor mandibular anterior alveolar ridge with blanching of tissue over implant region

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Figure 2: Shallow lower anterior labial vestibular region, lateral view

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Figure 3: Horizontal incision over the most blanched and bulged region

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Figure 4: Exposure of the cover screw over implant

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Figure 5: After removal of cover screw, ball abutment was tightened at 32 Ncm

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Figure 6: Pterygium sutures taken on both the labial and lingual sides of ball abutment

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Figure 7: Ball abutment covered with the periimplant mucosal tissue in follow-up after 3 months

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Figure 8: Exposure of ball abutment with diode laser

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Figure 9: Metal housing was attached over the ball abutment

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Figure 10: Follow-up after 1 year

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  Discussion Top


Single implant-retained overdenture provides an effective treatment modality for the edentulous patient, who has very poor mandibular alveolar ridge with the proximity of mental nerve and persistent problems with the use of a conventional mandibular denture.[2] In most cases, failure of loaded implant is accompanied by a gradual process of breakdown of supporting soft and hard tissues following plaque accumulation. The superstructures and the underlying permucosal portions of the implants become difficult to clean by the patients when there is tension over peri-implant tissue. Furthermore, in many cases, oral hygiene maintenance become painful, because of the thin labial and peri-implant-attached gingival mucosa, which is often formed after implant placement procedures.[3]

The anatomy and soft-tissue support around implants are different than that around teeth. It has been suggested that the attached mucosa adheres to the surface of the titanium implant by means of hemidesmosomes. However, no periodontal ligament or root cementum is present around implant. Therefore, a direct anchorage of connective tissue to the surface of the implant is not possible, and the mechanical quality of this attachment is low. This is especially important because the implant-supported restoration is located beneath the oral mucosa. These differences are important to understand the susceptibility of implant to infection in the case of implant-supported overdenture with inadequate width of keratinized gingiva and shallow vestibule.[3] In such type of case during second-stage implant exposure procedure, vestibular extension procedure followed by sutures – which do not allow both edges of the epithelium to come in contact during the process of healing with somewhat apical repositioning of labial flap – can serve the purpose of retention and oral hygiene maintenance by reducing surrounding muscle pull and mucosal interference. Many vestibular extension techniques have been described in previous periodontal mucogingival surgery literature till today such as Kazanjian, Godwin, Trauner, Clark, Obwegeser, Howe, Steinhauser, and Tortorelli. Vestibuloplasty techniques can be generally categorized as mucosal advancement, secondary epithelization, and grafting vestibuloplasty.[4] The pterygium sutures through the center of the incision, guide the reattachment of the epithelium, which is healed by secondary intention. In the present case report, conventional vestibular extension procedure with secondary epithelization technique had been performed followed by pterygium sutures.

Literature suggests that the diode laser shows significant difference in comparison with scalpel vestibular extension on VAS scale during and after surgery. And also, the diode laser shows less events of postoperative edema and swelling.[5] Therefore, the diode laser was used to achieve adequate peri-implant tissue, in the follow-up visit of the present case report.

SIROD has been proved economically good option for the patients with poor mandibular alveolar ridge. However, oral hygiene maintenance remains always challenging in such type of cases. Vestibular extension procedure followed by pterygium sutures and diode laser could give promising results in such type of cases.[6] Further research work with comparative analytical data collection is invited to demonstrate better outcomes in this direction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name 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.
Mahoorkar S, Bhat S, Kant R. Single implant supported mandibular overdenture: A literature review. J Indian Prosthodont Soc 2016;16:75-82.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Padmanabhan H, Kumar SM, Kumar VA. Single implant retained overdenture treatment protocol: A systematic review and meta-analysis. J Prosthodont 2020;29:287-97.  Back to cited text no. 2
    
3.
Elkhaweldi A, Rincon Soler C, Cayarga R, Suzuki T, Kaufman Z. Various techniques to increase keratinized tissue for implant supported overdentures: Retrospective case series. Int J Dent 2015;2015. Doi: https://doi.org/10.1155/2015/104903.  Back to cited text no. 3
    
4.
Singh GP, Srivastava R, Kaur M, Singh R. An innovation in Vestibular/Gingival Extension procedure- A case Report. Asian J Oral Health Allied Sci 2011;1:47-50.  Back to cited text no. 4
    
5.
Kalakonda B, Farista S, Koppolu P, Baroudi K, Uppada U, Mishra A, et al. Evaluation of patient perceptions after vestibuloplasty procedure: A comparison of diode laser and scalpel techniques. J Clin Diagn Res 2016;10:ZC96-100.  Back to cited text no. 5
    
6.
Nehal N, Chandra D, Ahmed R, Saimbi CS. A newer technique of suture placement in scalpel and laser-assisted vestibular deepening. BMJ Case Rep 2017;2017:bcr2017221719.  Back to cited text no. 6
    


    Figures

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



 

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