Dental Traumatology 2003; 19: 126±131 Copyright # Blackwell Munksgaard 2003

Printed in Denmark. All rights reserved

DENTAL TRAUMATOLOGY
ISSN 1600±4469

Single-tooth implant treatment in the anterior

region of the maxilla for treatment of tooth loss
after trauma: a retrospective clinical and
interview study
Andersson L, Emami-Kristiansen Z, Ho«gstromJ. Single-tooth Lars Andersson1,2,
implant treatment in the anterior region of the maxilla for treatment Zina Emami-Kristiansen1,
of tooth loss after trauma: a retrospective clinical and interview study. Jan Ho«gstro«m3
Dent Traumatol 2003;19:126^131. # Blackwell Munksgaard, 2003. 1
Department of Oral & Maxillofacial Surgery, Central
Hospital, Vasteras, Sweden; 2Department of Surgical
Abstract ^ The aim of this study was to evaluate the results of single- Sciences, Faculty of Dentistry, Kuwait University,
tooth implant treatment in patients where teeth have been lost as a Kuwait; 3Department of Prosthodontics, Central
Hospital, Vasteras, Sweden
result of trauma. Also, the patients'and professionals'opinions
regarding the final outcome of treatment were assessed. Thirty-four
patients with 42 lost teeth were evaluated by clinical and
radiographic examinations and interviews 2^5 years after treatment.
A professional who had not taken part in the treatment evaluated the
implant crowns. Central maxillary incisors were the most frequently
lost and replaced teeth after trauma (75%) followed by lateral
incisors (21%). In patients with incomplete growth, implant
treatment was generally postponed until completion of growth. Lack
of space was treated by presurgical orthodontics (7%) or by selecting
an implant with a reduced diameter (5%). Deficiency of bone was
seen in 17% and was treated by bone grafting or local augmentation
prior to implant surgery. Patients who had lost two or more teeth after
trauma were all subjected to bone grafting. Preservation of roots in
the alveolar process seemed to maintain the bone volume enabling
better conditions for later implant placement. Forty-one implants
(97.6%) were integrated successfully. Complications were few and of
minor importance (9.5% before and 12% after cementation of
crowns) and could all be managed. No or minimal bone loss was seen.
In general, the patients felt that they received good care and that they
were well informed about their treatment. Some patients reported
that the local anesthesia procedure was not pain-free, but 71% of the
patients experienced the treatment as pain-free. For each of the
variables (color, shape, height, and size of the crowns), the highest
degree of satisfaction was noted in 93^98% of the patients and 91^
Key words: dental trauma; treatment; dental implant;
95% of the single evaluating professional. Given that the patients single-tooth implant restoration
have finished growth and a careful treatment planning and timing
Prof. Lars Andersson, Department of Surgical Sciences,
are performed, the functional and esthetical outcome of single-tooth Faculty of Dentistry, Kuwait University, PO Box 24923,
implant treatment today is excellent and can be recommended for Safat 13110, Kuwait
replacing tooth losses after trauma in the anterior region of the e-mail: [email protected]
maxilla. Accepted 29 October, 2002

126
 Single-tooth implant treatment after trauma

Dental trauma is a frequently occurring phenom- in the anterior maxilla, where the teeth have been lost
enon in our society, with the anterior region of the because of trauma. Another aim was to assess the
maxilla being by far the most a¡ected site (1, 2). patients' and professionals' opinions regarding the
Although many teeth are saved today by successful ¢nal outcome of treatment.
replantation (1,3), some of the avulsedteeth areneither
found at the site of the accident nor replanted for other Patients and methods
reasons. Other teeth are replantedbut some failtoheal
because they are later subjected to progressive root Study population
resorption and are ¢nallylost (4). Some teeth subjected
to trauma may also have deep crown^root fractures Patients who had been subjected to implant treatment
or root fractures that result in di¤culties in proper in the anterior region of the maxilla (incisors and
restorations (1). Some of the severely luxated teeth, canines) during the period 1994^98 at the Central
especially intruded teeth, are later subjected to pulp Hospital of Vasteras were selected. This paper exclu-
necrosis and root resorption (1). Although today we sively presents patients treated for tooth losses that
have numerous methods to treat severely injured were caused by dental trauma.There had been either
teeth, there are teeth that we cannot save because of an immediate loss of a tooth at the time of trauma or
various types of complication, which often necessitate an indirect one as a result of complications, which
later extraction. had not been possible to treat properly, resulting in
Over the years, various treatment methods have the need for later extraction of the tooth. Patients were
been used for replacement of lost anterior teeth, called in when a minimum of 2 years had passed since
including removable partial dentures and resin- the implant treatment was completed.
bonded or cemented bridges.With increasing patient Thirty-four trauma patients (22 males and 12
demands, many patients do not accept removable con- females) treated with implants attended the follow-
structions as a ¢nal solution. In addition, esthetic up examination. The majority of the patients were
demands are very high in the maxillary front region. young adults with a median age of 13 years at the time
Finally, both patients and professionals are aware of of the dental trauma and a median age of 20 years at
and prefer not to use intact non-injured adjacent teeth the time of the ¢rst implant surgery. In ¢ve patients,
for grinding and anchoring of ¢xed constructions. single-tooth implants were used to replace the loss of
This objectionable procedure can be avoided by three teeth. In one patient, three teeth were lost and
implant treatment, where the lost tooth is replaced replaced with a single-tooth implant. In total, 42 lost
by an implant-supported crown without involving teeth had been replaced in the 34 patients.
intact adjacent teeth. The lost teeth hadbeen replacedby one or more sin-
Implant treatment according to BrÔnemark's gle implants in the incisor and/or canine regions. Five
method has been in use since the late1970s, and favor- patients with bone de¢ciency required bone grafting
able prognosis for totally edentulous and partially 5^7 months before implant installation. In three of
edentulous cases have been reported (5, 6). Since the these patients, general anesthesia was required. All
late 1980s, implant treatment has been used on surgery for implant installation was performed in
patients with single-tooth losses. The ¢rst cases, in local anesthesia using Xylocaine^adrenalin 2%
which screw ¢xation of the implant was applied, did (Astra, So«derta«lje, Sweden). Surgical treatment was
not always produce esthetic results; in addition, fre- performed according to BrÔnemark's method in
quent problems with loosening of the crown screws which a two-stage surgical procedure was used (18).
were observed. When cemented porcelain crowns on Twelve of the patients (38%) were given premedica-
a loosening resistant gold screw (Cera-One, Nobel tion in addition to local anesthesia. Premedication
Bio care, Gothenburg, Sweden) were introduced in was given orally in doses of 10^20 mg benzodiazepam
1991, a more reliable, functional, and esthetically (Stesolid, Dumex, Helsingborg, Sweden) or per oral
pleasing rehabilitation of single-tooth losses was possi- in doses of 10^25 mg midazolam extempore. Tempor-
ble (7,8). In a number of studies, single-tooth implants ary prosthetic constructions were performed within
have been used in situations with aplasia and for the 2 weeks after ¢rst stage of surgery. Healing periods
replacement of lost teeth in various parts of the oral ranged from 6 to 8 months between the ¢rst stage sur-
cavity.These studies have reported a high-success rate geries (i.e. implant installation) and second stage sur-
and low frequency of complications (8^17). gical uncovering and abutment application. After
During the past decade, in our specialist center the second stage surgery, prosthetic treatment with
implant treatment with cemented porcelain crowns all ceramic crowns (Cera-One, Nobelbiocare,
has been the method of choice for replacing lost teeth Gothenburg) were performed according to the
in the anterior region. The purpose of the present Cera-One method as described by Andersson et al.
study was to clinically evaluate the results of single- (7). The patients were recalled after a minimum of
tooth implant treatment for replacement of teeth lost 2 years following completion of treatment.

127
Andersson et al.

given, the care of the patient as well as the patients'

Registration of data from medical files
opinions regarding whether treatment was painful
The following variables were registered from the ¢les: or not, were evaluated. Patients were invited to give
Age at time of trauma comments in addition to their answers. Descriptive
Region of missing tooth statistics were used in the evaluation of the data.
Reason for dental trauma
Type of temporary construction before implant treat- Results
ment
Preoperative lack of space present and preoperative Thirty-four patients presented with 42 teeth with a
orthodontics required previous history of trauma: nine indicated avulsion
Age at time of implant surgery without replantation; 16 showed complications after
Type and length of implant replantation; nine exhibited complications after
Bone augmentation crown and/or root fractures; and eight su¡ered com-
Failure of osseointegration plications after various luxation injuries.The most fre-
Removed implants quently replaced teeth were the central maxillary
Complications incisors (34 teeth or 75%), followed by lateral incisors
(six teeth or 21%) and canines (two teeth or 4%).
Clinical registration Implant treatment took place from 6 months up to
11years after trauma. The shortest times were regis-
The patients were registered clinically and radiogra- tered in patients inwhich growth hadbeen completed.
phically. In addition, all patients were interviewed. One reason for waiting for implant treatment was
A dentist who had not taken part in the treatment per- the strategy of intentionally postponing treatment
formed the registration. Sulcus depth was measured until growth had been completed in the younger
by probing, and presence of gingival bleeding was patients. Another reason for late implant treatment
registered. Sulcus depth >4 mm was registered as was that a ¢nal decision on implant treatment was
increased sulcus depth. Four sites per implant were not taken until many years after other treatment alter-
registered. Interference of the crown in occlusion natives (e.g. acid etch bonded-bridges and removable
and articulation was noted. The relation of the cervi- partial dentures). A majority of the patients with
cal crown margin to the gingival margin on the facial resin-bondedbridges reportedthat thesebridges came
surface was classi¢ed as supra- or subgingival and loose as a result of inadequate bonding to enamel.
infraposition was measured in relation to neighboring In ¢ve implant sites, mesio-distal de¢ciency of space
teeth. Compromised ¢xture placement in bucco-lin- interdentally was registered before treatment. Three
gual or mesio-distal direction was noted. of these cases were treatedby presurgical orthodontics
Radiographic examination was performed with while in the remaining two cases an implant screw
panoramic ¢lms and dental ¢lms using a ¢lm holder with a smaller diameter was chosen as an alternative
and a parallel technique to obtain orthoradial radio- to orthodontic treatment. De¢ciency of bone before
graphs. The level of the bone was registered relative surgery was observed in seven implant sites (17%). In
to the threads of the implants. two of these, a horizontal widening of the crest was
performed by crestal splitting before later implant
Evaluation of the patients and the professionals' opinion of installation. In ¢ve of the patients withbone de¢ciency,
treatment outcome local onlay bone grafts were required, in which case
the grafts were taken from the mentum or trigonum
On the same occasion, the patients were askedto com- region of the mandible. In one case of bone de¢ciency,
plete a self-administered questionnaire. The patients osteopromotivemembranewasusedforaugmentation.
were asked to rate if they were satis¢ed with the color, The most frequently used type of implants was self-
shape, height, and size of the implant-supported tapping Mk 2 ¢xtures (Nobel Biocare, Go«teborg,
crown on a 4-point scale with: 1 ˆyes; 2 ˆ yes with Sweden), which were used in 31 (74%) of all installed
doubt;3 ˆ nowith doubt; and 4 ˆ no.Theprofessional implants. In the remaining 11 (26%), implants stan-
evaluator, a general dentist, had not taken part in dard ¢xtures were used. A normal ¢xture diameter
the treatment of the patient and met the patient for of 3.8 mm (regular platform) was used in 40 (95%)
the ¢rst time during the evaluation phase of the study. of the 42 installations; in the two remaining ¢xtures
After this phase, and without knowledge of the regis- a reduced diameter of 3.2 mm (narrow platform)
tration of the evaluator, the patients were asked to was used. The lengths of the implants were 13 mm
evaluate the same variables as the professional evalua- (62%),15 mm (33%), or 18 mm (5%).
tor. Finally, the patients answered questions about Forty-one implants (97.6%) integrated successfully.
chewing function and speech. The patients' views on Complications are summarized inTable1. Complica-
how the pre- and postoperative information was tions during the surgical healing period were noted

128
 Single-tooth implant treatment after trauma
Table1. Number (%) of complications observed in implants (n ˆ 42) in the Table 2. Patients' (n ˆ 34) self-reports of satisfaction with care and treat-
anterior maxilla ment

Number (%) Degree of satisfaction (%)

Complications during the postsurgical healing period 1 2 3 4

Non-integration 1 (2) I received sufficient information 28 (82.4) 6 (17.6)
Loose abutment screw 1 (2) before treatment
Exposed implant 2 (7) I received sufficient information 33 (97.1) 1 (2.9)
Complications after cementation of crown after surgery
Loose crown 1 (2) The implant treatment was 24 (70.62) 6 (17.6) 2 (5.9) 2 (5.9)
Porcelain fracture 1 (2) pain-free
Infraposition 2 (7) The care from the staff was good 31 (91.2) 3 (8.8)
Fistula 1 (2) I can bite and chew with my 32 (94.2) 1 (2.9) 1 (2.9)
implant
I can pronounce all sounds 32 (94.2) 1 (2.9) 1 (2.9)

Degree of satisfaction was rated on a 4-point scale with: 1 ˆyes; 2 ˆ yes with
in 4 (9.5%) of the 42 implants installed. One implant doubt; 3 ˆ no with doubt; and 4 ˆ no.
was not integrated as detected at second stage surgery.
After removal of the non-integrated ¢xture andinstal-
lation of a new ¢xture, healing with osseointegration of insertion was seen in two implants: both were more
was observed and the patient could be rehabilitated. mesially positioned than ideal.
In two patients, exposure of the cover screws of the Table 2 summarizes the patients' self-reports on
implants was seen during the healing period but no some parameters on care andtreatment they received.
further action was required. A loose cover screw was In general, the patients felt they received good care
discovered in one patient during the healing period. and that they were well informed about their treat-
Complications after cementation of the crowns ment. Twenty-four patients (71%) experienced the
were seen in ¢ve patients (12%). In one patient, the treatment as pain-free. However, 10 patients (29%)
crown was loose and thus had to be re-cemented. In reported that they experienced some pain. Surgery
another patient, a second crown had been made itself was not experienced as painful, but the local
because of a porcelain fracture. Infraposition relative anesthesia procedure was frequently reported as the
to the neighboring tooth was found in two patients. worst part of treatment. All but 1 of the 34 patients
One of these patients presented with 2 mm infraposi- (97%) answered that they could bite and chew with
tion of a central incisor 3 years after treatment, and their implant. Only one patient avoided biting on
thus a secondcrown hadtobe made.The otherpatient the implant, fearing that it may come loose if she
presented with an infraposition of a central incisor of would bite hard. One patient reported di¤culties in
1mm, but was satis¢ed with his crown. The cervical pronouncing sounds.
crown margin was positioned subgingivally in 41 of Table 3 showsthe evaluation of the ¢nal esthetic out-
the 42 implants. One patient presented with a ¢stula come of the treatment concerning color, shape, height,
in the marginal gingival after cementation of the and size of the crown. For each of the variables (color,
crown, which closed spontaneously after curettage shape, height, and size of the crowns), the highest
in the gingival sulcus. Patients showed good oral
hygiene ingeneral and soft tissue pathology wasrarely
Table 3. Patients and professionals'evaluation of degree of satisfaction (%) of
detected. Bleeding on probing was noted in 21 (13%) the 42 implant crowns
of 168 sites registered. In two implants, a sulcus depth
more than 4 mm was registered. In one of these 1 2 3 4
patients, a 1-mm loss in mesial bone level was found.
I am satisfied with the color of the crown
In all other implants (98%), the bone level was regis- Professional 38 (90.5) 3 (7.1) 1 (2.4)
tered at the ¢rst thread from the inferior part of the Patients 41 (97.6) 1 (2.4)
implant 2 years after implant installation. No occlusal I am satisfied with the shape of the crown
interferences of the crowns were registered in occlu- Professional 40 (95.2) 2 (4.8)
sion or articulation in any patient. Patient 41 (97.6) 1 (2.4)
Placement of implants was assessed as optimal in 36 I am satisfied with the height of the crown
implants (86%), andthusthe construction of an esthe- Professional 39 (92.8) 2 (4.8) 1 (2.4)
tically and functionally optimal crown could be Patient 41 (97.6) 1 (2.4)
accomplished. Compromised directions in the sagit- I am satisfied with the size of the crown
tal plane were registered in six cases. In four cases, Professional 39 (92.8) 2 (4.8) 1 (2.4)
Patient 39 (92.8) 1 (2.4) 1 (2.4) 1 (2.4)
the implants were proclined and in two cases retro-
clined in relation to an ideal direction of insertion. Degree of satisfaction (%) was rated on a 4-point scale with: 1 ˆyes; 2 ˆ yes
Inthe mesio-distal direction a compromised direction with doubt; 3 ˆ no with doubt; 4 ˆ no.

129
Andersson et al.

degree of satisfaction was noted in 93^98% of the patients treated in the study period. In one of these
patients and 91^95% of the single evaluating profes- patients, another implant crown was made.The other
sionals. One patient was dissatis¢ed with the outcome patient had a minor infraposition of less than 1mm
of the size of the implant supporting crown. but was pleased with his crown. Nowadays, before
we start installation of implants, we always wait until
Discussion we receive a con¢rmation by a registration of body
height that growth is completed (19, 20).
The results of our study demonstrate that anterior We could not ¢nd any speci¢c reason for the lost
teeth lost after trauma in the maxilla can be success- implant. This implant was removed, and the patient
fully replaced by single-tooth implants. A good ¢nal had a new installation 5 months later, which proved
treatment result, functionally and esthetically, can successful. Other complications observed were minor
be attained where both the patients and the profes- and little in number. Soft tissue conditions and oral
sionals are satis¢ed with the results. Complications hygiene were generallygood.The occurrence ofbleed-
are few and can be managed should they occur. In ing, increased sulcus depth and resorbed marginal
contrast to bridge therapy, the main advantage of bone levels was low and in accordance with other stu-
using implants is that intact adjacent teeth do not have dies (13, 15, 16). The anterior area of the maxilla is an
to be involved in anchoring. area where it is generally easier to maintain good oral
Replacing lost teeth after trauma in the anterior hygiene. The placement of the crown margin in the
region of the maxilla presents special problems to peri-implant sulcus did not seem to cause any in£am-
the profession. Because many of the trauma patients mation or recession of soft tissue. It is important to
are young and still growing, several factors have to bear in mind that an observation period of 2 years is
be considered in treatment planning. In order not to premature to draw any ¢nal conclusions about long-
interfere with growth and development of the tissues, term prognosis, though these short-term results indi-
¢nal implant treatment often has to be postponed cate favorable conditions.
until the patient has completed growth (19). Timing Patients with space de¢ciency bene¢ted from pre-
is essential and treatment must be planned in relation operative orthodontic widening of the space before
to the growth of the patient (20). Many of our younger placement of the implants. In 83% of the patients, a
patients, in this study, had to wait several years after direct installation without orthodontic treatment for
the trauma event before implant treatment could be bone augmentation by bone graft was performed. In
performed. During this time, it is critical to maintain the majority of patients, an exceedingly good result
the volume of the alveolar process in order to avoid was achieved. However, with single implants in the
atrophy. Our patients who required bone graft had front region, it is of utmost importance to be able to
an area of tooth lossthat hadbeen left for severalyears. install implants in an optimal directionto enable good
We also noted that the patients who had lost two or esthetic results. In some patients, installation was per-
more adjacent teeth were all subjected to bone graft- formed with a compromised direction and three
ing. However, patients in our material that had been patients were not completely satis¢ed with the shape
subjectedtotemporary measures, such aspreservation of the crowns. This dissatisfaction was related to sub-
of roots in the alveolar bone until implant treatment optimal directions of implant insertion, making the
could be performed were in general good candidates crown somewhat thicker compared with the adjacent
for implant treatment without bone grafting. These tooth. In some patients, it may be better to ¢rst aug-
¢ndings punctuate the importance of roots being pre- ment bone by grafting before installing an implant.
sent in the alveolar process to maintain its volume This was done in ¢ve patients with successful results.
and development and to avoid atrophy. Consequently, The long extra time, usually more than 6 months,
in treatment planning it is extremely important to required for preoperative orthodontics and bone
treat and save teeth and roots as long as possible rather grafting is well worth the time to achieve an esthetical
than extracting early while waiting for implant treat- optimal result, which is especially important in the
ment. Given that there is no root infection, it may anterior region of the maxilla.
maintain the volume of the alveolar bone for later Patients were generally highly satis¢ed with the
implant treatment. However, saving an infected root information and care given and the function of the
is not recommended because this will most likely con- implants was generally very good. The patient who
tribute to more rapid bone resorption. was hesitant to bite hard on the implant was even-
Infraposition was seen in two patients, indicating tually encouragedto go ahead. Problems withthe pro-
that the growth of the alveolar process was not fully nunciation of some sounds, as a result of escaping of
completed when these implants were installed. Later, air through the interproximal embraces, have been
this observation was also veri¢ed by asking for these reported by Moberg et al. (16).This problem, however,
patients' growth registration data from their school was minor for the one patient in our study reporting
nurse. These two patients were among our ¢rst pronunciation di¤culties. Because an injection is

130
 Single-tooth implant treatment after trauma

di¤cult to give without some degree of pain, the ¢nd- grated oral implants in the rehabilitation of partial edentu-
lism. A prospective multicenter study 558 fixtures. Int J
ing that almost 30% remembered the application of Oral Maxillofac Implants 1990;5:272^81.
the local anesthesia procedure as painful is not sur- 7. Andersson B, O«dman P, Carlsson L, BrÔnemark P-I. A new
prising. Although patients do not normally mention BrÔnemark single tooth abutment. Handling and early clin-
this fear, many are afraid of injections. Thus, perhaps ical experiences. Int J Oral Maxillofac Implants 1992;7:
we should have given all the patients premedication. 105^11.
8. Andersson B, O«dman P, Carlsson GE. A study of 184 con-
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