Pain on Left Side Due to Fractured Bridge and Surgical Extraction and Immediate Implant Placement In

Patient Complaint:

A patient presented to our clinic with the complaint of pain and inability to chew from the left side of the jaw. The patient reported that the discomfort had been persistent for the past several weeks and worsened while eating. The patient also noted a feeling of looseness and movement in the bridge in that area.

Clinical Examination:

Intraoral examination revealed:

• A fractured metal-ceramic bridge spanning from tooth 34 to 37.
• Tooth 34 (mandibular left first premolar) and tooth 37 (mandibular left second molar) were grossly decayed and mobile.
• The gingiva around the prosthesis was inflamed, and plaque accumulation was seen underneath the fractured bridge.
• No signs of trismus, paresthesia, or facial swelling.

Medical History:

• No known medical conditions.
• Patient is not on any long-term medications.
• Fit for minor oral surgical procedures under local anaesthesia.

Radiographic Evaluation:

A CBCT scan was advised to:

• Assess bone density and volume in regions 34 and 37.
• Determine the position of the inferior alveolar nerve.
• Check for any periapical pathology or cortical bone defects.

CBCT Findings:

• Tooth 34: Deep secondary caries with loss of buccal wall.
• Tooth 37: Severely carious and non-restorable.
• Adequate buccolingual bone width in both regions for immediate implant placement.
• The inferior alveolar canal was at a safe distance in relation to 37.

Final Diagnosis:

• Fractured FDP (Fixed Dental Prosthesis) from 34 to 37.
• Grossly decayed and non-restorable teeth 34 and 37.
• Adequate bone is available for immediate implant placement post-extraction.

Treatment Plan:

• Surgical removal of the fractured bridge.
• Atraumatic extraction of teeth 34 and 37.
• Immediate implant placement at extraction sockets.
• Healing phase of 3 months followed by prosthetic rehabilitation.

Surgical Procedure (Step-by-Step)

 Step 1: Preparation & Anaesthesia

• Surgical site was disinfected using 0.2% chlorhexidine rinse.
• Inferior alveolar, lingual, and buccal nerve blocks were administered using 2% lignocaine with 1:100,000 adrenaline.
• Patient was draped, and aseptic protocol was followed throughout.

 Step 2: Removal of Fractured Bridge

• Using a carbide bur, the metal-ceramic bridge was sectioned at the connectors between 34–35 and 36–37.
• Careful elevation of segments using a crown remover to prevent damage to underlying teeth and tissues.

 Step 3: Atraumatic Extraction of 34 and 37

• Tooth 34 was severely decayed and fractured during elevation.
• Periotomes and fine elevators were used to luxate and remove root fragments.
• Similarly, tooth 37 was sectioned into mesial and distal roots and removed with minimal trauma.
• All sockets were curetted and irrigated thoroughly to remove any granulation tissue and ensure a clean bed for implants.

 Step 4: Osteotomy and Immediate Implant Placement

• Based on CBCT measurements and clinical judgment, implant sites were marked in the extraction sockets of 34 and 37.
• A sequential drilling protocol was followed to create osteotomies in the healed bone.
• Two titanium implants were placed
• Both implants achieved excellent primary stability with insertion torque >35 Ncm.
• Cover screws were placed.

 Step 5: Flap Closure

• Since no flap was raised initially, a slight releasing incision was given to allow for tension-free closure over the implants.
• Sutures were placed using resorbable 4-0 sutures (Vicryl).

Post-Operative Care:

The patient was prescribed:

• Amoxicillin 500 mg TDS for 5 days
• Ibuprofen + Paracetamol SOS for pain
• 0.2% Chlorhexidine mouthwash twice daily after 24 hours
• Ice packs intermittently for 24 hours
• Soft diet and strict avoidance of chewing on the left side for 2 weeks

Follow-Up Protocol:

• 1-week post-op: Healing satisfactory, no signs of infection or swelling
• Monthly reviews to monitor osseointegration
• At 3 months: CBCT and clinical assessment done. Implants showed excellent integration.

Final Prosthetic Phase:

• Healing abutments placed, followed by final impressions.
• Metal-ceramic bridge was fabricated and cemented from 34 to 37 on the two implants.
• Occlusion adjusted to eliminate any premature contacts.

Outcome

The patient reported complete relief of symptoms with improved chewing efficiency and comfort. The aesthetic and functional outcomes were excellent, with long-term success expected due to proper case selection, technique, and follow-up care.

Clinical Insights:

• Immediate implant placement significantly reduces overall treatment time.
• Atraumatic extraction and careful preservation of socket architecture are crucial for long-term success.
• CBCT evaluation plays a vital role in safe implant planning, especially near anatomical landmarks.

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