|Year : 2022 | Volume
| Issue : 4 | Page : 404-411
Natural teeth and implant-retained prosthesis in treated periodontitis subjects
Farhan Durrani, Samidha Pandey, Rakhshinda Nahid, Aishwarya Pandey, Preeti Singh
Division of Periodontology, Faculty of Dental Sciences, IMS BHU, Varanasi, Uttar Pradesh, India
|Date of Submission||01-Aug-2020|
|Date of Decision||07-Mar-2021|
|Date of Acceptance||21-Mar-2021|
|Date of Web Publication||27-Sep-2021|
D 37/40 Baradeo Godowlia, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
History of periodontal disease is a risk factor for the development of peri-implantitis. Implant treatment in susceptible patients should be followed by adequate periodontal treatment and stringent supportive programs. The assessment of the patient needs to be carefully evaluated before the procedure for implants. The risk associated with the sites to be treated requires evaluation with regular visits. The completion of treatment will still require committed follow-up visits with checks for pockets, bone loss, and plaque scores around implant-retained prosthesis as well as complete dentition. In our report, we describe in detail the reconstruction of lost dentition with implants in treated periodontitis subjects. The patients are still being followed with regular recall programs.
Keywords: Follow-ups, implants, periodontitis, rehabilitations
|How to cite this article:|
Durrani F, Pandey S, Nahid R, Pandey A, Singh P. Natural teeth and implant-retained prosthesis in treated periodontitis subjects. J Indian Soc Periodontol 2022;26:404-11
|How to cite this URL:|
Durrani F, Pandey S, Nahid R, Pandey A, Singh P. Natural teeth and implant-retained prosthesis in treated periodontitis subjects. J Indian Soc Periodontol [serial online] 2022 [cited 2022 Aug 11];26:404-11. Available from: https://www.jisponline.com/text.asp?2022/26/4/404/349744
| Introduction|| |
Periodontitis is an inflammation of gums and supporting tissues of teeth. It is a bacterial-induced chronic disease which affects the periodontium. Untreated periodontitis cases can lead to loss of attachment and alveolar bone around teeth. Successful treatment of moderate periodontitis cases and retaining the affected teeth is more cost-effective. However, in certain clinical conditions, extraction and replacement with implants may become a necessity. Dental implants are the most comprehensive treatment for the replacement of teeth. In our report, we describe two complex cases of treated chronic periodontitis subjects where partial rehabilitation with implants was completed in the same and opposite arches. The report emphasizes the importance of keeping the affected/treated teeth along with implants. The adjustments of occlusion and periodontal health maintenance were meticulously planned. The aim was to check implant longevity and survival of reconstructed prosthesis. Marginal bone loss and probing pocket depth around implants were evaluated as secondary parameters. The effective periodontal therapy is a must for active periodontitis before the use of oral implants for missing teeth. The past disease can be a cause of future peri-implantitis as per several studies. An observational study of meta-analysis and systematic review on periodontitis stated that determination of potential factors associated with peri-implantitis is fundamental for preventive strategies.
| Case Reports|| |
A 62-year-old female patient presented herself with the chief complaint of mobile teeth in her mouth. The patient was healthy for her age and was neither suffering from any systemic diseases nor taking any medications. On oral examination, the maxillary teeth looked healthy and firm in their respective sockets. There was a supra eruption of two central incisors and mild recession on adjacent laterals. She was wearing a six-unit fixed partial prosthesis having lower canines as abutments. The tooth-supported bridge was mobile. There was bleeding on probing and pocket depth of on an average of 7 mm around each tooth in the lower arch. The radiographic examination showed generalized bone loss in the mandible, both first and second molars had Grade 3 furcation lesion. All other teeth were mobile with attachment loss of >50% [Figure 1]. Basic periodontal examination was done for both arches to decide the treatment needs [Table 1]. This index is a screening tool that indicates the level of further examination needed and provides guidance for treatment needed. It is minimum standard for periodontal assessment developed by the British Society of Periodontology. The instrument used for the examination is the CPITN probe (WHO probe). It has 0.5 mm ball on its tip, black band from 3.5 mm to 5.5 mm, and 8.5 mm till 11.5 mm. The dentition is divided into six sextants (17–14, 13–23, and 24–27 upper) (47–44, 43–33, and 34–37 lower). All the teeth are examined in each sextant, the probe is walked/around the sulcus/pocket in each sextant, and the highest score is recorded. The patient was suffering from periodontitis (Stage 4, Grade C) in the mandible and the maxillary arch had gingivitis (associated with biofilm alone) [Table 2].
The patient was explained about the doubtful prognosis of dentition in the lower arch. The desire of the patient was having fixed teeth. The treatment options/plan of rehabilitation of lost dentition were explained. Looking at the current clinical situation, a well-distributed fixed implant-retained prosthesis in the mandible against a natural dentition would be an evidence-based approach treatment for her. The patient preferences were longitudinal efficacy of the treatment, the cost, and maintenance. In a study by Papaspyridakos et al. on fixed implant prosthesis, the survival rate in the edentulous mandible was one piece with the incorporation of posterior cantilevers. However, it was also stated that cantilevers may be associated with technical complications, but it had no influence on prosthesis survival. Other option could be segmented prosthesis with implants in strategic positions. This design can also improve ease of fabrication, maintenance issues and will be without cantilevers. The treatment plan was explained to the patient; total extraction of teeth in the mandible and fabrication of fixed detachable segmented implant-retained prosthesis. The patient gave the consent and underwent full mouth scaling and root planning and was recalled after 3 weeks of healing. All the teeth along with six unit bridge were removed from the lower arch in one appointment. The patient was kept on antibiotics (amoxicillin 500 mg), ibugesic plus both three times daily for 7 days. The sockets were packed with collagen sponges and sutured with 5-0 sutures (Vicryl, Ethicon USA). Another 3 weeks were given for soft-tissue closure of the extraction sockets [Figure 2]. A reverse planning started, intermaxillary relations were established with casts mounted on a semi-adjustable articulator with correct jaw relationships between natural teeth of the maxillary arch and edentulous arch of the mandible (Articulator A7 Plus and Elite Facebow, Bio Art). A mandibular complete denture was fabricated during the healing period of tissues to maintain the correct vertical dimension of occlusion. This helped with the recording of the jaw relationship. Gallucci et al. proposed detachable prosthesis segmented by six or more implants along with posterior implants in the mandible which carries an advantage over cantilevered prosthesis as it accommodates diverging implants, obtaining passive fit, retrievability, and simplicity of repair. According to computed tomography measurements, the lower ridge width and length seemed adequate as the extractions of teeth were done 6 weeks back [Figure 3]a, [Figure 3]b, [Figure 3]c. Six implants were placed as per the surgical template fabricated from the replica of the lower denture in planned positions. All were internal hex implants (3.75/10 mm, T. A. G. Medical Products Corporation Ltd, Israel). Implant locations were 33, 34, 36, 43, 44, and 46 [Figure 4]. After a waiting period of 4 months, the integration of implants was checked with the placement of healing abutments and radiographs. Another 3 weeks were given for the formation of biological width around implants. The impression procedure started with open tray impression posts splinted together on implants using the pickup technique with addition silicone (Aquasil, Dentsply) [Figure 5]a, [Figure 5]b, [Figure 5]c. The laboratory fabricated three-segmented metal framework of palladium silver alloy (dSIGN® 30 Ivoclar Vivadent A. G. Liechtenstein, Europe) on six straight castable abutments with a collar height of 1 mm. All the three were tested in the patient mouth for passive fit [Figure 6]. The screw of the framework would be passive if there is no static load and strain. This was further verified with the Sheffield test (one screw test) for conforming the screw seating and misfit. Here, one screw was tightened at one end on the distal most implant of the delivered framework and at the other end, i.e., the mesial end should be seating perfectly without screwing the implant, and also intraoral periapical radiographs of each were taken for confirmation. The bite was recorded using bite registration material in centric occlusion (Imprint 4VPS Bite Registration Material-3M, USA). The framework along with the bite registration material was returned to the laboratory along with desired shade of the teeth for the final fabrication of three-unit porcelain fused metal (PFM) segmented prosthesis with a gingival mask [Figure 7]a and [Figure 7]b. The final trial was done after 2 weeks with the delivered CAD-CAM-designed prosthesis. This was screwed starting from the posterior prosthesis bilaterally (44–46 and 34–36) and then anterior prosthesis (33–43). A canine-guided occlusion was given bilaterally and posterior interferences were removed during anterior guidance of the prosthesis [Figure 8]a, [Figure 8]b, [Figure 8]c. Final torque of 35N was given to each screw after 1 week and access holes of the screws were closed with Teflon tape and composite plugs (Ivoclar Vivadent, Zurich). The patient was instructed to use fluoride toothpaste for brushing over the prosthesis two times daily and Super floss (Oral-B) for cleaning intaglio surfaces of the prosthesis as well as in between the segmented areas. A night guard of acrylic was given for maxillary ridge for initial 3 months for protection of the prosthesis. The recall period was set initially for 3 months and then every 6 months for the next 2 years. The marginal bone loss was evaluated with recall orthopantomogram which were satisfactory and probing pocket depth which ranged around 4 mm with relation to implants even after 2 years [Figure 9] and [Figure 10]. At every recall, plaque index, bleeding index, and periodontal pockets around implants and teeth present were evaluated. The segmented prosthesis was unscrewed and intaglio surfaces were checked for food entrapment and mucositis of the tissues. With reinforced regular visits of recall patient's periodontal indices, scores were <25% without the presence of inflammatory pockets. The occlusion was also evaluated carefully during every visit.
|Figure 3: (a) Three dimensional view of the edentulous mandible; (b) Cross sectional view of the anterior mandible; (c) Cross sectional view of the posterior mandible|
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|Figure 5: (a) Impression posts on implants ties with floss; (b) Pattern resin on floss; (c) Pick up impression|
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|Figure 8: (a) Frontal view of the prosthesis; (b) Left lateral view; (c) Right lateral view|
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A 59-year-old male patient presented with a chief complaint of bleeding gums and mobile teeth. On medical evaluation, the patient was devoid of any systemic health problem. On oral examination, there were supragingival calculus visible all along the lower teeth. Grade 3 mobility was associated with 46, 45, 44, 43, 42, 41, 31, 32, and 33. In the upper arch, 16 and 17 were missing. Teeth 24 and 25 had porcelain fused metal crowns with grade 3 mobility. Teeth 15, 14, 13, 23, 26, 33, 34, 35, 36, 37, and 47 had deep cervical abrasion. Recession was present on 11, 12, 21, and 22 [Figure 11]a, [Figure 11]b, [Figure 11]c.
|Figure 11: (a) Preoperative clinical picture (periodontitis); (b) Right lateral view; (c) Left lateral view|
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The patient diagnosis was periodontitis (Stage 4 Grade C for mandible from 47 to 33 and Stage 2 Grade B from 34 to 37 and Periodontitis (Stage 2 Grade B) for the maxilla [Table 3].
The patient was informed about the prognosis of individual teeth in both the arches and probable treatment aspects. The mobility and attachment loss were checked for each individual tooth. The tooth having <30% attachment loss and with no mobility were graded with a better prognosis., The others were having a doubtful or poor prognosis. The treatment began with the extraction of tooth number 46, 45, 44, 43, 42, 41, 31, 32, 33 in lower arch 24 and 25 in the upper arch. These teeth were mobile, had >50 attachment loss and Grade 3 furcation lesion in molars. The patient was kept on antibiotics (amoxicillin 500 mg) and ibugesic plus both three times daily for 7 days. The sockets were packed with collagen sponges and sutured with 5-0 sutures (Vicryl, Ethicon USA). Following 6 weeks of healing of the sockets, the patient underwent supra and subgingival debridement of all the remaining teeth, and an interim partial denture was provided for maintenance of vertical dimension. Class 5 restorations with resin-modified glass ionomer cement (Vitremer, 3M ESPE) were done with respect to 15, 14, 13, 23, 26, 34, 35, 36, 37, and 47 [Figure 12]. The patient was kept on recall for the next 3 weeks. The assessment for the plaque was done every week through the scores achieved and strict oral hygiene measures were enforced at every visit.
Based on the assessment of computed tomography scan, it was decided to place six implants in the mandible (from 33 to 46) and four implants in the maxilla (17, 16.24, and 25) [Figure 13]a and [Figure 13]b. A surgical guide was fabricated from negative replica of the existing denture of the edentulous mandibular arch [Figure 14]. After an acceptable plaque score <25%, the patient had implants in the mandible and maxilla, all were of the same size; 3.3/10 mm (Dentin Implants, Technologies, Mizpe Aviv, Israel). The buccal aspect of each implant in the mandible was augmented with xenograft (Bio-Oss, Geistlich Pharma, Switzerland) and covered with collagen membrane (Bio-Gide, Geistlich Pharma, Switzerland) [Figure 15]a and [Figure 15]b. Maxillary ridge received four implants of the same size on the right side two in the molar region and two in the premolar region on the opposite side [Figure 16]. After a waiting period of 6 months, the healing formers were attached on all the implants and osseointegration was further verified with percussion test and intraoral radiographs. Three weeks were given for maturation of tissues and biological width formation [Figure 17]a and [Figure 17]b.
|Figure 13: (a) Preoperative orthopantamogram. (b) Cross sectional slices of the anterior mandible|
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|Figure 15: (a) Six implants placed in the mandible; (b) Bone grafts covering the buccal part of the ridge|
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Impression for both upper and lower arches was taken through pick up technique with polyether material (Impregum 3M) [Figure 18]a, [Figure 18]b, [Figure 18]c, [Figure 18]d, [Figure 18]e. The lower partial denture verified the jaw relationship on the semi-adjustable articulator and face bow records provided the correct spatial relationship of the maxillary arch (Articulator A7 Plus and Elite Facebow, Bio Art). Single piece detachable framework of palladium silver alloy (dSIGN® 30 Ivoclar Vivadent A. G. Liechtenstein, Europe) was fabricated through CAD-CAM design on six straight castable abutments with collar height of 2 mm for mandible extending from tooth number 46 to tooth number 33 [Figure 19]. Upper ridge had couple of frameworks for tooth numbers 16, 17 and 24, 25 on custom abutments of the same collar height. They were evaluated for passive fit after screwing on each implant and verified radiographically for micro gaps [Figure 20]. Sheffield Test (one screw test) was used for conforming the screw seating and misfit. Here, one screw was tightened at one end on the distal most implant of the delivered framework and at the other end, i.e., mesial end seating was checked on the implant. The bite was recorded with bite registration material in centric relation (Imprint 4VPS Bite Registration Material-3M, USA) [Figure 21]. A single FP-2 detachable porcelain fused metal prosthesis of nine teeth was made with a gingival mask of composite resins for the mandible. Two screw-retained splinted PFM crowns with narrow occlusal tables were for both molars and premolars bilaterally in the maxilla. All three-prosthesis had polished intaglio surfaces with a convex profile. They were tried in the mouth after screwing them on the individual implants for their passivity and interferences during movement of the mandible [Figure 22]a and [Figure 22]b. The occlusion was canine-guided bilaterally and no posterior interferences during anterior guidance. After 1 week of trial, the screws were tightened with 35 N torque; access holes were closed with Teflon tape and composite plugs (Ivoclar Vivadent, Zurich). The patient was instructed to maintain oral hygiene with fluoride toothpaste and use of super floss (Oral-B) for the intaglio surface of the prosthesis. A night guard of acrylic for the maxillary ridge was given for the initial 3 months and was advised to be used during sleeping. The recall period was set initially for 3 and then 6 months for the next 2 years. The visits gave us the estimation of marginal bone loss and pocket depth through orthopantomogram [Figure 23] and [Figure 24]. At every recall, periodontal indices and periodontal pockets around implants and teeth present were evaluated. The prosthesis was unscrewed and intaglio surfaces were checked for food entrapment and mucositis of the tissues. The regular visits of recall plaque score were <25%. The occlusion was also evaluated during every visit.
|Figure 18: (a) Impression posts on implants in the mandible; (b) Special tray accommodating all the implants; (c) Pick up impression; (d) Maxillary impression; (e) Analogs attached over posts|
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|Figure 22: (a) Intaglio surface of the prosthesis; (b) Prosthesis screwed in the mouth|
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| Discussion|| |
Several reports have 92%–97% survival rate of dental implants for replacement of missing teeth in partially or fully edentulous patients., However, the past periodontal disease had been one of the risk factors for loss of implants in treated patients. Ong et al. stated that patients with previous periodontitis had a higher percentage of biological complications with implants than nonimplant patients. The importance of supportive periodontal therapy had been emphasized in several studies in treated periodontitis patients with implants as by Roccuzzo et al. in a prospective cohort study. However, a systematic review confirmed that the presence of residual pockets after successful periodontal therapy may lead to biological complications. An interesting case series study, with three well-matched groups of periodontitis patients was completed in 10 years. Periodontally, healthy, moderately compromised, and severe compromised, all group of patients had missing teeth which were to be replaced with implant prosthesis. The plaque control was <25% before any implant surgery and had received periodontal therapy to keep the environment healthy in all the three groups. Following implant prosthesis fabrication in each group, they were kept on individualized supportive periodontal therapy with varying intervals. The results of the observation were moderate involvement and patients had >3 mm bone loss sites and severe cases with >6 mm of pocket depth around implant sites with long-term follow-up of 10 years. These findings emphasized long-term maintenance and treatment needs for implant patients with a past history of periodontal disease. For partially dentate-treated periodontitis patients with oral implants, a positive association with the peri-implant condition was found after 10 years. Cho-Yan Lee et al. suggested deterioration of the periodontal condition of residual dentition after implant placement may indicate patient susceptibility for peri-implant bone loss. The study also said that periodontitis-treated patients with implants having a pocket depth of more than 6 mm within a follow-up of 5 years have greater bone loss and pocket depth as compared to nontreated group. There is a plethora of evidence with a lack of supportive periodontal implant therapy and greater incidence of peri-implant bone loss with follow-up of 10 years. In our both cases, supportive periodontal therapy was for initial 3 months then every 6 months for the next 2 years and the said protocol is followed till date. The plaque score is taken at every visit, prostheses are removed, tissues underneath evaluated for any erythematic surface or food accumulation. The patients were satisfied with their new set of teeth and carried a motivated attitude for maintaining a healthy periodontium. The marginal bone loss and probing pocket depth were well within the range of successful integration of implants with the bone even after 2 years of follow-up. Our report with two patients who had both natural dentitions along with implant-supported prosthesis were successful without complications. Another 5 years follow-up may define the prognosis of complex reconstruction. The regular supportive periodontal therapy at every recall may be the key for long-term survival.
| Conclusion|| |
The patients were suffering from periodontitis. They underwent comprehensive treatment planning and rehabilitations with the oral implants for lost teeth. The supportive periodontal therapy after the treatment every 6 months for the next 2 years after completion became an important and integral part for complex prosthesis survival. Our report explains the possibility of retaining moderately compromised periodontal teeth along with implant prosthesis in a stable environment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names 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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24]
[Table 1], [Table 2], [Table 3]