Journal of Indian Society of Periodontology

CASE REPORT
Year
: 2021  |  Volume : 25  |  Issue : 2  |  Page : 176--180

Terminal dentition to functional esthetic full-mouth implant reconstruction: Evidence-based approach


Farhan Durrani, Himani Painuly, Akanksha Shukla, Rakhshinda Nahid, Samidha Pandey 
 Department of Periodontics, Faculty of Dental Sciences, IMS BHU, Varanasi, Uttar Pradesh, India

Correspondence Address:
Farhan Durrani
Department of Periodontics, Faculty of Dental Sciences, IMS BHU, Varanasi, Uttar Pradesh
India

Abstract

Implant-supported fixed dental prosthesis is a well-accepted treatment option for edentulism. Loss of teeth due to extensive caries or severe periodontitis presents a challenge to the clinicians. Young age disability with either of these problems can further make full-mouth rehabilitation on implants a complex procedure. The outcome of implant surgery with periapical infections and periodontal inflammation is unpredictable and often delays the placement of dental implants. Here, we describe a case of full-mouth reconstruction with implant-supported prosthesis in a young individual who lost all her teeth due to extensive caries. The journey from terminal dentition to functional esthetic rehabilitation was uneventful.



How to cite this article:
Durrani F, Painuly H, Shukla A, Nahid R, Pandey S. Terminal dentition to functional esthetic full-mouth implant reconstruction: Evidence-based approach.J Indian Soc Periodontol 2021;25:176-180


How to cite this URL:
Durrani F, Painuly H, Shukla A, Nahid R, Pandey S. Terminal dentition to functional esthetic full-mouth implant reconstruction: Evidence-based approach. J Indian Soc Periodontol [serial online] 2021 [cited 2021 May 17 ];25:176-180
Available from: https://www.jisponline.com/text.asp?2021/25/2/176/310576


Full Text



 Introduction



Dental implant as prosthodontic rehabilitation for missing teeth have a predictable prognosis with minimal biological trauma at a reasonable cost. In a young individual, an edentulism is devastating, as masticatory function, phonetics, and esthetics are lost. Accurate diagnosis and treatment planning is essential for a successful treatment. Restoring the oral function and esthetics is a challenge for the clinician. Loss of tooth structure at young age makes the complete rehabilitation a challenging reconstruction. Furthermore, in patients with chronic periodontitis and multiple endo lesions, often, the remaining infection prevents simultaneous tooth extraction and implant placement. In periodontally susceptible individuals, the pathogens may jeopardize the success of implant placement in partial or complete edentulous situations. In the past, edentulous patients with a history of periodontitis were considered safe for implants. However, in a recent study conducted on bacterial floras of edentulous patients who were without teeth for a year, periodontal pathogens such as Actinomyces species and Porphyromonas gingivalis were observed in significant numbers.[1] Therefore, careful implant placement and maintenance will be the requirement for successful reconstruction.

We present the case of a young female suffering from extensive tooth loss due to caries and poor oral hygiene. Clinical examination revealed decay on all the existing tooth structure, bleeding gums and calculus on the lingual and occlusal surfaces of the lower dentition. Considering her age, the patient was referred for endodontic evaluation. The presence of extensive caries on visible tooth structures made, restoration seemed hopeless with unpredictable long term prognosis. The option left was complete extraction and providing a denture or an implant-retained fixed dentition. In our report, we completed fixed detachable implant-retained prosthesis keeping in consideration the esthetics and longevity.

 Case Report



A 22-year-old female presented to the faculty practice with the chief complaint of inability to chew the food properly. The patient was in good spirits with no systemic health problems. In the maxilla, tooth numbers 11, 12, 13, 15, 16, 21, 22, and 23 were severely decayed and broken. In the mandible, 31, 32, 34, 35, 41, 42, 43, 45, and 47 were also affected by caries with loss of tooth structure. There were periapical infections and swelling associated with respect to 16, 33, 35, 44, and 47. Grade III mobility was associated with 31, 32, and 41 and generalized bleeding gums, although periodontitis was localized to the lower anterior dentition [Figure 1].{Figure 1}

Looking at the current situation, the treatment plan for the patient was complete extraction of the existing terminal dentition. The rehabilitation will be done with strategic placement of implants in the existing bone. A screw-retained detachable fixed prosthesis for both upper and lower arches was planned. The patient gave consent for the said treatment with follow-up; of every 6 months for 3 years. The removal of the teeth was done in a phased manner: first the mobile and infected teeth were extracted. The remaining teeth underwent scaling and root planing and hygiene was evaluated for the next 3 weeks through regular plaque scores. As the plaque score came <25%, rest all of the teeth were also removed [Figure 2]a and [Figure 2]b. Tissues were allowed to heal for the next three weeks. At this stage, impressions were taken of the upper and lower arches and the centric position was recorded. The articulation was done with a semi-adjustable articulator (Bio Art Articulator A7 plus with Elite Facebow, Panadent, UK), and wax-up done of both the arches were used for fabricating a surgical templates.{Figure 2}

Twelve implants (Dentin implants technology, Mitspe Aviv, Israel), six in the maxilla 3.75 × 13 for #15, 3.3 × 10 for #13, 3.3 × 8 for #11, 3.3 × 10 for #21.23, and 3.3 × 11 for #25 and six in the mandible 3.3 × 10 for #33, 43, 34, 44, 36, and 46, were selected according to the cone beam computed tomography measurements. The maxillary ridge width varied from 4.4 to 5.5 mm just anterior to the pneumatized maxillary sinus bilaterally, and the mandibular ridge width ranged from 4.7 mm to 5.5 mm till the decided molars' position bilaterally. The anatomy of the existing ridges of both arches was knife edge (Atwood's classification, order IV) [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e, [Figure 3]f.{Figure 3}

After adequate anesthesia, each arch was taken individually; the surgical template guided the placement of implants. For maxilla, after full-thickness reflection of the mucoperiosteal flap, the nasopalatine foramen was taken as a guide for parallelism of each implant position. Six implants were placed through osseodensification (Densah® Bur kit VDBK-Versah 2000 Spring Arbor Rd. Suite D Jackson, Michigan 49203 USA) between the maxillary sinuses bilaterally. The implants in the second premolar area in the upper arch were tilted 17° to extend the anterior posterior spread. The density of residual ridge was <500 HU (Lekholms and Zarb classification, quality 4). To get primary stability with the implants placed in 15, 13, 11, 23, and 25 regions, the osteotomies were modified. The buccal bone of the maxillary ridge was augmented with autogenous bone fillers and xenograft material with 1:1 mixture ratio (Bio-Oss®, Geistlich Pharma, Geistlich Pharma AG Bahnhofstrasse 40 CH - 6110 Wolhusen) and covered by a collagen membrane (Bio-GideGeistliichPharma) [Figure 4]a and [Figure 4]b. The mandible had six implants which were placed at the canines, 1st premolars, and 1st molars positions. One implant at the 43 position went buccal because of compromised ridge in the area [Figure 5] and [Figure 6]. The flaps were sutured (4-0 Vicryl, Ethicon, Johnson & Johnson Medical Devices Companies, USA) after the surgery, and postoperative instructions were given. Warm saline gargle, soft diet, and medications along with mouthwash (amoxyclav 625 mg, ibuprofen 400 mg, and chlorhexidine) were advised for 7 days. Three weeks were given for the soft tissues to mature. Temporary prosthesis on implants was not decided as the torque values of implants achieved during surgery were not adequate. After waiting period of six months, healing screws were attached on each implants. Three more weeks were given for biological width formation of tissues around each implants. During the healing period patient had interim dentures. Impression procedures started after screwing the posts on each implant and splinting with a pattern resin (GC, Corporation Tokyo, Japan). Open-tray impressions were taken with an addition silicone (Aquasil LV, Dentsply Sirona, USA) and poured with ultra-rock die stone (Kalabhai Kalstone Deccan Dental, Depot Pvt. Ltd, India) [Figure 7]a and [Figure 7]b. Intraoral verification of the fabricated jig was further tried in the mouth for passive fit of the prosthesis [Figure 8]. This was mounted on the semi-adjustable articulator (Bio-Art A7 Plus) at the correct spatial relationship. The vertical relationship was further verified with a temporary setup in wax [Figure 9]. One straight castable abutment for 21 and five multiunit abutments (17°) were used for implants on positions 15, 13, 11, 23, 11, and 25 for correction of angulations. In the mandible, five straight and one angulated (17°) castable abutments were used. Initially, prosthesis for both arches were planned with three segments in each arch, but due to angulation issues, complete arch screw-retained prosthesis was fabricated in a single design till the molars. Maxillary and mandibular frameworks were fabricated with a palladium silver alloy (d. SIGN® 30 Ivoclar Vivadent A. G. Liechenstein, Europe). They were tested in mouth (Sheffield Test), verified radiographically, and checked for their passive fit.{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}

Interocclusal space for porcelain veneering was analyzed three dimensionally, and a bite registration record was taken with silicone material (DMG O-Bite) DMG America LLC Headquarters. Bisque trials checked interferences, eccentric relations, and the proper fit of prosthesis in each arch. The patient's smile was designed keeping in mind the midline, width of upper laterals, centrals, and canines in proportion to the display. Porcelain-fused-to-metal detachable prosthesis were made and checked in mouth for the passive fit [Figure 10]. The prosthesis screws were tightened to 25 N/cm on each implant. The occlusion was mutually protected with group function. The screw access holes were closed with composite plugs (Fermit™–N Ivoclar Vivadent, Liechenstein, Europe). The patient reported drastic improvement in mastication and confidence levels and was pleased with the esthetic smile [Figure 11]a, [Figure 11]b, [Figure 11]c, [Figure 11]d. Proper oral hygiene measures were given to the patient which included twice brushing with fluoride toothpaste daily and was instructed to clean the intaglio surface of the fixed implant prosthesis with a super floss (Oral-B). The patient was recalled every 6 months for follow-up, and orthopantomogram was again taken at the end of 2 years [Figure 12]. The attached gingiva remained >2 mm around the prosthesis in both the arches, leading to minimal plaque accumulation [Figure 10].{Figure 10}{Figure 11}{Figure 12}

 Discussion



Reconstruction of edentulous ridges in a young individual requires comprehensive treatment planning. The prosthesis, whether on four, six, or eight implants, requires recommendations for treatment planning. An experienced team with a thorough knowledge of surgical/restorative aspects related to complex rehabilitation is essential. Patient-centered parameters such as age, esthetic requirement, and preferences have to be taken in consideration. An experienced laboratory with careful adjustment of occlusion on delivery and different recall programs is a prerequisite of the restorative process.

In our case, we used six implants in the maxilla as Lambert[2] et al. in a systematic review suggested that prosthodontic survival rates were significantly greater with six or more implants. They also stated that there was no difference in one piece or segmented prosthesis. Another interesting point for longterm prosthesis survival in maxilla depends upon implant distribution. An assumption stated that when implants are placed in between the bicuspids, their survival was limited to a maximum of 10 years. This could be because of poor anteroposterior distribution. However, we compensated the anteroposterior spread by tilting the posterior most implants in the bicuspid regions bilaterally in maxilla and till the molars in the mandible. In one meta-analysis, the authors found no difference between axial or tilted implants in their long-term success.[3] In a recent study by Bruschi et al.,[4] the authors compared marginal bone loss around axial and tilted implants rehabilitated with Toronto bridges, fixed partial dentures, and even single crowns. The conclusion of the study was no significant difference between marginal bone levels with any type of prosthesis. The placement of tilted implants as in our case offered both surgical and prosthodontics advantage: increasing osseointegration surface, primary stability by anchoring more than one cortical bone and limiting cantilever extensions by placing implant more distal with optimum load distribution.[5]

In another study by Francetti et al.[6] on tilted implants followed for 60 months, no significant marginal bone loss was found when tilted or axial implants were compared in case of immediate loading in edentulous maxilla. In another meta-analysis by Ata-Ali et al.,[3] there was no difference in long-term success between axial and tilted implants. In our case, for edentulous maxilla, we followed an evidence-based approach for the patient. This was done keeping in mind her age and prosthesis survival for long time.

Earlier, four or five implants were placed between the interforaminal region in the edentulous mandible for complete fixed implant retained prosthesis as single piece. This design can cause flexure that changes the shape and width of the mandible due to contraction of the lateral pterygoid muscle. Further studies said that full-arch single-piece prosthesis caused peri-implant bone strain.[7] Latest reports suggest that if the prosthesis is segmented the stress is often reduced.[8],[9]

Recently, Martin-Fernandez et al.[10] stated that the framework in a single piece exhibits a better biomechanical environment with lesser bone peri-implant stress for all implant locations. This result supports the theory that rigid splinting of complete mandibular arch can provide additional resistance, thus counteracting the flexure. This design is in agreement with other studies that stimulating occlusion at maximum intercuspation reported that unseparated super structures are much better in relieving peri-implant bone stress.[11] We gave our patient six implants in the maxilla and mandible in strategic positions, i.e., canine, premolars, and molars, each side for better load distribution. All the implants were splinted together in a single framework and the prosthesis were extended till the first molars.

We placed implants in the extraction sockets after 6 weeks of tooth removal. The reasons were biological events which favour the clinician. The soft tissues healing provided an additional 3–5 mm of keratinized mucosa. The site had high osteoclastic activity as the bundle bone was resorbing.[12] In a recent report by Chappuis et al.,[13] there is sevenfold increase in soft-tissue thickness during this period. This provides enhanced vascularity in the flap, improving the healing capacity. Furthermore, the implant site will be with reduced bacterial risk as acute and chronic infections would have resolved. We followed evidence-based approach for a young patient who had lost all her teeth due to negligence and poor oral care. The patient had been kept on regular follow-up for another 3 years.

 Conclusion



Loss of teeth due to caries at young age can be devastating for the psychology of the girl. It was a challenge for us to reconstruct and rehabilitate an esthetic makeover with an implant-fixed detachable prosthesis. All the parameters covered for the fabrication were evidence based. The patient was very happy after receiving her teeth back and her masticatory efficiency improved to a great extent.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

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