Systematic Reviews Partial Dentures on Periodontally Unstable Teeth

Dental implant success requires placement after periodontal therapy, with acceptable bone volume, plaque control, principal stability, control of risk factors, and employ of well-designed prostheses. This study describes the surgical and prosthetic direction of a patient with severe iatrogenic periodontal/periimplant bone destruction. Methods. A 55-twelvemonth-old female smoker with fixed partial dentures (FPDs) supported on teeth and implants presented with oral pain, swelling, bleeding, and a 10-yr history of multiple implant placements and implants/prosthesis failures/replacements. Radiographs showed severe bone loss, subgingival caries, and periapical lesions. All implants and teeth were removed except implants #four and #ten which served to retain an acting maxillary restoration. Os defects were covered with nonresorbable dPTFE membranes. In the mandible, 3 new implants were placed and loaded immediately with a bar-retained temporary denture. Results. Seven months postoperatively, the bone defects were regenerated, and three additional mandibular implants were placed. All mandibular implants were splinted and loaded with a removable overdenture. Conclusions. In this case, periimplant infection and tissue destruction resulted from the lack of periodontal treatment/maintenance and failure to use evidence-based surgical and loading protocols. Combination therapy resolved the disease and the patient's astringent discomfort while providing firsthand function and an artful solution.

1. Background

Present, implant-supported restorations are more often than not accepted as a land-of-the-art treatment pick. Many advances in materials and techniques, in surgical and loading protocols, in restorative blueprint as well as a better understanding of the biological/mechanical concepts of osseointegration and of the importance of infection resolution before placement and maintenance, made implants more acceptable past the dental customs. Furthermore, appropriate implant treatments are becoming increasingly important as well for the general dentists every bit the number of implants placed per year continues to increase. Gaviria et al. [one] analyzing information of the American Association of Oral and Maxillofacial Surgeons reported that approximately 100,000 to 300,000 dental implants are being placed every year. Also in Germany, the published information showed 200,000 placed implants in the year 2000, and co-ordinate to statements of scientific societies, the recent number of placed implants is one.2 million [2].

Periimplantitis, ane of the principal factors of implant failure, is an inflammatory condition involving the soft and difficult tissue surrounding the implant. The 6th European Workshop on Periodontology considered bacterial plaque every bit the main etiological cistron for periimplant tissue harm and as well included poor oral hygiene and history of periodontitis as adventure indicators [3]. Despite technological, surgical, and cloth advancements that contribute to enhanced implant survival and/or success, placing dental implants still requires thorough education, training, and continuous professional development in order to learn the knowledge of which materials, which surgical techniques, which type of loading, and which type of restorations are indicated in every clinical scenario. In other words, implants should be placed by well-trained, qualified clinicians [iv].

This report describes the surgical and prosthetic management of a patient with severe iatrogenic periodontal and periimplant bone destruction.

2. Case Presentation

A 55-year-sometime female, smoker (iv–6 cigarettes/twenty-four hour period), in expert general health presented in our clinic in May 2015 with the master complaint of strong and astute hurting in both arches too equally generalized spontaneous bleeding and suppuration (see Example Direction). The patient did non consent to intraoral photography at the initial visit. She reported that the aforementioned dentist had performed all prior treatments.

2.1. Treatment History

In January 2004, generalized astringent periodontal affliction with deep pockets and astringent mobility was diagnosed (Figure 1(a)). The patient was non informed about the presence of or need to treat astringent periodontitis. In April 2004, teeth #21, #29, and #32 were extracted, and implants were placed in positions #xviii, #twenty, #30, and #31/32 (Figure 1(b)). The bone defect at position #21 was not augmented, and no periodontal treatment was performed. In July 2004, the implants were loaded with fixed partial dentures (FPDs) connecting to teeth #22 and #27 (Figure 2(a)). The bone defect at position #21, periimplant bone loss at position #twenty, and progressing periodontal affliction were non treated.

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In January 2006, partial healing of extraction socket #21, a os defect with periapical interest (#23), and two periimplant defects (#xx and #31; >50% and <l% implant length, resp.) were diagnosed (Effigy 2(b)). Tooth #xv was extracted, an implant program was made (as shown in the orthopantomograph (OPG)), and no further periodontal/periimplant treatment was performed. Between the end of January and October 2006, teeth #5–eight, #10, #12, and #fifteen were extracted; a composite veneered FPD was inserted with teeth #4, #ix, and #eleven as abutments; and an implant in position #fifteen/16 was placed, but appeared to take only 50% bone contact (Figure three(a)). No further periodontal/periimplant treatment was performed.

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The patient reported visiting the dental office frequently due to pain, resulting in the fitting of a new maxillary restoration with firsthand implant placement and loading in Nov 2006. The mandibular periimplant defects showed further progression (Figure iii(b)). A new implant in position #15 was placed (compare with implant geometry on Figure 3(a)), tooth #12 was replaced with an implant, and additional implants were placed in positions #1, #4–6, and #8. The new implants had bereft bone contact; the implant in position #1 had simply apical contact with bone. In the subsequent ii years, the patient complained ofttimes near hurting and visited the dental office regularly. However, other than superficial cleaning, no periodontal/periimplant treatment was performed.

An OPG taken in November 2009 demonstrated farther progression of bone loss (Figure four(a)). The patient reported that the dentist in 2010 removed the mandibular FPDs, implants, and the majority of teeth and inserted another fixed restoration with immediate placement and loading, connecting the three implants with teeth #22 and #27. No OPG showing this treatment or follow-up were available. The patient visited the dental office regularly for cleaning and complained of new pain. In 2015, she was referred for periodontal consultation. Comparison of Figures 4(a) and 4(b) shows that the mandibular implants were explanted, and three new implants were placed and loaded.

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ii.2. Case Management

Comprehensive dental and periodontal examinations were performed, and an OPG was made (Effigy 4(b)). All maxillary and mandibular implants and teeth showed radiographic severe os loss, and teeth #ix, #xi, and #27 additionally showed subgingival caries and periapical lesions. Periimplant pockets were 6–10 mm deep with spontaneous haemorrhage, soft-tissue swelling, and pain on palpation.

Subsequently receiving oral and written descriptions of the proposed treatment, including surgical procedures, the patient provided written informed consent. To address the astute condition, mandibular periimplant abscesses were drained through the pockets, and clindamycin (800 mg/24-hour interval) was prescribed, due to the patient's reported allergy to penicillin. The patient's file and radiographs were retrieved from her former dentist.

All mandibular and maxillary implants and teeth were removed, except implants #4 and #x which served to temporarily retain an acting maxillary restoration. During surgery and later on removal of the mandibular teeth and implants and cleaning of the os defects, a cone beam computed tomograph (CBCT) was fabricated (Figures v(a) and 5(b)). The extraction sockets and periimplant bone defects were cleaned, and gentamicin-loaded collagen fleeces (Jason; Botiss Biomaterials, Zossen, Germany) were placed in the defects [5]. Later on, the defects were covered with nonresorbable dense polytetrafluoroethylene membranes (dPTFE; Cytoplast Ti-250; Osteogenics Biomedical, Lubbock, TX, Us) without boosted bone grafting, as previously described [6]. Implants (K3Pro rapid; 3.5 mm diameter, 11 mm length: Argon Dental, Bingen/R, Germany) were placed in positions #24, #26, and #xxx and loaded the same day with a bar-retained removable temporary denture. The membranes were removed iv weeks postoperatively (Figures five(c), half dozen(a), and b6(b)). The bar was milled of blazon three CrCo alloy (ZENOTEC NP; Wieland, Pforzheim, Germany), a metallic base was constructed, and elastic plastic clips (Preci Matrice, CEKA, Waregem, Kingdom of belgium) were used to retain the base of operations over the bar.

On the same 24-hour interval, all remaining maxillary teeth and implants, except #iv and #10, were extracted, periimplant lesions on #four and #ten were treated (Figures half dozen(c) and 6(d)), and the maxilla was temporarily restored with a milled FPD stock-still on the implants #iv and 10 using provisional cement (Implant Provisional; Alvelogro Inc., Snoqualmie, WA, USA) and a removable fractional denture for the molar areas (Figure 7).

Seven months postoperatively, the os defects were regenerated, and three additional mandibular implants were placed in positions #22, #28, and #31/32 (K3Pro rapid; 4.5 mm diameter, 9 and 11 mm lengths, Argon Dental) (Figure eight(a)). All six mandibular implants were splinted with a milled bar and loaded equally described previously (Figures 8(b) and 9).

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3. Discussion and Conclusions

In the present instance report, the surgical and prosthetic management of a patient with multiple teeth and implants with severe bone loss and a hopeless prognosis due to iatrogenic factors, with extractions, bone regeneration, immediate implant placement, and insertion of prosthesis, is discussed. The patient was treated by the same dentist in the menstruum between January 2004 and April 2015.

Dental implant success and survival requires placement after periodontal therapy, adequate bone volume/quality, nontraumatic surgery, primary stability, control of risk factors, and use of well-designed prostheses. In improver, adequate plaque control and regular maintenance (infection control) and early detection and treatment of periimplant inflammation are as well important for long-term success [7–14].

Implants in patients treated for periodontal disease are associated with higher incidence of biologic complications and lower survival rates than those in periodontally healthy patients, and astringent forms of periodontal illness are associated with college rates of implant loss [7]. Several studies and systematic reviews have concluded that, before implant placement, any existing periodontal disease must exist treated, periodontally susceptible patients have a college risk of developing periimplantitis, and in cases with periodontally compromised teeth with probing depths >v mm, the colonization of implants by periodontal pathogens is possible and could be considered equally a take a chance cistron. Furthermore, there is evidence that bone loss in periodontitis patients will progress in the absence of periodontal treatment [7–11].

The importance of an accurate diagnosis and an advisable treatment plan are essential in direction of periodontal disease [7]. Based on the radiographs and the information obtained by the patient's file submitted past the previous dentist, one tin conclude that she was suffering from severe chronic periodontal illness which was left untreated. In addition, the progression of periimplant inflammation was ignored and not treated although periimplant bone destruction was visible on the regularly taken radiographs. The patient reported regular oral hygiene appointments in the dental role but just supragingival debridement was performed.

Currently, there is not enough focus on the prevention of periimplant diseases, as compared to periodontal maintenance [7, thirteen]. Information technology is well known that, in periodontitis susceptible patients treated with dental implants, residual pockets correspond a significant risk for the development of periimplantitis and implant loss. Moreover, patients in supportive periodontal treatment developing reinfections are at greater hazard for periimplantitis and implant loss than periodontally stable patients [14].

An boosted finding, after examining the patient's file, was the absenteeism of accurate radiographs of diagnostic quality or the utilise of surgical guidance for implant placement. The used OPGs were of extremely poor quality, with a double representation of teeth and implants and significant distortion (Figures 1–3, 4(a), and 10). Thus, they had to exist processed with a raster graphics editor (Photoshop Elements fifteen, Adobe Systems, Munich, Frg) for presentation reasons (Figures ane–3 and 4(a)). An authentic diagnosis was non possible on these OPGs, and they should not have been used for surgical planning. Although the use of two- or three-dimensional radiography in all or selected implant cases [xv] and the routine utilise of dissimilar types of surgical guides or navigated implantology [16] is still a contend, the use of minimal advisable diagnostic tools and procedures likewise equally medical and dental standards is mandatory for a successful event after implant placement.

Another treatment modality, which was repeatedly applied in the presented case, was immediate implant placement and loading in infected and compromized periodontal tissues as well as the connection of teeth and implants. Furthermore, the restorations did not fit on the abutments (Figure 4(b)). These could be additional factors for teeth and implants loss. In the nowadays case, an immediate implant placement and eventually loading could be possible, just by following established rules and clinical protocols as well as guidelines from the scientific literature. However, the lack of knowledge has led to a disaster [4, 17, 18].

Combination therapy resolved the disease and the patient's severe discomfort while providing firsthand office and an aesthetic solution. Patient'southward rehabilitation was achieved by elimination of the infection, bone regeneration, and implant placement. In the mandible, three implants were placed during the outset surgery, splinted and loaded with an overdenture, restoring function, and aesthetics. In addition, the bar-retained mandibular overdenture protected the augmented areas from pressure during the healing period. In the maxilla, implants were removed, periimplant lesions in the remaining two implants were treated, and an aesthetic and functionally acceptable long-term provisional restoration was fabricated.

The long-term periodontal and periimplant infection and tissue devastation presented in this example resulted from lack of periodontal and periimplant treatment as well every bit maintenance and failure to apply bear witness-based diagnostic, surgical, and restorative procedures. Combination therapy resolved the affliction and the patient's severe discomfort while providing immediate part and an aesthetic solution.

Conflicts of Interest

The authors declare that they accept no conflicts of involvement.

Copyright

Copyright © 2018 Gregor-Georg Zafiropoulos et al. This is an open up admission article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Source: https://www.hindawi.com/journals/crid/2018/7174608/