Jan Lindhe. Clinical Periodontology

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REHABILITATION BY MEANS OF IMPLANTS: CASE REPORTS • 987

Table 42-5. Periodontal findings and prognosis at completion of active therapy

Clinical periodontal examination

Prognosis

Pocket depth

Furcation

involvement

questionable

maintain

Tooth

b d

114 3 2 2 3

13 3 2 2 2

12 2 1 2 2

11 2 2 2 1

21 2 1 2 1

22 2 1 2 1

23 2 2 2 2

124 3 2 3 2

47 4 3 4 2 b

46 4 2 3 2

45 3 2 4 2

44 3 2 3 1

43 3 2 2 1

42 2 1 3 1

41 2 2 2 1

1 3 1

32 2 2 3 1

33 3 2

34 3

1 3

35 3 2 4 3

36 4 2 3 2

37 3 3 3 3

Concluding remarks

This case demonstrates the sequence of therapy when

dental implants are to be placed in patients with peri

odontal disease. Successful completion of cause-re-

lated therapy including professional as well as per-

sonal plaque removal represents a

conditio

sine qua non

for implantation with predictable success. Further-

more, in situations where minimal amounts of bone

are available for implant placement, the concept of

shortened dental arches will limit therapy to standard

dental procedures. Finally, proper attention to per-

sonal and professional plaque removal will allow the

maintenance of a successful treatment outcome.

PATIENT 3

IMPLANTS USED TO RESTORE

FUNCTION IN THE MAXILLA

Initial examination

The condition of the dentition of this 49-year-old

woman is illustrated in the radiographs of Fig. 42-6

and the periodontal status (pocket depth, furcation

involvement, tooth mobility and diagnoses) from the

clinical examination in Fig. 42-7. The analysis of the

data discloses a case of moderately advanced peri-

odontal disease. The overall plaque score was 3

and

the corresponding bleeding on probing (BoP) score

was 60%.

Treatment planning

The combined periodontal, endodontal and caries le

sions in both tooth 16 and the root fractures in teeth 15

and 14 called for extraction of these three teeth. In the

maxilla the following teeth were judged as maintain-

able: teeth 13, 12, 11, 21, 22, 23. Tooth 26, which dis

played both periodontal and endodontal lesions, was

regarded as questionable.

In the mandibular dentition both first molars (36

and 46) were furcation involved and displayed signs

of periapical pathology. In the mandible the following

teeth could be maintained: 47, 45... 35 and 37. From a

rehabilitation point of view, the mandible offered no

marked problem. The maxillary restoration, however,

was more difficult. Different alternatives were consid

ered.

988 • CHAPTER

Fig. 42-6a-c.

Case: B.O. female, 49 years

PLI: 35%

BoP: 60%

Periodontal charting

Tooth

Pocket depth

Furcation

involvement

Tooth

mobility

18"

1.7

16 6 7 6

m,b,d:lll

15 6 6 1

14 5 5 8 2

13 6 4 6 4 1

12 5 4 6 4 1

11 4 5 4 1

21 5 5 5 1

22 6 5 5

23 6 5 5

26 6 4 8 5

m: II, b: I

Tooth

Pocket depth

Furcation

involvement

Tooth

mobility

47 6 4 6 4

46 4 5 4 4

45 6 6

44 5 6 4

43 4 4

42 5 5 1

41 5 4 5 1

31 5 4 1

32 4 4 6 4 1

33 4 4

34 5 6 4

35 6 6 4

36 4 4

III

38 5 5 4

Diagnosis

REHABILITATION

MEANS OF IMPLANTS: CASE REPORTS • 989

Fig. 42-8a-d.

Alternative 1

A removable partial denture anchored with attach-

ments or clasps to the canines/incisiors. This solution

was not readily acceptable to the patient.

Alternative

A fixed, cross-arch bridge extending from tooth 13 (

with cantilever in position 14) to tooth 26 (palatal

root).

Alternative 3

One implant-supported bridge distal of tooth 13, and

one tooth-supported fixed bridge extending from 23

to 26 (provided that at least one root in the molar tooth

could be maintained following furcation therapy and

root resection).

Treatment

Initial therapy

The cause-related therapy included oral hygiene in-

struction and meticulous scaling and root planing.

Teeth 16, 15 and 14 were extracted and a temporary

restoration placed on 13 and 12 with cantilevers on

positions 15 and 14 (Fig. 42-8). The cantilever in posi

tion 15 was in infraocclusion. The existing restoration

22...26 was removed and replaced with a temporary

reconstruction in acrylic. Teeth 26, 36 and 46 were

exposed to endodontic therapy.

Corrective therapy

A re-examinmation performed 3 months after the end

of the initial therapy phase disclosed that the patient's

self-performed plaque control was excellent. Several

deep pockets with positive BoP still existed. Flap sur

gery was performed in both the maxilla and mandible

to get access for proper scaling and root planing.

During surgery tooth 26 was subjected to root resec

tion and the remaining roots were subsequently fitted

with a post.

Implant therapy

The edentulous region of the right maxilla was anes

thetized. An incision, extending from region 13 to

region 16, was made at the top of the crest and full

thickness flaps were raised. Three fixture sites were

prepared in positions 14, 15 and 16. Fixtures of the

Astra Tech Implants

Dental System were installed;

diameter = 3.5 mm; length = 13 mm (position 14), 11

mm (position 15), and 11 mm (position 15). Abutment

connection was 6 months later in a second stage pro

cedure.

Restorative therapy

Two bridges — porcelain fused to gold — were fabri-

cated; one for the implant section (position 14... 16)

(

Fig. 42-9) and one for the tooth section (22... 26) (Fig.

42-10). In addition, single crowns were produced for

teeth 13 and 12 (Fig. 42-11).

990 • CHAPTER

Fig. 42-9a,b.

Fig. 42-10a,b.

Fig. 42-11.

Maintenance therapy

the implant and the tooth segments — will allow the

The supportive care included recall appointments

patient to exercise proper plaque control (Fig. 42-12).

with the dental hygienist every 3 months for plaque

control evaluation and, if indicated, professional de-

bridement at tooth sites exhibiting positive BoP val-

ues.

Concluding remarks

This case illustrates how implants can be used to

restore function in a periodontally compromised pa-

tient, and how the design of the restoration — both in

REHABILITATION BY MEANS OF IMPLANTS: CASE REPORTS • 991

Fig. 42-12a-c.

PATIENT 4

IMPLANTS USED IN A

CROSS-ARCH BRIDGE

RESTORATION

Initial examination

The clinical and radiographic characteristics of this

58-year-old man are illustrated in Figs. 42-13 and 42-14

and the periodontal conditions (pocket depth, furca-

tion involvement, tooth mobility and diagnoses) from

the initial examination in Fig. 42-15. The analysis of

the data disclosed a case of severely advanced peri-

odontal disease. At several teeth the destruction of the

periodontal tissues had reached a level close to their

apices. Tooth 15 exhibited a wide apico-marginal coun

munication, all remaining molars exhibited furcation

involvement of degree III. The overall plaque score

was 92% and the corresponding bleeding on probing

BoP - score was 86%.

Trea Intent planning

Tooth 15 required immediate endodontic therapy, al

though the prognosis was very questionable. The root

canal was debrided, widened and a calcium hydrox-

ide filling was placed. A clinical and radiographic

examination 8 weeks later disclosed that no proper

healing had occurred, the apico-marginal communi-

cation persisted and tooth 15 was extracted (Fig. 42

16). The severely involved mandibular molars (47, 46

and 37) as well as teeth 31 and 41 could not be main

tained and were scheduled for extraction. Teeth 13, 26

and 27 were regarded as questionable from a treat-

ment point of view. The remaining teeth in the maxilla

and mandible could be maintained following peri-

odontal therapy.

The prosthetic rehabilitation of the case was consid

ered difficult but different options could be

examined.

Alternative 1

A fixed, cross-arch bridge extending from tooth 13 (

with cantilever in position 14) to tooth 26 (27) could

have been considered, had the prognosis for tooth 13

been good. This particular tooth, however, was root

filled, exhibited advanced marginal bone loss and was

not regarded as a proper final abutment for a cross

arch splint.

Alternative

A removable partial denture anchored with attach-

ments to a fixed bridge extending from tooth 11 to 25.

This would allow the extraction of the two question-

able maxillary molars (26, 27).

992 • CHAPTER 42

Fig. 42-13a-c.

Fig. 42-14a-c.

Alternative 3

One implant-supported bridge distal of tooth 11, and

one tooth-supported fixed bridge extending from 11

to 25 (alternatively to 26/27, provided that at least one

root in this region could be maintained following

furcation therapy and root resection).

Treatment

Initial therapy

The cause-related therapy included oral hygiene in-

struction and meticulous scaling and root planing.

Teeth 15, 13, 47, 46, 31, 41 and 37 were extracted. A

temporary fixed bridge extending from 11 to 27 was

inserted (Fig. 42-17) and a removable partial denture

was produced to restore function in the right maxilla.

A temporary fixed bridge for the mandible extending

from 35 to 45 was also inserted. Teeth 26 and 27 were

exposed to endodontic therapy.

Corrective therapy

A re-examination performed 3 months after the end of

the initial therapy phase disclosed that the patient's

self-performed plaque control was excellent. Al-

though a marked pocket depth reduction had oc-

curred, several deep pockets still existed. Flap surgery

was performed in both the maxilla and mandible to

get access for proper scaling and root planing. During

surgery it was observed that all roots of 26 had to be

removed, while the palatal root of 27 could be main-

tained. This root was subsequently fitted with a

post.

Implant therapy

The edentulous region of the right maxilla was anes

thetized. An incision, extending from region 11 to

REHABILITATION BY MEANS OF IMPLANTS: CASE REPORTS • 993

Case: L.F. male, 58 years

PLI: 92%

BoP: 86%

Periodontal charting

Tooth

Pocket depth

Furcation

involvement

Tooth

mobility

18"

1/7

15 6 8 6

13 8 7 7

11 8 8 7

21 6 6 6

22 6 8 6

23 10 8 8

24 7 5 8

25 6 7 6

26 8 8 8 8 m,b,d:Ill

21 9 8

10 4

m,b,d:Ill

Tooth

Pocket depth

Furcation

involvement

Tooth

mobility

47 6 6 6

III

46 5 6 8 8

III

45 6 6 5

44 8 6 5

43 8 6 6

42 6 8 4 1

41 6 6 4 3

31 6 6 6 3

32 6 4 6 5 1

33 5 4

3-4

35 4 4

37 not probed

Fig. 42-15.

was made at the top of the crest and full thickness flaps

were raised. Three fixture sites were prepared in posi-

tion 12, 13 and 15. Fixtures of the Astra Tech Implant

Dental System were installed; diameter = 3.5 mm;

length =13 mm (position

1205

mm (position 13), and

9 mm (position 15). Abutment connection was made

months later in a second stage procedure (Fig. 42-18).

Restorative therapy

A cross-arch bridge made of porcelain fused to gold

was fabricated for the mandible. This bridge extended

from 35 to 45 and had one cantilever unit distal to both

35 and 45.

In the maxilla, two bridges - porcelain fused to gold

were fabricated; one for the implant section and one

for

the tooth section (Fig. 42-19). The two bridges were

connected with an attachment that allowed movement

in apicocoronal direction but prevented horizon

tal

deflection (Fig. 42-20). The restoration at the try-in

appointment is illustrated in Fig. 42-21. The outcome

Fig. 42-16a,b.

994 • CHAPTER 42

Fig. 42-17.

Fig. 42-18a-c.

of treatment is illustrated in clinical photographs and

radiographs in Figs. 42-22 and 42-23.

Maintenance therapy

The supportive care included recall appointment with

the dental hygienist every 3 months for plaque control

evaluation and, if indicated, professional debride-

ment at tooth sites exhibiting positive BoP values.

Concluding remarks

This case illustrates how implants can be (1) used to

restore function in a periodontally compromised pa-

tient, (2) combined with a conventional bridge with an

attachment that allows apicocoronal movement of the

tooth-carrying segment but prevents horizontal de-

flection.

REHABILITATION BY MEANS OF IMPLANTS: CASE REPORTS • 995

Fig. 42-19a-c.

Fig. 42-20a,b.

Fig. 42-21a,b.

996 • CHAPTER 42

Fig. 42-22a-c.

Fig. 42-23a-c.