Rehabilitation of Anterior Maxilla with Dental Implants in Periodontally Compromised Patient.

Although implant is the treatment of choice for rehabilitation of patients with aggressive periodontitis, it is also challenging for the dentists. There are various views about success of implant therapy for these patients. Few authors have proposed that aggressive periodontitis patients have less success rate of implant survival, while many authors have shown successful management of aggressive periodontitis patients with implants. For implants to be successful in these patient, it is important to control the periodontal disease before placement of implants. Thus a multidisciplinary approach is essential for successful rehabilitation of these patients. This case report aims at discussing the periodontal management and implant rehabilitation in a patient with aggressive periodontitis.

INTRODUCTION

Periodontitis is a disease caused by bacterial infection and is considered the main cause for tooth loss. Both chronic and aggressive forms of periodontitis are characterized by bone loss and can lead to tooth loss. Aggressive periodontitis is an early loss of tooth. Rehabilitation of such patients is challenging and often needs a multidisciplinary approach. Aggressive periodontitis, if not diagnosed and treated early, can lead to tooth loss, and rehabilitation of such patients may be difficult. To treat such patients, it is important to understand the nature of the disease, biology of the bone, its response to the disease, and the microbiology involved.

Aggressive periodontitis is characterized by rapid destruction of the periodontal tissues and usually occurs at early decades of age. It is found to have familial aggregation. These patients are believed to have a defective immune system. Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis are the microorganism found to be associated with aggressive periodontitis. Studies have shown that these microorganisms remain in the patient's mouth up to 1 year after extraction of teeth. Bone density is believed to be reduced in these patients.[1]

Rehabilitation of aggressive periodontitis patients with implants is the treatment of choice, considering the patient's age. Rehabilitation is also challenging, considering the nature of the disease. Placement of implants in aggressive periodontitis patients is not a contraindication, but it should be considered only after successfully controlling the progression of periodontal disease.

Earlier, it was believed that implant patients have more chance of developing peri-implantitis. According to Ong et al., there is some evidence that patients treated for periodontics may experience more implant loss and implant complications than nonperiodontitis patients. According to Klokkevold and Han, a history of treated periodontitis does not seem to adversely affect implant survival, but that these patients may experience more complications and a lower success rate, particularly over longer periods.

Karoussis et al.[2] found that there was no statistically significant difference in either short- or long-term implant survival. Quirynen et al. found in patients with a history of treated periodontitis who had implants with minimally/moderate rough surface and received supportive periodontal therapy, the implant failure rate, and marginal bone loss remained low. According to Schou et al., there was also significantly more marginal bone loss observed in a patient with periodontitis-associated tooth loss after 5 years.

Schou concluded that while implant survival is high in individuals with periodontitis-associated tooth loss, the high incidence of peri-implantitis might jeopardize the long-term outcome of implant treatment in periodontitis-susceptible patients. Van Der Weijden et al. found implant survival and success might be different in patients with and without a history of treated periodontitis.

Today, newer implant surfaces and implant design have drastically improved the success rate of implant therapy. However, there are few things to be remembered while treating these patients. Before placement of implants, periodontal and dental disease should be controlled. No recommendations can be made to define a period that should elapse before initiating implant therapy. There are a limited number of studies addressing the survival rate in patients with aggressive periodontitis. It is unknown what effect retention of questionable prognosis teeth in these patients will have on the success rate of implants in individuals who had aggressive periodontitis.

The aim of this case report is to describe the periodontal and implant rehabilitation in a patient with aggressive periodontitis.

CASE REPORT

A 25-year-old female patient reported to the Department of Periodontics, CSI College of dental Science, Madurai, with a chief complaint of the mobile upper front teeth. The patient also complains of spacing between upper and lower anteriors that keep increasing over a period of 6 months. All teeth were present with root stump in relation to 16 and 26. Her oral hygiene status was fair. No familial history could be elicited.

Her gingival examination revealed reddish discoloration in the upper and lower anterior region, with rounded margins in the anteriors. The gingiva in the anterior region was soft and edematous, with loss of stippling. There was generalized bleeding on probing evident. The gingival margin was apically placed in relation to the upper and lower anteriors.

A full-mouth periodontal charting revealed generalized periodontal pockets and clinical attachment loss. Pocket depths were deeper in the molar and incisor region with recession evident in the upper and lower incisor region. Clinical attachment loss ranged from 7 to 10 mm in the incisor region and 5–7 mm in the molar region. Most of the teeth were Grade I mobile, with Grade II mobility in 12, 22, 24, 31, 32, 41, 42 and Grade III mobile 11, 21.

An orthopantomogram and a full-mouth intraoral radiograph were taken. Radiographic findings revealed generalized horizontal bone loss with severe bone loss in the anterior region. There was a typical arch-shaped bone loss in relation to the first molar region [Figure 1]. A routine blood investigation revealed no abnormal findings.

Figure 1

Aggressive periodontitis

Based on the patient's history, clinical findings, and radiographic findings, it was diagnosed as generalized aggressive periodontitis, according to AAP 1999 classification.

Management

A through supragingival scaling was done, and oral hygiene instruction was given to the patient. Modified bass method was advised and chlorhexidine mouthwash was prescribed. Amoxicillin 500 mg and metronidazole 400 mg were prescribed for 7 days, and the patient was recalled after 14 days for review and subgingival scaling.

At the second visit subgingival scaling was completed. The patient was advised to continue chlorhexidine mouthwash, and oral hygiene maintenance was reinforced, with additional use of interdental cleaning with an interdental brush. Two weeks after subgingival scaling, there was marked a reduction in pocket depth and no bleeding on probing was present.

Overall treatment was planned with a multidisciplinary approach, with consultations from the Department of Orthodontics, Department of Endodontics, Department of Oral Surgery, and Department of Prosthodontics for complete rehabilitation of the patient. Teeth with hopeless prognosis were identified. Implants were planned for the upper anteriors.

Quadrant-wise full-mouth flap surgery was done, except on the upper anterior region. Kirkland flap was raised; with respective bone surgery was done. Extraction of root stumps in relation to 16 and 26 was done. Interrupted silk sutures were placed and co-pak was given.

Sutures were removed after 10 days. After suture removal impression with alginate impression material was made for immediate denture in the upper anterior region. After 1 week, extraction of 11, 12, 21, and 22 was done [Figure 2], and the areas were curetted thoroughly before freshly prepared platelet-rich fibrin was placed in the socket, for socket preservation and sutured [Figures 3-5]. A passively fitting immediate denture was inserted. The patient was instructed not to disturb the surgical area for 1 week. Betadine gargle was prescribed. Sutures were removed after 1 week. The patient was recalled after 45 days for implant placement.

Figure 2

After extraction

Figure 3

Platelet-rich fibrin

Figure 5

Platelet-rich fibrin placed

Platelet-rich fibrin placement

After 45 days, implant placement was planned for the replacement of 11, 12, 21, and 22. A full-thickness mucoperiosteal flap was raised in the upper anterior region. Bone quality was poor (Type 3). Furthermore, there was reduced vertical dimension. Sequential drilling was done, up to 2.8 mm final twist drill. Three implants of 3.75 mm × 11.5 mm were placed. The implant in relation to 12 was angulated more palatally because of lack of buccal bone. Interrupted sutures were placed and radiograph was taken to check the implant position [Figure 6]. Second-stage surgery was planned after 8 months. Sutures were removed after 1 week.

Figure 6

Implants placed

After 1 week, sutures were removed and the RPD was adjusted before fitting. The patient was under review every month for the next 8 months. After 8 months, second-stage implant surgery was done, healing abutments were connected, and sutures placed. Sutures were removed after 10 days and an open tray impression was taken with rubber base impression material, after that the impression coping was splinted with pattern resin. The impression was send to the laboratory for processing.

Gig trial was checked after 10 days, and Cementable final denture was delivered in 15 days. The patient was recalled after 1 week for checkup. After which, the patient is reviewed every 6 months, for the past 2 years.

DISCUSSION

There are controversies on placing implants in a patient with aggressive periodontitis. Some studies have reported that patients with aggressive periodontitis are at a greater risk of developing peri-implantitis. There are also studies that report long-term success of implants in periodontitis patients is not different from nonperiodontitis patients.[23] However, these studies had short follow-up periods and less number of patients.

When treating aggressive periodontitis patients, it is important to control the progression of disease and extract all hopeless teeth before the placement of implants. Treating the periodontal condition first is most important.

A team approach is always necessary to rehabilitate such patients. An interdisciplinary approach is essential to evaluate, diagnose, and restore the function and esthetic problems using a combination of periodontist, prosthodontist, and oral surgeon. In this case, even orthodontic opinion was obtained to view the possibility of space maintenance. Periodontist worked on controlling the disease before implant placement and prosthodontist participated in the surgery for implant positioning. An improperly placed implant may result in compromised esthetic and functional outcome.

Successful implant placement and osseointegration have been demonstrated.[4] Thus, successful implant therapy can be a treatment of choice for patients with aggressive periodontitis, with an interdisciplinary approach and proper prosthetic replacement, without future bone loss.

CONCLUSION

Rehabilitation of patients who have lost their teeth due to aggressive periodontitis is always challenging because of the quality and amount of remaining bone. Early diagnosis and management of the periodontal condition is the most important part of treating such patients. This case report describes successful management and rehabilitation of an aggressive periodontitis patient with implants. Implant prosthesis improved the quality of life for this patient, and considering the psychological problems, the patient encountered before treatment. A multidisciplinary approach is necessary for diagnosis and treatment planning to improve the esthetic and functional outcome.

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.