Comprehensive rehabilitation using dental implants in generalized aggressive periodontitis.

Generalized aggressive periodontitis (GAP) is a debilitating form of the disease and it results in deteriorating effects on the esthetic and functional aspects of the oral cavity. This case report describes the comprehensive rehabilitation of GAP patient using dental implants. The treatment planning involved thorough scaling and root planning (SRP) with oral hygiene instructions. The patient was motivated to adhere to a strict oral hygiene regimen following which periodontal flap surgery employing guided tissue regeneration and bone grafts was performed. Bacterial culture for anaerobic microorganisms was done using a gas pack pre- and postperiodontal treatment to confirm the effectiveness of the periodontal treatment regimen and also to proceed with dental implant placement. The rigorous maintenance program ensured the stability of the periodontium following which immediate placement of dental implants in the maxillary and mandibular anterior region was done. The fixed metal-ceramic prosthesis was fabricated in a step-by-step process and the patient was recalled on a periodic basis over a 3-year follow-up duration. This case is a testimonial to the postperiodontal treatment long-term stability with excellent patient cooperation and strict maintenance protocol.

INTRODUCTION

Aggressive periodontitis is the most severe form of periodontal disease affecting an individual at an early age. According to the American Academy of Periodontology classification, generalized aggressive periodontitis (GAP) can be defined as interproximal attachment loss that affects at least three permanent teeth other than the first molars and incisors.[1] The early diagnosis and treatment planning in GAP cases is of paramount importance because tooth loss is an eventual complication and the prosthetic restoration of these sites can get affected or delayed.[23] Dental implants have become an integral component of prosthetic rehabilitation, and implant-supported prosthesis in periodontitis cases has been a subject of debate over the years.[45]

A systematic review and meta-analysis done by Monje et al. in 2014 included 6 prospective clinical trials with a mean follow-up of 2 years. It concluded that the risk ratio for implant failure is significantly higher in GAP patients when compared to chronic periodontitis and healthy controls.[6] However, in lieu of this systemic review, a contradictory report was published in “Evidence based Dentistry-2015” where Alqutaibi and Algabri stated that there are limited quality- and patient-oriented evidence to suggest a high risk of implant failure rates in individuals with GAP.[7] Another systematic review in favor of dental implant treatment in GAP patients stated that the implant survival rates were between 97.4% and 100% in short-term studies, and long-term survival rates were between 83.3% and 96%.[8]

It is reasonable to suppose that implant treatment in GAP patients is not contraindicated provided adequate periodontal infection control is ensured and a rigorous maintenance program is achieved. This case report discusses the interdisciplinary management of a GAP patient in a sequential manner for ease of understanding to the clinicians.

CASE REPORT

A 24-year-old male patient reported to the department of periodontics, on February 2013, with the chief complaint of mobile teeth in his upper and lower front teeth region. On elaborating, the mobility started 6 months back and the patient reported no history of trauma in that region. The patient was systemically healthy and gave no history of recent professional oral hygiene maintenance. The family history was positive where the patient's mother had early tooth loss and severe mobility associated with it. On clinical examination, the plaque index revealed good oral hygiene yet there was bleeding on probing observed in >50% of the sites. On periodontal probing (UNC 15 Probe), there were deep periodontal pockets in the majority of the sites involving all the sextants. Miller's Grade III mobility was observed in #11, #22, Grade II mobility in #12, #21 and Grade I mobility in relation to #16, #26, #36, #32, #31, #42, #46 [Figure 1].

Figure 1

Preoperative clinical image depicting generalized aggressive periodontitis

Radiographic examination revealed angular defects extending till the apical third of the root in the maxillary, mandibular molar and maxillary anterior regions and up to the middle third of the roots in the other areas [Figure 2]. On correlating patient's age, familial history, and clinical and radiographic features, the case was diagnosed as GAP. An informed consent was obtained from the patient prior to the start of periodontal treatment.

Figure 2

Preoperative orthopantomograph showing angular defects

Periodontal therapy

The preliminary phase involved extraction of teeth #18, #28, #38, #48 (impacted third molars) and hopeless #11, #22 (periodontally compromised). The pooled subgingival plaque samples from deep periodontal pockets were collected and cultured using the gas pack in an anaerobic jar (BD GASPAK EZ) for detection of anaerobic microorganisms. Prior to SRP, one-stage, full-mouth disinfection protocol was done using 0.2% chlorhexidine.[9] The patient was recalled to undergo supragingival and subgingival scaling, and systemic antibiotic therapy (10-day prescription of 500 mg amoxicillin and 400 mg metronidazole three times daily) was used as an adjunct to SRP in the first phase. The patient was reevaluated 6 weeks after the phase-1 therapy, following which full-mouth periodontal flap surgery using guided tissue regeneration (Periocol®) along with xenograft (Osseograf®) was performed in sites with three-walled and combined osseous defects (#16, #26, #36, #46) [Figure 3]. The patient was recalled on monthly intervals for 6 months, and subgingival plaque samples were again collected toward the end of the maintenance phase for bacterial culture and they did not show any anaerobic growth of microorganisms. The postoperative radiographs after 6 months showed significant bone fill at the defect sites [Figure 4].

Figure 3

Intraoperative image showing guided tissue regeneration and xenograft at the defect sites

Figure 4

Postoperative radiograph after 6 months showing significant bone gain at defect sites (#36, #46)

Implant placement

The periodontal parameters were assessed periodically during the maintenance phase. After the reduction in the metrics, placement of dental implants was planned [Figure 5]. The implant planning was done using cone-beam computed tomography [Figure 6]. Since prosthetic prognosis was hopeless in #11, #32, #42, extraction and immediate implant placement were planned in those regions. Under local anesthesia, atraumatic extraction of #11, #32, #42 was performed using periotome and the osteotomy sites were prepared (#11, #21, #32, #42) for implant placement. Three implants of size 4.3 mm × 13 mm (Nobel Biocare Replace® for #21, #32, #42) and one implant of size 3.5 mm × 13 mm (Nobel Biocare Replace® for #11) were placed with adequate primary stability (torque >30 N) [Figure 7]. The surgical site was sutured with 3-0 black silk suture and it was removed after 1 week. The patient was recalled after 4 months for prosthetic rehabilitation.

Figure 5

Postoperative clinical image showing reduction in periodontal parameters after 6 months

Figure 6

Cone-beam computed tomography images employed for implant planning

Figure 7

Nobel Biocare implants in relation to #11, #21, #32, #42

Prosthetic restoration

After 4 months, the radiographs showed successful osseointegration of the dental implants without any biological complications. The second stage surgery was performed and the healing caps were placed. After complete healing of soft tissues around the healing cap, abutment was placed and a closed tray final impression was taken, following which laboratory models were prepared [Figure 8]. After cementation of the prosthesis, a 3-year close follow-up showed an esthetic and functionally stable restoration both clinically and radiographically [Figures 9 and 10].

Figure 8

Clinical image showing implants with regular platform abutments

Figure 9

Final cementation of metal-ceramic implant-supported prosthesis

Figure 10

Radiographic image showing functional implant and prosthesis at 3-years follow-up

DISCUSSION

This case represents a challenging management of GAP patient where the esthetics and function had to be restored. The existing literature shows that dental implants and implant-supported prosthesis can be a predictable treatment modality in periodontal diseases.[101112] In this case, teeth with a hopeless prognosis were extracted and replaced with immediate implants following periodontal surgery. The other teeth with insufficient bone support were retained because they did not show further bone resorption during the follow-up.

The niches for bacterial accumulation were eradicated using the one-stage, full-mouth disinfection protocol and during the various phases of periodontal treatment. The surgical periodontal therapy phase utilized the predictable modalities of regeneration using guided tissue regeneration and xenografts. To completely alleviate the doubt of recurrence, a bacterial culture was performed to rule out the presence of anaerobic microorganisms. Polymerase chain reaction could have been used to detect the microbiological parameters and this is a potential limitation of this report. The dental implants were planned after all these steps were carried out in a sequential manner.

Atraumatic extraction of the teeth planned for immediate implants was carried out using a periotome and the emphasis lies on the minimal trauma to the tissues to maintain the tooth-gingival contour.[13] The teeth and implants did not show any sign of instability or biological complications during the follow-up period of 3 years. Successful oral rehabilitation using osseointegrated implants and prosthesis can be accomplished in a GAP patient with periodontal therapy, strict disinfection protocol, and a rigorous maintenance regimen.

CONCLUSION

The stigma in using fixed prosthetic rehabilitation for GAP can be slowly minimized with an effective treatment and maintenance regimen. Although the current research poses a debate on this topic, an implant-supported prosthesis can be a definitive and viable treatment option for young GAP patients where esthetics and functional aspects have to be catered where a positive interplay of factors such as patient cooperation and a strict maintenance regimen is utilized.

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.