treatment planning and sequence for implant therapy in a young adult with generalized aggressive...

Treatment Planning and Sequence forImplant Therapy in a Young Adult WithGeneralized Aggressive PeriodontitisAvinash S. Bidra, BDS, MS, FACP1*Murad Shaqman, BDS, MS2

Treatment planning for full-mouth rehabilitation in patients with generalized aggressive

periodontitis often requires a staged approach. Few articles have addressed treatment

planning and sequencing issues in this patient population. This report describes the

multidisciplinary management of a young adult by a combination of periodontal and implant

therapy and rehabilitation with fixed prostheses. At a 2-year follow-up, the patient’s

periodontal health and peri-implant conditions were stable. Prosthodontic rationale and

treatment planning concepts in a patient with multiple challenges are discussed.

Key Words: aggressive periodontitis, treatment planning, implants, hybrid prosthesis,staged treatment, angled abutments

INTRODUCTION

Aggressive periodontitis is

characterized by rapid pro-

gression and destruction of

periodontal tissues, which is

often associated with the

early onset of the disease, an elevated

degree of therapy resistance, and a high

tendency toward relapse.1 Treatment for

patients with aggressive periodontitis fre-

quently involves a combination of tradi-

tional and modern periodontal therapy.

While it is desirable to retain natural teeth

whenever possible, the decision to extract

some or all teeth in these patients

depends on the periodontal prognosis

and prosthodontic treatment plan. It isalso important that patient motivation,esthetics, and occlusion dictate this deci-sion. The extracted teeth could be re-placed successfully with implant therapy,similar to periodontally healthy individuals;however, an adequate maintenance sched-ule phase is necessary after the initialtreatment.2,3

Due to limited evidence, the literatureis inconclusive about the long-term out-come of implant therapy in periodontitispatients.4 However, a few long-term stud-ies done up to 10 years have shownpromising results.2,5,6 Based on a compre-hensive literature review, Karoussis et al7

have shown no statistically significantdifferences in implant survival betweenpatients with a history of chronic peri-odontitis and periodontally healthy indi-viduals. However, it has been noted thatperiodontitis patients may display greaterperi-implant bone loss, periodontal pocket

1 Department of Reconstructive Sciences, Universityof Connecticut Health Center, Farmington, Conn.2 Department of Oral Surgery, Oral Medicine andPeriodontology, University of Jordan, Amman, Jordan.* Corresponding author, e-mail: [email protected]: 10.1563/AAID-JOI-D-10-00118

Journal of Oral Implantology 405

CASE REPORT

depth and incidence of peri-implantitiscompared with periodontally healthy sub-jects over a long-term period.2,4,7

Patients with generalized aggressiveperiodontitis may require a staged ap-proach for full mouth extractions topsychologically aid in acclimatization tocomplete edentulism. Oftentimes, suchpatients are young adults, and the psycho-logical impact of sudden loss of all teeth inthe mouth may be tremendous. Anotherreason for using a staged extractionapproach is to provide a proper base forplacement of the immediate denture.8–10

This method calls for extraction of all ormost of the posterior teeth first to allowthe posterior ridges to heal adequately andfacilitate accurate final impressions. A pairof opposing posterior natural teeth isgenerally retained to assist in establishingthe occlusal vertical dimension for theimmediate denture.9,10 After a few weeksof healing, optimal final impressions aremade and the denture is fabricated. Theanterior teeth are then extracted and theimmediate denture is inserted.10,11 A well-fabricated immediate denture made in thismanner is indispensable during the treat-ment period before a final prosthesis canbe fabricated.12

Treatment planning for an estheticimplant-supported fixed prosthesis in theedentulous maxilla is known to be com-plex.13–15 Various esthetic parameters suchas amount of tissue loss, position ofanterior teeth in relation to the residualridge, smile line, lip support, and the needfor gingiva-colored prosthetic materialaffect the design of the prosthesis. There-fore, patients have been classified into 4types for diagnosis and decision-makingfor design of the fixed prosthesis.16 Class Ipatients are those who require gingiva-colored prosthetic material to obtainesthetic tooth proportions, optimal pros-thesis contour, and adequate lip support.Class II patients are those who requiregingiva-colored prosthetic material only toobtain esthetic or ideal tooth proportionsand for prosthesis contour. Lip support is

not a consideration in this categorybecause the difference in lip projectionwith and without any prosthesis is gener-ally insignificant. Class III patients will notrequire any gingiva-colored prostheticmaterial. Class IV patients are distinct asthey are the only class of patients whohave a high or a gummy smile; they may ormay not require gingiva-colored prostheticmaterial, based on the outcome of thepreprosthetic intervention to reduce theexcessive amount of bone and correctionof the gummy smile.16

CASE REPORT

A 39-year-old African-American male wasreferred to the periodontist for evaluationof periodontal health and consideration ofreplacing missing posterior teeth withdental implants. Evaluation of the patient’sdental history and radiographic examina-tion revealed that the patient had beendiagnosed with generalized aggressiveperiodontitis 10 years ago. He had re-ceived nonsurgical periodontal treatment,multiple extractions, and irregular peri-odontal maintenance over the years (Fig-ure 1). The patient was asymptomatic andhad an unremarkable medical history. Hewas referred to his physician for a com-plete physical examination, which ruledout any undiagnosed medical condition.

A comprehensive periodontal examina-tion was performed, which showed aplaque score of 80% and a bleeding scoreof 70%. The patient had supragingival andsubgingival calculus. The periodontalprobing depth ranged from 3–9 mm, andsuppuration was evident on several teeth.Multiple teeth had a mobility of grade IIand grade III. Pathological tooth migrationwas observed on several of the maxillaryanterior teeth. Radiographic examinationshowed severe bone loss and a combina-tion of horizontal and vertical bony de-fects. The mandibular anterior teeth had aprobing depth range of 3–6 mm. They hadshort clinical crowns and the probingdepths were mostly pseudopockets. No

406 Vol. XXXVIII / No. Four / 2012

Implant Therapy With Generalized Aggressive Periodontitis

mobility was observed. Periapical radio-

graphs showed minimal horizontal bone

loss. A prosthodontic consultation was

then obtained, and diagnostic casts were

mounted on a semiadjustable articulator.

Diagnosis and treatment plan

The patient was diagnosed with general-

ized aggressive periodontitis, secondary

occlusal trauma, partial edentulism, and

bimaxillary protrusion with anterior cross-

bite. His facial profile showed a prognathic

maxilla and mandible (Figure 2). After a

careful analysis of the clinical situation and

patient’s expectations, different treatment

options were presented to the patient.

With the exception of mandibular anterior

teeth, all teeth in the mouth had a poor-

hopeless prognosis, and it was decided to

extract them followed by replacement

with prosthetic teeth. The retained man-

dibular anterior teeth were planned for

nonsurgical and surgical periodontal ther-

apy. Periodontal therapy was aimed at root

instrumentation, pocket elimination, and

exposure of the anatomical crown. As the

patient desired fixed prosthetic solutions

for replacement of his teeth, he was

treatment-planned for a screw-retained

metal-resin fixed prosthesis (hybrid pros-

thesis) supported by 6 implants in the

maxilla; screw-retained metal-ceramic fixed

partial dentures (FPDs) were planned for

the posterior mandible. Regular periodon-

tal maintenance was to supplement the

active treatment phase.

Initial treatment

The patient received full mouth supragin-

gival and subgingival debridement and

detailed oral hygiene instructions. The

patient’s plaque control was evaluated

FIGURES 1–4. FIGURE 1. Pretreatment radiograph of the patient revealing bone loss associated withgeneralized aggressive periodontitis. FIGURE 2. Pretreatment profile image of the patient showing aconvex profile with prognathic maxilla and mandible. FIGURE 3. Panoramic radiograph after extractionof maxillary and mandibular posterior teeth. Mandibular left premolar was in articulation with maxillarycanine and was retained for maintenance of occlusal vertical dimension. FIGURE 4. Frontal view of theteeth in maximum intercuspation after extraction of posterior teeth. Note the anterior crossbite andthe pseudopockets around the mandibular anterior teeth.


Bidra and Shaqman

frequently during the treatment planning

and consultation phase, and he demon-

strated significant improvement (plaque

score ,30%). A staged-extraction protocol

was used, and posterior teeth from both

arches were first extracted (Figure 3).

Fabrication of the immediate maxillary

denture commenced after complete heal-

ing of the extraction sites (Figure 4). The

diagnostic casts were mounted on a semi-

adjustable articulator, and an ideal maxil-

lary diagnostic wax-up with correction of

the anterior crossbite was completed. The

positions of the mandibular posterior teeth

were then determined based on the

opposing maxillary teeth (Figure 5). A

maxillary complete denture was then

fabricated, and the mandibular wax-up

FIGURES 5–10. FIGURE 5. Diagnostic waxing for immediate maxillary complete denture and mandibularposterior teeth for fabrication of surgical guide for implant surgery. FIGURE 6. Profile image of thepatient after being made edentulous in the maxilla. Notice obvious loss of lip support in comparison toFigure 2. FIGURE 7. Duplicate of the diagnostic denture used for radiographic and surgical guidepurposes. FIGURE 8. Autogenous block graft harvested from the ramus being placed in the anteriormaxilla in the lateral incisor regions. FIGURE 9. Frontal view of the immediate maxillary completedenture and definitive mandibular fixed partial dentures (FPDs) in maximum intercuspation. The FPDswere inserted during the healing process of the maxillary bone grafts. FIGURE 10. Six implants wereplaced in the planned positions of the maxilla. Notice the parallelism between the implants.



was preserved as the patient refused towear an interim mandibular removableprosthesis. Periodontal surgery was thenperformed on the mandibular anteriorteeth to eliminate pseudopockets as wellas to accomplish root instrumentation. Themaxillary anterior teeth were extractedwithout any complications, and the imme-diate maxillary complete denture wasinserted. The patient was prescribed0.12% chlorhexidine rinse (Periogard, Col-gate-Palmolive, Morristown, NJ) for usetwice daily.

Implant planning

After 4 months of healing, diagnosticimaging and clinical evaluation were donefor implant placement. As the clinician, thepatient, and his family accepted theesthetics of the immediate maxillary den-ture, it eliminated the need for a newdiagnostic wax-up. Based on estheticparameters provided by this denture, hewas diagnosed as a Class I patient forfabrication of a fixed implant-supportedprosthesis for the edentulous maxilla16

(Figure 6). The immediate denture wasduplicated in clear autopolymerizing resin(Splint Acrylic Resin, Great Lakes Ortho-dontics, Tonawanda, NY) for 3 purposes:(a) fabrication of a radiographic guide forcone-beam computerized tomography(CBCT) image (Figure 7); (b) fabrication ofa surgical guide; and (c) performance ofprosthetic space analysis. Evaluation ofCBCT images revealed that the anteriormaxilla was deficient buccolingually, andthe maxillary sinuses were pneumatized.As the patient presented with a proclinedmaxilla, it was anticipated that it would bea challenge to angle the implants linguallyin order accommodate optimal position ofscrew-access channels in the final prosthe-sis. It was expected that anterior ridgeaugmentation would ameliorate the situa-tion, but the possibility of using angledabutments in the final prosthesis was notruled out.

Six maxillary implants were planned inthe position of teeth no. 3, 5, 7, 10, 12, and

14. Onlay block grafting to augment theanterior maxillary region and osteotome-assisted maxillary sinus floor elevations inthe posterior region were planned. Ade-quate ridge height and width for implantplacement in the mandible in the positionsof teeth no. 19, 21, 28, and 30 wereverified.

Maxillary preprosthetic surgery andmandibular implant surgery

Autogenous block grafts were harvestedfrom the patient’s left ramus, the implantsites in the anterior maxilla (no. 7 and 10)were horizontally augmented, and primaryclosure of the soft tissues was obtained(Figure 8). The healing of the donor andrecipient sites was uneventful. Thereafter,2 implants (Standard Plus, Straumann,Waldenburg, Switzerland) were placed oneach side of the posterior mandible usingthe surgical guide fabricated from themandibular diagnostic wax-up. The mesialimplants were of dimensions 4.1 3 12 mm,and the posterior implants were 4.8 3 12mm. The implants had primary stabilityupon closure, and healing abutments wereplaced (Straumann) for nonsubmergedhealing.

Mandibular prosthesis

Two months after surgery, the healingabutments were removed, and the im-plants demonstrated no mobility, boneloss, or clinical signs of infection. It wasdecided to proceed with the fabrication ofthe definitive restorations in the mandiblein order to provide posterior mandibularsupport and better function for the patientduring the treatment phase of the maxilla.An implant-level final impression wasmade using polyether impression material(Impregum Pentasoft, 3M ESPE DentalProducts, St Paul, Minn), and a definitivecast was poured in type IV stone (Den-stone, Heraeus Kulzer, South Bend, Ind).Using bite registration aids (Straumann)connected by resin (Triad, Dentsply, York,Pa), a jig was made over the implants andmaxillomandibular relationships were re-


Bidra and Shaqman

corded against the maxillary complete

denture. Screw-retained metal-ceramic

FPDs were then fabricated. The definitive

abutments (Synocta 1.5 mm, Straumann)

were tightened to 35 N/Cm, and the

occlusal screws were hand-tightened at

this stage. It was anticipated that the final

tightening would be done when the

maxillary prosthesis would be inserted

(Figure 9).

Maxillary implant surgery

Two months after insertion of the man-

dibular FPDs (4 months after the bone

graft procedure in the anterior maxilla), a

second CBCT image was acquired for the

maxilla. This was done to evaluate the

healing of the block grafts and the

resulting ridge dimensions. Radiographic

evaluation revealed that the block grafts

demonstrated adequate integration into

the recipient bed. Using a surgical guide, 6

maxillary implants (4 3 11 mm) were

placed in the planned positions (Osseo-

speed, Astra Tech, Waltham, Mass) (Figure

10). Simultaneous osteotome sinus floor

elevation was accomplished in the region

of teeth no. 3, 5, 13, and 14. Cover screws

(Astra) were placed and primary closure

was obtained over the implants, and the

implants underwent submerged healing

for 2 months.

Maxillary prosthesis

After 2 months, all implants were uncov-

ered and demonstrated no mobility, bone

loss, or clinical signs of infection. An

implant-level final impression was made

using polyether impression material (Im-

pregum Pentasoft), and a definitive cast

FIGURES 11–13. FIGURE 11. Master cast showing the effect of lingualization of the access holes with thehelp of angulated abutments. These were necessary to compensate for the implants placed in thepatient’s proclined maxilla. FIGURE 12a. Occlusal view of the final prosthesis after insertion. Note thelingualized position of the anterior access holes. FIGURE 12b. Frontal view of the final prostheses inmaximum intercuspation. An end-to-end anterior occlusion was required to compensate for thelabially inclined mandibular anterior teeth and correction of the pretreatment anterior crossbite. FIGURE

13. Profile image of the patient with final prosthesis. Note restoration of lip support to pretreatmentcondition. Compare with Figures 2 and 6.



was poured in type IV stone (Denstone). Adiagnostic cast was also prepared for themandibular arch, which now included theposterior FPDs. Standard prosthodonticprinciples were then followed, whichincluded verification of the maxillary mas-ter cast, maxillomandibular relationshiprecords, and a trial wax denture. As thepatient desired duplication of esthetics ofhis immediate complete denture in thefinal prosthesis, the process of teetharrangement was uncomplicated. Using aputty matrix from this teeth arrangement,the choice of abutment and type of metalframework was made. As anticipated, useof angled abutments was necessary tocompensate for the direction of theimplants in the proclined maxilla (Figure11). As all of the implants were relativelyparallel, angled abutments (Angled Abut-ment, Astra Tech) were used to ensure theoptimal positioning of the screw accesschannels in the final prosthesis. A castmetal framework was then fabricated overthe abutments from silver-palladium alloy,using the putty matrix as a guide to attainoptimal contours.

The passivity and fit of the finishedmetal framework was then confirmed onthe master cast using visual, tactile, andthe Sheffield’s 1-screw test. After trying inthe patient’s mouth, prosthetic teeth weretransferred over the metal frameworkusing a prefabricated index. A final esthetictry-in was performed to confirm accuratetransfer of teeth; esthetics, phonetics, andocclusion were reverified; and the finalprosthesis was fabricated in heat-polymer-ized acrylic resin (Lucitone, Dentsply).

Insertion, follow-up and maintenance

The angled abutments were tightened tothe manufacturer recommended force of20 Ncm, and the maxillary prosthesis wasthen inserted in the patient’s mouth. Theocclusal screws of the maxillary andmandibular prostheses were then tight-ened to 15 Ncm, and final occlusion wasverified and adjusted. The screw channelswere filled with silicone (Fit Checker, GC

America Inc, Alsip, Ill) and sealed withcomposite resin after 4 weeks (Figure 12aand b). The patient was given postopera-tive cleaning instructions using superfloss,proxabrushes, and electrical water irriga-tion system. He was educated aboutmaintenance and all potential complica-tions related to the prosthesis (Figure 13).The patient was initially placed on a 4-month recall for periodontal maintenance.During these recalls, periodontal statuswas assessed, routine supragingival andsubgingival debridement was performed,and oral hygiene instructions were rein-forced (Figure 14A). At a 2-year recall, allimplants were stable, and the prosthesisdid not have any complications. Theperiodontal condition of the remainingnatural teeth was stable; the probingdepth ranged from 2–4 mm, plaque scorewas 31%, and bleeding score was 20%.Periapical radiographs revealed bone lev-els around the implants were withinnormal limits (Figure 14B). The patientremained satisfied with both prostheses(Figure 15).

DISCUSSION

The patient was diagnosed with aggressiveperiodontitis based on the rapid bone losshe experienced and the absence of anunderlying medical condition.17 Althoughminimal local factors are often a charac-teristic of aggressive periodontal disease, itis not a primary diagnostic criterion.17 Inthis patient, the rapid periodontal boneloss cannot be explained solely by thepresence of local factors, considering thatthe patient already had severe periodontaldisease in the third decade of his life.Moreover, the periodontal treatment re-ceived, albeit irregular, was expected tohave slowed down the progression of thedisease18,19; nevertheless, the patient ex-perienced continued periodontal destruc-tion leading to tooth loss. This denotes theaggressive nature of this patient’s disease.

Different implant-supported prosth-odontic options were considered for the


Bidra and Shaqman

patient, which included: (1) removable

overdenture retained by individual attach-

ments; (2) removable overdenture retained

by a bar; (3) screw-retained fixed prosthe-

sis in metal-resin; (4) screw-retained fixed

prosthesis in metal-porcelain; (5) cement-

ed, fixed prosthesis in metal-resin; (6)

cemented, fixed prosthesis in metal-porce-

FIGURE 14. a. Periapical radiographs of all implants taken at a 4-month follow-up. b. Periapicalradiographs of all implants taken at a 2-year follow-up show bone levels within normal limits. Comparewith Figure 14a.



lain; and (7) single screw-retained metalsubstructure with individually cementedcrowns. The patient refused a removableprosthetic option, and other fixed optionsdescribed above were not considered dueto financial reasons.

Though cephalometric analyses werenot performed, patient history, clinicalexamination, and CBCT analysis revealedthat the patient had bimaxillary protrusion.Therefore, implants placed in the anteriormaxilla had anteriorly directed angulationsdespite the bone augmentation proce-dure. Consequently, the use of angledabutments was anticipated in order tohave optimal placement of screw-accesschannels. This was also the reason that themaxilla was treated with a bone-levelimplant system (Astra Tech) as opposedto a tissue-level implant system (Strau-mann) that was used in the mandible.Though use of the same implant systemon both arches would have been prefera-ble for simplicity, the tissue level implant(Straumann) was not considered in themaxilla because: (1) the manufacturer ofthis implant system does not recommendthe use of angled abutments on this typeof implant (Synocta System; Straumann)for complete arch fixed (hybrid) prosthesis,and (2) this implant manufacturer does notprovide a nonindexed University of Cal-ifornia at Los Angeles-type prostheticabutment for this type of implant (Stan-dard Plus, Straumann).

It was decided to retain the 6 mandib-ular teeth because they had a good

periodontal prognosis. Extraction of theselabially inclined teeth may have providedbetter control in establishing optimalhorizontal and vertical overlap of anteriorteeth, as in a completely edentuloussituation. However, the patient was moti-vated to retain these teeth as it addedpsychological benefit to him and his familyfor not being completely edentulous.Therefore, the maxillary incisors had tobe arranged in an end-to-end positionover the mandibular natural teeth. Placingthe maxillary anterior teeth any morelabially would have resulted in a protuber-ant maxillary lip (Figure 13). It can beargued that a single stage extraction of allmaxillary teeth with or without immediateimplant placement may have shortenedthe treatment time for this patient. How-ever, a single stage extraction may beunacceptable in many young adults due tothe psychological impact of losing all teethsimultaneously. Immediate placement ofimplants was not considered due toinsufficient bone in the maxillary anteriorregion and the necessity for maxillary sinusfloor elevation in the posterior region.Immediate loading of maxillary implantswas not considered as an option becausethe patient was satisfied with his interimmaxillary denture. Therefore, a clear ad-vantage of the procedure for this patientcould not be established. Furthermore,there is limited evidence in the literaturefor immediate and early loading of im-plants for fixed prosthesis in the maxilla,especially on grafted bone.20–22

The patient was educated that peri-odontal therapy and maintenance alongwith his motivation could ensure long-lasting periodontal health of his naturalteeth. This has been pointed out in othersimilar case reports as an importantelement for long-term success.23–25 Thepatient was also cautioned that his man-dibular teeth might need to be extractedand replaced with implants if futureperiodontal disease creates a poor prog-nosis. Therefore, screw-retained FPDs werefavored over cementable FPDs in the

FIGURE 15. Posttreatment close-up smile of thepatient with definitive prostheses.


Bidra and Shaqman

posterior region due to their retrievability,in the event that these implants were tobecome a part of a full arch prosthesis inthe future.

CONCLUSION

This clinical report described the treatmentplanning and sequencing in the manage-ment of a young adult with generalizedaggressive periodontitis. The treatmentwas accomplished in a strategic mannerby using staged extractions and periodon-tal therapy, followed by bone grafts andimplant placement. The subsequentprosthodontic therapy was also accom-plished in stages. This approach helped tomaximize patient adaptation and comfort,as well as allowed for evaluation of thepatient’s compliance with periodontaltherapy. Furthermore, it helped the patientfinancially, by allowing distribution oftreatment expenses over a period of time.This approach may be a suitable option inthe management of young adults withgeneralized aggressive periodontitis whorequire full mouth extraction and replace-ment by prosthesis.

ABBREVIATIONS

CBCT: cone-beam computerized tomogra-phyFPD: fixed partial denture

ACKNOWLEDGMENT

The authors would like to thank Dr Shiza N.Khan, BDS for her valuable help with datacollection.

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