|Year : 2015 | Volume
| Issue : 5 | Page : 625-629
Management of aggressive periodontitis patient with implant supported prosthesis
Garima Jain, Rajesh Kumar, Shrikant Vishnu Dhodapkar, Gagan Jaiswal
Department of Periodontics, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
|Date of Web Publication||10-Sep-2015|
501-B, Akanksha Building, Sri Aurobindo Medical College, Indore-Ujjain road, Indore, Madhya Pradesh, 452001
Source of Support: Nil., Conflict of Interest: None declared.
Aggressive periodontitis (AgP) comprises a group of rare, often severe, rapidly progressive forms of periodontitis which is characterized by an early age of clinical manifestations. It usually affects people under 30 years of age, but patients may be older. Microbiota associated are Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis. The presence of highly pathogenic bacteria, severe periodontal bone destruction and the refractory nature of this disease tends to deter the clinician from placing implants in these patients. This case report demonstrates the placement of implants in a patient with AgP with successful 18 months follow-up.
Keywords: Aggressive periodontitis, dental implants, guided bone regeneration, implant supported prosthesis
|How to cite this article:|
Jain G, Kumar R, Dhodapkar SV, Jaiswal G. Management of aggressive periodontitis patient with implant supported prosthesis. Med J DY Patil Univ 2015;8:625-9
| Introduction|| |
Aggressive periodontitis (AgP) is an uncommon condition characterized by severe loss of attachment and destruction of alveolar bone around one or more permanent teeth in otherwise healthy adolescent. The disease has a predilection for first molars and incisors and when limited to these teeth, is termed localized AgP. A generalized aggressive periodontitis (GAP) is characterized by the involvement of at least three permanent teeth other than first molars and incisors. AgP becomes apparent about the time of puberty, usually between the age of 10 and 15 years. As the disease progresses, the affected teeth may become increasingly mobile, with labial movement and spacing of incisors. This destructive form of periodontal disease frequently remain undetected in young individuals, until increased tooth mobility, drifting, and spacing of teeth with abscess formation occurs.
Implant therapy is currently considered as a successful and acceptable means to restore missing teeth. During the decades that have passed since the widespread acceptance of implant dentistry, placement protocols have evolved to vary the timing of implant placement from late (in completely healed sites) through delayed and finally, immediate placement following extraction. These procedures were developed to better meet patient's expectations.,
The definition of periodontally compromised/periodontally susceptible patients has been used when evaluating survival and success rates of implants, because periodontal disease has been considered as a risk factor for implant therapy.,
| Case Report|| |
A 30-year-old male nonsmoker, systemically healthy patient reported to the Department of Periodontology of Sri Aurobindo College of Dentistry, Indore (M.P.) with chief complaints of teeth malpositioning and mobility and gingival discomfort. Clinical examination revealed tooth displacement with pathological migrations, and poor periodontal tissue quality (fiery red, acutely inflamed marginal and attached gingiva). Periodontal examination disclosed deep periodontal pockets (mean 7 mm) with purulent exudate from most of the teeth [Figure 1]. Severe alveolar destruction was evident in radiograph around all the teeth [Figure 2].
Initial periodontal therapy consisted of thorough training in techniques of plaque control with scaling and root planing and administration of doxycycline 100 mg once a day for 21 days. Extraction of teeth with hopeless prognosis and root canal treatment of teeth with periapical pathology was planned and executed. Following the completion of this phase of treatment, the patient was scheduled on recall visits for the evaluation of gingival health, pocket depth reduction and oral hygiene assessment. On follow-up visits, mobility was present in all his teeth with minimal reduction in pocket depth but patient had maintained oral hygiene. On subsequent visits full mouth flap surgery was performed around all remaining teeth to eliminate periodontal pockets and regenerative procedures with demineralized freeze dried bone allograft (DFDBA- DEMBONE™, The Pacific Coast Tissue Bank, Los Angeles, USA), platelet rich fibrin (PRF) and guided tissue regeneration membrane (GTR-HEALIGUIDE™, Advanced Biotech Products (P) Ltd, Alathur, India) were performed in 16, 26, 27, 46, 47. PRF was prepared according to the technique described by Dohan et al. Over a period of 6 months the gingival condition was improved with reduction in periodontal pocket depth and improved oral hygiene. For the replacement of missing teeth, endosseous dental implants and fixed partial prosthesis were considered as treatment options. After discussing with the patient, immediate dental implants (MIS Implant Technologies Ltd, Israel) were placed in extraction socket in 12 (4.2 × 13), 14 (4.2 × 11.5), 15 (3.75 × 11.5), 22 (4.2 × 13), 35 (4.2 × 11.5), 36 (4.2 × 10) and in 41 (3.75 × 10) region. In areas of deficit bone, guided bone regeneration (with DFDBA, PRF and GTR membrane), was also done with implant placement.
The bone height w.r.t 14 and 15 was insufficient for the implant placement so indirect sinus lift procedure by osteotomy technique (Summer's technique) along with regenerative materials (DFDBA + PRF) were also performed. Antibiotics (amoxicillin 500 mg BD for 5 days) were prescribed postsurgically.
After 6 months, second stage implant surgery was performed and cement retained prosthesis were placed [Figure 3] and [Figure 4]. Multiple recall visits were planned over a period of 18 months to evaluate the patient's ability to maintain oral hygiene and to assess the health of the implant supported prosthesis. After 18 months satisfactory outcome of the treatment was well evident with functional and esthetic dental unit [Figure 4] and with good radiographic bony support [Figure 5a], [Figure 5b], [Figure 5c], [Figure 5d] and [Figure 6].
|Figure 3a: Postoperative clinical presentation of maxillary arch after prosthesis placement|
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|Figure 4: Postoperative clinical presentation after prosthesis placement|
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|Figure 5a: Six months postoperative intraoral periapical radiographs in relation to 12|
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|Figure 5b: Six months postoperative intraoral periapical radiographs in relation to 14 and 15|
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|Figure 5c: Six months postoperative intraoral periapical radiographs in relation to 22|
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|Figure 5d: 6 months postoperative intraoral periapical radiographs in relation to 35 and 36|
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| Discussion|| |
The rehabilitation of edentulous sites, with dental implants can satisfy patient's esthetic, functional and phonetic needs as close as natural dentition. Periodontally compromised patients have been defined as patients that have had a history of periodontitis (chronic or aggressive), but with no active disease at the time of implant placement. The patients are usually subjected to "successful" periodontal therapy (nonsurgical and/or surgical) before implant placement. The criteria for successful implant placement are mentioned below:
Proposal by Alberktsson et al.
- That an individual, unattached implant is immobile when tested clinically.
- That a radiograph does not demonstrate any evidence of peri-implant radiolucency.
- That vertical bone loss is <0.2 mm annually following the implant's 1st year of service.
- That implant performance be characterized by an absence of persistent and/or irreversible signs and symptoms such as pain and infections, neuropathies, paresthesia or violation of the mandibular canal.
- That in the context of the above, a successful rate of 85% at the end of a 5 years observation period and 80% at the end of a 10-year period is a minimum criterion for success.
Though reports exist regarding the successful placement of implants in patients with AgP, the general consensus is that the placement of implants in these patients is unpredictable., The long term prognosis has been questioned in these patients.
A study of a patient with GAP conducted over 18 months reported that marginal bone loss and inflammation was not found around all implants. The survival rate of those implants was100%. Another studies and systematic reviews reported on similar cases with a positiveoutcome.,,
Another 5 years follow-up study, conducted in patients with GAP has shown that 45% of implants exhibited marginal bone loss of 1.5 mm and 30% cases displayed pockets of more than 6 mm.
On the contrary, recent reports have found that once the disease is controlled, implants can be placed successfully. Mengel et al. showed a successful follow-up of upto 10 years in partially edentulous subjects of GAP with osseointegrated implants. However, the bone and attachment loss at the implants were higher than in periodontally healthy subjects.
In a prospective longitudinal 10 years cohort study has demonstrated that oral implants may successfully be placed and maintained in patients with and without a history of periodontitis. However, patients with a history of periodontitis yielded lower survival (90.5% vs. 96.5%), significantly higher complication (28.6% vs. 5.8%) and significantly lower success rates (e.g., 71.4% vs. 94.5%) than patients who had lost their teeth for reasons other than periodontitis.
In the present case report, the patient was evaluated at 6, 9, 12 and 18 months interval after loading for the following criteria:
Definition of survival (interpreted as success) included absence of severe inflammation, progressive bone loss, chronic pain related to implant, injury of the mental nerve, implant mobility, damage of the implant beyond repair, implant loss; gingival index of 3 at any of the four assessed sites around the implant.
When an implant is said to be successful, it obeys there quested demands. These relate to:
- Mechanical function (ability to chew, speak),
- Tissue physiology (presence of osseointegration, maintenance of supporting bone and absence of inflammation).
- Psychology (absence of pain and discomfort as well as presence of acceptable aesthetics).
Standardized orthopantomogram (OPG) were taken at the time of implant placement, 6, 9, 12 and 18 months postoperatively. OPG and intraoral periapical radiograph did not demonstrate any radiolucency or other pathological conditions adjacent to the implant.
Therefore, there were no features of peri-implantitis or peri-implant mucositis found and patient was instructed to maintain oral hygiene at each interval.
| Conclusion|| |
The goal of periodontal therapy is the maintenance of the dentition and/or its implants placement in a state of health, comfort, function, and esthetics for the duration of a patient's life. Patients with a history of periodontitis represent a unique group of individuals who previously submitted to a bacterial challenge. Therefore, it is important to address the management and survival rate of implants in these patients. On the basis of previous case reports and systematic reviews GAP can be rehabilitated successfully with osseointegrated implants. However more bone and attachment loss at the implants have reported than in periodontally healthy subjects. This case report described successful management of AgP patient, rehabilitated with endosseous dental implants.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5a], [Figure 5b], [Figure 5c], [Figure 5d], [Figure 6]