Decision Process in Treatment of Reduced Periodontium: a Case Report

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Decision Process in Treatment of Reduced Periodontium: A Case Report

Rohit Mathur, BDS, MPH, MS1 Periodontal health is defined by the David Wessel, DMD2 World Health Organization as a state Max Nahon, DDS2 free from inflammatory periodontal Michelle Torres, DMD, MS3 disease that allows an individual to 2 Thomas J. Balshi, DDS, PhD function normally and avoid conse- quences (mental or physical) due to The relationship between attachment loss and occlusal trauma has been current or past disease. A practical debated for many years. When a patient presents with advanced periodontal definition of periodontal health is a disease, a decision has to be made on whether the teeth can be saved or state free from inflammatory peri- extracted. In this treatment example, the decision process in therapeutic odontal disease. This, in turn, means planning for a patient with stage IV periodontal disease is discussed. The main dilemma is whether the patient should receive a prosthodontic that absence of inflammation asso- reconstruction supported by osseointegrated implants or by periodontally ciated with gingivitis or periodontitis compromised natural teeth. It is assumed that implants do better than teeth is assessed clinically as a prerequi- over the long term based on firm documentation in the literature, but this article site for defining periodontal health.1 describes why a periodontal prosthesis is still a viable treatment option. Int J Labial flaring, extrusion, rotation, Periodontics Restorative Dent 2020;40:e197–e204. doi: 10.11607/prd.4585 spacing, mobility, bone loss, ex- posed root surfaces, and drifting of the teeth are all related to periodontal support.2 These changes hap- pen as the periodontal ligament is unable to stabilize the teeth against external forces placed upon them.3 According to the American Academy of Periodontology glossa- ry of terms, primary occlusal trauma is defined as an injury resulting in tissue changes from excessive occlusal forces applied to a tooth or teeth with normal osseous and soft tissue support; secondary occlusal 1Private practice, Lubbock, Texas; Department of Prosthodontics, Nova Southeastern trauma is defined as an injury result- University College of Dental Medicine, Fort Lauderdale, Florida, USA. ing in tissue changes from normal or 2Postgraduate Prosthodontics, Nova Southeastern University College of Dental Medicine, Fort Lauderdale, Florida, USA. excessive occlusal forces applied to 3Private practice, Lubbock, Texas, USA. a tooth or teeth with reduced support. Chronic trauma from occlusion Correspondence to: Dr Rohit Mathur, 3200 S. University Drive, Davie, FL 33328, USA. is seen more frequently than acute Email: [email protected] trauma. This progresses from ongo- Submitted August 14, 2019; accepted November 13, 2019. ©2020 by Quintessence Publishing Co Inc. ing changes in occlusion produced

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© 2020 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e198 by tooth wear, drifting movement, Patient Therapy Report was no contact on the left side, even and extrusion of teeth, combined without the anterior provisional res- with parafunctional habits such as A 55-year-old man presented (Fig torations. bruxism and clenching.4 1a) with a chief complaint of need- Further evaluating the patient’s The relationship between at- ing to “get [his] teeth fixed” and clinical findings, he presented with tachment loss and occlusal trauma regular dislocation of temporary moderate to severe attachment loss has been debated for many years. restorations. The patient’s medi- in the maxilla and mild to moderate It has been understood that trauma cal history was positive for arthritis, attachment loss in the mandible. He by itself does not cause attachment and he had no drug allergies. His also experienced inadequate pos- loss. However, trauma in conjunc- initial dental examination revealed terior support, infrabony defects in tion with biofilm-induced inflam- 6- to 7-mm probing depths in the the maxilla, recession, and fremitus matory disease does seem to play maxillary right sextant, and probing associated with secondary occlusal a role in attachment loss. In the depths ranging from 3 to 5 mm in trauma. The patient had shortened past, occlusion has been described the maxillary anterior and left pos- roots subsequent to orthodontic as a co-destructive local factor.5 It terior sextants. The attachment loss treatment as well as bone loss, giv- has been discussed that occlusal was 4 to 9 mm, 2 to 5 mm, and 4 to ing him a reduced periodontium. stresses can evoke a biochemical 8 mm in the maxillary right, anterior, Thus, he was given the diagnosis of response that initiates a cascade of and left sextants, respectively. The stage IV, grade B periodontitis. The biologic and pharmacologic events patient appeared to have Grade II full-mouth radiographs are shown in that contribute to attachment loss.6,7 furcation on tooth 17 (FDI system) Fig 1b. In order to treat these patients ef- and Grade I furcation on teeth 16 When treating a patient with ad- fectively, both the periodontal dis- and 26. The patient presented with vanced periodontal disease, a deci- ease and the occlusion need to be Grade II mobility on teeth 14, 15, 24, sion should be made on whether the treated. Periodontal prostheses are and 25, and Grade I mobility on all treatment will involve only teeth, a defined as those restorative and other maxillary teeth. The mandibu- combination of teeth and implants, prosthetic endeavors that are abso- lar segment was more stable, with or just implants. In the present situ- lutely essential in the treatment of probing depths ranging from 3 to ation, the authors believed that the advanced periodontal disease.8 5 mm and isolated Grade I mobility. mobility was present due to inad- When a patient presents with The patient had a history of orth- equate posterior support. Thus, it secondary occlusal trauma associ- odontic treatment as an adolescent. was the clinical impression that once ated with migration of teeth, a de- The patient presented with a Class the patient received posterior sup- cision has to be made whether the III molar relation and fremitus on port, the mobility would be reduced. teeth can be saved or extracted. teeth 11 to 13 and 21 to 23 in maxi- Diagnostic impressions were Two main treatment options can be mum intercuspation; there was also made and articulated. A diagnostic presented to a patient with stage fremitus on tooth 15 in the right lat- wax-up of the maxillary arch was IV, grade B periodontitis: treatment eral excursion. When checked with based on the decided incisal edge with an implant-supported prosthe- a shim stock occlusion foil (Henry position. A full-arch provisional shell sis or a restoration utilizing only the Schein), the patient only had occlu- was created using Jet Tooth Shade teeth. In this case report, a patient is sion on the right side, and the shim acrylic (Lang Dental Manufacturing). shown with a reduced periodontium stock could be pulled out on the The maxillary teeth were prepared and a diagnosis of stage IV, grade left side without any resistance. The for complete-coverage crowns. Car- B periodontitis, and the decision- initial thought was that the anterior ies were found in the mesial fur- making process on how to treat this provisional restorations might have cations of teeth 16 and 26. A patient with advanced periodontal heavier contacts, preventing poste- mesiobuccal root resection was re- disease is demonstrated. rior tooth contact. However, there quired for tooth 16. On tooth 26,

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Fig 1 Preoperative (a) clinical and (b) full- mouth radiographic views.

barreling of the mesial furcation was mately 1 year, which included 6 months to restore them with a periodontal performed, which eradicated the postperiodontal surgery. It was an- prosthesis. horizontal component of the furca- ticipated that the anterior mobil- Final tooth preparations were tion as well as the caries. After initial ity would be reduced because the performed, establishing a single tooth preparation was completed, patient received posterior support, path of draw (Fig 2a). A double cord the one-piece provisional shell was and that the patient would receive technique was used, and the final relined using Jet Tooth Shade. Once two three-unit fixed partial denture impression was made using heavy- the patient received the provisional prostheses (FPDPs) while the re- and light-body Impregum impres- restoration, he was referred to the maining teeth would receive single sion material (3M ESPE) in a custom periodontal department. Scaling crowns. However, there was no im- tray. Two separate impressions were and root planing were performed, provement in the mobility, despite made for the left and right sides (Fig followed by resective osseous sur- the patient appearing to be peri- 2b). The impressions were poured gery for the purpose of pocket re- odontally and occlusally stable. At with ResinRock die stone (Whip duction. The patient received the this point, the decision had to be Mix) and were articulated on a semi- provisionals prior to periodontal made whether to extract the teeth adjustable articulator (Model 2240, treatment to enhance the smile and with Grade II mobility and replace Whip Mix). The lab created individu- control mobility. Teeth 12 and 14 them with implants, or to construct al castings (Fig 2c), which were tried were extracted as they were nonre- a periodontal prosthesis. It was de- in the patient’s mouth, confirming storable. cided that the patient would ben- the individual fit using Fit Checker The patient wore the splinted efit from maintaining the remaining (GC America). The metal copings provisional restorations for approxi teeth and bone, and it was decided were then joined together using

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a b

c d

e f Figs 2a to 2f (a) Tooth preparations. (b) Impressions of the right and left sides, respectively, made with polyether. (c) Try-in of the castings. (d) Metal framework. (e) Pick-up impression. (f) Bisque try-in.

Pattern Resin (GC America) and im- out the process, as determined by was constructed and articulated. mediately invested for soldering. the provisional restorations. The Porcelain was applied to the frame, The metal frame (Fig 2d) was tried framework was then picked up with and a bisque try-in was done, which in the patient’s mouth. The vertical heavy-body Impregum in a custom included adjusting the occlusion dimension was maintained through- tray (Fig 2e). A master stone model and checking the distal contacts

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g h

i Figs 2g to 2i (g) Glazed final prosthesis. (h) Cementation with Zinc Phosphate (Henry Schein). (i) Radiographic view after cementation radiographs.

(Fig 2f). Once the occlusion and issues, and fractured porcelain can periodontal and restorative treat- contacts were confirmed, the pros- sometimes occur. If telescopic cop- ment. In the United States, approxi- thesis received ceramic character- ings are used, a less-permanent ce- mately 47% of the population suffers ization and glazing (Fig 2g). ment can be used, which will aid in from periodontitis.9 When looking at The prosthesis was delivered longer maintenance of the maintain- peri-implant diseases, the literature for 1 week without any cement with ing the prosthesis. varies, reporting that 28% to 56% of the hypothesis that micromove- The patient was seen every patients suffer from peri-implantitis.10 ments of the abutment teeth would 3 months for periodontal mainte- Derks et al found the incidence of induce more accurate seating. The nance, and the clinical and radio- peri-implantitis to be 45% over a prosthesis was then delivered with graphic views at the 2-year follow-up 9-year period.11 This number is close Temp-Bond (Kerr) and Vaseline for 4 are shown in Fig 3. The bone levels to the number of patients suffering weeks. No cement washout was ob- appear to remain stable, and the pa- from periodontitis. Recent systemat- served, so the prosthesis was then tient is happy with the restoration. ic reviews have shown that implants delivered with Zinc Phosphate Ce- placed in periodontitis-susceptible ment (Henry Schein; Fig 2h). Postde- patients have increased chances livery radiographs confirmed both Discussion of biologic complications like peri- the fit and cement removal (Fig 2i). implantitis and have lower success The patient received a hard occlusal When treating a periodontally sus- and survival rates than those placed guard with canine guidance to pro- ceptible patient, the question arises in periodontally healthy patients.12,13 tect the restoration. It must be not- as to whether the patient should be Additionally, there is currently no ed that in the long term, problems treated with dental implants or sim- strong evidence to suggest the like recurrent caries, endodontic ply using the existing teeth for the most effective treatment for peri-

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Fig 3 (a) Intraoral and (b) radiographic views at the 2-year follow-up.

implantitis.14 Contrarily, a long-term The extraction of periodontally mon FPDP complications are pros- report shows that implants are suc- compromised teeth does not elimi- thesis fracture and loss of retention. cessful in periodontitis-susceptible nate the underlying host response These were found to be very rare patients, even after 32 years.15 How- nor the patient’s susceptibility to occurrences with a periodontal ever, that report is on an individual peri-implantitis. Even treated but prosthesis, as the periodontal dis- patient. still periodontally compromised ease patient presented with long Extracting teeth and replac- teeth have survival rates of around clinical crowns for tooth prepara- ing them with implants is a very 90% in well-maintained patients. In tion, providing adequate length for frequently performed procedure addition, cross-arch FDPDs on teeth retention and resistance form.19 Sim- to manage periodontally compro- with significantly reduced periodon- ilarly, because of the long crowns, mised dentition. Dentists assume tal support seem to function equally there were adequate metal dimen- that implants will do better than the as well as implant-supported recon- sions in the framework to provide patient’s dentition, notwithstand- structions.17 It has been shown that good connector height, which in ing that the literature shows that utilizing teeth to support the pros- turn helps prevent flexure and frac- periodontitis-susceptible patients thesis at an earlier age can be bene- ture of the prosthesis.19 When com- are at an increased risk to develop ficial in predictably preserving bone paring the incidence of technical peri-implantitis.12 When planning for the patient, allowing implants to complications, it was an incidence the treatment for a periodontally be utilized in the future, at a time rate of 39% for implant-supported compromised patient, the main when the patient’s teeth may not be reconstructions as opposed to 16% goal should focus on maintaining salvageable.18 for tooth-supported reconstructions the teeth through periodontal treat- The potential for technical com- after 5 years.20 ment, thus delaying the placement plications is another aspect that When considering the long- of dental implants.16 needs to be considered. Two com- term outcomes of cross-arch sta-

The International Journal of Periodontics & Restorative Dentistry

© 2020 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e203 bilizing FPDPs, the literature has cause noble or high noble metals continued long-term implant suc- shown that the estimated survival are often used, and it is difficult to cess. rate is around 98% at 10 years.21 find laboratories that know how to When looking at a systematic review make the appropriate restoration. of the same, the success rate was Lastly, the process is very time con- Acknowledgments above 90%.22 Previously, root resec- suming, and patients want to re- tion and hemisection were routinely ceive their new, fixed teeth faster The authors declare no conflicts of interest. used procedures. However, with the than previous decades, making advent of implants, these proce- hybrid restorations a popular treat- dures are seldom used today, owing ment option compared to peri- References to the fact that implant placement is odontal prostheses. In addition, the 1. Chapple ILC, Mealey BL, Van Dyke TE, 23 considered a better option. Root All-on-Four treatment protocol has et al. Periodontal health and gingival resection and hemisection proce- shown a high success rate.26 How- diseases and conditions on an intact dures are done because the mor- ever, the major question remains: At and a reduced periodontium: Consen- sus report of Workgroup 1 of the 2017 phology of the defect provides an what point in a patient’s life do we World Workshop on the Classification of environment for bacterial growth use up “end stage procedures”? Periodontal and Peri-implant Diseases and Conditions. J Periodontol 2018;89 and limits self-performed and pro- (suppl 1):s74–s84. fessional plaque control.24 A sys- 2. Towfighi PP, Brunsvold MA, Storey AT, tematic review concluded that high Conclusions Arnold RM, Willman DE, McMahan CA. Pathologic migration of anterior teeth in survival rates are achieved with root patients with moderate to severe peri- resection and hemisection, making It must be kept in mind that im- odontitis. J Periodontol 1997;68:967–972. 3. Antoun JS, Mei L, Gibbs K, Farella M. Ef- them a dependable option for treat- plants are not better than teeth. fect of orthodontic treatment on the ment of furcated molars that often When a patient has periodontally in- periodontal tissues. Periodontol 2000 are considered for extraction and volved teeth, even though they may 2017;74:140 –157. 4. Saravanan R, Babu PJ, Rajakumar P. implant placement.25 be extracted, the underlying host Trauma from occlusion—An orthodon- A question now arises: If a response is not eliminated. One tist’s perspective. J Indian Soc Peri- odontol 2010;14:144–145. periodontal prosthesis and all its consideration from the 2008 Scan- 5. Lindhe J, Svanberg G. Influence of trau- principles work well, why is it not dinavian Consensus Conference is ma from occlusion on progression of considered the treatment of choice that “the survival rates of teeth in experimental periodontitis in the bea- gle dog. J Clin Periodontol 1974;1:3–14. for the periodontally involved denti- periodontal well-maintained pa- 6. Wang HL, Decker AM. Effects of occlu- tion? The answer is that it is assumed tients are in general higher than sion on periodontal wound healing. Compend Contin Educ Dent 2018;39: 27 that implants would resolve the situ- that of implants.” Because there 608 – 612. ation better than treating periodon- are clinical centers with 30 or more 7. Chen GY, Nuñez G. Sterile inflammation: tally involved teeth. However, the years of long-term implant success Sensing and reacting to damage. Nat Rev Immunol 2010;10:826–837. literature shows that this is not true. with unpublished data, additional 8. Amsterdam M. Periodontal prosthesis. Certainly, the periodontal prosthe- data-gathering in the future may re- Twenty-five years in retrospect. Alpha Omegan 1974;67:8–52. sis patients present a greater chal- veal higher success rates with well- 9. Eke PI, Dye BA, Wei L, et al. Prevalence lenge, starting with diagnosis and placed implants over periodontally of periodontitis in adults in the United treatment planning, tooth prepara- compromised teeth. An economic States: 2009 and 2010. J Dent Res 2012; 91:914–920. tion, impressions, and the fitting of consideration of patients with repet- 10. Zitzmann NU, Berglundh T. Definition the fixed prosthesis, which requires itive/revision treatment to transition and prevalence of peri-implant diseases. J Clin Periodontol 2008;35(suppl 8): a highly skilled clinician. These cases from a periodontal prosthesis to an s286–s291. need a team of specialists who are implant-supported prosthesis is also trained to handle such cases. Also, an important factor to consider for the laboratory fee is very high be- long-term treatment planning and

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11. Derks J, Schaller D, Håkansson J, 17. Donos N, Laurell L, Mardas N. Hierarchi- 23. Perel ML. Are we needlessly retaining Wennström JL, Tomasi C, Berglundh T. cal decisions on teeth vs. implants in the “hopeless” teeth? Dent Implantol Up- Effectiveness of implant therapy ana- periodontitis-susceptible patient: The date 1991;2:1,12. lyzed in a Swedish population: Preva- modern dilemma. Periodontol 2000 24. Al-Shammari KF, Kazor CE, Wang HL. lence of peri-implantitis. J Dent Res 2012;59:89–110. Molar root anatomy and management 2016;95:43–49. 18. Balshi TJ, Balshi SF, Wolfinger GJ. The of furcation defects. J Clin Periodontol 12. Ferreira SD, Martins CC, Amaral SA, et evolution of advanced prosthodontic 2001;28:730 –740. al. Periodontitis as a risk factor for peri- care: A 30-year patient report. J Prosth- 25. Mokbel N, Kassir AR, Naaman N, implantitis: Systematic review and meta- odont 2007;16:43– 49. Megarbane JM. Root resection and analysis of observational studies. J Dent 19. Laurell L, Lundgren D, Falk H, Hugoson hemisection revisited. Part I: A system- 2018;79:1–10. A. Long-term prognosis of extensive atic review. Int J Periodontics Restor- 13. Sousa V, Mardas N, Farias B, et al. A sys- polyunit cantilevered fixed partial den- ative Dent 2019;39:e11–e31. tematic review of implant outcomes in tures. J Prosthet Dent 1991;66:545–552. 26. Balshi TJ, Wolfinger GJ, Slauch RW, treated periodontitis patients. Clin Oral 20. Pjetursson BE, Brägger U, Lang NP, Balshi SF. A retrospective analysis of Implants Res 2016;27:787–844. Zwahlen M. Comparison of survival and 800 Brånemark system implants follow- 14. Ting M, Craig J, Balkin BE, Suzuki JB. complication rates of tooth-supported ing the All-on-Four protocol. J Prostho- Peri-implantitis: A comprehensive over- fixed dental prostheses (FDPs) and dont 2014;23:83–88. view of systematic reviews. J Oral Im- implant-supported FDPs and single 27. Gotfredsen K, Carlsson GE, Jokstad A, plantol 2018;44:225–247. crowns (SCs). Clin Oral Implants Res et al. Implants and/or teeth: Consensus 15. Balshi TJ, Wolfinger GJ, Balshi SF, Nev- 2007;18(suppl 3):s97–s113. statements and recommendations. J ins M, Kim DM. Thirty-two–year success 21. Fardal O, Linden GJ. Long-term out- Oral Rehabil 2008;35(suppl 1):s2–s8. of dental implants in periodontally com- comes for cross-arch stabilizing bridges promised dentition. Int J Periodontics in periodontal maintenance patients— Restorative Dent 2018;38:827–831. A retrospective study. J Clin Periodon- 16. Lundgren D, Rylander H, Laurell L. To tol 2010;37:299–304. save or to extract, that is the question. 22. Lulic M, Brägger U, Lang NP, Zwahlen Natural teeth or dental implants in peri- M, Salvi GE. Ante’s (1926) law revisited: odontitis-susceptible patients: Clinical A systematic review on survival rates decision-making and treatment strate- and complications of fixed dental pros- gies exemplified with patient case pre- theses (FDPs) on severely reduced peri- sentations. Periodontol 2000 2008;47: odontal tissue support. Clin Oral 27–50. Implants Res 2007;18(suppl 3):s63–s72.

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