e197 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 periodon- tal 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 oc- clusal 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 sup- port. 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 Volume 40, Number 5, 2020 © 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- mesio buccal root resection was re- disease is demonstrated. rior tooth contact. However, there quired for tooth 16. On tooth 26, 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. e199 Fig 1 Preoperative (a) clinical and (b) full- mouth radiographic views. a b 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.