A full-mouth rehabilitation with FP1 prosthesis using advanced prosthodontics and periodontics approach: A case report (Part 2 of 2)

from ODA Journal May/June 2023

DIFFERENTIAL DIAGNOSIS: The Umbilicated Lesion

By: Jaewon Kim1, DDS, MSD, PhD, Jekita Kaenploy2, DDS, MS 1Division of Periodontics, University of Oklahoma, College of Dentistry, OK 2Department of Restorative Dentistry, University at Buffalo, NY

Discussion

Prosthodontic perspective

Full-mouth reconstruction requires thorough data acquisition and treatment planning. A diagnostic work-up will guide clinicians to successful treatment outcomes by formulating a prosthetically-driven plan. In this case, the patient presented with chronic infection and pain. The initial treatment aimed to treat the infection. Regarding the decision to endodontically re-treat tooth #9, the overall success rate for secondarily endodontically treated teeth is 77%. However, higher success rates in maxillary teeth have been noted in the literature (1). Therefore, a referral to an endodontist was made for re-treatment of tooth #9. There was also an extensive chronic periapical abscess from teeth #27-29 which were deemed non-restorable, and teeth #19, 21, and 26 were present with minimal tooth structure remaining. The decision was made to extract all lower teeth except the molars based on long-term prognosis and the patient’s desire for fixed prostheses. Other potential treatment options included a partial denture on the lower arch in combination with surveyed crowns or implants. However, teeth #21, 22, and 26 had questionable restorative prognosis due to extensive loss of tooth structure. Consequently, they would not be suitable abutments for a removable partial denture. An implantsupported removable partial denture was another alternative, but the long-term prognosis and esthetic outcomes would be deficient in meeting the patient’s expectations.

The virtual implant planning was performed with immediate placement and loading concepts. According to Gallucci et al (2), immediate loading in extended partially edentulous sites is predictable and there is high evidence of success when the implants are splinted during the interim phase. The ITI consensus statements from 2013 stated that implants to be placed immediately require correct 3D position of the implant and there is a minimum of 2 mm distance from the buccal wall of the socket to the surface of the implant (3). In this case, all the planned implant positions met these requirements, so immediate placement could be performed.

The intaglio surface contours of the interim prosthesis is crucial for the emergence profile of the final prostheses and oral hygiene maintenance (4). Care was taken to ensure that the intaglio surface of the pontic areas were convex and exhibited slight pressure to the tissue to create proper emergence profile (5).

The mandibular arch was restored with implant-supported zirconia crowns and bridge. Zirconia has high strength and desirable mechanical properties which made the material a great choice to support a bridge in this case. The natural dentition on the maxilla was restored with lithium disilicate crowns for superior bonding to the tooth structure and better esthetics compared to zirconia. Conversely, zirconia exhibits better biocompatibility and lower plaque retention than glass ceramics (6). Hence, it is a great material to be used to fabricate implant-supported restorations with the emergence profile intimately adapted to the soft tissue.

Periodontal perspective

For diagnosis, this case was classified as stage III as the patient was not aware of the reason for tooth loss. According to the 2018 AAP classification, interdental clinical attachment loss should be detectable at ≥2 non-adjacent teeth, and buccal or oral clinical attachment loss ≥3mm with pocketing of >3mm as detectable at ≥2 teeth. However, according to Kornman et al (7), if a single tooth shows enough evidence of periodontitis, then it will be classified as it is. A history of periodontitis in this patient was a strong concern as previous literature has shown a negative relationship to implant survival. According to Schwartz, previous history of periodontitis, poor plaque control, and no regular maintenance is a risk factor for peri-implantitis (8). The patient came regularly for supportive peri-implant maintenance therapy to monitor implant status after completion of treatment. According to Monje’s systematic review, a minimum of 5-6 months of maintenance is effective (9).

Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) have been extensively studied in the field of wound healing. PRP was first studied in the 1990s and is composed mainly of platelets, which secrete growth factors for initial wound healing. PRF, which is the complex fibrin matrix of autologous platelets and leukocytes, holds growth factors and cytokines that are valuable for wound healing. In Miron’s systematic review, PRF combined with an open flap approach to treatment, statistically noticeable benefit to healing was observed (10). The author used PRP to mix with bone graft, while using PRF on top of the membrane to have favorable wound healing when submerged under the flap.

Socket grafting was utilized to preserve the volume of the alveolar ridge after extraction. However, throughout the healing process the bone resorbed both vertically and horizontally. According to a systematic review by Avia-Ortiz, the clinical magnitude of alveolar ridge preservation compared with extraction sites without any graft was 2mm horizontal/mid buccal, 1mm vertical/midlingual, 0.5mm mesial and 0.2mm distal height changes (11).

When multiple implants are placed, it is important to note that the bone densities will be different at each location of osteotomy preparation. This be evaluated preliminarily via radiograph or CBCT, and the tactile feedback during osteotomy preparation. In this case, one implant lost stability and spun upon removal of the temporary cylinder. This potentially could have been prevented with gentle screw-tightening. Moreover, a study found that lower insertional torque values show inferior outcomes (12). Thus, in this case, the decision was made to keep the implant submerged and wait for a healing period of 4 months. Ultimately, the implant osseointegrated and functioned well.

For the conscious intravenous moderate sedation, dexmedetomidine was used. Dexmedetomidine (Precedex, Pfizer) is a highly selective alpha-2 adrenergic receptor agonist. It creates sedative and analgesic action via the central nervous system. Moreover, it may also result in bradycardia, which is a common side effect. It is recommended to dilute to 4mcg/ml prior to administration; combination with midazolam or fentanyl is also a possible protocol. Previous cohort studies have shown that dexmedetomidine can be a good alternative to midazolam and fentanyl (13). In this case, even though the patient was ASA III, there was no issue with sedation with Richmond Agitation Sedation Scale (RASS) score being evenly maintained with -3 throughout the procedure.

Conclusion

This case was successfully managed with advanced digital prosthodontic and periodontal surgical techniques. Cooperation between both departments was a key factor. Clear and open communication between the patient and treatment team is essential to predictable outcomes. The digital workflow used for surgical planning and immediate load prosthesis CAD design illustrates the capacity to generate true-to-design accuracy for implant placement through the use of surgical guide and prosthesis stabilization utilizing existing teeth prior to their extraction. However, the use of the On1™ concept in this case has its limitations in terms of clinical applications and digital workflow. Proper diagnosis, along with the thorough treatment planning and execution of therapy will ultimately achieve better outcomes for the patient and clinician.

The figures and tables are on pages 40-42. Part 1 was printed in the March/April Journal .

References

1. Ng YL, Mann V, Gulabivala K. Outcome of secondary root canal treatment: a systematic review of the literature. Int Endod J. 2008;41(12):1026-46.

2.Gallucci GO, Benic GI, Eckert SE, Papaspyridakos P, Schimmel M, Schrott A, et al. Consensus statements and clinical recommendations for implant loading protocols. The International journal of oral & maxillofacial implants. 2014;29:287-90.

3. Morton D, Chen ST, Martin WC, Levine RA, Buser D. Consensus statements and recommended clinical procedures regarding optimizing esthetic outcomes in implant dentistry. International journal of oral & maxillofacial implants. 2014;29(Suppl):216-20.

4. Able FB, Campanha NH, Younes IA, Sartori IAdM. Evaluation of the intaglio surface shape of implant-supported complete-arch maxillary prostheses and its association with biological complications: An analytical cross-sectional study. The Journal of Prosthetic Dentistry. 2022;128(2):174-80.

5. Pozzi A, Tallarico M, Moy PK. The Implant Biologic Pontic Designed Interface: Description of the Technique and Cone-Beam Computed Tomography Evaluation. Clin Implant Dent Relat Res. 2015;17 Suppl 2:e711-20.

6. Zarone F, Di Mauro MI, Ausiello P, Ruggiero G, Sorrentino R. Current status on lithium disilicate and zirconia: a narrative review. BMC Oral Health. 2019;19(1):134.

7. Kornman KS, Papapanou PN. Clinical application of the new classification of periodontal diseases: Ground rules, clarifications and "gray zones". J Periodontol. 2020;91(3):352-60.

8. Schwarz F, Derks J, Monje A, Wang HL. Peri-implantitis. J Periodontol. 2018;89 Suppl 1:S267-S90.

9. Monje A, Aranda L, Diaz KT, Alarcon MA, Bagramian RA, Wang HL, et al. Impact of Maintenance Therapy for the Prevention of Peri-implant Diseases: A Systematic Review and Meta-analysis. J Dent Res. 2016;95(4):372-9.

10. Miron RJ, Zucchelli G, Pikos MA, Salama M, Lee S, Guillemette V, et al. Use of platelet-rich fibrin in regenerative dentistry: a systematic review. Clin Oral Investig. 2017;21(6):1913-27.

11. Avila-Ortiz G, Elangovan S, Kramer KW, Blanchette D, Dawson DV. Effect of alveolar ridge preservation after tooth extraction: a systematic review and metaanalysis. J Dent Res. 2014;93(10):950-8.

12. Walker LR, Morris GA, Novotny PJ. Implant insertional torque values predict outcomes. J Oral Maxillofac Surg. 2011;69(5):1344-9.

13. Zhang Y, Li C, Shi J, Gong Y, Zeng T, Lin M, et al. Comparison of dexmedetomidine with midazolam for dental surgery: A systematic review and metaanalysis. Medicine (Baltimore). 2020;99(43):e22288.study. The Journal of Prosthetic Dentistry. 2022;128(2):174-80.

6. Zarone F, Di Mauro MI, Ausiello P, Ruggiero G, Sorrentino R. Current

Figure Legend

FIGURE 1: Preoperative intraoral photographs. (a) Right lateral, (b) Front, (c) Left lateral, (d) Maxillary occlusal, (e) Mandibular occlusal view, (f) Fullmouth series radiographs.

FIGURE 2: The digital workflow and fabrication of the immediate provisional restoration. (a) Front, (b) Occlusal.

FIGURE 3: (a) After extractions, teeth #24 and 25 remained to seat the surgical guide with tripod support. (b) #29 had bone loss in the apical area communicating through the buccal cortex (blue arrow). (c) Implant surgical guide seated. (d) Implants #22, 27, and 29 were placed immediately. Then the remaining teeth were extracted (e) Nobel Active Ti Ultra fixture. (f) Bone reduction guide. (g) After all implants were placed, the fenestration was grafted with a PRP-infused bone graft. (h) Bio-Gide membrane placed on top of the grafted sites. (i) PRF membrane was placed on top of the Bio-Gide membrane before flap closure. (j) After the healing abutment placement and bone graft, sutures were placed.

FIGURE 4: The digital workflow and fabrication of the second set of provisional restorations. (a) Front, (b) Occlusal.

FIGURE 5: The fabrication of the final restorations. (a) Jaw relation recorded in centric relation, (b) The provisional restorations used as a blueprint for the final restorations, (c) Final restorations designed using 3Shape software, (d) Milled and finished final restorations.

FIGURE 6: Comparison between initial presentation (a, b), temporary restorations (c), and final results (d,e).

FIGURE 7: Comparison between initial (a) and one-year postoperative full mouth series radiographs (b).