A fixed solution for a mobile dentition due to long-term periodontitis

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  Posted by: Dental Design      27th March 2022

A 55-year-old gentleman attended the clinic looking to improve his confidence and smile aesthetics, which had been affected by drifting teeth. He reported that tooth mobility had compromised his chewing ability and altered his speech – “F” and “V” sounds were particularly difficult due to labial drift of the upper and lower incisors. 

The patient’s medical history was unremarkable. He was a previous smoker, having stopped more than 10 years ago, and he consumed 0-5 units of alcohol per week.

Assessment

An extraoral examination revealed:

• Ovoid facial form
• Slight increase in facial height in the lower third
• Compensatory prognathism to achieve lip competence
• A medium lip line
• No support to the upper lip
• Asymmetry due to drifting central incisors
• No hyperactivity in the muscles of mastication
• Mouth opening was unrestricted

The intraoral assessment revealed:

• Remarkably good oral hygiene
• Deep upper and lower sulci
• Prominent upper labial frenum, which was in close proximity to the gingival margins of 11 and 21
• Thick and fibrous gingival biotype
• Ample keratinised tissue around the anterior upper and lower teeth
• Mucogingival distortion in the lower right quadrant, causing a lack of unattached non-keratinised tissue around 34
• BPE score of 4’s in all sextants
• Generalised deep pocketing and bleeding on tooth 37 in the furcation area (Class I)
• All teeth grade 2-3 mobile
• Grade 3 mobile lower bridge
• Occlusion – incisors occluded edge to edge as a first contact in CR. No anterior or lateral guidance

Upper and lower CBCT scans revealed 2/3rd horizontal bone loss around all the existing dentition with angular defects on 22, 24, 25, 35 and 37. Tooth 37 had bone loss into the furcation and 35 had a large periodontal lesion with bone loss to its apex.

The left maxillary sinus showed very minimal thickening as opposed to large thickening in the right sinus concomitant with non-symptomatic mucosal thickening. 

The patient was diagnosed with generalised periodontitis Stage 4 Grade B (BSP 2017 classification) and apical periodontitis on LL5, in addition to compromised function and aesthetics due to drifting and mobility of dentition.

Treatment Options

The patient had been seeing the dental hygienist for many years to help manage the periodontitis. Due to the severity of the bone loss and tooth mobility, he desired the removal of all teeth and a fixed prosthesis. The ultimate aim of treatment was to achieve an aesthetic smile while improving phonetics, lip support and function. The following treatment options were presented:

• Do nothing – continue seeing the hygienist to prolong teeth for as long as possible. There would be a negligible improvement in function, aesthetics and phonetics.
• Removal of teeth and fabrication of complete dentures – to provide an improvement in aesthetics, but function would be compromised.
• Implant-retained upper and lower dentures – extraction, three-months healing and then placement of four interforaminal and four upper implants to support a complete denture. This would improve function and aesthetics, facilitating oral hygiene measures with a removable prosthesis, but function would still be compromised.
• Implant-retained upper and lower fixed prostheses without bone grafting –despite contention about placing immediate implants in periodontally compromised patients, it is possible and offers an improvement in aesthetics and function.
• Removal of teeth and provision of complete denture – followed by bilateral sinus grafts with horizontal GBR to restore the maxillary bone and FP1 bridges to restore the upper or lower arches.

All options were discussed with the patient in detail. He chose an upper and lower full arch, immediately loaded bridge, followed by a definitive bridge 4-6 months thereafter. From the final bridge materials offered, the patient preferred the milled titanium bar with an acrylic wrap around due to its flexibility for relayering and relining in the future. Pre-operative photos, CBCT scan, upper and lower impressions and a CR record were shared with clinical dental technician, Richard Clegg.

Treatment provision

The surgical stent was constructed to ensure adequate alveoplasty could be carried out in the upper arch. This would ensure space for a titanium milled bar (15mm from bone level to prospective incisor edge) and hide the transition line of the prosthesis. To enhance lip support, an additional 1mm of alveoplasty was carried out in order to “gently” profile the prosthesis more labially. The lower arch also needed alveoplasty to create sufficient space for a titanium bar. This would also allow more lingual implant positioning for a Class I occlusion.

On the day of surgery, intravenous midazolam was administered, and both the extractions and alveoplasty were performed as per the prescription designed within the prosthetically guided surgical stent. A frenectomy increased the vestibular depth to facilitate future oral hygiene around the prosthesis.

Neodent® GM® Helix implants were placed – 4x10mm and 4x13mm anteriorly and posteriorly, respectively. The distal implants were angulated to avoid the sinuses and mental foramens. The apex of the distal implant on the left side was at risk of being too close to the implant in the 22 position, so a sinus lift was performed and the implant placed in a less angulated position.

Miniconical abutments (straight, 30 degrees) with a gingival height of 3.5mm were placed onto the anterior and posterior implants respectively. The impression copings were placed and splinted with LuxaBite (DMG) to ensure an accurate impression was made. The immediate bridges were fabricated using the denture conversion technique and loaded on the same day, ensuring cross arch stabilisation.

Two weeks later, the patient was reviewed and occlusion checked to ensure no interferences or heavy contacts. Three months post-operatively, the patient’s bridges were removed and another open tray impression was taken of the splinted implants. A verification jig was later used to check the passivity through the Sheffield test, which was confirmed. The bite block was recorded in CR at the same OVD. Wax was added to the buccal corridor and labial area to give further lip support and to restore the smile. Two weeks later the try in was confirmed, providing total restoration of aesthetics, lip support and phonetics.

The final bridge was fitted 3 weeks afterwards. A milled titanium bar with an acrylic wrap around prosthesis was provided. The molars are in light ICP to allow immediate discussion on lateral excursions. The fitting surfaces of the upper and lower prostheses have 0.5mm space for cleaning, and the pink acrylic was highly polished and smoothed to further facilitate plaque removal.

Outcome

The patient was extremely happy with the final result. All his initial concerns were addressed and highly satisfactory aesthetic and functional outcomes were achieved.

 

For more information, please visit https: www.neodent-uk.co

 

Dr Adeel Ali qualified from Guy’s King’s and St Thomas’ Dental college, London, in 2008. He has since obtained his Diploma of Membership of the Joint Dental faculties of England of the Royal College of Surgeons (MJDF RCS) and is a mentor and lecturer in the field of dental implants.  Dradeelali.com

 

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