Perio
Perio-Prosthetic Treatment Planning in Implant Dentistry
Marc Alexander, DDS
Marc Alexander, DDS, maintains a full-time private practice
in Santa Barbara, Calif.
Copyright 2003 Journal of the California Dental Association.
When reviewing the literature on perio-prosthetics, Amsterdam’s article on 25 years in retrospect1 is the classic paper that documented and taught the multidisciplinary approach to treating the compromised dentition.
Treatment protocol using orthodontics, endodontics, and periodontics in conjunction with prosthetic rehabilitation of the periodontally compromised patient to create the classic perio-prosthesis has greatly changed. Treatment planning the patient with periodontal disease (such as A.K.) has changed, thanks to implant-supported dental reconstruction. Periodontally involved teeth with poor prognoses do not need to be relied upon as abutments for multiple-unit prostheses. However, the above-mentioned conventional techniques still have their place in the medically compromised patient.
With the increasing success of dental implants, the accepted standard of care is dynamically changing. It has become unacceptable for the dental professional to neglect offering implants as an option when treatment planning for patients with missing or compromised teeth. As Rempfer2 pointed out in a 2002 demographic analysis, there is an exponential increase in demand and patient expectation in optimal dental treatment.
When considering the periodontally involved patient, the challenging issues in treatment planning are not the teeth with poor or hopeless prognoses, for which the treatment is obvious, but the teeth that are fair to guarded in their prognoses.
The dental practitioner enters a gray area if he or she needs to make an evidenced-based decision about whether to extract a tooth with a fair prognosis and replace it with an implant with an excellent prognosis. Implant success rates are high, 93 percent to 98 percent,3,4 depending upon the patient, area of placement, bone type, and implant surface and type. To determine the treatment prognosis for a patient with moderate to advanced adult periodontitis or high periodontal susceptibility, accurate risk assessment is essential.
Factors Influencing Evaluation of Risk
Wilson described individual risk factors affecting the prognosis of the periodontally involved patient and emphasized the importance of risk assessment in treatment planning.5 Some of the factors to consider when evaluating risk are diagnosis of periodontal condition, patient compliance,6,7 genetic susceptibility,8-11 and smoking.12-15
Evaluating Prognosis of Treating Patients With Chronic Periodontitis (Patient A.K.)
Hirschfeld and Wasserman16 looked at 600 patients who were treated for periodontal disease over a 22-year period. During the observation period, 50 percent of the patients did not lose any teeth, 33 percent lost three teeth, 12 percent lost nine teeth, and 4 percent lost 25 teeth. Thirty-one percent of questionable teeth were lost. The authors concluded that tooth loss was related to case type, not treatment performed. The extreme downhill patients are classified as having aggressive periodontitis and/or refractory periodontitis.
McFall17 studied 100 patients over 15 years and concluded that tooth loss was symmetrical, with the maxillary second molars being the most susceptible, and the mandibular cuspids the most likely to survive. Over the 15-year evaluation, 9.8 percent of teeth were lost to periodontal disease. Goldman and Ross18 did a similar retrospective study over 15 to 34 years and drew similar conclusions.
Consequently, patient A.K. -- with refractory periodontal disease, early extraction in the posterior maxilla, and implant placement -- would offer excellent prognosis without involved site development (sinus grafting and staged implant placement).
Becker,19 Bahat, and Handelsman20 show success rates of 95.7 percent and 96.3 percent with dental implants in the posterior maxilla.
When to Extract
Optimum prosthetic treatment should be restorative-driven rather than bone-driven implant positioning.21,22 The challenge is to evaluate how much bone the patient can afford to lose before compromising an implant site, without having to do additional grafting procedures to regain bone volume. A desirable goal in reconstructive treatment planning is to achieve longevity without duplicating surgical intervention in the short term. In patient A.K., early extraction of maxillary posterior teeth would have enabled simultaneous sinus grafting and implant placement. In 1991, patient A.K. would have required more-extensive sinus grafts, four to six months of healing, and implant placement. Several surgeries and an extended restorative timeline would be required.
Resective Procedures
Blomlof reported survival rates of root-resected molars were 27 percent over 10 years. High failure rates were due to persistent periodontal breakdown.23 Langer and Stein reported 66 percent success over 10 years, where 50 percent failed due to root fractures.24 Carnevale report 93 percent success over 10 years, but patients were kept on a strict hygiene maintenance protocol.25
The 1989 World Workshop in Clinical Periodontics26 concluded: "Root resective procedures may be performed only where other therapeutic approaches are not considered feasible and a very strategic tooth is involved."
In Hirschfeld and Wasserman’s16 study, 31 percent of the lost teeth were due to furcation involvement. In McFall’s17 study, 50 percent of the molars with furcation involvement were lost after treatment.
One needs to balance the success rates of specific periodontal procedures with the increasing implant success rates and long-term prognosis. In patient A.K., resection of No. 18 served the patient for six years. Early extraction of No. 18 and implant placement in Nos. 18 and 19 positions would be the current treatment of choice. This would separate the risk from teeth with a dubious prognosis.
Conclusion
Current perio-prosthetic treatment planning involves accurate risk assessment. Implant therapy must be considered an integral modality in treatment planning. Plan to individualize risk to individual teeth or implants, without incorporating splinted teeth or long-span fixed partial dentures. Today, treatment for patient A.K. would involve the following sequence of therapy: initial therapy, scaling and root planing, caries control, evaluation of periodontal prognosis of remaining teeth and occlusal forces, extraction of hopeless teeth, teeth with poor prognosis used for interim fixed provisional prosthesis (develop occlusal scheme and staged implant placement), site development and grafting, implant placement (immediate placement, immediate load, one-stage, two-stage), and restoration.
Acknowledgment
Thank you to Dr. Mark Handelsman for his input in this paper
References
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2. Rempfer RK, Changing issues and demographics affecting periodontal and implant therapy. J Cal Dent Assoc 30:351-4, 2002.
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23. Blomlof L, Jansson L, et al, Prognosis and mortality of root-resected molars. Int J Periodontics Restorative Dent 17:190-201, 1997.
24. Langer B, Stein SD, Wagenberg B, An evaluation of root resections. A ten-year study. J Periodontol 52:719-22, 1981.
25. Carnevale G, et al, Long-term effects of root-resective therapy in furcation-involved molars. A 10-year longitudinal study. J Clin Periodontol 25:209-14, 1998.
26. Proceedings of the World Workshop in Clinical Periodontics: 1989, July 23-27.
Marc L. Alexander, DDS, 1165 Coast Village Road, Suite J, Montecito, CA 93108-3769.
