Patient
AK Patient Presentation
Robert G. Tupac, DDS
Robert G. Tupac, DDS, is a clinical professor at the
University of Southern California School of Dentistry. He also maintains
a private practice in Beverly Hills, Calif.
Copyright 2003 Journal of the California Dental Association.
Amsterdam1 eloquently established that prosthodontic treatment
of the advanced periodontal patient requires the application of fundamental
fixed prosthodontic principles, surgical periodontal procedures, and more-complicated
treatment techniques. It is multidisciplinary in nature. Often, control
of the situation is tenuous at best, making these treatment plans exponentially
more difficult than normal. The advanced periodontal patient is characterized
by crown-to-root ratios of 1:1 or greater, tooth mobility, occlusal traumatism,
posterior occlusal collapse with anterior tooth migration, loss of occlusal
vertical dimension due to wear, tipping or loss of posterior teeth, and
often, multiple missing teeth.
The goals of prosthodontic treatment in these situations are:
* To provide posterior occlusal support to maintain the vertical dimension of occlusion and prevent displacement of the anterior teeth. This requires bilaterior posterior bone-borne tooth-to-tooth stops. The vertical dimension of occlusion may be reduced at the expense of the more crippled arch to improve the crown-to-root ratio and direct forces along the long axes of teeth;
* To create an occlusal scheme that provides anterior guidance to disarticulate the posterior teeth and prevent harmful lateral forces in excursive movements and axially loaded posterior teeth to prevent displacement of the anterior teeth;
* To stabilize the teeth to reduce or eliminate secondary occlusal trauma by splinting in a straight line or cross arch;
* To replace missing teeth as necessary to achieve these goals;
* To create restorations that preserve the biologic width and enhance, not impede, oral hygiene; and
* To promote a sense of well-being for the patient.
Inherent in the traditional perio-prosthodontic model is the premise that natural teeth are to be retained as long as possible. Since periodontal disease is a disease of progressive deterioration characterized by plateaus of stability and maintenance, study of this progression provides guidelines on how to rethink treatment planning.
AK, a 40-year-old female in good health, presented in May 1977 (Figure 1) because she was aware of a loose bridge on her lower left. Missing tooth No. 19 was replaced with a three-unit fixed partial denture and No. 18 was carious through the furcation, with both residual roots independently mobile. The restoration was removed, caries excavated, and she was sent for endodontic therapy of the residual roots to see if they stabilized. A comprehensive examination was performed. The existing restorations were more than 10 years old. She was referred for periodontal evaluation. The initial periodontal diagnosis was acute/chronic severe adult periodontitis with generalized horizontal bone loss and areas of vertical bone loss and furcation involvements, especially the posterior teeth. Pretreatment periodontal probings are shown in Figure 2. Her medical history was unremarkable, and there were no social habits believed to be contributory to her periodontal condition. Full-mouth pocket elimination therapy was performed. All infraboney defects were eliminated. There were no root amputations since the horizontal aspects of furcations were eliminated by surgery and fluted tooth preparations. Postsurgically, teeth Nos. 4, 5, 12, 13, 14, and 15 exhibited class I mobility; and the crown-to-root ratio of the maxillary arch was compromised. Therefore, all teeth except the lower anteriors were restored, the vertical dimension was reduced at the expense of the maxillary arch, and the posterior quadrants were each splinted. The mesial root of No. 18 was stable and used as a posterior abutment (Figures 3 and 4). An occlusal guard was fabricated for nighttime wear. The root of No. 18 lasted six years and was replaced with a unilateral subperiosteal implant, which failed after one year and was removed. A single osseointegrated implant was then placed, ultimately fractured, and was removed. During the more than 20-year period following periodontal surgery, AK was maintained periodontally every three months. Her home care was considered above average. A full-mouth series of radiographs in 1987 (Figure 5), 10 years after she first presented, shows all furcations deeply involved. Nos. 15 and 31 were removed (after 10 years) while the rest were maintained. After 14 years, two osseointegrated implants were placed on the mandibular right (due to No. 30) and restored from Nos. 29 through 31. Also after 14 years, in 1991, the remaining maxillary posterior teeth were removed, rest preparations made in the existing anterior crowns, and a maxillary bilateral distal extension removable partial denture fabricated. Due to further alveolar bone loss from the periodontal deterioration during the 14 years, implant placement in the maxillary posterior quadrants was not possible at that time without sinus grafting/bone augmentation procedures. After 21 years, Nos. 20 and 21, supporting a third premolar cantilever, failed endodontically; and the mandibular left quadrant was restored with three osseointegrated implants. As of today, 25 years after AK presented, maxillary anterior restorations are still in place, and the removable partial is 11 years old (Figure 6). The mandibular left and right osseointegrated implants are stable and maintained, and the anterior teeth are still unrestored.
It was not possible to know in 1977, but, in hindsight, AK had downhill progressive refractory periodontal disease, i.e., no matter the excellence of her level of oral hygiene, nor the excellence and compliance/frequency of maintenance therapy, though there were some plateaus of stability, her periodontal condition would still continue to deteriorate. Fortunately for AK, the existence of periodontal disease is not a contraindication or deterrent to implant therapy.
There is a body of evidence of implant success that is now the foundation of predictable treatment planning. The decision of when to extract, how to handle edentulous spaces, and when and where to place implants is evolving. There is a point at which an osseointegrated implant is more predictable than a retained periodontally or endodontically involved tooth. In the consideration of the overall oral condition and the prosthodontic needs of the patient, every edentulous space is a potential implant site.
Reference
1. Amsterdam M, Weisgold AS, Periodontal prosthesis. Twenty-five years in retrospect. Alpha Omegan 67(3):8-52, 1974.
To request a printed copy of this article, please contact/Robert G. Tupac, DDS, 465 N. Roxbury Drive, Suite 801, Beverly Hills, CA 90210-4211.
Legends
Figure 1. Full-mouth pretreatment X-rays, 1977.
Figure 2. Pretreatment periodontal probings for AK.
Figure 3. Full-mouth post-treatment X-rays, 1978.
Figure 4. Post-treatment photographs, 1978.
Figure 5. Full-mouth X-rays, 1987.
Figure 6. Full-mouth X-rays, 2003.
