Case Study: Discuss the treatment options of a case that you have treatment planned as part of your ICEi clinical portfolio.
Patient complaint: Had a bridge in upper left area which had fractured and wanted to enquire about the possibility of implant treatment to replace the teeth and close the gap .
History of present condition: Patient had a bridge for years for his one front missing tooth , and had recently fractured the bridge .No pain or discomfort from the broken tooth and has left the gap as such .Patient also had tried dentures for his other missing teeth but was not able to get used to them. Patient wanted to explore the options to replace his front missing teeth, in particular with dental implants. Patient not in any discomfort, and did not report any other dental problems.
Patients’ expectation from the treatment is to replace front teeth, so that they look, function and feel like his own teeth and can give him confidence to smile as before .
Social History: Patient rarely consumes alcohol and is a non-smoker
Low sugar intake in diet
Medical History: High blood pressure
Medications: Ramipril, Cardioplen (Felodipine) / Simvastatin
Extra oral examination: No abnormality detected
Intra oral examination
Soft Tissue: The soft tissues intra-orally were in good health.
Periodontal condition: Bleeding on probing at some areas and calculus in lower front teeth. Grade 1 mobility with LR1, LL1 teeth but the pocketing depth was within normal range. Patient had average oral hygiene.
Teeth :Teeth and existing restorations and crowns were generally in good condition.
Generalised mild attrition was noted.
Missing teeth: UR8 UR7 UR6 UR5
UL3 UL6 UL7 UL8
LR7 LR6 LR5
LL5 LL6 LL7
Crowned teeth (PBC) - UR4 UR3 UR2 UR1 UL2
Restored teeth - UL5 LR8 LR4 LL8 restored with amalgam restoration
LR8 LL8 drifted mesially.
UL4 tooth was fractured which was an abutment for mesial cantilever bridge
(UL3-pontic, UL4- retainer crown), No caries, minimal coronal tooth structure present
Upper arch - Kennedy’s Class 1, Modification 1, considering missing UL3.
Lower arch - Kennedy's Class 3, Modification 1 relationship was present.
Due to missing posterior teeth in both upper and lower arch, patient had an edge to edge bite
No obvious canine guidance or group function on lateral movements.
Lip / Smile line:
Lip and smile lines were positioned in such a way that when smiling broadly some of the gum margins of teeth were seen. An average (Moderate) lip line was hence recorded.(Van der Geld, Oosterveld et al. 2011).
Bone morphology on palpation:
UL3 area was noted to have buccal bone defect on palpation.
UL4 tooth was having good hard tissue height and width due to the presence of the tooth.
DPT x-ray was done to assess the alveolar bone levels
Periapical X-ray UL34 was done to assess the quality and quantity of bone available for the implant fixture.
Front view (close up) to record the lip line
Intraoral view of UL3, UL4 area
Bone defect picture
- Failed anterior cantilever bridge (UL3 pontic, UL4 retainer)
- UL4 fracture tooth (no caries - minimal tooth to restore)
- Upper and Lower partially edentulous arches.
- Generalised chronic mild gingivitis
Patient wishes: Patient prefers a fixed option for the gap in the front.
Treatment planning, objectives and considerations:
Treatment is indicated to restore aesthetics and function and would also benefit the patient psychologically to have confidence in his smile again (Lindsay, And et al. 7).
Considering patient desires, specific objectives of the treatment should be to restore missing
UL3 tooth and UL4 tooth with a fixed option.
The bone around the fractured tooth (UL4) is adequate, and there is sufficient bone height and width to allow the restoration of implant fixture. However, the bone around the missing tooth (UL3) was inadequate with bony defect and would need bone grafting to aid the long-term stability of the fixture. This can also further help to improve aesthetic results after implant treatment.
Risk factors / limitations:
Fracture of buccal bone can occur during extraction of UL4.
UL3 has been noted to have less adequate bone, the implant restoration may have a higher restoration margin than the natural teeth, and tooth might appear to emerge higher up the gum than the adjacent teeth.
No posterior support present in the present compromised occlusion and risk of excessive load on implants and hence failure of implants due to biomechanical reason and occlusion overloading(Kim, Oh et al. 2).
Lack of primary stability of implants and Implant failure.
(Chrcanovic, Chrcanovic et al. 6).
Treatment options for the replacement of the missing teeth are:
- No treatment - Leave Gap UL3 (Kanno, Carlsson 2006),Leave alone UL4
- Extraction of UL4 and partial dentures (Davenport, Basker et al. 2000).
- Bridge (Not advised in this case, considering UL2 heavily restored and not suitable as an abutment). (Anonymous 2007).
- Implant options :
- UL4 implant and mesial cantilever bridge with UL3 UL4
(Implant supported bridge), (Kim, Ivanovski et al. 2).
b. UL4 implant supported crown and UL3 Implant supported crown with
bone grafting in UL3 (Al-Khaldi, Sleeman et al. 2011).
Advantages and Disadvantages of different treatment options :
1. Leave, accept gap / Leave alone fractured UL4
No treatment required
Accept gap, no cost
Drifting / Tilting of adjacent teeth
Function and phonetic compromised
Continuous bone loss, making restoring site more challenging at later date.
Development of occlusal interferences
Risk of caries developing UL4
Risk of acute pain / swelling and infection UL4
2. Partial dentures
Few visits for treatments
May be unstable
Does not prevent bone loss
Tolerance can be difficult
3. Bridge work (Not advised / feasible in this case)
Few visits for treatments
Teeth are fixed
Healthy teeth prepared for support, Risk of loss of vitality ,may need Root canal treatment or Extraction at later date .
Food accumulation as difficult to floss
Does not prevent bone loss
Fracture of bridge or any part of it , needs replacing with new bridge as difficult to repair .
- Implant options:
a) UL4 implant and mesial cantilever bridge with UL3 UL4 (Implant supported bridge)
Less cost as one implant to be placed
No bone grafting needed, one surgical visit would be less.
Treatment completion would be early as no bone augmentation needed.
Prevent bone loss at UL4 site
Disadvantages / Limitations:
Risk of implant failure is high due to excessive occlusal load due to missing posterior support.
Compromised aesthetic outcome for UL3 due to bone defect present.
If bridge work fails, would then plan to put two implants as planned as the next option and hence further cost.
Oral hygiene needs to be maintained.
b) UL4 implant supported single crown and UL3 Implant supported single crown with bone grafting in UL3 area.
Prevent further bone loss at UL3 UL4 sites.
Better aesthetic results.
Individual implants, easy to maintain oral hygiene.
Risk of failure due to occlusal load decreases as forces divided on two fixtures.
If an implant fails, they could be replaced or treated individually.
Long term clinical data reveals that the prognosis for implant treatment is very high, in the region of 90-95%. (Pjetursson, Pjetursson et al. 6).
Disadvantages / Limitations:
More cost as two implants and bone augmentation required.
One surgical appointment added and wait for bone material to mature and hence prolonged treatment time.
Risk of implant fixtures failure to ossteointegrate.
The success of implant treatment will mainly depend on the ability to maintain a very high level of oral hygiene and plaque control measures in the long term.
Need to attend dentist at 3-6 monthly intervals to ensure good periodontal (gum) condition is maintained around your implant fixture and standing natural teeth.
Provisional restoration options:
No Provisional restoration or Denture
Patient opted for No Provisional restoration
Type of bone grafting options :( Dib 2010)
An osseous graft can be osteogenic, osteoinductive or osteoconductive agent.
Osteogenic graft contains vital cells, which will contribute to new bone growth.
Osteoinductive graft stimulates the differentiation of osteoprogenitor cells into osteoblasts due to the bone morphogenetic proteins (BMPs).
Osteoconductive graft will serve as a scaffold for new bone formation.
Graft materials are also classifies as:
Autograft bone, obtained from the same individual.
Allograft bone, obtained from a different individual, but from the same species
Xenograft bone, obtained from different species (Bovine)
Alloplast graft is made of synthetic materials.
Patient had no reservation for xenograft and hence xenograft Bio-oss was agreed to be used. Patient information leaflet given on same.
Treatment agreed and planned:
From the options discussed and considering patients’ wishes , it was agreed to plan two individual implant retained single crowns with bone augmentation at UL3 site and it was proposed to do:
- Scale and polish
- Extract the UL4 tooth and Bone Graft UL3 area
- Place two implant UL3 and UL4
- Fabricate new upper and lower partial dentures
- Maintenance instruction and regular follow up
A report was sent to the patient with all the options written after the consultation and attached with a breakdown of the costs for consideration and consent to proceed.
Reference list :
AL-KHALDI, N., SLEEMAN, D. and ALLEN, F., 2011. Stability of dental implants in grafted bone in the anterior maxilla: longitudinal study. British Journal of Oral and Maxillofacial Surgery, 49(4), pp. 319-323.
ANONYMOUS, 2007. Long-term survival of complete crowns, fixed dental prostheses, and cantilever fixed prostheses with posts and cores on root canal-treated teeth. British Dental Journal, 203(9), pp. 523.
DAVENPORT, J., BASKER, R., HEATH, J., RALPH, J. and GLANTZ, P., 2000. The removable partial denture equation. British Dental Journal, 189(8), pp. 414-24.
DIB, M., 2010. Successful Bone Grafting. Oral Health, 100(4), pp. 106-107,109.
KANNO, T. and CARLSSON, G.E., 2006. A review of the shortened dental arch concept focusing on the work by the Käyser/Nijmegen group. England: Blackwell Publishing Ltd.
KIM, P., IVANOVSKI, S., LATCHAM, N. and MATTHEOS, N., 2. The impact of cantilevers on biological and technical success outcomes of implantâ€supported fixed partial dentures. A retrospective cohort study. Clinical oral implants research, 25(2), pp. 175; 175-184; 184.
KIM, Y., OH, T., MISCH, C.E. and WANG, H., 2. Occlusal considerations in implant therapy: clinical guidelines with biomechanical rationale. Clinical oral implants research, 16(1), pp. 26; 26-35; 35.
LINDSAY, S., AND, K. and JENNINGS, K., 7. The psychological benefits of dental implants in patients distressed by untolerated dentures. Psychology & Health, 15(4), pp. 451; 451-466; 466.
PJETURSSON, B.E., PJETURSSON, B.E., BRÄGGER, U., LANG, N.P. and ZWAHLEN, M., 6. Comparison of survival and complication rates of toothâ€supported fixed dental prostheses (FDPs) and implantâ€supported FDPs and single crowns (SCs). Clinical oral implants research, 18, pp. 97; 97-113; 113.
VAN DER GELD, P., OOSTERVELD, P., SCHOLS, J. and KUIJPERS-JAGTMAN, A.M., 2011. Smile line assessment comparing quantitative measurement and visual estimation. American Journal of Orthodontics and Dentofacial Orthopedics, 139(2), pp. 174-180.
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