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Transitioning patients: Teeth to Implants

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  • 1. implants c da j o u r n a l , vo l 3 6 , n º 4 r s Transitioning patients: Teeth to Implants arun b. sharma, bds, msc; craig y. yonemura, dds; donald a. curtis, dmd; and frederick c. finzen, dds a bstract The transition of patients from a dentate state to an implant-supported restoration requires significant planning. Traditionally, protocols have included the extraction of teeth and interim use of a removable prosthesis. Newer protocols include approaches to decrease the period of time a patient is required to use a traditional denture. The authors’ purpose is to outline options and provide clinical examples when transitioning patients from natural dentition to an implant-supported prosthesis. Iauthors arun b. sharma, bds, msc, Donald a. Curtis, dmd, is n treatment planning the restoration patients to a more normal masticatoryis a health sciences clinical a professor, Department of an edentulous space, the use of function and an improved lifestyle.professor, Department of Preventive and Restor- dental implants should be considered. Edentulous patients who present withof Preventive and Restor- ative Dental Sciences,ative Dental Sciences, University of California, Implant-supported prostheses have concerns about function and comfortUniversity of California, San Francisco, School of a high rate of success, as reported by with their complete dentures are typi-San Francisco, School of Dentistry. Adell et al., Zarb, and Symington.1-3 In cally treated with a traditional protocol.Dentistry. a multicenter study by Albrektsson in Implants are placed and restored using a frederick C. finzen, dds, edentulous patients, the 10-year survival two-stage surgical protocol that requiresCraig y. yonemura, dds, is is a health sciences clinicalin private practice limited professor and chair, Divi- rates of such implants were 82 percent for the patients to continue using their exist-to periodontics in San sion of Prosthodontics, the maxilla and 94 percent for the mandi- ing dentures during the healing phase.Francisco. Department of Preventive ble.4 Attard and Zarb reported 96 percent Patients who present with an intact denti- and Restorative Dental implant cumulative survival/success rates tion with advanced periodontal disease Sciences, University of (CSR) for overdentures and 87 percent or a dentition that has a poor restorative California, San Francisco, School of Dentistry. CSR for fixed bridges.5,6 Ekelund et al. prognosis are usually treated with extrac- reported 99 percent CSR for implants tions and immediate dentures. Following supporting a fixed bridge in the edentu- a healing period, implants are placed using lous mandible over a 20-year period.7 the two-stage surgical protocol similar to Implant-supported prostheses patients who presented in an edentulous provide a number of advantages. In state. In transitioning these patients to the edentulous patient, implants pro- implant-supported restorations, it is often vide increased support, retention, necessary to have patients use a remov- and stability for prosthesis. The use able prosthesis for up to nine months. of implants to restore dentitions has With current immediate-loading enabled the dentist to rehabilitate protocols, edentulous patients can avoid a p r i l 2 0 0 8   269
  • 2. implants c da j o u r n a l , vo l 3 6 , n º 4the phase of using complete denturesafter implant placement.8-11 However;these immediate-loading protocols can-not be used for all patients who presentwith an intact dentition. The purpose f igure 1 a. Pretreatment panoramic radiograph. f i g u r e 1 b. Postextraction panoramic radiograph.of this paper is to present patients whowere transitioned from an intact denti-tion to an implant-supported restora-tion and to discuss the rationale forthe selected treatment sequence.patient no. 1 A 49-year-old-female presented to theauthors’ offices in January 2005, seek-ing comprehensive dental treatment. f igure 1 c . Frontal view of provisional fixed f i g u r e 1 d . Panoramic radiograph with provi-Her medical history was significant for partial dentures sional restoration.a history of hepatitis B (noncarrier) andnoninsulin-dependent diabetes mellitus,NIDDM. Her diabetes was under faircontrol, taking 500 mg metformin and priority, so she accepted the plan of ex- 2007. In June, fixed provisional restorations10 mg glyburide both b.i.d., and her most traction of her dentition, insertion of im- (figures 1c-d) were delivered in both arches.recent glycosylated hemoglobin was 7.4. mediate dentures, placement of implants, As is the authors’ standard protocol, Her periodontium suffered from and restoration with fixed prostheses. definitive porcelain fused to metal resto-advanced attachment loss with each The transition from fully dentate to rations are not fabricated for at least sixtooth having lost at least 6 mm (figure edentulous arches was done in a traditional months. During the six months with the1a ). Mobilities ranged from 1-3 and with fashion. Removal of the posterior teeth, provisional restorations, both the patientall molars having Class III furcations with with the exception of the first premolars, and the provider have the opportunity tothe exception of the maxillary second was performed in June 2005. The ridges evaluate speech, esthetics, and the abilitymolars, which had fused roots. The were allowed to heal for six months, im- to maintain satisfactory oral hygiene.radiographs clearly show the advanced pressions were made, and immediate den-horizontal, vertical, and circumferential tures were fabricated. After a healing period patient no. 2defects. Calculus deposits were general- (figure 1b), in October 2006, six implant A 49-year-old male patient presentedized, and tooth No. 14 had a hopeless fixtures were placed in the maxilla. These with many defective restorations andprognosis from a periodontal, restor- were all 13 mm in length, and the most extensive caries (figure 2a ). He was in-ative, and endodontics perspective. posterior on either side required osteotome terested in implants and wanted to avoid Given the advanced nature of the peri- sinus elevation for the apical 2 to 3 mm of a removable prosthesis if possible. Afterodontal disease, and only fair metabolic the fixture. The mandible received three 15 an extensive evaluation that includedcontrol of the NIDDM, there was a limited mm fixtures between the mental fora- radiographs, diagnostic casts, and a fullpossibility of maintaining the existing men, and two 11.5 mm fixtures were placed examination, a treatment plan was for-dentition. She desired predictability but posterior to the mental foramen on either mulated. In the maxillary arch after cariesalso wanted to retain her teeth. Several side. None of the fixtures required bone removal, the treatment plan includeddetailed discussions were required before augmentation in the coronal portions of conventional crowns and bridges. In theshe understood that tooth retention and the fixtures. Amoxicillin 500 mg t.i.d. was mandibular arch, the treatment plan thea predictable restoration were, in her prescribed postoperatively for eight days. patient accepted involved extraction ofcase, mutually exclusive. Ultimately, she The postoperative period was uneventful, all remaining teeth and an immediatedecided that predictability was her highest and healing abutments were placed in April complete denture. After a short heal-2 70   a p r i l 2 0 0 8
  • 3. c da j o u r n a l , vo l 3 6 , n º 4fig ure 2a. Pretreatment panoramic radiograph. f igure 2b. Implant placement, standard f i g u r e 2 c. Provisionals. and temporary.fig ure 2d. Mandibular provisional on implants. f igure 2e . Completed treatment panoramic f i g u r e 2 f. Definitive restorations (prosthodon- radiograph. tic treatment by Tony Chammas, DDS).ing phase, six implants (figure 2b ) were patient no. 3 having problems, mostly in the man-placed following a two-stage surgical The patient was originally referred to dibular arch, with root caries, pain withprotocol. At the time of implant place- a periodontal office in 1974 when she was normal functioning, and increasing mobil-ment, six transitional implants (Dentatus 19 years old. Her medical and social his- ity (figures 3a-b ). Because periodontalModular Transitional Implants, Denta- tory did not contribute to her periodontal therapy began at such an early time in hertus USA Ltd., New York, N.Y.) were also condition. The pocket depths ranged from life, she was aware that tooth loss was aplaced to support an immediate-fixed 4 mm to 6 mm in all areas, except the distinct possibility for her. The discussionprovisional restoration (figure 2c ). maxillary anterior segment, which had of implant therapy was thus initiated, but After second-stage surgery, a pro- only 2 mm to 3 mm probing depths. There she wanted to avoid a removable interimvisional restoration was delivered on was 10 percent to 30 percent horizontal prosthesis. Additionally, while she wasthe definitive implants and the transi- bone loss with superimposed shallow aware that the maxillary arch would likelytional implants were removed (figure vertical and circumferential defects in follow a similar fate, she was only able to2d ). Definitive prosthodontic treatment multiple areas. The periodontal diagnosis restore the mandibular arch at that time.(figures 2e-f ) was then completed fol- in 1974 may have been juvenile periodon- Transitioning this patient to anlowing the standard protocol at post- titis or rapidly progressive periodontitis, implant-supported restoration involvedgraduate prosthodontic program at the but the current terminology would assign two challenges: first transitioning a den-University of California, San Francisco. the diagnosis of aggressive periodontitis.12 tate mandibular arch to an edentulous, The treatment selected for this patient Pocket reduction was performed in implant-supported dentition withoutallowed a transition from a fully dentate 1975 and 1979 in the posterior sextants. A a removable interim prosthesis; andmandibular arch to an implant-supported three-month recall/maintenance schedule second, transitioning each arch at differ-fixed restoration in a period of nine was followed closely from 1975-1997 when ent times, perhaps several years apart.months. Utilization of the transitional one author accepted the responsibility for To transition the mandibular arch,implants limited the use of a removable the patient. Between 1991-2003, operative it is critical to have adequate abutmentcomplete denture to two months. The procedures, fixed prosthodontics, endo- teeth for a provisional fixed partialtreatment for this patient was completed dontics, surgical endodontics, extracoro- denture. The requirements for abut-before currently available immediate- nal splinting, and root amputations were ment teeth to support a provisional fixedloading protocols were routine therapy. performed. In 2004, the patient began partial denture are obviously different a p r i l 2 0 0 8   27 1
  • 4. implants c da j o u r n a l , vo l 3 6 , n º 4from those for a definitive fixed partialdenture because the provisional abut-ment teeth need to support the restora-tion for only months rather than years. Nonetheless, provisional abutment f igure 3 a . Pretreatment frontal view. f i g u r e 3 b. Pretreatment panoramic radiograph.teeth need to be distributed in a patternthat will accept normal masticatory forcesfor six to 12 months. In this case, thecuspids and second molars were prepared,the remaining teeth were extracted, anda 12-unit fixed provisional was fabricatedand cemented (figures 3c-d ). The implantswere placed in the areas of Nos. 19, 21,23, 26, 28, and 30. Following second-stagesurgery to uncover the implants, a fixture f igure 3 c . Prepared teeth for provisional. f i g u r e 3 d . Provisional fixed partial denture onlevel impression was made and a provi- four abutment teeth.sional implant supported restoration wasfabricated (figure 3e ). The provisional wasdelivered when the provisional abutmentteeth were extracted (figure 3f ). The de-finitive porcelain fused to metal restora-tion was delivered approximately ninemonths later following complete healingof the extraction sites (figures 3g-h ). Because the maxillary arch will be re-stored in the future, the mandibular archwas restored to an ideal occlusal plane. f igure 3 e . Fixture level impression copings. f i g u r e 3 f. Provisional fixed partial denture onThe maxillary teeth were adjusted to ac- implants after extraction of four teeth.commodate the mandibular restoration.patient no. 4 A 6o-year-old female patient pre-sented with the desire to have hermaxillary arch restored with a fixedimplant restoration. She had used atooth-supported removable partialdenture for many years, but now manyof the abutment teeth were failing. There f igure 3 g. Definitive mandibular fixed partial f i g u r e 3 h . Panoramic radiograph of completedwas inadequate bone height and width denture. treatment.for placement of a sufficient number ofimplants to support a fixed restoration.Three-dimensional radiographs demon- treatment sequence: (1) extraction of teeth Nos. 2, 8, 9, and 15 for a provi-strated the need for ridge augmentation teeth Nos. 3, 6, and 14, with addition of sional fixed partial denture (figure 4b ).in both height and width. After many these teeth to the existing removable In order to increase ridge width,joint discussions on the treatment op- partial denture; (2) after healing from onlay grafts were planned for the areas oftions, the following was the selected the extractions (figure 4a ) preparing teeth Nos. 4, 5, 6, 11, 12, and 13. To avoid2 72   a p r i l 2 0 0 8
  • 5. c da j o u r n a l , vo l 3 6 , n º 4f ig ur e 4a. Pretreatment. f igure 4b . Maxillary provisional on teeth Nos. f i g u r e 4 c. Panoramic radiograph of metal rein- 2, 8, 9, and 15. forced provisional during implant integration phase.f ig ur e 4d. Maxillary provisional on implants. f igure 4 e . Definitive maxillary fixed partial f i g u r e 4 f. Panoramic radiograph of completed denture. treatmenta tissue-borne removable prosthesis in method that is available today, but not 11. Raghoebar GM, Friberg B. et al, Three-year prospective multicenter study on one-stage implant surgery and earlythe area of the bone graft, the area was all patients who present with an exist- loading in the edentulous mandible. Clin Implant Dent Relatrestored with a provisional fixed partial ing dentition are appropriate candidates Res 5:39-46, 2003.denture; (3), bone graft (Dr. Pham) to for the immediate-loading protocol. 12. Armitage, GC, Development of a classification system for periodontal diseases and conditions, Ann Periodontol 4:1-6,both maxillary sinuses and right and left 1999.residual alveolar ridges; (4) placement re f e re n c e s 1. Adell R, Lekholm U, et al, A 15-year study of osseointegratedof eight implants (Dr. Pham) (figure implants in the treatment of the edentulous jaw. Int J Oral Surg to request a printed copy of this article, please contact Arun B. Sharma, BDS, MSc, University of California,4c ); (5) second-stage surgery to uncover 10:387-416, 1981. San Francisco, School of Dentistry, 707 Parnassus Ave., Roomimplants and fixture level impression to 2. Adell R, Ericksson B, et al, A long-term follow-up study of os- D4000, San Francisco, Calif., 94143. seointegrated implants in the treatment of totally edentulousfabricate provisional implant supported jaws. Int J Oral Maxillofac Implants 4:347-59, 1990.prosthesis; (6) extraction of teeth Nos. 3. Zarb G, Symington J, Osseointegrated dental implants:2, 8, 9, and 15, and insertion of provi- preliminary report on replication study. J Prosthet Dent 50:271-5, 1983.sional implant-supported fixed partial 4. Albrektsson T, A multicenter report on osseointegrated oraldenture (figure 4d ); and (7), fabrication implants. J Prosthet Dent 60:75-84, 1988.of a definitive porcelain fused to metal- 5. Attard NJ, Zarb GA, Long-term treatment outcomes in eden- tulous patients with implant-fixed prostheses: the Torontofixed partial denture (figures 4e-f ). study. Int J Prosthodont 17:417-24, 2004. 6. Attard NJ, Zarb GA, Long-term treatment outcomes inConclusion edentulous patients with implant overdentures: the Toronto study. Int J Prosthodont 17:425-33, 2004. There are many options available today 7. Ekelund JA, Lindquist L, et al, Implant treatment in thethat will allow a practitioner to transi- edentulous mandible: a prospective study on Branemarktion patients from the dentate state to system implants over more than 20 years. Int J Prosthodont 16:602-8, 2003.implant-supported restorations. Some 8. Schnitman PA, Branemark implants loaded with fixed provi-of these options will eliminate the use sional prostheses at fixture placement. Nine-year follow-up. Jof a removable prosthesis. In this paper Oral Implantol 21:234, 1995. 9. Schnitman PA, Whorle PS, et al, Ten-year results for Brane-using clinical examples of four patients, mark implants immediately loaded with fixed prostheses at im-the authors have presented the treatment plant placement. Int J Oral Maxillofac Implants 12:495-503, 1997.sequence and the rationale for the selec- 10. Randow K, Ericsson I, et al, Immediate functional loading of Branemark dental implants. An 18-month clinical follow-uption. Immediate loading is an additional study. Clin Oral Impl Res 10:8-15, 1999. a p r i l 2 0 0 8   27 3