Periodontal treatment before implants: right direction?
I have a patient who may be in serious need of periodontal treatment prior to implant installation. His #1,2,3 [maxillary right third, second and first molars; 18, 17, 16] are mobile and will be extracted. His #6, 11 [maxillary right canine and maxillary left canine; 13, 23] are still intact so I plan to retain them whilst having the implants installed in his maxillary right and left posterior quadrants with bone grafts. Now his mandibular teeth have bars where his remaining teeth were used as abutments. Because the prostheses were too long, it compromised the abutments periodontal support resulting in severe bone loss on his mandibular teeth. What I plan to do is extract all the mandibular teeth then replace them with 6 implants then a bar overdenture. Am I moving in the right direction in this case?
![]Panoramic xray](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/11/Implant-case.jpg)
12 Comments on Periodontal treatment before implants: right direction?
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Guy Carnazza DMD
11/18/2013
Hard to evaluate max anteriors but max. posteriors look hopeless. Extract all teeth and immediate upper and lower immediate dentures. Then ct scans to plan for implant placement.
Armi
11/18/2013
Hi Dr Carnazza, the existing case on the lower teeth is actually placed with Hader Bars. Because the patient has a poor oral hygiene, he was unable to keep the surfaces clean on the abutments which lead to pus formation and bone resorption especially on the lower left canine. I was thinking of placing at least 6-7 implants then construct a telescopic denture afterwards. I feel that this prosthesis may be more friendly to the gums since he was not successful with the Hader Bars in the past. What do you think of this treatment?
CRS
11/18/2013
One tip extract the mandibular posterior teeth so that they won't be banging on your maxillary grafts. I also recommend perio treatment on the anterior s to get the patient compliant he'll have to still maintain the implants. Staging or even provisional minis will help prevent bone resorption if you go the full denture route or allow 6-12 months healing prior to the retrofit. A new denture rubbing on implants while they are integrating is not a good thing.
Armi
11/18/2013
Hi Dr CRS,
Actually the upper anteriors are subject for extraction and hopefully we can place implants as well if the bone is sufficient. I am thinking if the patient will want to have implants on the upper right side, I can suggest a sinus lift then implants after 6-8 mos. What do you think?
CRS
11/18/2013
Try to keep pressure off the healing implants if you keep the anterior s and do bilateral sinus lifts with immediate placement, let things heal then do the anterior s with a couple of minis for stabilization . Any other comments would be very helpful, I've had this resorption happen to me with fresh extractions probably remodeling and I had to redo the failed implants. I think it was due to a mobile prosthesis . Any one else have this happen? I know the perio sounds futile but I would LANAP the teeth to sterilize the area. If you get some improvement the patient could tolerate a implant retained upper partial and a full lower.Or have him sign a waiver since he won't keep the implants clean I really like staging it allows for better healing, patient compliance and easier on the pocketbook !
Armi
11/19/2013
Thanks Dr. CRS. Your pointers were very helpful. Although I could not recommend the LANAP procedure yet because here in Asia its not yet available. I believe its only available in the US and Europe. What are the other options I have aside from the LANAP Procedure?
CRS
11/19/2013
Good old scaling and root planing just get the patient motivated to keep future implants. Staging the implants and surgery is very helpful in these cases.
Richard Hughes, DDS, FAAI
11/19/2013
Perio Tx prior to implant tx is classic dentistry.
yasser niazi
11/20/2013
one of the main ABC of implantology.....
poor oral hygine ...................NO IMPLANT
full dentures and thats it ,,, wait for a while and check the dentures , if he is giving time to clean them , he ll give time to clean your implants in the futures
Tuss
11/20/2013
Like CRS said, use whats there to get the patient motivated so at least they will know how to clean around implants. it will also reduce the bacterial load prior to surgery. Choice is really do you "all-on-4" or classic techniques. Theres nothing wrong with a decent set of dentures (stabilised with mini implants) to restore vertical and occlusal scheme - you'll be hard pushed to get th at right by jumping straight in with immediate load
JLW
11/22/2013
Just remember, if he has severe periodontits and non-compliance now, he/she can have severe peri-implantitis later. He/she isn't a good candidate for a lower bar until he /she can clean his teeth. I would remove "all of the bad bugs" out via forceps with immediates (with socket grafting where necessary and a few minis as transitional implants to give the patient some lower retention while healing (I just use a reline material like Lynal over them, not the O-rings initially). Later, use the dentures to duplicate as a stent with radiographic markers for your CT scan and plan from there. If you wish or the patients wishes to retain the maxillary anteriors for a time, then start with scaling, root planing and oral hygiene with a stayplate or other prosthesis. I just wouldn't start placing implants until the tissue heals from the hopeless teeth. Good luck!
Richard Hughes, DDS, FAAI
11/27/2013
I've done a good number of these type of cases. Follow a classic protocol.
Obtain vertical and centric which may be reliable. If the teeth are severely mobile, the patient may be splinting upon occlusion. Fabricate immediate dentures, extract with alveloplasties. Any remaining deep sockets may be grafted with a particulate graft such as OsteoGen.
Prior to surgery (extractions etc), place the patient on antibiotics. I use augmenting with flagyl for a week prior. Let the arches heal and place the implants in the desired locations. The remaining vertical will determine if a bar can be used and the desired attachments.
If the occlusion is off, which can happen with sever perio cases, you may have to retrain the patient or remake the dentures. The occlusion may be off because the patients anterior guidance and proprioception are influenced by pain from the perio condition.
I like these cases because the results are dramatic. This is a great service to the patient.
