Case 63 | Prosthodontic Award 2015 | Italy
Dr. Edoardo Foce
Complex prosthetic rehabilitation, with multidisciplinary approach, regarding a case of severe and generalized periodontitis, with obvious structural alterations and biological dentition that was aggravated by significant imbalances of physiological interdental and occlusal relationships .
Controls in the medium to long term ( about 14/15 years )
The patient comes to my office in May 2000, very discouraged and worried because, as a result of a sudden worsening of an oral condition that he knew, already, as serious, he could no longer handle the situation both in regard to the functionmasticatory, both from the postural point of view (no longer able to find a stable position in close teeth), both from the phonetic point of view and aesthetic. Besides his concern, it contributed to make it worse the therapeutic solutions that, in the meantime, had been envisaged and proposed by several colleagues with whom she had been, at that time, to ask for opinions.
In practice, almost everywhere, had been raised, as the only solution, the extraction of teeth of the upper and the subsequent restoration with a removable full dentures, after necessary step, as the healing of tissues, through a temporary denture or remaining edentulous awaiting healing.
Equally unique was the result of opinion in regard to the treatment of the lower arches which consisted, basically, in two therapeutic options:
1) Extraction of the second molars (4.7 and 3.7) bilaterally. Therapy cleaning maintenance, “quod valetudinem” with possible splinting teeth incisor with corresponding canines to reduce mobility and improve chewing ability and comfort.
2) Cleaning maintenance therapy, “quod valetudinem”. Molar extractions, the group incisive and 3.5 and restore the missing elements with removable prosthesis type skeletonized.
After the necessary diagnostic tests was performed an accurate non-surgical periodontal therapy with scaling, root planing, oral hygiene instruction and motivation and extractions of the elements deemed unrecoverable and potentially infectious (1.1, virtually divorced and 4.7). During active therapy, according to a periodontal susceptibility, the patient was administered oral antibiotics, such as amoxicillin / clavulanic acid and metronidazole.
For several reasons, the cleaning therapy lasted a pretty long time, but this, to some extent, allowed her to be able to better control and longer behavior dento periodontal and then be less uncertain about the choice of treatment that we were going to propose.
Which resolved the status inflammatory and re-evaluated the situation after the initial phase of periodontal therapy, both in general and in particular, the patient was proposed rehabilitation of the two arches, through a course of treatment that included a multidisciplinary nature, according to a defined plan treatment and related operational sequence and under constant careful and demanding treatment of periodontal support, the following therapies:
TREATMENT PLAN IN OPERATING SEQUENCE:
– Treatments endo-reconstructive
– Preparations Prosthetic Preliminaries
– Separations root and any extractions or root provided that became necessary when treating. – Inserting, relining, finishing and functionalization of the first provisional acrylic resin.
– Impressions of the patient’s teeth, preparations of teeth and interocclusal registration and facial arch for mounting of working models in the articulator to average values and for the construction of the second provisional acrylic resin, armed with a metal casting.
STATEMENT OF PROSTHETIC CHOICE:
The elements 17 and 16 for alterations coronal, periodontal (see inter root defects), location and mobility needed to be treated endodontically and proshesized.
15 was treated endodontically and featured an extensive and incongruous amalgam restoration.
14 resulted with no crown.
The 13 served to strengthen the front group which presented the loss of 11 and a reduced periodontal support to the remaining elements, as well as problems related to the position in the arch of the teeth and severe deficiency of an aesthetic nature to be taken into consideration.
On the other side the molars 26 and 27 had severe side impaiments on inter root and supporting periodontal deficit.
The teeth 23,24,25, periodontally compromised, but with no other issues, were not involved in the prosthetic treatment plan.
The other prostheses concern the site edentulous in the lower left rear, which was recovered by the addition of two fixtures, and two crowns cemented to the respective abutments, screwed to the fixtures, which have an internal hexagonal connection.
– Insertion of implants in the edentulous lower left
– Periodontal osseus resective surgery for elimination of pockets and for other purposes, such as the realignment of the level of the parables gum, lengthening clinical crowns of some elements and the correction architectures reverse interproximal soft tissue.
Besides that by itself, some of the directions surgical periodontal were referable to the prosthetic treatment plan
– Preparation Prosthetic intraoperative of the dental elements
– Uncovering implants, soft tissue management and provisional until maturation and stabilization of tissue
– Re-evaluation in general and specifically the individual therapies, the results achieved
– Preparations prosthetic final, final impressions
– Registration Pantografica, three waxes centric and mounting articulator to individual values
– Finalizing definitive prosthetic with gold-ceramic crowns
After treatment, the patient was well and appeared to be reborn.
The effect of dental treatment had gone well beyond recovery, even though complex and with a very appreciable result, teeth and gums.
Despite having the patient not fully focused on how to preserve her oral hygiene at home, the patient has almost always presented regularly, during these years, to the appointments recall of periodontal hygiene, demonstrating a strong motivation and commitment to get properly cured.
After about 14 years of the start of treatment and 11 of the final cementation and prosthetic final, the situation is stable and there have been no failures or recurrence of disease, such as caries, lesions of endodontic origin, onset of pockets or other periodontal diseases, which may have altered the state of health achieved with the rehabilitation treatment regarding the biological or abnormalities have occurred in terms of structural mechanics, such as crown fractures and / or root and / or prosthetic. Other problems that could have occurred such as decementation of prosthetic crowns.
I think this result confirms the validity of certain therapeutic procedures that I am certain, these still have much space, today as yesterday, even though, a number of conditions, may have reduced the absolute indications and, definitely, their application in situations extreme, which once could be supported and justified by the absence or lesser reliability prognostic knowledge of alternative therapies.
It is also true that, without denying what I just said in the previous paragraph, reflecting on this specific case, “here and now”, if I had to deal with such a case I would do exactly the same things and in the same procedural.