|Year : 2012 | Volume
| Issue : 3 | Page : 211-214
Full mouth re-restoration of partially edentulous dentition: A periodontic, endodontic, orthodontic and prosthodontic interrelationship-2 year follow-up
Santhosh Kumar, G Subraya Bhat, K Mahalinga Bhat
Department of Periodontics, MCODS, Manipal University, Manipal, Udupi, Karnataka, India
|Date of Web Publication||11-Jun-2013|
Department of Periodontics, MCODS, Manipal University, Manipal, Udupi, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
An interdisciplinary approach towards full mouth re-restoration of severely compromised dentition requires; complete understanding of the patient's problem through history and examination of the dentition. The treatment approach should begin with an appropriate diagnosis and predictable prognosis sequencing it with specialty treatment to obtain a successful result. This clinical case report describes the implementation of a diagnostically based treatment plan for treating the maxillary arch with flap surgery and intrusion, partially edentulous mandibular arch treated by extracting the hopeless teeth and replacing the missing with an over-denture. During follow-up esthetic management of the gingival recession with respect to upper right central incisor was done using a sub-epithelial connective tissue graft procedure and paramount importance was placed on supportive periodontal therapy during the follow-up period of 2 years.
Clinical Relevance to Interdisciplinary Dentistry
- The article describes an interdisciplinary approach for a successful implementation of interdisciplinary treatment to resolve dental problems for an individual requiring full-mouth re-restoration.
- Describes an unique way of restoring lost aesthetics and function.
Keywords: Connective tissue, edentulous, graft, intrusion, recession
|How to cite this article:|
Kumar S, Bhat G S, Bhat K M. Full mouth re-restoration of partially edentulous dentition: A periodontic, endodontic, orthodontic and prosthodontic interrelationship-2 year follow-up. J Interdiscip Dentistry 2012;2:211-4
|How to cite this URL:|
Kumar S, Bhat G S, Bhat K M. Full mouth re-restoration of partially edentulous dentition: A periodontic, endodontic, orthodontic and prosthodontic interrelationship-2 year follow-up. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Jun 18];2:211-4. Available from: http://www.jidonline.com/text.asp?2012/2/3/211/113265
| Introduction|| |
The demands for treatment with fixed partial prosthesis are increasing and it is essential to replace the missing teeth as well as create a biological balance between conjunct prosthesis and prosthetic field. When the forces, which maintain the tooth in position is changed trauma can occur. Hence, it is necessary to create an occlusal field with dentoperiosteal tolerance by realigning the migrated teeth.
Pathological migration is defined as "presence of a developing diastema in the upper anterior sextant, which was not present in the past or already existed but increased."  The degree of migration will differ from tooth to tooth, according to the periodontal destruction and can also produce extrusion of the teeth.  This can be treated by orthodontic intrusion. There is histological evidence of new cementum and collagen attachment formation following orthodontic intrusion if good oral hygiene is maintained. 
In many partially edentulous situations implant assisted prosthesis has become a modern treatment of choice. But the combination of implant and fixed restoration is difficult to implement.  Moreover, there is a paucity of studies concerning the combination of implants and removable partial dentures.
| Case Report|| |
A 38-year-old systemically healthy female patient visited the dental clinic with a chief complaint of extruded upper front teeth and missing lower-posterior teeth.
On intra-oral hard tissue examination: Upper anterior teeth and upper-posterior teeth were extruded beyond the line of occlusion with grade 2 mobility.  The fixed partial denture replacing the lower anterior was impinging the labial marginal gingiva and the missing posteriors except the 2 nd molars was replaced by an interim denture.
Soft-tissue examination showed: Generalized bleeding on probing. Upper anterior tooth (11) showed compound pocket probing depth of 7-8 mm. Miller's Class III gingival recession  of 2-3 mm was noticed with respect to (16) and (26) [Figure 1] and [Figure 2].
Based on the examination the following treatment plan was implemented:
Phase I therapy included supra gingival, sub gingival scaling and root planning, local drug therapy, re-evaluation to be done after 15 days. In the Phase II therapy-open flap de-bridement for the pocket reduction in relation to (11) and (21); extraction of the mobile lower anterior and pre-molar after removal of the fixed partial denture.
Root coverage with respect to (11), re-evaluation of the patient to be done after 15 days, Maintenance phase included recall and re-evaluation in 3 months. In the Phase III therapy-intrusion of the upper anterior and posteriors, replacement of the lower with an over-denture and occlusal bite equilibration, re-evaluation was advised after every month. Phase IV therapy included maintenance of the dentition by recall and re-evaluation after every 3 months.
| Clinical Procedure|| |
The patient was advised to take orthopantomogram and intraoral periapical radiographs. Supragingival and sub gingival scaling and root planning was completed. Recall period was scheduled and local drug delivery using tetracycline fiber (periodontal plus - AB, Chennai, Tamil Nadu, India) was planned after 15-20 days. After 3 months of the initial therapy open flap de-bridement was done due to the persistent pocket depth and BioGraft® HT (Beta-tricalcium phosphate) (IFGL Bioceramics, Kolkata, West Bengal, India) was placed into the site.
The patient was referred to the department of orthodontics for intrusion of the upper teeth after a maintenance period of 3-4 months [Figure 3]. The intrusion was done using a fixed appliance with a Niti wire for arch alignment. Stainless steel wire was used for the final adjustment. Slots of 0.016 by 0.002 for the wire was used to stabilize the tooth and for realigning the tooth to the arch.
On completion of intrusion the lower fixed partial denture [Figure 4] and [Figure 5] was removed and the extractions of the abutment teeth (32), (33), (42) and mobile left first premolar (34) was done, remaining canine (43) and the molars (37) and (47) were prepared for receiving coping [Figure 6]. Later partially edentulous arch was replaced with an over-denture [Figure 7].
|Figure 4: Intra-oral periapical post orthodontic intrusion showing radioopacity surrounding tooth suggestive of bone fill|
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During the recall visit after 2-3 months the patient showed a persistent sinus tract with respect to the upper (11). Hence, the tooth under-went root canal therapy and rescheduled for treatment of the recession. The recession dimension was found out to be 5 mm × 2.5 mm. Classified to be a Millers Class III recession.  Sub epithelial connective tissue graft was harvested using a trap door technique from the palatal donor site and transferred into a pouch created at the recipient site. [Figure 8]. Healing was uneventful. After 2-3 weeks recall, 2-3 mm of attachment gain was noted.
Two years follow-up after the procedure showed acceptable change in the hard-tissue and the soft-tissue components. There was about 12.1% foreshortening of the root of incisor which was within the acceptable range. The patient was satisfied with the treatment done and was extremely pleased with the overall appearance of the dentition and its function [Figure 9] and [Figure 10].
|Figure 10: Intra-oral periapical after 2 years showing improvement in bone support|
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| Discussion|| |
Patient with periodontitis or history of periodontitis demonstrate a greater incidence of tooth migration than teeth without bone loss due to reduced osseous support.  Periodontal therapy is usually initiated (whether non-surgical or surgical) before re-positioning the teeth orthodontically.  Following the orthodontic therapy the gingival recession persisted but the overall bone gain and tooth contact improved.
The gingival recession on the incisor following the intrusion was treated using Langer and Langer technique. The sub-epithelial connective tissue graft, as described by Langer and Langer predictably increased root coverage of Miller Class I and II recessions to more than 90%.  The gingival esthetic treatment was done only after the orthodontic procedures. In this study, the association of the procedures can be suggested as safe, predictable, and the final result was consistent with scientific literature. ,
Replacement of the missing teeth with an over-denture overcomes the harmful consequences of wearing conventional complete dentures. Due to its various advantages, the tooth supported over-denture is an excellent treatment option for maintaining the integrity of the alveolar ridge in an edentulous patient.  Oral prophylaxis was performed at an interval of 3-4 weeks during the orthodontic treatment and at an interval of 3-4 months after the definitive prosthetic replacement.
| Conclusion|| |
A long range planning is required for periodontal treatment. Its value to the patient is measured in years of healthy functioning of the entire dentition. The health of the dentition should not be compromised by a heroic attempt to retain questionable teeth. Removal, retention or temporary (interim) retention of one or more teeth is a hugely crucial part of the overall treatment plan. Supportive periodontal care is of paramount importance and it should consist of examination, treatment including instructions in oral hygiene and scheduling next procedure.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]