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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 74-78

Management of reduced interarch space using interdisciplinary approach for implant rehabilitation


1 Department of Periodontology, GGSDC, Burhanpur, Madhya Pradesh, India
2 Department of Periodontology, CDSRC, Bopal, Ahmedabad, Gujarat, India
3 Department of Prosthodontics, CDSRC, Bopal, Ahmedabad, Gujarat, India
4 Department of Orthodontics, CDSRC, Bopal, Ahmedabad, Gujarat, India

Date of Submission07-Oct-2019
Date of Acceptance02-Apr-2020
Date of Web Publication21-Aug-2020

Correspondence Address:
Dr. Ganesh Nair
GGSDC, Burhanpur, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_56_19

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   Abstract 


The increasing demand for fixed prosthetic replacement has led to a rise in the development of new methods and materials in the field of implantology. A team approach with different disciplines in dentistry brings forth new ideas and variations in treatment planning and implant placement. The case report describes rehabilitation of reduced interarch space dentition using orthodontic and periodontic interdisciplinary approach. It encompasses the use of orthodontic approach to create space for ideal implant rehabilitation. The interdisciplinary approach aided reaching our goal of restoration using implants by increasing interarch space and also achieving patient satisfaction in the process.

Keywords: Implantology, interarch space management, intrusion, orthodontic-periodontology


How to cite this article:
Nair G, Panchal A, Shah H, Somani D, Mehta S, Khimmsera R. Management of reduced interarch space using interdisciplinary approach for implant rehabilitation. J Interdiscip Dentistry 2020;10:74-8

How to cite this URL:
Nair G, Panchal A, Shah H, Somani D, Mehta S, Khimmsera R. Management of reduced interarch space using interdisciplinary approach for implant rehabilitation. J Interdiscip Dentistry [serial online] 2020 [cited 2020 Sep 22];10:74-8. Available from: http://www.jidonline.com/text.asp?2020/10/2/74/292918




   Clinical Relevance to Interdisciplinary Dentistry Top


The interdisciplinary approach of orthodontics and periodontics for the management of reduced interarch space. The case focuses on the functional restoration of missing teeth in a reduced interarch space dentition using the orthodontic approach to create space for restoration using implants.


   Introduction Top


Ideal edentulous spaces with textbook dimensions for single or multiple tooth restoration are a rare find. Interdisciplinary approach helps in achieving the required dimensions for a prosthetically driven implant rehabilitation. Partially, edentulous patients are common cases for restoration with implants, but the presence of the remaining dentition adds to more challenges, such as occlusal schemes, periodontal health status, spatial relationships, and esthetics, which are not usually seen in edentulous patients.[1]

It is necessary to determine whether implant therapy is possible and practical, and perhaps, most important whether it is indicated for the particular patient who is seeking restoration using implant therapy. Before implant placement, the following criteria must be checked, such as measuring available alveolar bone height, width, spatial relationship, and prosthetic restorability are essential considerations in determining whether restoration using implant (s) is possible. However, making an assessment of the patient and determining whether that patient is a good candidate for implants is an equally important part of the evaluation process. The patient evaluation includes identifying factors that might increase the risk of failure or the possibility of complications, as well as determining whether the patient's expectations are reasonable.[2]

The dental arches are in a state of dynamic equilibrium, with the teeth supporting each other. Loss of tooth disrupts the structural integrity of the dental arch, and it realigns to the changes to achieve a new state of equilibrium. Teeth adjacent to or opposing the edentulous space frequently moves into it. In case of severe intrusion or supraeruption, it is not enough to just replace the missing tooth. To achieve complete function free of any interference, it is necessary to correct the tooth opposing or adjacent to the edentulous space. In severe cases, this may necessitate the devitalization of the supraerupted opposing tooth to permit sufficient shortening to correct the plane of occlusion.[3]

Periorestorative patients may be substantially benefitted by the orthodontic tooth movement. If adjacent teeth have drifted into edentulous spaces, orthodontic therapy is often helpful to provide the ideal amount of space for implants and subsequent restorations.

This case report elaborates on the management of a posterior edentulous quadrant with loss in vertical dimension using periodontic–orthodontic interdisciplinary approach for implant rehabilitation.


   Case Report Top


A 50-year-old female patient in good general health reported with a chief complaint of difficulty in chewing and wanted fixed replacement of the missing tooth. No abnormalities were detected in extraoral examinations, the patient had an average built, and facial features were symmetrical, and temporomandibular joints (TMJ) movements were synchronized with no deviations, clicking sound, or tenderness. The patient was systemically healthy, and no parafunctional habits were observed or revealed in the case history of the patient.

Intraoral examinations revealed Kennedy's Class I Modification 1 edentulous area in the maxillary arch with missing teeth being 14, 15, 16, 17, and 26, and in the lower arch Kennedy Class III edentulous area with the missing tooth being 46. There was observable supraeruption and mesial tilting of 47, and distal tilting of 45 was observed due to the absence of 46. An examination using periodontal probe (GDC®, UNC-15) showed only 1 mm space between the maxillary alveolar ridge and occlusal surface of 47 [Figure 1].
Figure 1: Preoperative interarch space

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There was a significant reduction in the interarch space in the right posterior region due to the supraeruption of 47, which further complicated by the mesial tilting of the second molar. Sufficient interarch space was observed in the region of 26. The patient was interested in fixed replacement prosthesis, so a cone-beam computed tomography was advised for the maxillary arch [Figure 2]. The radiographic examination D3 type bone density (Misch 1988).[4] Sufficient bone height and width were observed, which was a proper length for implant placement. The only complication was the reduced interocclusal space. A routine blood test was also advised before any treatment.
Figure 2: Cone-beam computed tomography plate

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Before starting the comprehensive treatment for increasing the interarch space and tooth rehabilitation a thorough case history, cast models, and phase I therapy was performed, this included oral prophylaxis and instructions for maintaining oral hygiene. Diagnostic casts were made to check for occlusal contacts and relationships. The patient was observed to be highly motivated and showed proper maintenance of oral hygiene during the follow-up.

The goals set to achieve in the treatment plan was to increase interarch dimensions in the right posterior sextant for implant rehabilitation for both the upper and lower arches. After discussion with the patient about the final treatment plan, it was decided for implant restoration for the maxillary distal extension and fixed bridge prosthesis in the missing mandibular tooth. A written consent as per the institutions protocol was taken from the patient regarding the treatment plan and the use of photographs.

The intrusion of 47 was carried out using orthodontic mini implant (Modern Ortho®, Ahmedabad, India) of dimensions 1.2 mm × 6 mm placed in the buccal aspect of 46. The mini screw was threaded 7 mm away from the alveolar crest with angulations of 30°–40° to the dental axis using a self-drilling mechanism (proper sterilization protocol was maintained during the procedure). The mini implant provided anchor for elastic band which was attached to a modified lingual arch [Figure 3].
Figure 3: Intrusion of 47 using single orthodontic mini implant and modified lingual arch

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Simultaneous staged implant placement in the maxillary posterior region was initiated with the intrusion of 47. Three implants were placed 3.8 mm × 13 mm, 3.8 mm × 13 mm, 3.8 mm × 11 mm and 3.8 mm x 11 mm (Saplings Oral Solutions, Myriad™, UAE) in 14, 16, 17, and 26 regions using a surgical stent of sizes, respectively [Figure 4].
Figure 4: Implants placed in the first quadrant

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The implants were left undisturbed for 6 months; the patient was recalled every month to check the progress of intrusion of 47 and the maintenance of oral hygiene during the healing phase of the implants. A gain of 4 mm was achieved in a span of 6 months [Figure 5], which was confirmed comparing preintrusion and postintrusion cast models of the patient and clinical measurement using a periodontal probe (GDC®, UNC-15). Restoration of both implants and mandibular posterior teeth were carried out after sufficient intrusion was achieved, and a healing period of 6 months was completed after implant placement. Both implant and the fixed prosthesis were porcelain fused to metal crowns [Figure 6], [Figure 7], [Figure 8]. A strict maintenance protocol was followed for the 1st year, and subsequent follow-up was advised for every 6 months.
Figure 5: Clinical view at 6 months postoperative

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Figure 6: Emergence profile

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Figure 7: Postoperative facial view after prosthesis delivery

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Figure 8: Postoperative view of the first and fourth quadrant

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   Discussion Top


The present case report focuses on an interesting interdisciplinary approach between the disciplines of periodontology and orthodontics. Although conventional orthodontic patient might be quite different from the periodontal patient, many useful interactions between the disciplines can be harnessed for the best treatment outcomes. Similar cases of reduced interarch spaces have been reported for the restoration using fixed prosthesis, for the case being discussed, functional restoration with conservative approach was considered to be the best line of approach.[5],[6],[7]

Mini screw orthodontic implants were used in the case of anchorage in combination with a modified lingual arch. Owing to the nature of their integration or stabilization in the alveolus, mini implants have been proven to be reliable and immobile sources of orthodontic anchorage, when properly planned and included can dramatically facilitate orthodontic therapy.[8] A minimum of 4 mm space gain was required for the fabrication of screw-retained prosthesis with a sustainable ferrule effect.[9],[10]

For correction of tooth migration, a multidisciplinary approach including orthodontic treatment is effective and more predictable. The improvement of facial esthetics and functional occlusion can contribute to the self-confidence of an adult patient with traumatic tooth migration and periodontal defects.[11] Various tooth movements that can be done to aid in various implant treatment planning such as tooth alignment, space redistribution, intrusion, and anchorage for distalization.[12]

Malocclusion caused by tooth loss, bruxism, and nontreated dental caries are sources of stress to the TMJ. These conditions can activate a cascade of unfavorable events leading to TMJ disorders.[13]

In the present case, it was essential to analyze the occlusion relationship between the upper and lower dental arches, to ensure the restoration of two quadrants are in harmony with normal occlusal relationship on the contralateral side. The first quadrant presented with reduced interarch space with a distal extension edentulous area, and the fourth quadrant presented with Kennedy Class III edentulous area with tipping of the teeth mesial and distal to the edentulous area. Hence, elaborate treatment planning with implants and fixed prosthesis was planned to full fill the requirements of the patient for a fixed sustainable restoration of the posterior arches.

Drifting and supraeruption of teeth is a common finding in compromised periodontal condition, which can occur as a result of age changes in adult dentition. This could lead to the development or worsening of a malocclusion. Many orthodontists are often reluctant to provide fixed appliance therapy in adult patients. There is good evidence that proves, when high-quality periodontal intervention is carried out, and the patient can maintain adequate hygiene procedures to control the disease, even in the presence of previous alveolar bone loss, fixed appliance treatment can be carried out safely and satisfactorily.[14]

The most critical factor for successful treatment of a partially edentulous patient is the planning process of the interdisciplinary team to formulate realistic treatment objectives and a sequence to ensure the quality of the final result. This is, especially, important when endosseous dental implants are planned. In the field of orthodontics, implants are used for therapeutic purposes, for example, to create an anchorage, in periodontics implants are used as model support to the periodontium in the edentulous area and also as abutments later for restoration using fixed prosthesis.[15]


   Conclusion Top


This case report represents the successful management of a partially edentulous adult patient using interdisciplinary team approach. An increase of the interarch space supported by the proper relationship between fixed prosthesis in the mandibular region and implant rehabilitation in the maxillary right quadrant. Effective and efficient orthodontic management of partially edentulous patients is biomechanically challenging and often requires a thorough treatment plan to predictably achieve the desired tooth movements.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lekholm U, Van Steenberghe D, Herrmann I. Osseointegrated implants in the treatment of partially endentulous jaws: A prospective 5-year multicenter study. Int J Oral Maxillofac Implants 1994;9:627-35.  Back to cited text no. 1
    
2.
Perry RK, David LC. Clinical evaluation of the implant patient. In: Newman MG, Carranza FA, editors. Clinical Periodontology. 13th ed. Philadelphia PA, USA: Elsevier; 2006. p. 741-52.  Back to cited text no. 2
    
3.
Shillingburg RT, Sumiya H. Treatment planning for replacement of missing teeth. In Shillingburg RT, editor. Fundamentals of Fixed Prosthodontics. 3rd ed. Carol Stream, IL: Quintessence Publishing; 1997. p. 85-103.  Back to cited text no. 3
    
4.
Carl EM. Bone density: A key determinant for treatment planning. In: Carl EM, editor. Contemporary Implant Dentistry. 2nd ed. Missouri, USA: Mosby Elsevier; 1993. p. 237-52.  Back to cited text no. 4
    
5.
Asef K. Implants and orthodontics for the general practitioner: A case report describing multidisciplinary treatment. J Can Dent Assoc 2007;72:907-11.  Back to cited text no. 5
    
6.
Flavio U, Nandakumar J, Ravindra N. Interdisciplinary approach for increasing the vertical dimension of occlusion in an adult patient with several missing teeth. Am J Orthod Dentofacial Orthop 2013;143:867-76.  Back to cited text no. 6
    
7.
Rath SK, Datan SK, Gupta A. Ortho-perio management of malocclusion in an adult patient. J Interdiscip Dent 2017;7:41-4.  Back to cited text no. 7
    
8.
Higuchi KW, Slack JM. The use of titanium fixtures for intraoral anchorage to facilitate orthodontic tooth movement. Int J Oral Maxillofac Implants 1991;6:338-44.  Back to cited text no. 8
    
9.
Chee W, Jivraj S. Screw versus cemented implant supported restorations. Br Dent J 2006;201:501-7.  Back to cited text no. 9
    
10.
Ng DY, Wong AY, Liston PN. Multidisciplinary approach to implants: A review. N Z Dent J 2012;108:123-8.  Back to cited text no. 10
    
11.
Xie Y, Zhao Q, Tan Z, Yang S. Orthodontic treatment in a periodontal patient with pathologic migration of anterior teeth. Am J Ortho Dentofacial Orthop 2014;145:685-93.  Back to cited text no. 11
    
12.
Singh G, Batra P. The orthodontic periodontal interface: A narrative review. J Int Clin Dent Res Organ 2014;6:77-85.  Back to cited text no. 12
  [Full text]  
13.
de Molon RS, de Avila ED, Cirelli JA, Cardoso Mde A, Capelozza-Filho L, Borelli Barros LA. Optimizing maxillary aesthetics of a severe compromised tooth through orthodontic movement and dental implants. Case Rep Dent 2014;2014:103808.  Back to cited text no. 13
    
14.
Willmot D. Orthodontic treatment and the compromised periodontal patient. Eur J Dent 2008;2:1-2.  Back to cited text no. 14
    
15.
Kokich VG. Managing complex orthodontic problems: The use of implants for anchorage. Semin Orthod 1996;2:153-60.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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