The treatment planning of patients with periodontal problems is always particularly complex, especially when involve relatively young patients (between 40 and 50 years) who need to undergo multiple extractions. In these cases it is particularly difficult to motivate the patient to acquire adequate standards of oral hygiene and correct lifestyles.
Once the acute phase of periodontal disease has been resolved, it is necessary to establish a correct treatment plan and above all, to understand how to replace the dental elements that must be extracted.
A history of periodontitis is a well-established risk factor for implant failure, peri-implantitis and increased marginal bone loss, particularly in advanced cases.
Therefore, comprehensive periodontal assessment and disease stabilization are recommended prior to implant placement in patients with a history of periodontal disease. Regular periodontal maintenance reduces the risk of implant complications in this population.
If these objectives are achieved, it may be useful, in the aesthetic areas, to reason in terms of immediate post-extractive implants in order to solve the patient’s aesthetic problems and try to maintain the maximum quantity and quality of soft and hard tissues.
With this case you can understand how, with a correct implant-prosthetic planning and regular periodontal maintenance, is possible to obtain excellent aesthetics results after 10 years follow up.
Fig.1
In 2012 this 49-year-old patient came to our observation, in good general health but suffering from a severe form of chronic periodontitis, considerable loss of attachment on all dental elements of the lower frontal group and diffuse mobility of grade 2/3.
Fig.2
Radiographic status confirming the clinical diagnosis.
Fig.3
In 2014, after 2 years of periodontal causal therapy, it was decided, in agreement with the patient, to proceed with the replacement of dental elements from 43 to 33 with an implants supported prosthesis. For this reason, a diagnostic wax-up was performed from which this surgical guide for implant insertion was obtained.
Fig.4
Also starting from the diagnostic wax-up, a reinforced resin temporary is produced.
Fig.5
Once the lower front elements have been extracted, 2 immediate post-extraction implants were inserted in place of the canines using the surgical-prosthetic guide.
Fig.6
All post-extraction sites were filled with deproteinized bovine bone, while an absorbable membrane was inserted between the implant itself and the residual alveolar bone was added to contain the heterologous bone. A MUA abutment was connected to the implants on which a temporary cylinder was screwed.
Fig.7
The reinforced provisional, once rebased and finished, was screwed into the MUA abutments. The emerging profile of temporary crowns on implants has been made 360°concave to avoid any compression on the soft tissues, trying to maximize their regrowth. In the 33 area the concavity was intentionally exasperated because there was a lack of keratinazed soft tissue.
Fig.8
Xray control.
Fig.9
Clinical control after 9 months: good soft and hard tissues healing ready for the final impression. A great volume of keratinized tissue was obtained around the implant in position 33.
Fig.10
Clinical situation of the MUA abutment and surrounding soft tissues after the provisional removal ready for the impression.
Fig.11
At that time (2014) we have utilized a laboratory scan to transform the analogic workflow in a digital one to produce a cad-cam titanium framework.
Fig.12
A screw retained titanium-ceramic prosthesis was realized.
Fig.13
Final clinical situation in 2014.
Fig.14
Xray control.
Fig.15
Clinical situation in 2025 after more than 10 years of function and regular periodontal maintenance.
Conclusions
The prosthetic rehabilitation of the periodontally compromised patients is always challenging. Once that the periodontal situation has been resolved and the patient has been inserted in a periodontal maintenance program we have the possibility to plan the extractions of the hopeless teeth and simultaneously insert the post-extractive implants. This technique is already well established since the study of J.Kan in 2003 and then improved year by years learning how is possible to maintain and also improve the quality and quantity of the hard and soft tissues by extracting the tooth insert an implant and contemporary graft the socket around it with heterologous bone and connective tissue or connective substitutes. In 2007 Rompen et A. and in 2009 Redemagni et Al. have established the importante to create a concave emergency profile of the prosthetic rehabilitation in order to allow increase the amount of the keratinized tissue surrounding the implant.
In this case we have applied all those concepts in a severe periodontal compromised patient in order to obtain excellent aesthetic result in the lower anterior area and maintained them for more than 10 years with the cooperation of a well trained dental hygienist.
Bibliography
- Clinical Outcomes of Dental Implants in Patients with and without history of periodontitis: a 20-year prospective study: Journal of Clinical Periodontology. 2022 Roccuzzo A., Imber JC, Marruganti C., et al.
- Long term implant survival in Periodontitis Clinical Oral Implants Research. 2026 Kashta A., Baumeister SE, Ehmke B, Reckelkamm SL.
- The effect of factors related to periodontal status toward peri-implantitis Clinical Oral Implants Research 2019. Arunyanak SP, Sophon N., Tangsathian T.Int. J. Oral Maxillofac. Implants.
- Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study 2003 Int. J. Oral Maxillofac. Implants Kan J., et al.
- Soft tissue stability at the facial aspect of gingival converging abutments in the esthetic zone: a pilot clinical study 2007 J.of Prostetic Dent. Rompen., Raepsaet N., Domain O., Touati B., Van Dooren E.
- Soft tissue stability with immediate implants and concave abutments 2009 Redemagni M., Garlini G., et al.
