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Table of Contents
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 107-112

Functional rehabilitation of a patient with generalized Stage IV periodontitis: A clinical report

1 Department of Periodontics, Kusum Devi Sunderlal Dugar Jain Dental College and Hospital, Kolkata, West Bengal, India
2 Department of Prosthodontics and Crown and Bridge, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Date of Submission23-Aug-2021
Date of Acceptance25-Aug-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Kritika Rajan
118/1, Flat 3/1, Gautam Buddha Cooperative Housing, Street No. 257, Da Block, Action Area 1, Newtown, Kolkata - 700 156, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_33_21

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When inflammatory changes around the tooth reach the periodontal ligament and alveolar bone, it is known as periodontitis, which ultimately leads to tooth loss. Generalized Stage IV periodontitis is characterized by the rapid destruction of periodontal ligament and alveolar bone. It is characterized by pathologic migration of teeth and tooth loss, producing esthetic and functional problems for the patient. For restoration of the lost tooth, implant-supported rehabilitation is one of the most successful treatment options, for a fixed prosthesis. In postsurgical prosthodontic rehabilitation, hybrid prosthesis offers a number of advantages including reducing the impact force of dynamic occlusal loads, being less expensive to fabricate, and highly esthetic restorations. The purpose of this clinical report is to present the clinical experience and 1-year follow-up of treating a middle-aged patient suffering from generalized Stage IV periodontitis by means of the implant-supported hybrid prosthesis.

Keywords: Aggressive periodontitis, fixed implant prosthesis, FP3 prosthesis, generalized Grade IV periodontitis, hybrid dentures, implant-supported prosthesis

How to cite this article:
Ganguly R, Choudhury IR, Rajan K. Functional rehabilitation of a patient with generalized Stage IV periodontitis: A clinical report. J Interdiscip Dentistry 2022;12:107-12

How to cite this URL:
Ganguly R, Choudhury IR, Rajan K. Functional rehabilitation of a patient with generalized Stage IV periodontitis: A clinical report. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Mar 27];12:107-12. Available from: https://www.jidonline.com/text.asp?2022/12/3/107/365612

   Clinical Relevance to Interdisciplinary Dentistry Top

  • Generalized Stage IV periodontitis is a disease characterized by severe destruction of periodontal ligament and alveolar bone
  • The key to management of the lost tooth and its supporting structures is an interdisciplinary approach
  • In this case, the periodontist and the prosthodontist formed a liaison to provide an effective treatment.

   Introduction Top

The newly redesigned 2017 periodontal disease classification replaced the 1999 Armitage Classification of periodontal diseases wherein the words "Chronic" and "Aggressive" were replaced by the term "periodontitis" as a broad spectrum of diseases rather than two distinct ones.[1] Aggressive periodontitis, as mentioned in the Armitage Classification, was previously known as "early-onset periodontitis" in 1923.[2] The disease included both localized and generalized forms depending on the extent of spread. It was characterized by the rapid destruction of periodontal ligament and alveolar bone which occurred in otherwise systemically healthy individuals generally of a younger age group.[2],[3] It was said to have a strong genetic predilection and known to have an increased prevalence among females, which supports the hypothesis of an X-linked dominant inheritance.[3],[4] In severe cases, due to extensive bone loss, aggressive periodontitis led to premature tooth loss. This fact, combined with pathologic migration and tooth malposition, made functional and esthetic rehabilitation of these patients extremely challenging.[3],[4] In accordance with the newer classification, this condition can be graded based on the level of interdental clinical attachment loss, radiographic bone loss, and tooth loss as Stage IV generalized pattern of periodontal disease.[1]

Dental implants have become increasingly important in oral reconstruction. The high rate of successful osseointegration, improved retention and stability of prosthesis, satisfactory functional as well as esthetic results make it an excellent option for prosthodontic rehabilitation. With the help of extensive research work, advances have led to better implant materials and designs. Advanced techniques have given predictable success in the implant-supported prosthesis. For different clinical situations, several types of implant designs are available with numerous prosthetic options. The patient's function with a conventional complete denture prosthesis may be reduced to 60% as compared to the natural dentition.[5] The implant prosthesis – FP1 or FP2 or FP3 produces a more satisfactory treatment course than the traditional restorations.

A great and affordable alternative to the known pocket-pinching implant-supported fixed prosthesis is an implant-supported hybrid prosthesis. Implant-supported metal acrylic resin complete fixed dental prosthesis originally referred to as a hybrid prosthesis was introduced to address the problems caused by unstable and uncomfortable mandibular dentures. Hybrid prostheses offer a number of advantages including reducing the impact force of dynamic occlusal loads, being less expensive to fabricate, and highly esthetic restorations. Furthermore, they may be successfully used by a combination of tilted and axially placed implants in partial edentulism.

The purpose of this clinical report is to present the clinical experience and 1-year follow-up of treating a middle-aged patient suffering from generalized Stage IV periodontitis by means of the implant-supported hybrid prosthesis.

   Case Report Top

A 42-year-old female patient reported with a chief complaint of halitosis and multiple mobile teeth. Periodontal examination was conducted, wherein periapical radiographs were taken, and bone loss was calculated. Plaque index, bleeding on probing, periodontal probing depth, and clinical attachment loss were measured at six sites per tooth in all teeth. Results revealed that she had a mobility varying from Grade 2 to Grade 3 with pocket depths (measured using William Probe of GDC – POW6) ranging from 5 to 8 mm around all teeth. The orthopantamogram (OPG) revealed generalized bone destruction around the maxillary and mandibular teeth [Figure 1].
Figure 1: Preextraction orthopantomogram

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The patient was otherwise systemically healthy with no history of smoking or taking any specific drugs. Her family history also revealed early tooth loss in her parents and immediate blood relatives.

After clinical and radiological assessments, considering the loss of bone and labial support, two treatment options had been presented for the patient: implant-supported hybrid dentures or implant-supported fixed prosthesis. Considering her financial status, the patient refused the latter. Considering the health of the tissues around the teeth was poor, an immediate implant procedure was not opted for instead, a two-stage implant procedure would be done for each arch postextraction of all teeth.

Surgical phase

Sequential extraction was done with the posterior teeth being removed first followed by the anterior teeth. Irreversible hydrocolloid (Algitex; The Bombay Trading Corporation, Mumbai) impressions of the upper and lower arches were made and casts were poured with Type III dental stone (B. N. Stone; B. N. Chemicals, Kolkata). Final impressions were made. Jaw relation records were made and before the extraction of the upper and lower anterior teeth, her complete dentures were prepared using pink heat-polymerized poly-methyl methacrylate (DPI; Bombay Burmah Trading Corporation, India). The immediate dentures were delivered to the patient on the day of extraction of the remaining teeth.

After a waiting period of 3 months [Figure 2], the immediate dentures were relined to compensate for the bone loss. The planning for the implants in both arches was initiated. Radiographic markers were placed in the upper and lower dentures, and the patient was sent for a cone-bean computed tomography. The position of the implants was assessed accordingly. From the temporary denture, an implant guiding surgical stent was fabricated in clear heat-polymerized poly-methyl methacrylate (DPI-RR; Bombay Burmah Trading Corporation, India).
Figure 2: Three-months postextraction orthopantomogram

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Using the aforementioned stent, eight internal hexed titanium implants (Osstem implants, UK) were inserted according to the manufacturer's recommendations. Implant locations in the maxillary arch were 13, 15, 23, and 25 and in the mandibular arch were 33, 35, 43, and 45 regions [Figure 3]. Bone augmentation (G-Bone Modified HA Granules, Surgiwear, India) was done in the anterior maxillary region postimplant placement. The two-staged approach was employed and implants were left to submerged healing. After 6 months of an osseointegration period, healing abutments were placed by a palatal crestal incision.
Figure 3: Postimplant placement orthopantomogram

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A coronally repositioned flap from the palatal soft tissue was achieved to facilitate a gain of attached tissue and tension-free closure of the flap.

Prosthetic phase

Healing abutments were placed after the second stage of surgery. After a 3-week interval, the multiangled abutments were fixed to the fixtures. The angulations of the abutments were kept such that screw holes would not lie in the esthetic zone. The immediate dentures were converted into implant-supported fixed temporary dentures with the help of temporary abutments and pattern resin [Figure 4].
Figure 4: Implant-supported fixed temporary dentures

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Special tray was fabricated after a primary impression was made with alginate and perforated metal edentulous stock trays. Border molding was completed with a greenstick compound and the final impression was made with the open tray technique using medium body polyvinyl siloxane (Dentsply, Germany) and light body polyvinyl siloxane (Dentsply, Germany) in a single stage [Figure 5] and [Figure 6]. With the implant analogs in position, the definitive cast was poured with Type IV dental stone (Kalstone; Kalabhai Karson Pvt. Ltd., Mumbai) after positioning of implant analogs and the addition of silicon gingival mask.
Figure 5: Maxillary final impression

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Figure 6: Mandibular final impression

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Master casts were recovered and trimmed and record bases and occlusal rims were fabricated. The jig trial was carried out for the assessment of the accuracy of impression [Figure 7] and [Figure 8]. Special implant-supported occlusal rims were fabricated for jaw relation records [Figure 9]. A facebow record was made and the master casts were then mounted after recording the jaw relation on a semi-adjustable articulator (A7 Plus, BIO-ART articulator, Brazil).
Figure 7: Maxillary jig trial

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Figure 8: Mandibular jig trial

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Figure 9: Special implant-supported occlusal rims

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Wax-up for framework fabrication was carried out. The framework was waxed, cast, recovered, and fitted on the master cast. The laboratory sent the titanium metal substructure framework, which was tried in to evaluate and verify a passive fit intraorally. The maxillary and mandibular denture teeth were waxed to the hybrid framework, and a final wax try-in was performed to verify and correct maxillomandibular relations. At this appointment, the customized abutments along with the framework were connected to the implants for the final wax try-in [Figure 10].
Figure 10: Final wax try-in

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The definitive prosthesis was screwed into position. The final torque was established using a torque wrench [Figure 11], [Figure 12],[Figure 13]. The abutments screw holes were secured with teflon and zinc oxide-eugenol cement. Postinsertion instructions were given to the patient. Regular follow-up was done during which a thorough cleaning of the prosthesis was done, as required. A 1-year follow-up revealed the absence of clinical signs of implant failure or prosthesis failure.
Figure 11: Definitive prosthesis – frontal view

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Figure 12: Definitive prosthesis – right lateral view

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Figure 13: Definitive prosthesis – left lateral view

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   Discussion Top

Periodontal disease is an oral condition that is highly prevalent among the adult population. The management of periodontitis is a colossal task; untreated periodontal patients lose 0.28 teeth per patient per year, whereas treated patients lose 0.08 teeth per patient per year.[6]

Monie et al. conducted a study to find out whether dental implants placed in patients with generalized aggressive periodontitis (GAgP) had similar survival rates and marginal bone loss when compared with patients with chronic periodontitis (CP) and/or healthy patients (HPs). They concluded that implant placement in patients with a history of GAgP might be considered a viable option to restore oral function with survival outcomes similar to those found in both patients with CP and HPs. However, the risk ratio for failure in patients with AgP is significantly higher when compared with HP and those with CP. In the current case, implants have been limited only to those areas which had more than adequate healthy bone.[7]

Eglimex et al. stated that a hybrid denture is the recommended modality of treatment in cases, where there is excessive interarch space.[8] In the current case, the patient had an interarch space of 30 mm.[8]

An implant-supported hybrid prosthesis is an acrylic resin complete fixed dental prosthesis which is supported by implants, it helps in extreme cases, where esthetics, function, lip support, and speech are a great concern.[9]

Poly methyl methacrylate (PMMA) has various advantages over pink porcelain which is less natural-looking and usually requires more baking cycles that increase the risk of porcelain fracture. Hybrid prostheses have a great number of advantages including reducing the impact force of dynamic occlusal loads, being less expensive to fabricate, and highly esthetic restorations. The acrylic acts as an intermediary between the porcelain teeth and metal substructure, so they are indicated for implant restoration in large crown height spaces as a thumb rule.[10] However, rare cases of food impaction below the prosthesis, and issues with speech have been reported.[9],[10]

An important aspect, when fabricating implant-supported fixed complete prosthesis is the framework material. The veneered porcelain fracture and chipping of porcelain have always been a complication for bilayered ceramic restorations.[11] There has always been an debate whether rigid material can minimize the bending moment of the framework. Studies have shown that cobalt–chromium frameworks generate a very low amount of strain on the implants, due to the accuracy of fit of the framework.[12]

There has always been a question about mandibular flexion and connected bars over the implant. However, it is not completely clear about the significance of mandibular flexure on the success of implant treatment.[12] The amount of strain produced by mandibular flexure alone was not significant enough to stimulate bone modeling or remodeling.[12],[13] On the basis of these results, we could infer that splinting the implants in the mandible would not jeopardize the longevity of prostheses.

For the success of an implant-supported prosthesis, regular checkups are required every 6 or 12 months to avoid complications and to assess the status of the peri-implant tissue. It is necessary to measure radiographic peri-implant marginal bone loss during these visits.[10] Hence, regular checkup and assessment were carried out at 2, 6, and 12 months after the delivery of the prostheses.

   Conclusion Top

Dentists must consider the advantages and disadvantages of the available implant prosthetic options and match them to the patient's expectations. This case demanded superior esthetics and function despite the patient suffering from a generalized periodontal condition known as aggressive periodontitis leading to excessive bone loss and causing excessive interarch distance. Affordability was also a major concern. Keeping all these conditions in mind, the fabrication of a maxillary and mandibular implant screw-retained hybrid prosthesis was proposed and carried out successfully. The dental implants as well as the prosthesis revealed the absence of clinical signs of implant failure or prosthesis failure even after a 1-year follow-up.

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 her 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


Conflicts of interest

There are no conflicts of interest.

   References Top

Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the classification of periodontal and peri-implant diseases and conditions. J Clin Periodontol 2018;45 Suppl 20:S162-70.  Back to cited text no. 1
Albandar JM. Aggressive periodontitis: Case definition and diagnostic criteria. Periodontol 2000 2014;65:13-26.  Back to cited text no. 2
Carvalho CV, Saraiva L, Bauer FP, Kimura RY, Souto ML, Bernardo CC, et al. Orthodontic treatment in patients with aggressive periodontitis. Am J Orthod Dentofacial Orthop 2018;153:550-7.  Back to cited text no. 3
Shah A. Periodontitis – A review. Med Clin Rev 2017;3:14.  Back to cited text no. 4
Gowd MS, Shankar T, Ranjan R, Singh A. Prosthetic consideration in implant-supported prosthesis: A review of literature. J Int Soc Prev Community Dent 2017;7:S1-7.  Back to cited text no. 5
Cobb CM. Non-surgical pocket therapy: Mechanical. Ann Periodontol 1996;1:443-90.  Back to cited text no. 6
Meng H, Xu L, Li Q, Han J, Zhao Y. Determinants of host susceptibility in aggressive periodontitis. Periodontol 2000 2007;43:133-59.  Back to cited text no. 7
Monje A, Alcoforado G, Padial-Molina M, Suarez F, Lin GH, Wang HL. Generalized aggressive periodontitis as a risk factor for dental implant failure: A systematic review and meta-analysis. J Periodontol 2014;85:1398-407.  Back to cited text no. 8
Egilmez F, Ergun G, Cekic-Nagas I, Bozkaya S. Implant-supported hybrid prosthesis: Conventional treatment method for borderline cases. Eur J Dent 2015;9:442-8.  Back to cited text no. 9
[PUBMED]  [Full text]  
Misch CE. Contemporary Implant Dentistry. St. Louis, MO: Mosby Elsevier; 2008. p. 99-100.  Back to cited text no. 10
Priest G, Smith J, Wilson MG. Implant survival and prosthetic complications of mandibular metal – Acrylic resin implant complete fixed dental prostheses. J Prosthet Dent 2014;111:466-75.  Back to cited text no. 11
Law C, Bennani V, Lyons K, Swain M. Influence of implant framework and mandibular flexure on the strain distribution on a Kennedy class II mandible restored with a long – Span implant fixed restoration: A pilot study. J Prosthet Dent 2014;112:31-7.  Back to cited text no. 12
Demarosi F, Leghissa GC, Sardella A, Lodi G, Carrassi A. Localised maxillary ridge expansion with simultaneous implant placement: A case series. Br J Oral Maxillofac Surg 2009;47:535-40.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]


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