University of Medicine and Pharmacy Tg Mures
Faculty of Dentistry
Rehabilitation Department
A CONSERVATIVE APPROACH IN RESTAURATION WITH COMBINATION
FIXED PARTIAL PROSTHESES AND METAL BASED PARTIAL DENTURE.
CASE REPORT
Case report
37 years old male patient;
Non smoker;
No history with any systemic
disease(acut or cronic) or allergy;
Chief complaint: Complex oral reabilitation ( aesthetics,
mastication, functional);
Expectations
To have the best available treatment
option for his teeth;
Clinical examination
The fixed prostheses that already has is old and deteriorated;
Palpation shows mobilization of the fixed prosthesis;
2.1 tartric gingivitis with grade I mobility;
2.7 with grade I/II mobility; without acut symptoms;
Patient typology:
Cooprative patient and confident;
Radiographic examinations
The tooth 3.8 had periapical and inter-radicular radiolucency and an incomplete
root treatment, the upper left second molar had a deep periodontal pocket on
the mesial aspect of the root with grade 1 mobility, the tooth 2.1 had grade 2
mobility and tooth 3.5 with concurrent endodontic and periodontal disease that
communicated with each other. Both the lower third molars were mesial inclined
and had occlusal caries 4.8 or composite restoration 3.8. The 1.7 molar has over-
erupted into the space left by the missing tooth.
Radiographic examinations
The tooth 3.8 had apical and inter-radicular
radiolucency and an incomplete root-canal
treatment;
The tooth 2.7 , the upper left second
molar had a deep periodontal pocket on
the mesial aspect of the root with grade
1 mobility.
The tooth 3.5
1. with concurrent endodontic and
periodontal disease (that had
periodontal pocket on the mesial aspect
of the root) communicated with each
other;
2. Compozit coronal restauration;
Loss of bone supporting the frontal upper
teeth-there is a pocket around the teeth;
Diagnosis: 1. Partial edentulism (teeth 1.6, 22-26, 36-
37, 46-47 are missing); Maxilar Kennedy
class III/1; Mandibular Kennedy class
III/1;
2. Chronic apical periodontitis: 3.8;
3. Chronic marginal periodontitis 2.7, 3.5;
4. 2.1 tartric gingivitis with grade I mobility;
What are the options for treatment?
1. Conventional bridge : combined fixed partial prostheses and metal based
partial denture;
2. Conventional fixed-fixed bridge;
3. Conventional bridge: combined fixed partial denture in the upper teeth and
partial denture with acrylic resine base maxillary and 2 fixed partial denture
mandibulary;
4. Implants- supported bridge maxillary and mandibular;
5. A combination of all three: implants, fixed and removable prostheses;
6. Use conventional orthodontic treatment to re-align the teeth before restoring
and replacing teeth with crowns and bridges;
• After considering the patient’s wish and the clinical
situations we decided that the best long-term
treatment even if he is only 37 is : the option of
conventional bridge:
combined fixed partial prostheses and metal based
partial denture was chosen to restore the maxillary
arch;
conventional fixed-fixed bridge for the mandibular
arch;
Treatment procedures
Pre-prosthetic treatment
1. Desease Control Phase
1. At this stage we removed the old deteriorated fixed prostheses;
2. Scaling and root planning, dental polishing;
3. Patient motivation, oral hygiene instructions were given.
2. Periodontal treatment phase
1. In the following appointment we decided to treat the bone defects which
are related with teeth number (1.3, 1.2, 1.1, 2.1, 2.7, 3.5) using a
microinjector with bone graft substitutes to repair bone defects of
periodontal disease. The bone substitute used was synthetic calcium
phosphate with similar chemical components and structure to normal
bone.
2. Re-evaluation of periodontal condition after 3 months;
3. Endodontic treatment phase
1. The first step involved endodontic treatment of teeth 1.3, 1.2, 1.1,2.1, 2.7(in a
few sessions) . Following root canal treatment the tooth 1.3 recived fiber post
and composite build up, the rest of the teeth were restored only with
composite;
2. re-root treatment for the tooth number 3.8 because the root-canal treatment
is not satisfactory and apical and inter-radicular radiolucency remain
associated with the tooth;
3. Also we decided to do a re-root treatment for the tooth number 4.5 because
the coronal restoration was missing so the root canal treatment is
compromised;
4. The treatment for the tooth number 3.5 involved endodontic treatment
following by composite build up;
II Prosthodontics phase
Conventional bridge:
combined fixed partial
prostheses and metal based
partial denture ( removable
partial denture) was chosen
to restore the maxillary arch
and 2 conventional fixed-
fixed bridge for the
mandibular arch.
Prognosis
1. There are many factors that may affect the progression of both
endodontic and periodontal diseases. These factors may also affect
the outcome of any treatment provided.
2. Prognosis dependent on patients ability to sustain stable periodontal
conditions, this will be evalated throughout phase 1;
3. Having many root-canal treated teeth , fixed prosthesis and
removable partial denture all this are factors that could affect the
prognosis;
4. On the other hand, if the response to the periodontal treatment that
we decident to do has not been favourable, we need to think about
other options of rehabilitation.
Discussion
1. Evidence of high prevalence of periodontal disease amongst the population
with almost 72% of the individuals having at least one tooth with periodontal
disease was demostrated by K. P. Peter, B. R. Mute;[2]
2. The periodontal pathogens found around failing implants are very similar to
those associated with various forms of periodontal diseases. Genetic
susceptibility has been known to be an important risk factor for periodontitis
and periimplantitis and there have been numerous studies evaluating this in
different populations , Kadkhodazadeh M, Tabari ZA[1]
3. Patients with implants replacing teeth lost due to chronic periodontitis
demonstrated lower survival rates and more biological complications than
patients with implants replacing teeth lost due to reasons other than periodontitis
during a 10-year maintenance period. Furthermore, setting of thresholds for
success criteria is crucial to the reporting of success rates. Karoussin&Salvi[5];
Discussions
4. The reports of its prevalence vary but it is noted that the presence of periodontal
disease is a risk factor for peri-implantitis. The issue of peri-implantitis was raised in
the House of Lords in 2014. Complaints relating to implants is on the rise with the
General Dental Council. Placement of implants in patients with periodontal disease is
not a treatment that should be done without a full periodontal assessment and
stabilisation of periodontal disease first. King&Pattel 2016[4];
5. Synthetic substitutes are advantageous for applying for oral tissue engineering
because they have uniform particles, and are biocompatible. Compared with the
traditional GBR method, the microinjector for dental application is very convenient
because the bone defects could be filled by the substitutes carried by the
microinjector via a one-step injection [HC Tsai& MH Chen 2016];
Discussion
6 . The endodontic treatment that we chose was based on scientific research (I.
Rotstein& James 2014 Danemark, S. Evren& C. Keskin 2016 Turkey, PV Abbott& J.
Salgado 2009 Australia)
References
1. Relationship between Genetic Polymorphisms with Periodontitis and Peri-Implantitis in the
Iranian Population: A Literature Review.Kadkhodazadeh M, Tabari ZA, Pourseyediyan T2,
Najafi K, Amid R. J Long Term Eff Med Implants. 2016;26(2):183-190. doi:
10.1615/JLongTermEffMedImplants.2016015197;
2. . Kalpak Prafulla Peter1, Bhumika Ramchandra Mute2, Unnati Mahesh Pitale3, Sujan Shetty4,
Shashikiran. HC5, Pranali Shirish Satpute.Prevalence of Periodontal Disease and
Characterization of its Extent and Severity in an Adult PopulationAn Observational Study.
3. Hsiao-Cheng Tsai , Yi-Chen Li, Tai-Horng Young , Min-Huey Chen . Novel microinjector for
carrying bone substitutes for bone regeneration in periodontal diseases. Journal of
thMAGDALENA NATALIA DINA, RUXANDRA MĂRGĂRIT,OANA CELLA ANDREI Pontic
morphology as local risk factor in root decay and periodontal disease. Romanian Journal of
4. Br Dent J. 2016 Dec 9;221(11):705-711. doi: 10.1038/sj.bdj.2016.905.Should implants be
considered for patients with periodontal disease?King E1, Patel R2, Patel A2, Addy L3.
5. Clin Oral Implants Res. 2003 Jun;14(3):329-39.Long-term implant prognosis in patients with
and without a history of chronic periodontitis: a 10-year prospective cohort study of the ITI
Dental Implant System.Karoussis IK1, Salvi GE, Heitz-Mayfield LJ, Brägger U, Hämmerle CH,
Lang NP.
References
6 . Evren Sarıyılmaz, PhD, Cangül Keskin, DDS,Oznur Ozcan, DDS Retrospective
analysis of post-treatment apical periodontitis and quality of endodontic treatment and
coronal restorations in an elderly Turkish population. Journal of Clinical Gerontology
& Geriatrics;
7. PV Abbott,* J Castro Salgado, Strategies for the endodontic management of
concurrent endodontic and periodontal diseases; Australian Dental Journal 2009; 54:(1
Suppl): S70–S85;
8. Ilan Rotstein & James H. S. Simon Diagnosis, prognosis and decision-making
in the treatment of combine periodontalendodontic lesions Periodontology 2000,
Vol. 34, 2004, 165–203 Copyright # Blackwell Munksgaard 2004
