A 41-year-old woman with no relevant medical history was referred from a general dental clinic to a periodontics clinic in order to start a multidisciplinary treatment, except for being under hormonal replacement therapy.
The reason for consultation was to correct the aesthetic front, to solve the mobility of the 22 and the replacement of the lower molars.
In the anamnesis of his dental history he had smoked more than 20 cigarettes per day and had maternal history of periodontal disease.
1.
Dental examination revealed absence of 18/28/35/ 36/38/45 and fillings in several pieces.
Periodontal examination showed absence of bacterial plaque and gingival bleeding, probing depth between 4 and 7 mm, loss of generalized support; vestibular furcation grade 1 and lingual mobility grade 2 in 37; anterior superior furcation grade 2 in 47
Orthodontic examination revealed skeletal class III and dental malocclusion, anterior crossbite and, in centric relation, premature contact, associated with functional overload of anterior teeth.
In the orthotomy, it was found absence of teeth, good coronary relationship, generalized and horizontal bone loss of more than 50%, widened periodontal, angular defect in 37 neck and horizontal root gap 47 in cortical group.
Cephalometric study revealed skeletal class III, protrusion of lower limbs and increased facial height.
Location of the temporomandibular joint: no interest.
Based on the previously exposed data, the following diagnosis was established: generalized and advanced periodontal disease; skeletal class III and dental.
1.
Treatment exposure
The treatment was planned in four phases: periodontal regeneration, arch leveling by orthodontics, teeth replacement by implant-supported prosthesis and periodontal support therapy.
First phase: we began with periodontal treatment.
The patient had already been motivated and instructed in oral hygiene rules and habits by the dentist, which allowed to pass directly to the debridement of root surfaces, performing scrapings, contaminated and polished surfaces.
Since the patient was a heavy smoker, this phase was somewhat laborious.
We completed this phase with periodontal surgery of residual pockets, that is, those with bleeding on probing four weeks after the completion of the basic phase.
Once implanted, we managed to treat angular bone defects and furcation defects of 12, 22, 37 and 47, each of them with a small flap to regenerate periodontal tissues.
The time elapsed in the previous steps served to reinforce the patient's hygiene habits interchange and encourage him to quit smoking, which led to the onset of psychosis.
A relaxation splint had to be prepared because tobacco suppression caused a lot of anxiety, sensitivity and dental pain.
Maintenance review was also proposed every four months after completion of the remaining treatment phases if the periodontal situation and implants did not vary.
Second phase.
Twelve months after guided periodontal regeneration, the patient was referred to the orthodontist to continue treatment.
This phase began with fixed orthodontics, leveling the maxillary arch with a mandibular bite lift.
Once the anterior bite was resolved, the mandibular arch was leveled, preparing the spaces that would later serve to place implants, if the width of bone allowed it.
To achieve these spaces, mandibular posterior molars were leveled using arches with stairs so as not to interfere with chewing.
Although it was class III, it was necessary to push the third quadrant in class II dental without overloading the 22 upper limbs to the left side, so we avoided correcting Class II elastics.
To mesialize the third quadrant, a bone anchor was used by means of a microscrew and a spring of 19 x 25 TMA®, where we can observe the canine in class I of sealant.
Final records can be seen in Figure 9.
Finally, the orthodontist made an intracoronary retention, which the patient should carry for life.
1.
The third phase, or replacement phase of missing molars, initially required computed tomography (CT) of edentulous areas to assess the possibility of implant placement.
Thanks to the images of various sections, later manipulated with simulation programs for viable implants, it was concluded that it was possible to place fixations of 9 mm (Astra®) on each side of the 3.5 mm edentulous implants.
These fixations were guided and installed by a diagnostic-surgical splint, previously tapered by the prosthodontist, in the places corresponding to the teeth 35,36,45,46.
As is usual in these surgical treatments, the patient was presented, days before the surgery, along with the treatment plan and plan, from the College of Dentistry and Stomatology of possible risks to inform him about the intervention.
After meditate reading, the patient proceeded to preceptive informed consent.
On the other hand, the patient continued to carry the relaxation splint during the integration period, due to the comfort it provided.
In the fourth phase, the prosthodontist performed the implant-supported prosthesis in ceramic metal and cemented it since the general practitioner at that time did not place implants or make implant-supported prostheses.
Figure 11 shows the patient one year after orthodontic treatment with rehabilitated mouth.
In the third radiological control after placement of fixations, bone loss was observed in several fixations corresponding to 35' and 45'.
It was decided to keep this mucosa under a very strict oral hygiene regime, performing fortnightly controls of plaque, polishing of the surface of pieces and implants with rubber cup and peri-implant bleeding with chlorhexidine probe for 12 hours.
1.
The patient is currently undergoing periodontal maintenance treatment, with quarterly reviews to check the stability of its parts, implants and prostheses.
