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Removal of a Fractured Implant Abutment: Sykaras A Case Report Nikitas Sykaras DDS, PhD1 Abstract Background: Fractured abutments or abut- appropriate tools and instruments for pre- ment screws are a common complication of cise intraoral procedures. A drill-guide pro- implant supported restorations. However, their vides stability to the drill directing it parallel removal may be difficult and time-consuming to the long axis of the implant. Drills and taps depending on the configuration of the implant- of consecutive sizes are utilized to drill-out abutment connection, the location of the the threaded fragment and machine the pros- implant, the thickness of surrounding soft tis- thetic connection for new abutment insertion. sues and the experience of the clinician. The fractured component must be removed with- Results: The fractured abutment screw out damaging the internal nor the external sur- in this case report was easily removed. face of the implant, in order to ensure proper replacement and long lasting abutment stability. Conclusion: The use of precisely designed instruments, according to a prescribed step- Methods: This paper describes the clini- by-step procedure, not only minimizes the cal steps that must be followed to remove the risk of implant damage but equally important fractured threaded end of an abutment, uti- strengthens the confidence of the clinician in lizing a special rescue kit that provides the his difficult effort to overcome the complication. KEY WORDS: Dental implants, abutment, screw fracture 1. Lecturer, Department of Prosthodontics, University of Athens Dental School, Athens, Greece The Journal of Implant & Advanced Clinical Dentistry • 55
Sykaras INTRODUCTION Figure 1: Schematic representation of implant internal chamber and corresponding abutment. Dental implants deserve a wide share of pros- thetic rehabilitation today, since evidence based reported in the literature, problems and complica- treatment protocols and basic research ren- tions are often related to implant supported resto- der their clinical application highly predictable rations and vary in clinical significance and level of and successful.1,2 Single edentulous spaces or difficulty in treating them.14,15 These problems may complete edentulism can be restored with one be attributed to either the prosthesis itself or its or multiple implants properly inserted in pre- components. Abutment screw fracture is a very cisely prepared bone sites as directed by the common complication mainly associated with the treatment plan.3,4 The microscopic and macro- connection configuration, the prosthesis design scopic design of the implant surface is of para- mount importance for osseointegration to be accomplished and to ensure long lasting pres- ervation and health of the peri-implant tissues.5 Equally important for the success of the restorative procedure is the design of the pros- thetic connection. There are generally two major categories of implant-abutment connections: inter- nal and external.6 Within those two categories, various designs and configurations have been developed in an attempt to facilitate the intra- oral engagement of the two components, to pro- vide anti-rotation and thus secure the applied torque, to protect the abutment screw from functional loading and enhance load distribu- tion through implant body to the supporting bone tissue.7,8,9 Various parameters affect and deter- mine the design of the implant supported resto- ration and are in accordance with the anatomy and location of the edentulous space, the num- ber and dimensions of the implants, the type of opposing occlusion and patient’s desires.10,11 Inadequate number of implants with unfavorable distribution supporting a restoration that func- tions under bruxism, overloading or non-axial loading are detrimental factors for the develop- ment of biologic and technical problems.12,13 Despite the favorable rates of success that are 56 • Vol. 2, No. 4 • May 2010
Sykaras Figure 3: Implant/abutment used in this case report. Figure 2: Assembled implant-abutment complex in the Figure 4: Implant / abutment complex. Morse taper connection. clinical significance of this difference is that the and the tightening torque.16,17 The depth of the broken end of the abutment is not tightly threaded connection, the anti-rotational features, the pre- in the internal chamber of the implant body and cision tolerance, the surface area and the screw thus can typically be removed with relative ease. design are critical elements of the prosthetic con- nection that could enhance the stability of the The tightening torque differs in various implant implant-prosthesis complex.18,19 An example of an systems according to the components design, the internal implant-abutment connection is the Morse material of the screw, the thread design, the screw taper connection (figure 1).20,21 In this connec- head and the connection configuration.24,25 The tion design, two conical surfaces of 8o develop a manufacture suggested tightening torque, gener- mechanical friction when they adapt to each other ates an initial tensile preload that clamps the com- upon tightening torque (figure 2). The solid abut- ponents together to allow functional loading.26 For ment is a one piece threaded component with this reason torque control ratchets are available a manufacture suggested tightening torque of to ensure calibrated force application. However, 35Ncm (figure 3).22 As a result of the connec- under functional loading and in conjunction with tion design, 91% of the applied torque develops the previously mentioned clinical and mechanical in the conical engaging surface of the abutment parameters, loosening of the abutment screw may and 9% is transferred to the abutment threaded occur over time.27,28,29 If such loosening does not end in the form of pretension (figure 4).23 The occur, continuous functioning of a non-stable con- nection may lead to abutment or abutment screw fracture that must be resolved if the implant is to remain functional.30 Removal of the fractured component must take place in a way that does not jeopardize the integrity of the implant’s inter- The Journal of Implant & Advanced Clinical Dentistry • 57
Sykaras Figure 7: Working cast with abutments in place. Figure 5: Initial clinical presentation of patient. Figure 6: Implant installation. Figure 8: Final hybrid prosthesis in place nal chamber, thus allowing the implant to be func- CASE REPORT tional upon replacement of the component. This paper describes the process of fractured abut- A 62 year-old patient presented with a unilateral ment removal applying a technique that ensures edentulous space in his left mandible request- precision drilling while preserving internal implant ing fixed restoration (figure 5). The length of the surfaces for subsequent abutment connection. edentulous ridge, the periodontal support of the adjacent abutment teeth, and their morphology 58 • Vol. 2, No. 4 • May 2010
Sykaras Figure 9: Radiographic veri cation of prosthesis t. Figure 12: Fractured thread stuck in the implant. Figure 10: Fractured prosthesis. Figure 11: Removal of loose threaded fragments. Figure 13: Service set used for removal of fractured components. prevented the fabrication of a conventional fixed partial denture. Instead, an implant supported 4.1 X 12mm (Straumann, Basel, Switzerland) restoration was decided as an alternative option. were inserted and allowed to heal transmuco- sally for 3 months (figure 6). After 3 months, Diagnostic casts were mounted for the fab- initiation of the restorative phase involved the rication of a radiographic template which was installation of four solid abutments (Strau- then altered to a surgical guide. Four implants mann, Basel, Switzerland) and fabrication of a The Journal of Implant & Advanced Clinical Dentistry • 59
Sykaras Figure 14: Drill guide stabilized on the holder. Figure 16: Threaded taps used for screw removal. Figure 15: Drill guide stabilized in Morse taper and drilling Figure 17: Tap guide stabilized in Morse taper and thread of the fragment. tapping. cementable metal-acrylic restoration (figures Switzerland). This set contains all the neces- 7-9). After 14 months of function, the patient sary armamentarium for the safe and reliable presented with broken abutments and a loose elimination of any stuck and/or fractured com- restoration (figure 10). Three of the fractured ponents in Straumann implants (figure 13). threaded portions were removed utilizing plas- tic sticks with adhesive tips rotating in a coun- After cement and food debris removal, the ter clockwise direction (figure 11). However, area was flushed with physiological saline solu- in one implant the fractured abutment screw tion. Drilling guide No. 1 was secured in the was stuck (figure 12). For this reason the holder with an Allen screw and then stabilized “service set” was utilized (Straumann, Basel, with a firm fit in the Morse taper of the implant (figure 14). The drill was inserted into the guide 60 • Vol. 2, No. 4 • May 2010
Sykaras Figure 18: The fractured thread is removed and the completion of each step. All traces of metal implant is functional again. debris were flushed and repair of the internal chamber of the implant had been completed rotating counterclockwise at a maximum speed (figure 18). New solid abutments were inserted, of 600 RPM, with intermittent drilling and con- torqued to the suggested force and the same tinuous cooling (figure 15). Produced metal prosthesis was permanently cemented in place. chips were ejected continuously and the drill and guide were removed for cleaning at regular DISCUSSION intervals. The preparation was completed when the shank of the drill levels with the guide. The The aforementioned technique provides the internal chamber was cleaned thoroughly by clinician with the necessary tools and instru- flushing. Drilling guide No. 2 was secured in the ments to overcome the complication of a holder with an Allen screw and stabilized in the fractured implant screw. However, the impor- Morse taper. The thread was tapped using taps tance of regular recall program must be in their correct order (figure 16). The tap was emphasized because such technical prob- twisted carefully, by hand, in a clockwise direc- lems could give signs at an earlier time and be tion. Vaseline was applied to the tip of the tap resolved easier then.31 In addition to this, the to prevent tap from wedging. After each ½ turn patient needs to be informed about the pos- of tap, it was turned back by ¼ turn to release sibility of complications relating to implant the stress and clear the metal chips which were prosthodontics and be aware of the techni- removed with a pair of tweezers. The tap was cal and biological risks that are involved.32 twisted in the hole until it touched the end of the hole and leveled with the guide surface (fig- This rescue procedure may be time con- ure 17). Tapping continued with all six taps in suming depending on the clinical situation, the sequence and followed by careful cleaning after location of the implant, and the cooperation of the patient. For these reasons, it may be nec- essary to complete this process in consecutive appointments. The counterclockwise rotation of the drill may loosen the fractured fragment during its perforation. Therefore, the fragment should be evaluated for possible mobility using a sharp probe under visual magnification. In this way, subsequent tapping may be unneces- sary. The drilling hole during tapping should be axial and round. This can be accomplished if the guide is held comfortably yet stabilized with tight precision on the implant. In resolving this clinical complication, the clinician should evaluate the etiological factors that led to the component fracture in order to avoid future The Journal of Implant & Advanced Clinical Dentistry • 61
Sykaras recurrence.33 The use of precisely designed Correspondence: instruments according to a prescribed step-by- Dr. Nikitas Sykaras step procedure, not only minimizes the risk of Nikis 25, Halandri 15233, GREECE implant damage during fractured component Tel/Fax: +302106800636 removal, it also strengthens the confidence of e-mail: [email protected] the clinician to overcome the complication. Disclosure 12. Karoussis IK, Brägger U, Salvi GE, Bürgin W, 22. Higginbottom F, Belser U, Jones JD, Keith The author reports no conflicts of interest with Lang NP. Effect of implant design on survival SE. Prosthetic management of implants in the anything mentioned in this article. and success rates of titanium oral implants: esthetic zone. Int J Oral Maxillofac Implants a 10-year prospective cohort study of the ITI 2004;19(Suppl):62-72. References Dental Implant System. Clin Oral Implants Res. 1. Grossmann Y, Levin L. Success and survival of 2004 Feb;15(1):8-17 23. Schar AR, Merz BR. Mechanics of the Synocta Implant/Abutment Connection. Walnendburg, single dental implants placed in sites of previously 13. Kohavi D. Complications in the tissue integrated Switzerland: Institut Straumann; 1999. failed implants. J Periodontol 2007; 78(9):1670- prostheses components: clinical and mechanical 1674. evaluation. J Oral Rehabil 1993;20(4):413-422. 24. Lang LA, Wang RF, May KB. The influence of abutment screw tightening on screw joint 2. Smith DE, Zarb GA. Criteria for success of 14. Brägger U, Aeschlimann S, Bürgin W, Hämmerle configuration. J Prosthet Dent 2002;87(1):74- osseointegrated endosseous implants. J Prosthet CH, Lang NP. Biological and technical 79. Dent 1989;62(5):567-572. complications and failures with fixed partial dentures (FPD) on implants and teeth after four 25. Byrne D, Jacobs S, O’Connell B, Houston F, 3. Budtz-Jörgensen E. Restoration of the partially to five years of function. Clin Oral Implants Res Claffey N. Preloads generated with repeated edentulous mouth--a comparison of overdentures, 2001;12(1):26-34. tightening in three types of screws used in removable partial dentures, fixed partial dentures dental implant assemblies. J Prosthodont and implant treatment J Dent 1996;24(4):237- 15. Jung RE, Pjetursson BE, Glauser R, Zembic A, 2006;15(3):164-171. 244. Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of implant- 26. Haack JE, Sakaguchi RL, Sun T, Coffey JP. 4. Pjetursson BE, Lang NP.Prosthetic treatment supported single crowns. Clin Oral Implants Res Elongation and preload stress in dental implant planning on the basis of scientific evidence. J Oral 2008;19(2):119-130. abutment screws. Int J Oral Maxillofac Implants Rehabil 2008; 35 Suppl 1:72-79. 1995;10(5):529-536. 16. Brägger U, Karoussis I, Persson R, Pjetursson 5. Bhatavadekar N. Assessing the evidence B, Salvi G, Lang N. Technical and biological 27. Theoharidou A, Petridis HP, Tzannas K, Garefis supporting the claims of select dental implant complications/failures with single crowns and P. Abutment screw loosening in single-implant surfaces: a systematic review. Int Dent J fixed partial dentures on implants: a 10-year restorations: a systematic review. Int J Oral 2008;58(6):363-370. prospective cohort study. Clin Oral Implants Maxillofac Implants 2008;23(4):681-690. Res 2005;16(3):326-334. 6. Binon PP. Implants and components: entering 28. Alkan I, Sertgöz A, Ekici B. Influence of occlusal the new millennium. Int J Oral Maxillofac Implants 17. Schwarz MS. Mechanical complications of dental forces on stress distribution in preloaded 2000;15(1):76-94. implants. Clin Oral Implants Res 2000;11 Suppl dental implant screws. J Prosthet Dent 1:156-158. 2004;91(4):319-325. 7. Coppedê AR, Bersani E, de Mattos Mda G, Rodrigues RC, Sartori IA, Ribeiro RF. Fracture 18. Khraisat A. Stability of implant-abutment 29. Cho SC, Small PN, Elian N, Tarnow D. Screw resistance of the implant-abutment connection interface with a hexagon-mediated butt joint: loosening for standard and wide diameter in implants with internal hex and internal conical failure mode and bending resistance. Clin implants in partially edentulous cases: connections under oblique compressive Implant Dent Relat Res 2005;7(4):221-228. 3- to 7-year longitudinal data. Implant Dent loading: an in vitro study. Int J Prosthodont 2004;13(3):245-50. 2009;22(3):283-286. 19. Tawil G, Aboujaoude N, Younan R. Influence of prosthetic parameters on the survival and 30. Block MS, Castellon P, Zavala J. Replacement 8. Schulte JK, Coffey J. Comparison of screw complication rates of short implants. Int J Oral of a fixed partial denture secondary to abutment retention of nine abutment systems: a pilot study. Maxillofac Implants. 2006;21(2):275-282. fracture. J Am Dent Assoc 2007;138(6):785-790. Implant Dent 1997;6(1):28-31. 20. Levine RA, Clem D, Beagle J, Ganeles J, 31. Clarkson JE, Amaechi BT, Ngo H, Bonetti D. 9. McGlumphy EA, Mendel DA, Holloway JA. Johnson P, Solnit G, Keller GW. Multicenter Recall, reassessment and monitoring. Monogr Implant screw mechanics. Dent Clin North Am retrospective analysis of the solid-screw ITI Oral Sci 2009;21:188-198. 1998;42(1):71-89. implant for posterior single-tooth replacements. Int J Oral Maxillofac Implants 2002;17(4):550- 32. Pjetursson BE, Tan K, Lang NP, Brägger U, 10. Salinas TJ, Sheridan PJ, Castellon P, Block MS. 556. Egger M, Zwahlen M. A systematic review of Treatment planning for multiunit restorations--the the survival and complication rates of fixed use of diagnostic planning to predict implant 21. Mangano C, Bartolucci EG. Single tooth partial dentures (FPDs) after an observation and esthetic results in patients with congenitally replacement by Morse taper connection period of at least 5 years. Clin Oral Implants Res missing teeth. J Oral Maxillofac Surg 2005;63(9 implants: a retrospective study of 80 implants. 2004;15(6):625-642. Suppl 2):45-58. Int J Oral Maxillofac Implants 2001;16(5):675- 680. 33. Baumgarten HS, Chiche GJ. Diagnosis and 11. Taylor TD, Agar JR, Vogiatzi T. Implant evaluation of complications and failures prosthodontics: current perspective and future associated with osseointegrated implants. directions. Int J Oral Maxillofac Implants. 2000 Compend Contin Educ Dent 1995;16(8):814- Jan-Feb;15(1):66-75 818. 62 • Vol. 2, No. 4 • May 2010
The Predominant Cultivable Micro ora Gha ar et al Around Implants in Papillon-Lefevre Syndrome Khaled Abdel Gha ar1 • Salah Abdel Fatah2 • Ronald S. Brown3 Ashraf Abdel Monaem4 Abstract Background: The primary purpose of this study the sulci around implants in PLS patients (12 was to investigate the use of titanium implants months after their insertion) as well as from sulci in patients with papillon-lefevre syndrome (PLS) around natural teeth of control subjects. The and to investigate the periodontal pathogens prevalence of bacterial types and mean propor- associated with sites around implants compared tional counts of species were then investigated. to affected teeth sites. Twelve subjects, six PLS patients and six control healthy subjects partici- Conclusions: 1) Implants successfully osseoin- pated in the study. Sixteen implants were placed tegrated and minimized bone loss in PLS patients. in the mandibles of four PLS patients treated with 2) The periodontopathic micro-organisms mandibular overdentures and maxillary complete changes after extraction of teeth in PLS patients. dentures. Subgingival plaque samples were col- 3) The flora around implants in PLS is compa- lected from natural teeth of PLS patients, and rable to the flora in healthy control subjects. KEY WORDS: Papillon-Lefevre syndrome, periodontitis, microflora/microbiology, dental implants, genetics, prosthodontics 1. Professor of Oral Medicine and Periodontology, Faculty of Dentistry, Ein-Shams University, Cairo, Egypt 2. Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ein-Shams University, Cairo, Egypt 3. Professor of Diagnosis, Howard University College of Dentistry, Clinical Associate Professor of Otolaryngology, Georgetown University Medical Center, Washington, DC, USA 4. Associate Professor, of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt The Journal of Implant & Advanced Clinical Dentistry • 65
Gha ar et al INTRODUCTION phagocytosis along with a decreased phytohemag- glutinin response by T-lymphocytes and reduced Papillon-Lefevre syndrome (PLS) is a rare autoso- myeloperoxidase activity. PLS is also associ- mal recessive condition with a prevalence of 1-4 per ated with impaired neutrophil bactericidal func- million.1,2 Over 200 cases have been reported.3 tion and a depressed helper to suppressor T-cell There does not appear to be any noticeable ethnic or ratio and elevation of serum immunoglobulins.6,13,14 gender predilection. 4,5 Consanguinity is prevalent among parents of PLS affected patients in a signifi- PLS is also associated with impaired neutrophil cant number of cases.6,7 PLS is characterized by a bactericidal function and a depressed helper to diffuse transgradient palmoplantar hyperkeratosis suppressor T-cell ratio and elevation of serum immu- and rapidly progressive and devastating periodon- noglobulins.12,14 Microscopic changes include titis, affecting the primary as well as the permanent marked chronic inflammation with predominant dentition. After eruption of the primary teeth, the plasma cell infiltration, osteoclastic activity, and gingiva becomes severely inflamed. This is gen- lack of osteoblastic activity.15 The bacterial flora erally followed by a rapid destruction of the peri- in this disease is similar to those found in adult peri- odontium, and most affected children experience odonitis with a prevalence of gram negative cocci, premature loss of their primary teeth.8 The aggres- rods, and spirochetes.16 Such pathogenic micro- sive inflammatory periodontal process then repeats organisms as Porphyromonas gingivalis, Capno- itself after the eruption of the permanent teeth, and cytophaga, P.micros, P.Negrescens, Treponema in general, all or most of the permanent dentition denticola, Prevotella intermedia, Bacteroids forsy- is lost. These patients are usually edentulous and thus, Fusobacterium nucleatum, and Actinobacil- wearing complete dentures by their teen years. lus actinomycetimcomitans have been implicated with regards to this syndrome.17-20 This particular Because conventional periodontal treatment set of immune dysfunctions results in an increased usually fails to arrest the rapid progression of peri- susceptibility to periodontal infection.6,12,20,21 odontitis, severe loss of alveolar bone is often the result.9,10 Early extraction of all permanent teeth Physiologic as well as psychologic trauma has been considered as the treatment of choice of those patients because of early edentulism is to preserve the remaining supporting bone.11 reported due to progression of teeth looseness, hypermobility, drifting, migration and exfoliation PLS is an autosomal recessive genetic condi- of the teeth without evident signs of root resorp- tion. PLS patients have an increased incidence of tion. Furthermore, tooth mobility leads to pain on mutations of the cathepsin C gene which is located chewing. The radiographic features include inter- on the 11q14-p21 region of the chromosome. proximal angular defects, furcation radiolucencies Cathepsin C appears to be necessary for the devel- and severe loss of alveolar bone around the teeth opment and maintenance of the skin, and immune leading to a “floating in air” radiographic appear- cells involved in inflammation. The gene appears ance.4,22 Titanium implants have become an to be responsible for abnormalities in skin develop- important treatment alternative in order to replace ment and periodontal disease progression.12 The missing teeth. The use of implants in patients with periodontal manifestations of this genetic condition severe periodontitis has been reported.23,24 and are related to decreased neutrophil chemotaxis and 66 • Vol. 2, No. 4 • May 2010
Gha ar et al Figure 1: Teeth with aggressive periodontitis. Figure 2: Preoperative panoramic radiograph (after extractions). Figure 3: Severely a ected teeth were extracted. Figure 4: Immediate upper denture in place. the results indicate that periodontally compro- An investigation of implants in patients with PLS, mised patients can be successfully treated with a condition known for its poor prognosis with implants.25 Multiple studies have demonstrated regard to periodontal disease, hopefully will be the success of dental implants in patients with con- of value for edentulous and partially edentulous trolled diabetes, and osteoporosis, although ciga- patients with other medically complex conditions. rette smoking is noted as a prominent risk factor.26-29 MATERIALS AND METHODS This study was designed to investigate the use of titanium implants in PLS patients, and to We utilized implant therapy in the treatment of six compare the periodontal pathogens associated PLS patients and six health age-matched control with implant sites in PLS patients, to PLS affected patients. We evaluated and compared the peri- tooth sites and to tooth sites in normal subjects. odontal pathogens of these two groups. The age The Journal of Implant & Advanced Clinical Dentistry • 67
Gha ar et al Figure 5: Mandibular implants (remaining root encircled). Figure 6: Ball attachments in place Figure 7: Final prosthesis in patient mouth. Figure 8: Periapical radiograph demonstrating marginal bone level. range was between 12 and 26 years of age. Four PLS patients presented with some remaining natural dentures for two PLS patients noted for teeth with teeth (Figure 1) while two PLS patients were com- a very poor prognosis. We extracted the affected pletely edentulous. Panoramic radiographs revealed teeth of those PLS patients after taking bacterio- generalized loss of alveolar bone, especially in the logical samples from their gingival sulci (Figure 3) maxilla, severe aggressive periodontitis with bone and we then delivered and adjusted the immedi- resorption around the remaining teeth, and devel- ate dentures (Figure 4). The evaluated the other oping or partially erupting third molars (Figure 2). two PLS patients and scheduled these adolescent PLS patients for future implant placement. They We fabricated conventional complete dentures also participated in the bacteriological analysis. for the two completely edentulous PLS patients. We constructed immediate upper and lower complete After complete soft tissue healing of the extrac- tion sites, we duplicated the lower denture into 68 • Vol. 2, No. 4 • May 2010
Gha ar et al clear acrylic resin and used this acrylic duplicate At the delivery appointment, we checked the den- as a surgical template as an aid in installing the tures for proper extension, fitness and occlusion. implants in the proposed positions. We installed We relieved the lower dentures as necessary at four implants (10.5-12mm length and 3.5 or the implant sites to accommodate the attachments. 4.0mm diameter - Biohorizons Internal, Biohorizon Utilizing polymerizing acrylic resin while the patient Inc. USA) for each patient in the mandible between was closing in centric relation, the denture implant the mental foramina according to the submerging relationship was established (Figure 7). We technique protocol.30 The clinician performed one instructed the patients with regard to oral hygiene crestal and two vertical incisions In order to expose and we exposed standardized periapical radio- the bone between the second premolar areas. graphs for the implants (Figure 8). Patients were The clinician flattened the sharp bony edges In recalled ay 12 months with regard to the following: order to have a regular plateau at the areas of pro- posed implant sites. We utilized sequential drill- Collection of subgingival bacterial samples from ing with copious saline irrigation, at 800 rpm and the implant sites. 20 N/cm torque. We tabbed the Osteotomy sites Gingival indices (GI), plaque indices (PI), and and inserted implants and closed the flap inter- probing depth were recorded. rupted sutures. The lower denture was generously Standardized periapical radiographs were made relieved over the implant sites and lined with soft for the implants. liner (Reline Extra Soft, GC America.) We pre- scribed a regimen of 2 gm Amoxicillin per day for SAMPLING, CULTIVATION AND one week and instructed the patients with regard IDENTIFICATION: for proper oral hygiene. We installed four (12mm length and 3mm diameter) one-piece overdenture We collected subgingival plaque samples from the implants (Overdenture implant system, Biohori- sulci around all natural teeth of PLS patients, the zon Inc. USA) in the anterior maxilla in one of the sulci around implants in PLS patients (12 months PLS patients (Figure 5). The maxillary denture after their insertion) as well as from sulci around was generously relieved and lined with soft liner. natural teeth of control subjects. We cleansed the supragingival areas with sterile gauze. We Four to six months later, we exposed the inserted sterile medium paper points (Johnson implants through small crestal incisions, checked & Johnson, Windsor, NJ, USA) into each sulcus for osseointegration, and then we connected the until resistance was met and left these in place healing abutments. After two weeks, we replaced for 15 seconds under N2 gas flow and placed in the healing abutments with ball and socket abut- 1 ml aliquots of reduced transport fluid (RTF).31 ments (Figure 6). We snapped on the retentive We serially diluted the samples in RTF and culti- portions of the attachments on the abutments, and vated on duplicate plates of pre-reduced brucella completed elastomeric upper and lower impres- blood agar (BBA). These plates were used as sions. We then recorded jaw relation, arranged general-purpose medium plates and were incu- teeth, and completed the try-in procedures in the bated anaerobically for 5-6 days. In addition, a patient’s mouth. We had the dentures processed. selective medium for the isolation of Actinobacil- lus actinomyctom comitans (Aa) was also used. The Journal of Implant & Advanced Clinical Dentistry • 69
Gha ar et al Table 1: Prevalence and predominance of bacterial species recovered from PLS patients (a) Prevalence (b) Predominance Bacterial species subject site subject site (c) Rank 1 Porphyromonus gingivalis 83.34 40.3 3.8 6.5 2 3 A. actinomycetemcomitans 66.67 34.7 3.5 5.6 4 5 Prevotella intermedius 50.0 21.9 8.1 16.0 6 7 Peptostreptococcus micros 50.0 21.9 5.1 12.3 8 Streptococcus sanguis 33.34 18.4 4.5 10.8 Wolinella recta 33.34 15.8 3.9 10.5 Bacteroides forsythus 16.67 11.3 3.0 7.9 Treponema denticola 16.67 8.7 1.3 5.2 a = Percentage of total sites sampled yielding recoverable organisms b = Mean colony forming unit percent of cultivable flora recovered on brucella blood agar c = Bacterial ranked from 1to 8 in order of prevalence in patients or sites Identification was determined by morphological RESULTS category, gram-stain reaction, aerotolerance and presumptive spot tests (Catalase, oxidase and The one year follow-up periapical radiograph production of indole) when necessary for species showed continued success of mandibular identification, isolates were fully speculated by implants osseointegration. The recorded mean suitable API rapid identification systems (Rapid bone loss around the implants was 0.52 mm (± Strep system, Analytab Products, Painview, NY, 0.25) that was comparable to values recorded in USA) or by the use of conventional biochemi- literature for normal patients. The criteria for suc- cal methods as described by Holderman et al.32 cess were the absence of mobility, the absence of radiographic gap in the bone-implant inter- We utilized two criteria in assessing the micro- face, and the absence of pain or infection at the biological differences between implant sites and peri-implant area. However all the four one piece teeth sites: (1) The prevalence of the bacterial types; maxillary implants failed within a few weeks. (2) The predominance or mean proportional counts of species (CFU% vs. total counts at 10.3 dilution). Microbiological analysis of bacterial species recovered subgingivally from PLS patients com- 70 • Vol. 2, No. 4 • May 2010
Gha ar et al Table 2: Mean proportional counts and prevalence of major organisms associated with implant and teeth in PLS patients compared with healthy subjects Bacterial categories PLS implant sites PLS teeth sites Healthy subjects Black pigmented anaerobes Counts Prevalence Counts Prevalence Counts Prevalence Mean SD Mean SD 6.4 Mean SD 2.3 5.1 0.7 2.1 12.8 41.4 33.5 19.1 A. actinomycetemcomitans 5.5 18.9 4.2 29.6 33.2 17.1 2.3 5.1 6.4 Treponema denticola 3.5 6.3 4.0 35.6 31.5 18.2 1.5 1.9 3.2 Bacteroides forsythus 6.2 6.5 3.9 31.3 28.1 15.1 3.5 2.6 4.1 Total gram (+) cocci 12.6 8.1 9.1 16.9 16.3 21.3 2.5 6.8 15.0 Total gram (+) rods 6.9 10.3 10.6 25.3 9.7 23.1 3.4 2.1 11.2 Total gram (-) cocci 5.8 9.1 9.3 21.3 5.8 16.8 4.7 2.2 16.3 1. Statistical analysis was performed by ANOVA and independent t-test 2. Counts were experienced as colony forming units of total cultivable flora at 103 dilution prised of 8 different species (Table I). In order was also significantly higher in PLS patients with of decreasing prevalence, the 5 most common teeth 29.6 (±33.2) compared to PLS implant species in PLS were Porphyromonas gingiva- sites 5.5 (±18.4) or healthy controls 2.3 (±5.1). lis, Actinobacillus actinomycetemcomitans, Pre- votella intermedia, Peptostreptococcus micros Results of bacterial prevalence in PLS patients and Streptococcus sanguis. In addition to ana- with teeth, PLS implant patients and controls con- lyzing bacterial prevalence, sites were evaluated firmed that the initial colonies picked were gram neg- for the predominant species by calculating the ative rods and were isolated more often in the PLS colony forming units (CFU) for each cultivable teeth sites 25.3 (±9.7) than in PLS implant sites 6.9 species. Table II shows that counts of Black (±10.3) or in healthy subjects 3.4 (±2.1). Statisti- Pigmented anaerobes were significantly higher cal analysis was performed by ANOVA and inde- (P<0.05) in PLS patients with remaining teeth pendent t-test; counts were experienced as colony 41.4 (±33.5) than in PLS patients with implants forming units of total cultivable flora at 103 dilution. 2.3 (±5.1) or healthy controls 0.7 (±2.1). Aa Results of other tested organisms showed sig- nificantly higher counts in PLS patients with teeth The Journal of Implant & Advanced Clinical Dentistry • 71
Gha ar et al Table 3: Clinical indices around teeth and implants in PLS, compared to normal subjects Gingival Index Plaque Index Probing depth (mm) 0.5 (±0.6) a 0.4 (±0.3) a Healthy teeth 2.2 (±1.1) a PLS teeth 3.1 (±2.1) b 3.4 (±1.9) b 8.2 (±2.2) b PLS implants 0.6 (±0.4) a 0.3 (±0.2) a 1.2 (±1.0) a (Means with the same letter within each column are not significantly different at p 0.05) compared to PLS implant sites or healthy controls, patients. Rapid bone loss and exfoliation of teeth Treponima denticola 35.6 (±31.5) compared to 3.5 often lead to early edentulism and the need to wear (±6.3) and 1.5 (±1.9) respectively. Bacteroides removable dental prostheses.22 The fabrication forsythas 31.3 (±28.1) compared to 6.2 (±6.5) and of upper and lower complete dentures restored 3.5 (±2.6). Results of bacterial prevalence in PLS form and function for those patients. However, patients with teeth, PLS implant patients and con- because of the inadequate and continual loss of trols confirmed that the initial colonies picked were bone support, the stability of dentures is usually gram negative rods and were isolated more often in compromised. The treatment option of an implant- the PLS teeth sites 25.3 (±9.7) than in PLS implant retained prosthesis was then deemed appropriate. sites 6.9 (±10.3) or in healthy subjects 3.4 (±2.1). The removable implant retained overdenture offers several advantages including enhanced access for As shown in Table III, the mean gingival indices oral hygiene, easy modification of the prosthesis (GI), plaque indices (PI), probing depth (PD) of PLS base, and the provision of a labial flange that helps patients having teeth were 3.1 (±2.1), 3.4 (±1.9), in restoring the facial support.33 The implants and 8.2 (±2.2) mm respectively. For the healthy increased the retention and stability of the mandib- control subjects, the mean clinical indices were 0.5 ular dentures through their attachments and pre- (±0.6), 0.4 (±0.3), 2.2 (±1.1) and for GI, PI, and served the surrounding bone. As noticed from the PD respectively. In addition, the mean clinical indi- one year follow up periapical radiographs, not only ces around implants inserted in PLS patients were did the mandibular implants successfully osseo- 0.6 (±0.4), 0.3 (±0.2), and 1.2 (±1.0) respectively. integrate, but the supporting bone was also pre- served. These results concurred with the findings DISCUSSION of Woo et al,34 and Ullbro et al.35 Lack of sufficient attached gingival was noticed around the implants Papillon-Lefevre syndrome is a devastating dis- due to severe alveolar bone loss. It is sometimes ease process characterized by rapid destruction recommended to replace the unattached nonkera- of the dental alveolar complex. It starts affecting tinized mucosa with a gingival autograph.36 How- the individual during childhood and poses both physical and psychological challenges to these 72 • Vol. 2, No. 4 • May 2010
Gha ar et al ever, Adell et al30 did not find attached gingival nally developed to prevent alveolar bone resorp- to be a pre-requisite for gingival health. In gen- tion after extraction of teeth. In most cases, dental eral, the outcome of the mandibular implant treat- pulps were vitally preserved or root canal treat- ment in the present study was successful and the ments were performed before the procedure. The result did not seem to differ from what is normally RST eliminates the risk of periodontitis by pre- reported on implant treated in edentulous healthy venting epithelial down growth. The retention of patients. It seems that the aggressive periodontal a tooth root with its natural attachment apparatus reaction in PLS patient is linked to the presence allows for maximum preservation of the surround- of the natural periodontal structure and doesn’t ing alveolar bone and soft tissues.40 Accordingly, occur around osseointegrated titanium implants. root submerging may be a good practice to pre- serve alveolar bone in PLS patient till implants Treatment considerations for implant over- placement become convenient. Now the authors dentures on the maxilla appear to be different are conducting a research about the benefits of than for those on the mandible. Atrophy of eden- RST in preserving alveolar bone for PLS patients. tulous jaws may limit implant placement on the maxilla, whereas in the mandible, the reduction In conclusion, the microbiological results of of residual ridge often leaves a significant depth this study support the link previously made in and width of basal bone anteriorly to accommo- humans between the presence of gram nega- date implants. Insertion of implants in the anterior tive anaerobic, as sacharolytic rods and marked mandible basal bone necessitated tabbing of this attachment and bone loss,41 where gram nega- D1 type of bone before implant insertion to avoid tive anaerobes were more frequently isolated overstressing of bone. The maxilla consists of a from the PLS teeth sites than from implant looser arrangement of trabecular bone that is less sites or healthy sites. The findings of this study capable of stabilizing and supporting implants. further indicate that black pigmented bacte- For the patient treated with maxillary implants, the roids and Aa were the most prevalent gram- narrow ridge that was available only in the anterior negative anaerobic microorganisms at PLS region was the reason for placement of only four teeth sites compared to PLS implant sites and 3mm diameter single piece implants. Although teeth sites in healthy age-matched controls. the maxillary denture was relived and relined with soft liner, these non-submerged implants were Correspondence: unavoidably subjected to forces prematurely caus- ing their early failure.37-39 Figures 2 and 5 showed Ronald S. Brown, DDS, MS panoramic radiographs with more than 18 months interval. The presence of a remaining root could Professor of Diagnosis be noticed in the lower posterior quadrant. Com- paring the two radiographs revealed that this root Howard University College of Dentistry was not infected and preserved the alveolar bone at that area. This is exactly the target of the root 600 W Street, NW, Room 406 submergence technique (RST). RST was origi- Washington, DC 20059 202-806-0349;fax 202-806-0447 [email protected] The Journal of Implant & Advanced Clinical Dentistry • 73
Gha ar et al Disclosure 15. Martinez Lalis RR, Lopez Otero R, Carranza 30. Adell R, Lekholm U, Rockler B, Branemark PI, The authors report no conflicts of interest with FA Jr. A case of Papillon-Lefevre syndrome. Lindhe J, Eriksson B, Sbordone L. Marginal anything mentioned in this article. Periodontics 1965;3:292–5. tissue reactions at osseointegrated titanium fixtures. A 3-year longitudinal prospective References: 16. Newman MG, Angel L, Karge H. Bacterial study. International J Oral Maxillofac Surg 1. Gorlin RJ, Sedano H, Anderson VE. The studies of the Papillon-Lefevre syndrome. J 1986;15:39-52. Dent Res 1977;56:545-47. syndrome of palmar-plantar hyperkeratosis and 31. Rundell BB, Thomson LA, Loesche WJ, Stiles premature periodontal destruction of the teeth. 17. Pacheco JJ, Coelho C, Salazar F, Contreras HM. Evaluation of transport medium for the J Pediatr 1965;65:895-908. A, Slots J, Velazco CH. Treatment of Papillon- preservation of oral streptococci. Arch Oral Lefevre syndrome periodontitis. J Clin Biol 1992;18: 871-978. 2. De Vree H, Steenackers K, De Boever JA. Periodontol 2002;29:370-4. Periodontal treatment of rapid progressive 32. Holderman LV, Cato EP, Moore WE. Anaerobe periodontitis in 2 siblings with Papillon-Lefevre 18. Tinanoff N, Tempro P, Maderazo EG. Dental laboratory manual, 4th ed., Blacksburg, syndrome: 15-year follow-up. J Clin Periodontol treatment of Papillon-Lefevre syndrome: 15 VA:Virginia Polytechnique Institute and State 2000;27:354–60. year follow-up. J Clin Periodontol 1995;22(8): University, 1977:7-115. 609-12. 3. Hart TC, Shapira L. Papillon-Lefevre syndrome. 33. Sadowsky SJ. Mandibular implant-retained Periodontol 2000;1994, 6: 88-100. 19. Kleinfelder JW, Topoll HH, Preus HR, Muller overdentures: a literature review. J Prosthet RF, Lange DE, Bocker W. Microbiological and Dent 2001; 86:468-73. 4. De Freitqas AC, Assed S, De Silva LAB, Silva immunohistological findings in a patient with RAB. 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E ective Dentist / Dental Lab Mohr Communication for Complex Cases Uwe Mohr, MDT1 Abstract Effective communication between the den- the quality of preparations, the quality of impres- tist and the dental laboratory is essential sions, and effective communication from their for optimal patient care. While “on-time” referring dentists. With all cases, the final out- delivery is among the top concern for dentists, come depends on how well the dentist and lab- additional concerns include the laboratory prop- oratory technician communicate before, during erly reading, understanding, and following the and after the case. The purpose of this article is dentist’s prescriptions. Surveys of dental labs, on to discuss methods to improve such communica- the other hand, show that their top concerns are tions from the perspective of the dental laboratory. KEY WORDS: Communication, dental laboratory, prosthetics, dental implants 1. Owner, Smart Ceramics Dental Art Studio The Journal of Implant & Advanced Clinical Dentistry • 77
Mohr EDITORIAL Figure 1: Shade tab taken intra-orally. Evaluating the various boards and association done the way it was first imagined in preliminary surveys, it becomes clear that one of the hot discussions. However, with improved commu- topics concerning our profession is effective nication from the team members, the case will communication between the dentist and the morph into what can be accomplished with the dental laboratory. While “on-time” delivery is lab’s skills, knowledge, techniques, materials, among the top concern for dentists, additional and equipment to match the dentist’s require- concerns include the laboratory properly read- ments. To that end, labs have to become more ing, understanding, and following the dentist’s knowledgeable of modern manufacturing pro- prescriptions. Surveys of dental labs show that cesses, techniques, and materials. They must their top concerns are the quality of prepara- broaden their knowledge through continuing tions, the quality of impressions, and effective education and by attending serious presenta- communication from their referring dentists. tions from the top minds in our field, both on Frequent complaints among dental laboratories the Lab side and dentist side. It is extremely are: their technicians not reading the laboratory helpful if both technician and dentist attend prescription properly, returning the wrong crown some of these events together to build com- or wrong shade to the referring dentist, and mon ground. These demands are one of the lack of communication with the referring den- key reasons for the Master Dental Technician tist. So here we have 2 professions interdepen- Program in Germany, for example, to elevate dent on each other, both saying the same thing, the technician’s knowledge and skill level, their “We need better, more frequent, and detailed understanding of biology and surgical pro- communication with each other!” While com- cedures, all taught by the best and brightest munication can be difficult enough for simple in today’s dentistry, so he/she can communi- cases such as single crowns or quadrant solu- cate with the dentist on par. When we both tions (Figure 1), imagine the difficulties that understand the scope and limitations of our may arise on larger and more complex cases! fields, the patient is assured of the best pos- With all cases, the final outcome depends on how well the dentist and laboratory tech- nician communicate before, during and after the case. This requires the dentist and labo- ratory to document many or all of the steps, not only in their records, but also in inter- changeable media such as digital pictures, detailed and consecutive records, progressive study models, evaluations, and case discus- sions (Figures 2,3). There is no such thing as too many pictures or too much information. Rarely does a complex case end up being 78 • Vol. 2, No. 4 • May 2010
Mohr Figure 2: Chairside pictures and instructions. Figure 3: Impressions and bite registrations. Figure 4: Pre-operative picture. Figure 5: “Stickbite” registration. sible result. When we can communicate these situation, chief complaint and desired outcome. issues effectively with each other, we all win. What is the patient willing to do to get the result he/she wants and what can the dentist do Initial discussions between the dentist and to get them there? What are the restrictions/ lab usually focus on preliminary pictures (Fig- limitations? What are the patient’s budget con- ure 4), radiographs, and study models. To this straints? Once this information is collected, it end the dentist will have evaluated the patient’s The Journal of Implant & Advanced Clinical Dentistry • 79
Mohr Figure 6: Case log-in. Figure 7: Veri cation jig. Figure 8: Mounted casts on articulator. bite registration more efficiently (Figure 5). More and more dentists are using digi- should be sent to the lab with all other available records such as bite registrations, models, pic- tal transfer mediums such as CDs or memory tures, etc. One frequently asked question of sticks. While these are excellent tools, most dental laboratories is, “What bite registration dentists do not want to go through the effort of do you prefer?” One of the samples I refer to buying media, burning info, and duplicating pic- is http://www.smartceramics.com/Stickbite- tures, x-rays, etc. In light of this, the dental lab Presentation.html showing how to take a stick- needs to step up to these demands and create a communication friendly interface, such as a direct upload facility to their website. For this purpose, I created a client login portal on my Lab website (http://www.smartceramics.com/ clients) where clients can register/log in and then upload any amount of pictures and infor- mation into their own patient library (Figure 6). This is also an excellent tool to store commu- nication/discussion logs so that both dentist and technician can view the same information while discussing the case. This real time com- munication has substantially changed the way dental labs can discuss cases with clients. To take full advantage of this tool and utilize the 80 • Vol. 2, No. 4 • May 2010
Mohr Figure 9: Screw retained denture base. Figure 10: Implant retained denture on CAD/CAM bar. dental laboratory to its fullest capacity, the els with the bite records provided, an initial dentist needs to speak directly with the tech- case discussion can establish the fabrication nician involved in the case. For the dental lab, parameters such as desired restoration type, the technician must have the knowledge and materials and processes. One of the key fac- understanding to handle such cases and intel- tors to success is involving the lab as early as ligently discuss them with the referring dentist. possible. All too often, the dental lab receives A pitfall for many dental labs is that they are a set of final impressions with limited instruc- broken up into too many departments or pro- tions. With this minimal communication, it is duction lines with too few qualified technicians not uncommon for the dental laboratory tech- to communicate with individual dentists. All too nician to phone referring dentist and explain often, dentists end up speaking with account that, given the situation, the requested restora- managers at mass production labs who simply tions cannot be made or will be compromised record information; it is up to the technicians in due to location, material, design or other limit- each department, or completely different labo- ing factors. We must start treatment planning ratories, to interpret and follow this recorded with the final outcome in mind, so that the teeth script. While there are countless gifted techni- can be in ideal locations for maximum function cians in both lab types, close cooperation and and aesthetics. This preliminary discussion communication can be challenging and must will establish what we need to reach this point. be followed to achieve what can be done by a single person taking care of the entire process. Preoperative photographs, study mod- els, copy dentures, or duplicate mod- Now that the dentist has uploaded the pictures and the lab has mounted the mod- The Journal of Implant & Advanced Clinical Dentistry • 81
Mohr Figure 11: Denture set up at try-in. Figure 12: Matrixes for information transfer. els will show the dental lab technician the cases on a laboratory website (e.g, fixed pros- patient’s current situation (Figure 7). It thetics vs. screw retained hybrid bridge vs. is especially beneficial when models are screw retained hybrid denture versus implant mounted in a functional articulator (Figure 8). retained denture base) can assist the referring dentist in explaining different pricing options. At this stage the discussion centers on Imagine giving the patient 5 pricing options restorative options, material selection. What without him/her being able to visualize the dif- can we do with the limitations given? Here the ference between the different treatments. dental lab can provide the referring dentists pictures of similar cases or, better yet, have an The Lab can also provide you with pic- online library with case presentations of previ- tures of different sets of aesthetic solu- ously treated cases (http://www.smartceramics. tions to help narrow down the patients com/Lab-Presentation.html) (Figures 9,10). We preferences by using pictures of restora- do not simply want the manufacturers’ infor- tions finished in different styles such as: no mation here; we want to see what the dental gingiva, with gingiva, plain denture teeth/ lab can do with these materials, so the refer- advanced aesthetic denture teeth, flange, no ring dentist and/or patient can visualize avail- flange, etc. This type of visual information will able options. I encourage my dentists to use allow the dentist to treatment plan and price these tools when explaining treatment options based on the different types of restorations. in order to help the patient better understand different restoration types. When presenting Now that we have a desired outcome, a the patient with different treatment options, chosen restoration type, and pricing option pricing is often a topic. Presentations such as selected, we can launch into the restorative/sur- gical steps. Since we want to work backwards 82 • Vol. 2, No. 4 • May 2010
Mohr Figure 13: Patient at insertion. future reference and provides an opportunity to evaluate each other’s work. Communica- from an established position such as Aesthetic tion with the lab should not end once the case A and B point or a specific occlusal scheme, is inserted. The Lab can send survey cards any denture set up or wax up should be tried for the dentist to provide feedback. Labs with in, verified and documented (figure 11). Once customer service agents can call to discuss documented, the technician has a visual refer- details of the case and enter this data into ence and can make matrices to maintain this feedback systems. This allows the dental lab established point (figure 12). This is an impor- to get away from the normal lab reaction after tant milestone during fabrication of the restora- insertion, “Well, we didn’t hear anything, so tion. It is immensely helpful to the laboratory the case must have been okay.” (Figure 13) technician to see his work in situ as he/she may discover errors or nuances that need chang- The more diligently we both provide and ing. These pictures can show the technician evaluate feedback, the better we can progress exactly where adjustments need to be made on the next case and show our staff where we and how far off he/she is from their desired need to improve. This can lead to re-evalua- result. After adjustments are made, quite often tion of productions steps, staff training, finding on larger cases, a set of pictures is emailed more suitable techniques and materials, or find- to the dentist for evaluation/approval and ing better trained staff for these cases. Every can be used to fine tune the final prosthesis. case produced and inserted should lead to the next case being even better. A wise man once Once the restorations are inserted, it is said, “The moment you stop learning, you don’t helpful to the dental laboratory if before and stand still...you actually fall behind because after documentation is taken. This allows the everyone around you is moving forward.” dentist and the lab to establish a library for Correspondence: Uwe Mohr, MDT 577 Annette Street Toronto, ON M6S 2C3, Canada Telephone: 416 264 0787 Toll Free: 1888 264 0787 Email: [email protected] Disclosure Uwe Mohr is the owner of Smart Ceramics Dental Art Studio. The Journal of Implant & Advanced Clinical Dentistry • 83
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Severe Hereditary Gingival Fibromatosis McLeod et al A ecting the Deciduous and Permanent Dentitions: A Case Report Dwight E. McLeod, DDS1 • Je rey V.A. Burch, DDS2 • Elio Reyes Rosales, DDS3 Alvin R. Sams, DDS4 • Art Misischia, DDS5 Abstract Background: Hereditary gingival fibromatosis is condition recurred at age 12. A second gingi- a rare and benign genetic disorder that presents vectomy surgery was performed and the patient as gingival enlargement of varying degrees and was maintained for a year without recurrence. may affect the deciduous and permanent denti- tions. Hereditary gingival fibromatosis can occur Results: The gingivectomy surgeries alone or can be associated with other syndromes. healed without complications and resulted The condition has a high rate of recurrence, but in a satisfactory clinical outcome that was can be successfully managed with frequent maintained for one year, at which time follow-up care and retreatment as necessary. the patient was lost to further follow up. Methods: A Caucasian female with severe Conclusions: Gingivectomy is an effective hereditary gingival enlargement was treated with treatment for patients with hereditary gingi- gingivectomy at age 7. Failing to follow recall val fibromatosis, however, a strict maintenance visits, the patient returned for treatment after the program is essential to prevent relapse. KEY WORDS: Orthodontics, periodontics, osteopenia, bone graft 1. Associate Professor, Section Head of Periodontics and Chair of the Department of Dental Medicine at Southern Illinois University School of Dental Medicine. 2. Periodontist practicing in Rockford, Illinois. 3. Assistant Professor in the Section of Periodontics, Department of Applied Dental Medicine at Southern Illinois University School of Dental Medicine. 4. Pediatric Dentist practicing in Saint Louis, Missouri and part-time Clinical Associate Professor in the Section of Pediatric Dentistry, Department of Growth, Development and Structure at Southern Illinois University School of Dental Medicine 5. Associate Professor in the Section of Oral Surgery, Department of Applied Dental Medicine at Southern Illinois University School of Dental Medicine. The Journal of Implant & Advanced Clinical Dentistry • 87
McLeod et al INTRODUCTION which may require orthodontic correction.10-12 Histologic analysis of the gingival tissues Hereditary gingival fibromatosis (idiopathic fibromatosis, hereditary gingival hyperplasia, from patients with hereditary gingival fibromatosis elephantiasis, hypertrophied gingiva, and con- revealed dense connective tissue, multiple col- genital idiopathic gingival fibromatosis)1 occurs lagen fibers, epithelial hyperplasia, and the pres- at a prevalence of 1:75,000 in the population2 ence of long rete pegs. Mild, chronic inflammatory and can affect the deciduous and permanent infiltrates are often noted in subepithelial connec- dentitions. The condition can occur at birth, tive tissue. Other unusual findings may include but becomes more evident upon eruption of the small calcified particles, amyloid deposits, islands deciduous and permanent teeth.3 Hereditary gin- of odontogenic epithelium, osseous metapla- gival fibromatosis may occur as a separate entity sia, and ulceration of the overlying mucosa.5,13,14 or may be associated with systemic syndromes or conditions with no specific predilection to The treatment and management of patients gender. These syndromes include Zimmerman- with hereditary gingival fibromatosis varies from Labond, Murray-Puretice-Drescher, Rutherford case report to case report. Besides nonsurgical syndrome, Cowder’s syndrome, Cross syndrome, treatment and maintenance, surgical intervention and other conditions.4-6 Genetic studies have commonly involves conventional, electrocautery, or shown that hereditary gingival fibromatosis is a laser gingivectomy, internal beveled gingivectomy, hereditary condition that is passed on through apically positioned flap alone, or apically posi- an autosomal dominant or autosomal recessive tioned flap and osseous surgery (in older patients inheritance, with the former being more common.7 with periodontitis). In younger individuals, extrac- tion of the deciduous teeth is recommended to aid Hereditary gingival fibromatosis presents with in active eruption of the permanent teeth. Some normal gingival color, a wide band of keratinized patients may require orthodontic therapy to cor- tissue encasing deciduous or permanent teeth, rect mal-aligned teeth which is a common finding gingival stippling, fibrotic gingival texture in the in hereditary gingival fibromatosis patients.9,11,15-21 attached regions, and usually marginal gingival inflammation.3,7-9 The enlargement may be gener- This report documents a severe case of hered- alized or localized. The maxillary and mandibular itary gingival fibromatosis in a seven year old Cau- anterior teeth are more frequently affected: the casian girl. She underwent two surgical phases of degree of gingival enlargement may vary from treatment with short term successful outcome in patient to patient, and this may affect the propen- the first, which was followed by severe recurrence. sity for recurrence.7 In severe cases, the palatal Five years later, she was treated successfully, but tissues may exhibit enlargement beyond the vicin- was lost for further follow-up care after one year. ity of the teeth, leading to a rolled appearance and deformation from the normal “U shaped” palatal CASE REPORT vault. Hereditary gingival fibromatosis may exert undesirable forces on the teeth as the gingiva Initial Examination enlarges, thus resulting in mal-alignment of teeth, The patient was a 7 year old Caucasian female who, in June of 1999, was referred by her pediat- ric dentist in Saint Louis, Missouri to a periodon- 88 • Vol. 2, No. 4 • May 2010
McLeod et al tist in the same city for treatment of hereditary Figure 1: Frontal view of the patient at age 7 gingival fibromatosis. The patient’s mother demonstrating severe hereditary gingival bromatosis at was present during the interview process. She the initial visit. confirmed that there was no history of gingival enlargement on her side of the family, but that (figure 1). Panoramic evaluation dated June the patient’s father had gingival enlargement. 10, 1999 revealed normal tooth development She could not confirm how many other family with no unusual finding of the alveolar pro- members on his side of the family were affected. cesses. Since the Genetic Division at Wash- ington Medical School confirmed a diagnosis of At the time of presentation, the mother Hereditary Gingival Fibromatosis, the resected stated that her daughter was in good general gingiva was not submitted for histologic analysis. health. In October of 1992, the patient was hospitalized for dehydration and pneumonia. In Initial Treatment August of 1995, she had an atrial septum defect The patient was treatment planned for gingivec- repair, and in October of 1998, a benign tumor tomy in all 4 quadrants, and extraction of teeth was removed from the incision line of the afore- #’s N, O, P, and Q. We contemplated extrac- mentioned surgery. The patient was allergic to tion of teeth #’s D, E, F, and G, but decided to Amoxicillin, and the only medication that she delay extraction to prevent additional teasing of was taking was children’s acetaminophen as missing front teeth at school, which was trau- necessary for gingival pain. The chief complaint matic for the patient. The patient was treated was that “It hurts bad and other children make in two different appointments. During the first fun of my teeth”. A medical report from her phy- appointment, gingivectomy was performed in sician from Washington University School of the maxillary right and left quadrants, utilizing Medicine in Saint Louis, Missouri, Division of local anesthesia. The surgical procedure went Genetics and Department of Pediatrics revealed well without any complications, and the patient no other abnormalities or syndromes associ- was followed until the area was completely ated with her hereditary gingival enlargement. healed. Eight weeks after the first surgery, an Besides the gingival enlargement, intra and extraoral examinations revealed no soft tissue pathology. The patient had no clinical caries, but complained of occasional “gum ache.” The gingival tissues appeared firm, with stippling of the attached gingiva, and mild marginal gin- gival inflammation. The buccal and lingual sur- faces of deciduous teeth in both arches were almost completely covered with gingival tis- sue. Marked vertical segmentation of the inter- dental tissues between each tooth was clearly evident. All 20 deciduous teeth were present The Journal of Implant & Advanced Clinical Dentistry • 89
McLeod et al Figure 2: Frontal view 8 weeks after gingivectomy in Figure 3: Frontal smile view of the patient at age 12 during the maxilla, and immediately post gingivectomy and the re-examination visit. extraction of teeth #’s N, O, P, and Q. tory that was taken revealed the following attempt was made to treat the lower arch, but findings: history of non-pathologic heart mur- the patient became apprehensive, even after mur, general allergies, and psychiatric care. administering nitrous oxide anxiolysis. The Since early 2004, the patient was diagnosed surgery was postponed and was successfully with bipolar disorder and attention deficit accomplished three weeks later with gingivec- hyperactivity disorder (ADHD). She was tak- tomy of the mandibular right/left quadrants and ing Depakote 750mg (convulsant), Clonedine extraction of teeth #’s N, O, P, and Q under 0.2mg (adrenergic agonist), Seroquil 200mg local anesthesia and 10mg of diazepam orally (antipsychotic), and Adderall 40mg (ADHD). one hour before the appointment. Teeth #’s N, O, P and Q were extracted to enable eruption Clinical evaluation revealed a severe recur- of teeth #’s 23 – 26 (figure 2). The surgical rence of the gingival overgrowth with expan- site healed without complications. The remain- sion buccally and lingually, especially lingual of ing deciduous teeth were now visible, and the the maxillary anterior teeth (figures 4a-d). The patient and her mother were excited with the majority of teeth were completely covered in treatment outcome. The patient was followed up gingiva tissues except for the occlusal surface until 2003, but did not return for any additional follow-up care, despite numerous attempts. Second Examination In October of 2004, the patient was seen at Saint Louis University Center of Advanced Dental Education in the Department of Gradu- ate Periodontics (figure 3). The medical his- 90 • Vol. 2, No. 4 • May 2010
McLeod et al Figure 4a: Intraoral view at re-examination demonstrating Figure 4b: Intraoral view at re-examination demonstrating recurrence of the hereditary gingival bromatosis. recurrence of the hereditary gingival bromatosis. Maxillary palatal view. Mandibular occlusal view. Figure 4c: Intraoral view at re-examination demonstrating Figure 4d: Intraoral view at re-examination demonstrating recurrence of the hereditary gingival bromatosis. Right recurrence of the hereditary gingival bromatosis. Left buccal view. buccal view. of the posterior teeth, and the incisal edges of rior teeth was noticeable and was attributed to the anterior teeth. The gingiva appeared fibrotic the forces exerted by the severe gingival over- with mild areas of marginal inflammation. Dis- growth. Traces of plaque and calculus were placement of the maxillary and mandibular ante- evident. When the patient smiled, the gingival The Journal of Implant & Advanced Clinical Dentistry • 91
McLeod et al Figure 5: Panoramic radiographic taken in 2004 showing retained A, B, C, G, H, I, J, K, L, M, R, S, and T and all permanent teeth at di erent stages of eruption. overgrowth was completely evident, with only (30mg), midazolam (5mg), and local anesthesia slight visible traces of the maxillary anterior over a 2 hour period. The surgery proceeded teeth. The panoramic radiograph showed the without any complications. The patient was seen presence of all 16 permanent teeth in different for the first post-operative at SIUSDM, and all stages of eruption (figure 5). The deciduous teeth subsequent treatments occurred at SLUCADE. #’s A, B, C, G, H, I, J, K, L, M, R, S, and T were retained. No other unusual findings were noted. The follow up treatment included patient edu- cation/oral hygiene instructions, and maintenance Second Treatment with four prophylaxes from April of 2005 to April The patient was evaluated and treatment planned 2006: During the same period, four appoint- at the Graduate Periodontal program at Saint ments were either cancelled at the last min- Louis University, Center for Advanced Dental ute or broken. The post-operative photographs Education (SLUCADE). The surgical therapy revealed the anatomical crown of all maxillary consisting of full mouth gingivectomy (electrocau- and mandibular teeth (figures 6a-d). Multiple tery and conventional), was performed at South- diastemas were present between the maxillary ern Illinois University School of Dental Medicine and mandibular anterior teeth and the teeth were (SIUSDM) where the resident rotated. Dur- in mal-alignment. Even though the teeth were in ing the surgery, the patient received intravenous mal position, both the patient (figure 7) and her sedation with propofol (600mg), pentazocine mother were happy with the surgical outcome. During the short maintenance phase of one year, 92 • Vol. 2, No. 4 • May 2010
McLeod et al Figure 6a: Postoperative healing 4 weeks following Figure 6b: Postoperative healing 4 weeks following conventional and electrocautery gingivectomy surgeries. conventional and electrocautery gingivectomy surgeries. Frontal view. Maxillary palatal view. Figure 6c: Postoperative healing 4 weeks following Figure 6d: Postoperative healing 4 weeks following conventional and electrocautery gingivectomy surgeries. conventional and electrocautery gingivectomy surgeries. Right buccal view. Left buccal view. there was no recurrence, and the plan was to mother. Three years have elapsed without any proceed with orthodontic therapy. Because the recall care. There is no knowledge of whether mother was a single parent and was on state or not the hereditary gingival fibromatosis has assistance, an agreement was worked out by recurred and if so, to what degree or severity. the periodontal resident as a humanitarian ges- ture to assume all the orthodontic expenses. DISCUSSION However, the patient did not return for treat- ment despite several attempts to reach her Hereditary gingival fibromatosis is a gingival con- dition with a high rate of recurrence especially in The Journal of Implant & Advanced Clinical Dentistry • 93
McLeod et al Figure 7: Frontal view of a happily smiling 12 year old patient was helped by the gingivectomy which adolescent 4 weeks after surgery. reduced the gingival overgrowth and improved the esthetic short-term with recall therapy for younger indviduals.1,22,23 The treatment of mild over a year. Extraction of the lower decidu- cases may only require gingivectomy, and fre- ous teeth seemed to aid in the eruption of the quent recall care. However, in cases where lower permanent incisors. Other cases have the occurrence is severe, a multi-disciplinary reported treating hereditary gingival fibromato- approach may be necessary.10-12 Dental man- sis in the deciduous dentition in a similar man- agement of those cases may require aggressive ner with or without recurrence, or with eruption, gingival resection, intense plaque control, orth- and delayed eruption of the permanent teeth odontic intervention, and surgical re-treatment after extraction of the deciduous teeth.8,9,25 involving additional gingivectomy surgeries. Because the condition is rare, there are The prevalence of hereditary gingival hyper- no longitudinal randomized cases and con- plasia affecting the primary dentition is not trolled studies to support an evidence-based- rare.3,24 In our patient, the gingival condition approach to managing patients with hereditary was most likely present at birth and contin- gingival fibromatosis. Treatment is often based ued growing, leading to delayed exfoliation upon case reports or opinions, even though of the deciduous teeth, which further compli- there seems to be some agreement on treat- cated eruption of the permanent teeth. Our ment methods. The second surgery was per- formed on our patient at age 12, and because the maxillary and mandibular first molars and incisors were fully erupted, a more aggressive gingivectomy procedure, utilizing conventional gingivectomy,26 and electrosurgical gingivec- tomy to control hemostasis was utilized. Other reports have utilized internal bevel gingivec- tomy20,27 and/or apically positoned flap to man- age this condition,28 especially in older patients with underlying periodontitis.27 Our patient did not have periodontitis; the primary goal of treat- ment was to remove the gingival overgrowth to encourage eruption of the permanent teeth. In hindsight, extraction of all the remaining decidu- ous teeth to encourage active eruption of the molars and premolars would have been a more judicious treatment approach. Nonetheless, the surgical outcome was pleasing for everyone, and the postoperative period was uneventful 94 • Vol. 2, No. 4 • May 2010
McLeod et al for the patient. During the 12 months post- distance from the clinic and often depended surgically, and while the patient was being upon others or the state for transportation. closely monitored, no recurrence occurred. However, it is likely that this patient will return for treatment, considering the high recurrence Clearly, the forces exerted by the gingival rate, especially in the absence of routine den- overgrowth resulted in undesirable tooth move- tal care, and the treatment benefits that she ment in both arches, which was an esthetic con- has already received from previous surgeries. cern. Correction of the mal-alignment of teeth would have been beneficial for the patient; CONCLUSION considering there wouldn’t have been any cost incurred to the mother. Also, orthodontic Treatment and management of the patient with therapy would have given us another opportu- hereditary gingival fibromatosis varies. Because nity, beyond the periodontal re-care, to monitor of the rarity of this condition, there is no con- the patient’s care and to extract the remain- trol randomized longitudinal studies from which ing deciduous teeth as necessary to enable an evidenced based decision can be derived. eruption of the permanent posterior teeth. Regardless of the severity of the case, the age of diagnosis, treatment approach, and recall Hereditary gingival fibromatosis is often care, recurrence always seems likely. How- associated with other systemic syndromes.4-6 ever, it is encouraging that gingivectomy and In our patient, the hereditary gingival fibroma- other surgical approaches work, and can result tosis was an isolated condition and was not in an excellent outcome that can be maintained, associated with any other systemic syndromes. with or without the benefits from orthodontic Even though the patient was diagnosed with therapy. Regardless of the surgical treatment Attention Deficit Hyperactivity Disorder and utilized, a strict maintenance approach is rec- Bipolar Disorder, this was later on in life. One ommended to manage the patient with heredi- cannot help but to think if the rejection by tary gingival fibromatosis to prevent relapse. peers and the constant teasing could have contributed to the behavioral disorder. At four Correspondence: weeks postoperative, it was a pleasure to see Dr. Elio Reyes Rosales a beautiful smile with teeth showing, instead Southern Illinois University School of gingival tissues, on this twelve year old girl. of Dental Medicine. 2800 College Ave. Bldg #285 Compliance with dental treatment is often Alton, Illinois. 62002 difficult for many, especially if the patient is Phone (618) 474 7210; Fax (618) 474 7124 a minor, and from a single family and impov- e-mail: [email protected] erished household. Multiple broken appoint- ments do not necessarily indicate a lack of interest, but many times a lack of finances to pay for each visit as well as transportation to and from each appointment. In this case, the patient and her mother lived a considerable The Journal of Implant & Advanced Clinical Dentistry • 95
McLeod et al Disclosure: 12. Kelekis-Cholakis A, Wiltshire WA, Birek C. 24. Doufexi A, Mina M, Ioannidou E. Gingival The authors report no conflicts of interest with Treatment and long-term follow-up of a patient overgrowth in children: epidemiology, anything mentioned in this article. with hereditary gingival fibromatosis: a case pathogenesis, and complications. A literature report. J Can Dent Assoc 2002;68:290-294. review. J Periodontol 2005;76:3-10. References: 1. Fletcher JP. Gingival Abnormalities of Genetic 13. Farrer-Brown G, Lucas RB, Winstock D. 25. Kavvadia K, Pepelassi E, Alexandridis C, Familial gingival fibromatosis: an unusual Arkadopoulou A, Polyzois G, Tossios K. Origin: A Preliminary Communication with pathology. J Oral Pathol Med 1972;1:76-83. Gingival fibromatosis and significant tooth Special Reference to Hereditary Generalized eruption delay in an 11-year-old male: a Gingival Fibromatosis. J Dent Res 14. Gunhan O, Gardner DG, Bostanci H, 30-month follow-up. Int J Paediatr Dent 1966;45:597-612. Gunhan M. Familial gingival fibromatosis with 2005;15:294-302. unusual histologic findings. J Periodontol 2. Ramer M, Marrone J, Stahl B, Burakoff R. 1995;66:1008-1011. 26. Howe LC, Palmer RM. Periodontal and Hereditary gingival fibromatosis: identification, restorative treatment in a patient with treatment, control. J Am Dent Assoc 15. Bozzo L, de Almedia OP, Scully C, Aldred MJ. familial gingival fibromatosis: a case report. 1996;127:493-495. Hereditary gingival fibromatosis. Report of Quintessence Int 1991;22:871-872. an extensive four-generation pedigree. Oral 3. Neville BW, Damm DD, Allen CM, Bougguot JE. Surg Oral Med Oral Pathol Oral Radiol Endod 27. Casavecchia P, Uzel MI, Kantarci A, et al. Oral and Maxillofacial Pathology. St. Louis: WB 1994;78:452-454. Hereditary gingival fibromatosis associated with Saunders; 2002. generalized aggressive periodontitis: a case 16. Bozzo L, Machado MA, de Almeida OP, report. J Periodontol 2004;75:770-778. 4. Bakaeen G, Scully C. Hereditary gingival Lopes MA, Coletta RD. Hereditary gingival fibromatosis in a family with the Zimmermann- fibromatosis: report of three cases. J Clin 28. Brown RS, Trejo PM, Weltman R, Pinero G. Laband syndrome. J Oral Pathol Med Pediatr Dent 2000;25:41-46. Treatment of a patient with hereditary gingival 1991;20:457-459. fibromatosis: a case report. Spec Care Dentist 17. Lobao DS, Silva LC, Soares RV, Cruz RA. 1995;15:149-153. 5. Coletta RD, Graner E. Hereditary gingival Idiopathic gingival fibromatosis: a case report. fibromatosis: a systematic review. J Periodontol Quintessence Int 2007;38:699-704. 2006;77:753-764. 18. Martelli-Junior H, Lemos DP, Silva CO, Graner 6. Witkop CJ, Jr. Heterogeneity in gingival E, Coletta RD. Hereditary gingival fibromatosis: fibromatosis. Birth defects original article series report of a five-generation family using 1971;7:210-221. cellular proliferation analysis. J Periodontol 2005;76:2299-2305. 7. Singer SL, Goldblatt J, Hallam LA, Winters JC. Hereditary gingival fibromatosis with a recessive 19. Saygun I, Ozdemir A, Gunhan O, Aydintug YS, mode of inheritance. Case reports. Aust Dent J Karslioglu Y. Hereditary gingival fibromatosis 1993;38:427-432. and expression of Ki-67 antigen: a case report. J Periodontol 2003;74:873-878. 8. Henefer EP, Kay LA. Congenital idiopathic gingival fibromatosis in the deciduous dentition. 20. Sengun D, Hatipoglu H, Hatipoglu MG. Report of a case. Oral Surg Oral Med Oral Long-term uncontrolled hereditary gingival Pathol Oral Radiol Endod 1967;24:65-70. fibromatosis: a case report. J Contemp Dent Pract 2007;8:90-96. 9. Kamolmatyakul S, Kietthubthew S, Anusaksathien O. Long-term management of an 21. Mason C, Hopper C. The use of CO2 laser in idiopathic gingival fibromatosis patient with the the treatment of gingival fibromatosis: a case primary dentition. Pediatr Dent 2001;23:508- report. Int J Paediatr Dent 1994;4:105-109. 513. 22. Bittencourt LP, Campos V, Moliterno LF, 10. Clocheret K, Dekeyser C, Carels C, Willems Ribeiro DP, Sampaio RK. Hereditary gingival G. Idiopathic gingival hyperplasia and fibromatosis: review of the literature and a case orthodontic treatment: a case report. J Orthod report. Quintessence Int 2000;31:415-418. 2003;30:13-19. 23. Cuestas-Carnero R, Bornancini CA. Hereditary 11. Holzhausen M, Ribeiro FS, Goncalves generalized gingival fibromatosis associated D, Correa FO, Spolidorio LC, Orrico SR. with hypertrichosis: report of five cases in one Treatment of gingival fibromatosis associated family. J Oral Maxillofac Surg 1988;46:415- with Zimmermann-Laband syndrome. J 420. Periodontol 2005;76:1559-1562. 96 • Vol. 2, No. XX • XX 2010
Preliminary List of Invited Speakers Dr Eduardo Anitua, Spain Dr Ziv Mazor, Israel Dr R. Cancedda, Italy Dr Eitan Mijiritsky, Israel Dr Joseph Choukroun, France Dr Robert Miller, USA Dr Paulo Coelho, USA Dr Stefano Pagnutti, Italy Dr Danilo Di Stefano, Italy Dr G. Papaccio, Italy Dr Matteo Danza, Italy Dr Gabriele Edoardo Pecora, Italy Dr Marco Degidi, Italy Prof Adriano Piatelli, Italy Dr Stefano Fanali, Italy Dr Roberto Pistilli, Italy Dr Pietro Felice, Italy Dr Lorenzo Ravera, Italy Dr Massimo Frosecchi, Italy Dr U. Ripamonti, South Africa Dr Scott Ganz, USA Dr Paul Rosen, USA Dr Dan Holtzclaw, USA Dr Philippe Russe, France Dr Robert Horowitz, USA Dr Gilberto Sammartino, Italy Dr Michelle Jacotti, Italy Dr Marius Steigmann, Germany Dr Adi Lorean, Israel Dr Tiziano Testori, Italy Dr Jack Krauser, USA Dr Nicholas Toscano , USA Dr Carlo Mangano, Italy Secretariat Paragon Conventions 18 Avenue Louis-Casai, 1209 Geneva, Switzerland Tel: +41-(0)-22-5330-948, Fax: +41-(0)-22-5802-953 Email: [email protected]
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