PMC5870113_01
OPGs (original OPG of previous treatment modified for presentation reasons). (a) Before the initiation of previous treatment (January 2004). (b) After mandibular tooth extraction and implant placement (April 2004).
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In January 2004, generalized severe periodontal disease with deep pockets and severe mobility was diagnosed (Figure 1(a)). In April 2004, teeth #21, #29, and #32 were extracted, and implants were placed in positions #18, #20, #30, and #31/32 (Figure 1(b)).
OPGs (original OPG of previous treatment modified for presentation reasons). (a) After mandibular implant loading (July 2004). (b) After extraction of tooth #15 (January 2006).
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In July 2004, the implants were loaded with fixed partial dentures (FPDs) connecting to teeth #22 and #27 (Figure 2(a)). In January 2006, partial healing of extraction socket #21, a bone defect with periapical involvement (#23), and two periimplant defects (#20 and #31; >50% and <50% implant length, resp.) were diagnosed (Figure 2(b)).
OPGs (original OPG of previous treatment modified for presentation reasons). (a) After extraction of tooth #14 and implant placement in position #15/16 (November 2006). (b) After maxillary restoration (November 2007).
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Between the end of January and October 2006, teeth #5-8, #10, #12, and #15 were extracted; a composite veneered FPD was inserted with teeth #4, #9, and #11 as abutments; and an implant in position #15/16 was placed, but appeared to have only 50% bone contact (Figure 3(a)). The mandibular periimplant defects showed further progression (Figure 3(b)). A new implant in position #15 was placed (compare with implant geometry on Figure 3(a)), tooth #12 was replaced with an implant, and additional implants were placed in positions #1, #4-6, and #8.
OPGs. (a) Further progression of bone loss on November 2009 (not modified radiograph taken during current treatment). (b) At initial examination in June 2015 (not modified radiograph taken during current treatment).
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An OPG taken in November 2009 demonstrated further progression of bone loss (Figure 4(a)). Comparison of Figures 4(a) and 4(b) shows that the mandibular implants were explanted, and three new implants were placed and loaded. Comprehensive dental and periodontal examinations were performed, and an OPG was made (Figure 4(b)).
(a) Volumetric 3D representation of hard tissue and maxillary implants, taken during mandibular surgery, demonstrating large bone defects and loss of buccal bone plate in the maxilla. (b) Axial CBCT section of the maxilla showing misplaced implant #4. (c) OPG section showing bar retained on the remaining three mandibular implants (not modified radiograph taken during current treatment).
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During surgery and after removal of the mandibular teeth and implants and cleaning of the bone defects, a cone beam computed tomograph (CBCT) was made (Figures 5(a) and 5(b)). The membranes were removed 4 weeks postoperatively (Figures 5(c), 6(a), and b6(b)).
(a) Explanted mandibular implants and tooth #27. (b) Clinical view of the mandible 4 weeks postoperatively, before membrane removal. (c) The maxilla after FPD removal. (d) Explanted maxillary implant during FPD removal.
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The membranes were removed 4 weeks postoperatively (Figures 5(c), 6(a), and b6(b)).
(a, b) Maxillary temporary rehabilitation with FPD retained on implants #4 and #10 and removable denture for the molar areas. (c) OPG 4 weeks after surgery with the mandibular overdenture (not modified radiograph taken during current treatment).
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Mandibular OPG sections eight months postoperatively (not modified radiograph taken during current treatment). (a) After placement of three additional implants. (b) After bar mounting.
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Argon Dental) (Figure 8(a)). All six mandibular implants were splinted with a milled bar and loaded as described previously (Figures 8(b) and 9).