A Challenging Mandibular Anterior Implant Case · A Challenging Mandibular Anterior Implant Case approach in this case involved delicate management of bone and soft tissue, followed

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A Challenging Mandibular Anterior Implant Case

Volume 36 No. 5 Page 90

Authored by Ahmad Soolari, DMD, MS; George Kesten, DDS; and Amin Soolari, BS, CDRT

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Mandibular anterior teeth affected by periodontal disease are often difficult to treat for many reasons. First, the space available for implant treatment and

restoration can be restricted. Second, the buccal plate is typically thin, and can be partially or completely missing. Third, the soft tissue is typically either thin and translucent or the mucosa is not keratinized and, in some cases, a mucogingival defect is present along with an aberrant frenulum. Also, after the disease process destroys the alveolar bone and other supporting structures of the dentition, reconstruction of the alveolar ridge is a challenge, meaning that saving the tooth or replacement by an implant is often uncertain.1 In addition, the presence of periodontal pathogens, which may survive even after extensive treatment, can compromise any restoration efforts.2,3

In spite of these challenges, several authors have restored areas with implants in patients with current or previous perio dontal infections and have found that the implants can perform just as successfully as implants placed in periodon-tally healthy patients.4-8 One case report9 described implant prosthetic treatment of an anterior mandible in a patient with a history of severe periodontitis. Removal of just one tooth was required, and the resultant defect was successfully rebuilt with freeze-dried bone allograft and restored with an implant-supported prosthesis.

The patient in the following clinical case report had suffered from severe periodontal infection that had eroded the bone and periodontal ligaments in the anterior mandible. As can happen with periodontitis,7 in spite of multiple nonsurgical treatment attempts, the area developed an abscess, and the teeth became nontreatable. The purpose of this article is to demonstrate the successful management of undesirable effects of periodontal infection that caused injury to the supporting tissues in the anterior mandible.

CASE REPORTDiagnosis and Treatment Planning

A 65-year-old male patient was referred to our office for treat-ment of a periodontal abscess that had formed while other forms of nonsurgical treatment (such as scaling and root planing, laser therapy, Water Pik [Waterpik], systemic antibiotics, and local antibiotics like Arestin [Valeant Pharmaceuticals]) had failed to resolve the deep pockets associated with the mandibular central incisors (teeth Nos. 24 and 25). Clinical and radiographic eval-uation of Nos. 24 and 25 disclosed a missing buccal plate, deep probing (pocket depth of at least 7.0 mm), bleeding on probing, purulent exudate, labial positioning, lack of attached and kera-tinized soft tissue, and Class III mobility (Figures 1 and 2). There-fore, both teeth were diagnosed as hopeless.

The treatment plan proposed was to include the removal of No. 24 and No. 25, followed by hard- and soft-tissue grafting, CBCT to evaluate the result, and insertion of one narrow-diameter implant to replace the missing teeth. The patient refused extraction of the lateral incisors (Nos. 23 and 26) and replacement with an implant-supported prosthesis as a treatment option in these areas.

Clinical TreatmentThe patient was given the following medications prior to his surgical treatment: an antibiotic (clindamycin 150 mg, orally 3 times daily), an analgesic (Motrin 800 mg, 3 times daily as needed), anti-swelling medication (methylprednisolone [Medrol Dosepak]), and chlorhexidine rinse (Acclean 0.12% oral rinse USP [Henry Schein], twice daily).

A Challenging Mandibular Anterior Implant CaseEffective Date: 3/01/17 Expiration Date: 3/01/20

Dr. Soolari is a Diplomate and examiner of the American Board of Periodontology. He has a certificate in periodontics from Eastman Dental and an MS degree from the University of Rochester, Rochester, NY. He is a former clinical associate professor at the University of Maryland Dental School in Baltimore. He operates a specialty practice in the Silver Spring, Gaithersburg, and Potomac areas of Montgomery County, Md. He can be reached via email at [email protected].

Dr. Kesten graduated with honors from Howard University College of Dentistry in 1973. He maintains a private general dentistry practice in Chevy Chase, Md. He can be reached via email at [email protected].

Mr. Soolari has a bachelor’s degree in biological science from University of Maryland and is a first-year dental student at the University of Maryland School of Dentistry. He has been a dental assistant for 6 years and has experience in orthodontics, periodontics, and assisting in general treatment and oral surgery. He started his career in a periodontal office, where he became a Certified Dental Radiation Technologist in 2012. He can be reached via email at [email protected].

Disclosure: The authors report no disclosures.

About the Authors


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Vertical incisions were made on the mesial of teeth Nos. 22 and 27 to enable full access to the bony defects and coronal advancement of the flap. A horizontal incision was made with a No. 15 blade (Carbon Steel [Benco Dental]) to enable intrasulcu-lar incisions.

Periodontal flap surgery enabled access to the root and bony defect for diagnosis and treatment. Heavy subgingival calculus was present approach-ing the apices of the teeth, along with significant bone loss, including the missing buccal plates. Fol-lowing the removal of Nos. 24 and 25 and degranu-lation of the necrotic tissues, the defect was grafted with particulate freeze-dried bone allograft (Maxx-eus Dental Cortical Bone, Ref DN025) and cov-ered with a nonabsorbable titanium-reinforced membrane (Cytoplast [Osteogenics Biomedical]) to rebuild bone both vertically and horizontally (Figures 3 and 4). The patient left our office with a removable partial denture as a provisional pros-thesis (Figure 5). Five weeks later, the titanium-re-inforced membrane was removed. Since Nos. 24 and 25 did not have attached or keratinized tissue, free gingival grafting was performed 4 months after hard-tissue grafting to ensure that adequate soft tissue would be present around the implant.

By 5 months after extraction and hard-tissue grafting, significant gains in bone height and bone width had been achieved (Figures 6 to 8). This enabled insertion of a 3.2- x 10-mm implant (Legacy 2 Implant System [Implant Direct]) where minimal bone had been present at the time of extraction (Figure 9). The density of the bone at the time of im-plant placement was type 2.10 Because the mesiodistal space was only about 7 mm, only one implant was planned. The implant was restored 4 months later.

Figures 10 and 11 show the completed case with abundant firm, pink, and keratinized gingiva supporting the implant at 12 months after extraction and grafting.

DISCUSSIONIn a clinical scenario like this, the res torative dentist faces the challenge of replacing 2 missing teeth with just one implant in an area affected by periodontitis. The interdisciplinary


Figure 1. (a) Clinical and (b) radiographic evaluation disclosed generalized moderate and localized severe chronic periodontitis, along with moderate to severe gingival deformity.

a b

Figure 2. Pretreatment views. The mandibular central incisors (teeth Nos. 24 and 25) dis-played significant loss of attachment, widened periodontal ligaments, Class III mobility, highly edematous gingivae, bleeding on probing, and localized severe gingival deformities, including a lack of attached and keratinized gingival tissue.

a b

Figure 3. Teeth Nos. 24 and 25 were removed. (a) The buccal plates were missing entirely, so the area required ridge augmentation. (b) Heavy subgingival calculus was detected on the apical aspect of both extracted teeth.

a b


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approach in this case involved delicate management of bone and soft tissue, followed by implant surgery in a limited space, and delivery of crowns that met both the patient’s and the clinician’s demands.

The soft-tissue grafting provided tough, healthy kera-tinized tissue that would be strong enough to support an implant. The new connective tissue will resist toothbrush and occlusal trauma and prevent gingival recession. Without

soft-tissue grafting, the site would have been unstable and poorly suited for loading implants. Around implants, dense and keratinized peri-implant soft tissue has been associated with less bone loss, better tissue health, and improved aesthetics.11 The influence of soft-tis-sue thickness on peri-implant marginal bone loss was discussed by Suárez-López Del Amo et al,12 who suggested that implants placed in areas with initially thicker peri-implant soft tis-sue have less radiographic marginal bone loss.

Many years of experience with implants have shown them to be a viable option, even in patients with a history of peri-odontitis. Derks et al2 found a slightly higher odds ratio (4.08) for moderate to severe peri-implantitis in patients with a peri-odontal history; however, odds ratios were much higher (up to 15.08) when 4 or more implants had been placed (regardless of patient periodontal status), making the risk of peri-implan-titis in periodontal patients seem negligible in comparison.

Figure 4. (a) The ridge defect was augmented with freeze-dried bone allograft and (b) covered with a titanium-reinforced membrane. (c) The site was secured with polytetrafluoroethylene sutures.

a b c

Figure 5. A removable provisional denture was delivered to replace the missing Nos. 24 and 25 during healing.

a b

Figure 6. Left to right: (a) pretreatment, (b) immediately after extraction, (c) immediately after ridge augmentation, and (d) 5 months post-extraction.

a b c d


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Although Bakush4 observed some complications when placing implants in diseased sites, no sig-nificant differences were found in success or sur-vival rates for implants placed in diseased versus healthy sites. Courtney et al5 conducted a litera-ture review of implants in periodontal patients. They noted5 that careful ongoing supportive peri-odontal therapy could result in implant success, even after 5 and 10 years in situ, and concluded that “there has been no appropriate scientific ev-idence to conclude definitively that individuals with a previous history of periodontitis demon-strate increased failure rates when rehabilitated with dental implants.” Kim and Sung6 also em-phasized that diligent maintenance resulted in improved outcomes in implant patients with generalized aggressive periodontitis. Shankar et al7 observed less than 3 mm of bone loss and no recurrence of generalized aggressive periodontitis or any suggestive symptoms throughout a 5-year period in one patient, and a patient with nonden-tal severe health issues was treated successfully by Tizzoni et al8 with 6 implants.

CLOSING COMMENTSThe consensus among many researchers5-8 is that consistent, diligent maintenance is crucial to the success of implant-supported restorations placed in patients with a history of periodontitis. This necessitates careful patient selection, because patient compliance plays a key role in proper maintenance. In addition, Giannobile and Lang13 and Tarnow3 cautioned that clinicians must not be too quick to propose extraction and implant placement, given the excellent long-term track record of successful therapy for tooth preservation.14,15 We must avoid the tendency to propose implants for every tooth that has endo dontic or restorative problems, since implant complications are on the rise. Tarnow3 suggests that, in practicing informed consent with our patients, we must always stress the potential for complications, the necessity for excellent patient hygiene, and the requirement for excellent prosthetic design that allows long-term success.

Let’s use our expertise to preserve patients’ functional natural dentition for a lifetime.13 With good patient management

and an interdisciplinary approach, we can offer our patients excellent long-term solutions to the problems they encounter with their natural teeth by providing replacement teeth that mimic their natural dentition.F

Figure 7. Coronal and axial views of the reconstructed Nos. 24 and 25 areas at 4 months after augmentation. Significant gains in width and height can be seen. (a) The mesiodis-tal distance between Nos. 23 and 26 is about 7.04 mm, and (b) the buccolingual gain is about 5.00 mm. The white arrow (right) indicates the inferior most extent of gain in clinical height and width and the demarcation between the higher-density native cortical bone and the lower-density grafted bone. Measurements of the alveolar ridge height and width in the proposed implant site show that only one narrow-diameter implant can be placed. Homogeneously dense material is noted at the alveolar crest level in the region of the missing Nos. 24 and 25, consistent with the grafting material that had been placed.

a b

Figure 8. (a) Facial and (b) occlusal views 5 months after extraction and ridge augmenta-tion, just prior to implant placement. The occlusal view shows that significant faciolingual bone has been gained (4.0 to 5.0 mm). Also, the free gingival grafting has created a zone of attached and keratinized tissue in an area that previously had none.

a b

Figure 9. (a) The Legacy2 implant (Implant Direct) in place at 5 months post-extraction. (b) The radiograph shows grafted bone that is continuous with the native bone. (c) A 3.2- x 10-mm implant was placed in 5.0 mm of native bone and 5.0 mm of grafted bone. Primary stability was achieved in native bone.

a b c


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References1. Snyder MB. Treatment of a large postextraction buccal wall

defect with mineralized allograft, β-TCP, and rhPDGF-BB: a growth factor-mediated bone regenerative approach. Int J Periodontics Restorative Dent. 2012;32:705-711.

2. Derks J, Schaller D, Håkansson J, et al. Effectiveness of implant therapy analyzed in a Swedish population: preva-lence of peri-implantitis. J Dent Res. 2016;95:43-49.

3. Tarnow DP. Increasing prevalence of peri-implantitis: how will we manage? J Dent Res. 2016;95:7-8.

4. Bakush SMM. Outcome of Dental Implants in Patients with a History of Periodontitis [master’s thesis]. Münster, Ger-many: International Medical College; 2013.

5. Courtney M, Cottrell D, Ayilavarapu S. Dental implant ther-apy in patients with a history of perio dontitis: a literature review and clinical considerations. Compend Contin Educ Dent. 2012;33(7).

6. Kim KK, Sung HM. Outcomes of dental implant treatment in patients with generalized aggressive periodontitis: a sys-tematic review. J Adv Prosthodont. 2012;4:210-217.

7. Shankar S, Ramesh AV, Dwarakanath CD, et al. A 5-year follow-up of an implant placed in a patient with general-ized aggressive periodontitis. World Journal of Dentistry. 2011;2:155-158.

8. Tizzoni R, Veneroni L, Clerici CA. A patient with meningeal melanomatosis treated for periodontal disease with a bone regeneration procedure and dental implants: clinical and behavioral management to support medical compliance. Oral Implantol (Rome). 2014;6:75-81.

9. Soolari A, Soolari A. Management of nontreatable mandibular ante-rior tooth with ridge augmentation and dental implant. Dent Today. Nov 2016;35:105-109.

10. Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Albrektsson T, eds. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago, IL: Quintessence Publishing; 1985:199-209, chapter 12.

11. Mandelaris GA, Lu M, Rosenfeld AL. The use of a xenogeneic collagen matrix as an interpositional soft-tissue graft to enhance peri-implant soft-tissue outcomes: a clinical case report and histologic analysis. Clinical Advances in Periodontics. 2011;1:193-198.

12. Suárez-López Del Amo F, Lin GH, Monje A, et al. Influence of soft tissue thickness on peri-implant marginal bone loss: a systematic review and meta-analysis. J Periodontol. 2016;87:690-699.

13. Giannobile WV, Lang NP. Are dental implants a panacea or should we better strive to save teeth? J Dent Res. 2016;95:5-6.

14. Axelsson P, Lindhe J. The significance of maintenance care in the treat-ment of periodontal disease. J Clin Periodontol. 1981;8:281-294.

15. Lindhe J, Pacey L. There is an overuse of implants in the world and an underuse of teeth as targets for treatment. Br Dent J. 2014;217:396-397.

a b

Figure 11. The patient was very pleased with the outcome. Abundant firm, pink, and keratinized gingiva now supported the implant.

a b

Figure 10. (a) The definitive implant-supported prosthesis in place at 12 months post-extraction and (b) ridge augmentation.


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1. Several authors have restored areas with dental implants in patients with current or previous periodontal infections and have found that the implants can perform just as success-fully as implants placed in periodontally healthy patients.

a. True b. False

2. In the case presented, as can happen with periodontitis, in spite of multiple nonsurgical treatment attempts, the area developed an abscess, and the teeth became nontreatable.

a. True b. False

3. The interdisciplinary approach in this case involved delicate management of bone and soft tissue, followed by implant surgery in a limited space, and delivery of crowns that met both the patient’s and the clinician’s demands.

a. True b. False

4. According to this article, Bakush observed no complica-tions when implants were placed in diseased sites.

a. True b. False

5. According to the author, clinicians must avoid the tendency to propose implants for every tooth that has endodontic or restorative problems, since implant complications are on the rise.

a. True b. False

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A Challenging Mandibular Anterior Implant Case · A Challenging Mandibular Anterior Implant Case approach in this case involved delicate management of bone and soft tissue, followed