Case 1

Clinical Examination 

Medical History

The patient when presented was a well-controlled type II diabetic. His last glycated hemoglobin was 6.2, measured a month before his initial visit. He was taking metformin 1000 mg per day. Other than diabetes, the patient did not present with any other relevant medication condition, allergies, or any untoward incidents during his previous dental visits.

Review of Systems

• Vital signs
  • Blood pressure: 120/77 mmHg
  • Pulse rate: 76 beats/min (regular)
  • Respiration: 14 breaths/min

Social History

The patient did not smoke but he reported that he was a social consumer of alcohol.

Extraoral Examination

No significant findings were noted. The patient had no masses or swelling, and the temporomandibular joint was within normal limits. No facial asymmetry was noted, and lymph nodes assessment yielded normal results.

Intraoral Examination

• Oral cancer screening was negative.
• Soft tissue exam, including his buccal mucosa, tongue, and floor of the mouth, was within normal limits.
• Periodontal examination revealed pocket depths in the range 2–3 mm (Figure 1).
• Color, contour, and consistency of gingiva was within normal limits, with localized erythema of marginal gingiva in the lingual of mandibular anterior areas.

  

  

• Oral hygiene was good when he presented to the clinic (Figures 2, 3, and 4).
• Localized areas of dental plaque-induced gingival inflammation were noted.
• Slight supragingival calculus was noted in the mandibular lingual areas.
• Dental caries, both primary and recurrent, was noted in a few teeth.
• The ridge in the site #30 healed adequately, which revealed a slight buccal deficiency (Figure 5).

  

  

  

• On palpation, the ridge width was found to be adequate to place a standard diameter implant (to replace the molar tooth), without the need for additional bone grafting.
• No exaggerated lingual concavity was noted in the area.
• Normal thickness and width of keratinized mucosa was noted (Figure 3).
• No occlusal disharmony was noted, and there was adequate mesio-distal and apico-coronal space for the future implant crown (Figure 3).

Occlusion

There were no occlusal discrepancies or interferences noted (Figures 2, 3, and 4).

Radiographic Examination

A full mouth radiographic series was ordered. (See Figure 6 for patient’s periapical radiograph of the area of interest before extraction of #30 and after extraction and ridge preservation.) The postextraction radiograph revealed radiographic bone fill of the #30 socket. The crestal bone level was well maintained. Normal bone levels in the adjacent teeth were noted. The inferior alveolar canal was not visible in any of the three radiographs.

Diagnosis

American Academy of Periodontology diagnosis of plaque-induced gingivitis with acquired mucogingival deformities and conditions on edentulous ridges was made.

Treatment Plan

The treatment plan for this patient consisted of disease control therapy that included oral prophylaxis and oral hygiene instructions to address gingival inflammation. This was followed by implant placement. After an adequate time for osseointegration (4 months), the implant was restored.

Examination and Documental Visit

The patient when presented to our clinic had already lost tooth #30, which had been extracted 5 months previously. The healing at the extraction site was found to be satisfactory. Systemically, the patient was a diabetic but with good glycemic control and was a nonsmoker. Periodontal examination revealed healthy periodontium with localized areas of mild gingivitis. His part dental history revealed that he was a compliant patient and was on a regular dental maintenance schedule. Occlusal analysis revealed no occlusal disharmonies. These factors together made him a good candidate for dental implant therapy.

The site-specific clinical and radiographic evaluation revealed enough bucco-lingual width and mesiodistal and apico-coronal space for both the placement and the restoration of the implant. The inferior alveolar canal was not in the vicinity of the planned implant site. For these reasons, additional imaging analysis such as cone beam computed tomography (CBCT) was not planned. Impressions were taken during this initial visit that were utilized for doing diagnostic wax-up and for making a surgical guide. Extraoral and intraoral clinical photographs were taken during this visit for patient education and communication with the restoring dentist. Once the treatment plan was finalized, the patient was educated about the dental implant and the treatment sequence. This was followed by implant placement on a separate day using a surgical guide and a drilling sequence recommended by the implant manufacturer.

Case 2

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Medical Considerations

Medical History

At the time of treatment the patient presented with type II diabetes, controlled with medications (metformin). His last glycated hemoglobin (HbA1c) level was 6.7%, measured a few weeks before his initial exam. His fasting blood sugar was 120 mg/dL in the last physical exam. The patient was also hypertensive, controlled with medications (hydrochlorothiazide, doxazosin methylate, benazepril). In addition, he had hypercholesterolemia that was controlled with medication (simvastatin). Last, he suffered from a knee injury 4 years prior to his initial visit, which resulted in a blood clot formation that traveled to the lungs. The patient had surgery on his knee and has been taking Coumadin since then. The patient’s last international normalized ratio (INR) was 2.3. The patient’s body mass index was 33.9, which put him in the obese category. The patient denied having any known drug allergies.

Review of Systems

• Vital signs
  • Blood pressure: 135/70 mmHg
  • Pulse rate: 85 beats/min (regular)
  • Respiration: 16 breaths/min

Social History

The patient had no history of smoking or alcohol consumption at the time of treatment.

Extraoral Examination

There was no clinical pathology noted on extraoral examination. The patient had no masses or swelling. The temporomandibular joints were stable, functional, and comfortable. There was no facial asymmetry noted, and his lymph nodes were normal on palpation.

Intraoral Examination

• Oral cancer screening was negative.
• Soft tissue exam, including his tongue and floor of the mouth and fauces, showed no clinical pathology.
• Periodontal examination revealed pocket depths in the range 1–3 mm (Figure 3).
• Localized areas of slight gingival inflammation were noted.
• The color, size, shape, and consistency of the gingiva were normal. The keratinized tissue was firm and stippled.
• Generalized moderate with localized severe attachment loss and generalized recession were noted.
• An aberrant maxillary and mandibular bilateral labial frenum was also noted, which was extending also to the edentulous posterior areas.

  

• Localized plaque was found around the teeth, resulting in a plaque-free index of 90%.
• Evaluation of the alveolar ridge in the edentulous areas revealed both horizontal and vertical resorption of bone (Seibert class III).
• Class V composite restorations in teeth #20 and #21 buccally and a composite restoration in the incisal edge of #8 were also noted.

Occlusion

An overjet of 3.5 mm and overbite of 4 mm were noted. Angle’s molar classification could not be determined due to loss of these teeth. Canine classification could only be determined on the left side, which was class II. Signs of secondary occlusal trauma (worn dentition, mobility, fremitus) were also noted. Functional analysis of the occlusion revealed anterior guidance during protrusion and canine guidance during lateral extrusion movements.

Radiographic Examination

A panoramic and a full mouth radiographic series was ordered (Figure 4). Radiographic examination revealed generalized moderate horizontal bone loss. There was also vertical loss of bone noted in the edentulous areas. A cone beam computed tomography scan was also ordered for better evaluation of the edentulous areas. The height of bone between the crestal bone and maxillary right sinus, in the position of the future implant, as indicated by the radiographic stent, was 4.95 mm and the height of bone between the crestal bone and maxillary left sinus was 8 mm. The height of bone between the crestal bone and the inferior alveolar nerve canal was 12 mm bilaterally. The distance from the right mental foramen was 10 mm (Figure 5). The buccal–lingual width seemed adequate in all indicated positions for placement of dental implants.

A round, well-circumscribed radiopacity with well-defined borders was noted in the maxillary right sinus. The lesion occupied a big area of the right maxillary sinus space. Slight sinus membrane thickening was noted in the maxillary left sinus (Figure 5).

Diagnosis

A diagnosis of generalized moderate and localized severe chronic periodontitis with mucogingival deformities and conditions around teeth (facial, lingual, and interproximal recession and aberrant frenum), mucogingival deformities and conditions on the edentulous ridges (horizontal and vertical ridge deficiency in all edentulous areas and aberrant frenum), and occlusal trauma (secondary) was made. Additional diagnosis of partial edentulism with Kennedy class I in the maxilla and Kennedy class I (mod 2) in the mandible was made.

Treatment Plan

Figures 67