Dental News - Esthetics, prosthetics, periodontics, implants and bisphosphonates

Dr. David L. Hoexter, USA

Wed. 9 November 2011

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Controversy involving the oral cavity and the effects of using bisphosphonates is causing an obstacle for dentists to help patients achieve optimal health. The following case presentation demonstrates that the continuous use of oral bisphosphonates before, during and after treatment did not prevent an esthetic result involving implants, sinus augmentations, periodontal regenerative techniques, extractions and prosthetic restorative treatments.

This case presentation revolves around a 56-year-old woman who, for the past 10 years, had taken prescribed oral bisphosphonates for her osteoporosis. Her medical history, outside of her bisphosphonates, was non-contributory. The patient, whom we’ll call Mrs. G, is a lovely woman who enjoys traveling throughout the world. She was unhappy with her oral appearance and wished to improve it. She related a desire for oral health with a gracious glowing smile. She expressed that didn’t want an overtly white smile, or one that looked too “fabricated,” but rather a bright and glowing smile.

Medically, Mrs. G’s sole abnormal note was the fact that she had been taking oral bisphosphonates for more than 10 years. Her medical doctor had prescribed these as an aid in treating osteoporosis.

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Reviewing her existing image, radiographs, study models, and probing and charting all possible aids helped guide us toward our diagnostic goal. Most notable to Mrs. G was the mobility of her maxillary right posterior teeth, the worn smaller lower anterior teeth as well as the dull appearing smile. Preparing a sequential treatment plan, we initially recognized an occlusal relation discrepancy, among her other deficiencies.

Obvious to her as well, her lower anteriors were worn and shortened, making us cognizant of occlusal relation discrepancies. Due to abrasive grinding, the teeth on her lower anteriors were shortened, exposing the different yellowish tan color of the dentin inside her teeth. Her vertical relationship needed correction. However, the color of her teeth needed to be corrected as well as their shape and size.

Also obvious was the shape of the maxillary incisors. The square shape is unnatural. The normal shape of maxillary incisors is usually one that is longer than they are wide. This is also a more youthful appearance than the square, “older” look she had at her initial visit.

Her gingival horizontal lateral line was uneven and asymmetrical. There was, however, an adequate zone of pinkish, keratinized gingival tissue, which could be utilized and manipulated for our final goal of a symmetrically appearing periodontal background of esthetics, health and its maintenance in the future.

Correcting her vertical relation required support in her posterior areas to support the correct prosthesis and its newly corrected occlusal height. The patient also requested that a “non-removable prosthesis” be prominent in our treatment plan goal.

The radiographs indicated adequate osseous support in her mandible posteriors such that periodontal therapy, including surgical intervention, would be of a positive result, the latter of which will support the changes to be made to restore the vertical dimension.

The maxillary posterior, however, is a different entity altogether. This patient is utilizing prescribed oral bisphosphonates for her osteoprotic condition. By avoiding osteoporosis and its effects, she will be able to support and maintain oral endosseous implants and their functioning. Sinus-lift techniques to regenerate support for the maxillary posterior implants would need to be accomplished.

Would the fact that she is osteoporotic and utilized oral bisphosphonates hinder the acquisition of new regenerative support? All these factors are considered and discussed with the patient before commencing. If the patient desires, as this one does, non-removable prosthesis replacements, then implants and sinus lifts must be considered.

The maxillary right posterior had two prognostically poor teeth that were extracted. We recommended use of implants to support the new crowns with the corrected occlusal height restored. Yet, Mrs. G had inadequate bone support to support the implants in the posterior maxilla. Thus, we elected to initially us the sinus-lift technique to provide adequate support for the needed implants.

The patient has osteoporosis, and as previously stated, has taken oral bisphosphonates for more than 10 years. Questions that were discussed included the regeneration of osseous support be healthy enough or adequate to support the implants and their needed function.

Will such dental procedures be tolerated without being susceptible to osseous necrosis? Yes, because she has been on oral bisphosphonates all these years. Augmentation procedures were selected to acquire the adequate bone needed to support the implants.

Mrs. G’s upper left side had two teeth, #12 and #15, that were to be kept. Yet the area that initially had pontics above them, also needed a new bone to support forthcoming added implants, which will support the future restored crowns and the occlusal changes. A sinus augmentation procedure was done in the upper left to facilitate the fabrication of new osseous support.

The existing UL bridge was kept as a provisional splint while the sinus-lift technique was accomplished even around and apical to the preserved molar. After six months of uneventful healing, a provisional splint was placed in the UL, replacing the existing permanent bridge. Endosseous implants were then inserted and integrated in the #12 and #13 edentulous area. After six months, we began the restorative phase.

Both the UR posterior sinus lift and the UL sinus-lift surgeries were accomplished during the same surgical appointment. However, the UR #3 and #5 had a very poor prognosis and were extracted during the same treatment with osseous grafts added to the voided sockets.

The restorative phase for the posteriors was accomplished at the same time and after the use of provisionals. Then they were adjusted to achieve the proper occlusal relationship, especially in the posteriors initially. After the posteriors were restoratively corrected in provisionals, the anterior teeth were then treated. The maxillary anteriors were changed from the initial square appearance to a bright, more streamlined and youthful appearance.

With the posteriors restoring the vertical height, there was enough space and room for the return of correctly shaped lower anteriors. The chance to see her worn down stubs of older appearing teeth appear vibrantly youthful and regenerated in length, appearance and color was encouraging to Mrs. G.

All of this was made possible by restoring the correct vertical dimension by correcting the posterior teeth height. To achieve this, implants and sinus lifts with bone regeneration techniques were utilized. The restorative crowns allowed the stabilization and maintenance of the desired vertical height. The anterior component now had the height to allow the shape and length of the desired anterior teeth.

This is an example of a patient with osteoporosis for years, who utilized an oral bisphosphonate delivery system for 10 years and wished to have a non-removable, restored dentition supporting the reclaimed vertical space. Mrs. G’s restorations have been functioning for more than 10 years now. She also continues with the oral bisphosphonates as prescribed.

Thus, by using sinus augmentation, periodontal regeneration techniques and endosseous implants with permanent non-removable dental restoration, an esthetically restored smile was achieved. Youthful, longer appearing teeth aid Mrs. G’s glowing smile, but have proved to be maintainable as well.

Note: This article was originally published in Dental Tribune U.S. Edition, Vol. 6 No. 16, October 2011. To read Part 1 of this series, click here.

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