CASE-BASED

LEARNING
Holistic Management of a Periodontal Patient

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Student ID : SCM-021336
Group : B.1
Facilitator : Dr. Bennete
Semester :1
Content:
Introduction to Gingival Overgrowth
1. The Role of Plaque and Calculus in Causing Periodontal Disease & Gingival
Overgrowth
2. Gingival Enlargement Classification
3. Differential Diagnosis for Localized Gingival Overgrowth
4. Provisional Diagnosis for this Case (based on Clinical and Radiographical Findings)
5. Treatment Plan
6. Formation of Periodontal Pocket Etiology
7. The Significance of Non-Surgical Periodontal Therapy in Management of this
Periodontal Patient
8. Various types of biopsies with their indications.
9. Management of Persistent Localized Overgrowth after Non-Surgical Periodontal
Therapy.
10. Significance of Maintenance Phase of Periodontal Therapy for this patient.
11. Oral Hygiene Instructions
12. Advice given to the patient to avoid esthetic embarrassment resulting from losing
anterior tooth.
13. Possible treatment options that can be offered to the patient.
14. Difference between Bridge and Removable Partial Denture.
15. Treatment Plan Sequence that can be offered for the Patient to replace the Missing
Anterior Teeth
16. Various types of FPDs that can be offered to the patient to replace Lateral Incisors.
17. Design for the immediate RPD for the scenario of the maxillary arch after 12 is
missing.
18. Grading and causes of tooth mobility
Conclusion
Reference
Introduction: Gingival Enlargement
Gingival (Gum) enlargement, also known as gingival hyperplasia or hypertrophy, is an
abnormal overgrowth of gingival tissues.

There are several causes of gingival enlargement and they can be grouped into four
categories:
1) inflammatory gingival enlargement,
2) medication-induced gingival enlargement,
3) hereditary gingival fibromatosis,
4) systemic causes of gingival enlargement.

Inflammatory Gingival Enlargement

The gingival enlargement observed may be localized or generalized and is an inflammatory
response that occurs when plaque (collection of food debris and bacteria) accumulates on
the teeth. This is a result of the patient not accomplishing effective oral hygiene. An example
is noted to the right. Gums affected by this condition are often tender, soft, red, and bleed
easily. Fortunately, this condition usually resolves with effective oral hygiene practices (tooth
brushing, flossing) to remove the plaque and irritants on the teeth.

Medication-Induced Gingival Enlargement

Patients who take certain medications may develop gingival enlargement. In contrast to
inflammatory gingival enlargement, the gum tissues in such cases are typically firm, non-
tender, pale pink in color, and do not bleed easily. To the right is an example caused by the
cardiovascular drug nifedipine. In severe cases, the gingiva may completely cover the
crowns of the teeth causing periodontal (gum) disease (due to difficulty in keeping the teeth
clean) as well as problems with tooth eruption and alignment. Medication-induced gingival
enlargement may resolve either partially or completely when the medication is discontinued.
If the medication cannot be discontinued, surgical removal of the excess gingiva
(gingivectomy) may be performed but the condition will likely recur. As this condition is
somewhat worsen by the level of plaque accumulation on the teeth, effective oral hygiene
measures will reduce the severity.

Hereditary Gingival Fibromatosis

This is a rare hereditary condition that usually develops during childhood, although some
cases may not become evident until adulthood. The condition presents as a slowgrowing
generalized or occasionally localized non-tender, firm, pale pink enlargement of the gingival.
The example to the right reveals how the teeth may become covered by the exuberant
gingival overgrowth. Surgical removal of excess gingival is often necessary to avoid
impaction and displacement of teeth. Repeated surgical removals may be required because
of the recurrent nature of this condition.

Systemic Causes of Gingival Enlargement

There are numerous physiologic and systemic conditions that may promote localized and/or
generalized gingival enlargement such as pregnancy, hormonal imbalances, and leukemia.
To the right is an example of a localized gingival enlargement associated with pregnancy.
Gingival enlargement associated with systemic conditions usually resolves when the
underlying condition is treated or in the case of pregnancy, delivery of the child. As with
medication-induced gingival enlargement, effective oral hygiene measures will reduce the
risk of developing gingival enlargement.

The Role of Plaque and Calculus in Causing Periodontal Disease & Gingival
Overgrowth.
Plaque and calculus provides a fixed nidus for the continued accumulation of plaque and its
retention in close proximity to the gingiva. Plaque initiates gingival inflammation which then causes
pocket formation and the pocket in turn provides a sheltered area for plaque and bacterial
accumulation. Bacterial plaque that coats the teeth is the main etiologic factor in the development
of periodontal disease.
Calculus plays an important role in maintaining and accentuating periodontal disease by keeping
plaque in close contact with the gingival tissue and creating areas where plaque removal is
impossible.

Non-specific plaque hypothesis

Periodontal disease is due to bacterial accumulation, irrespective of its composition.

This implies that no one specific bacterial species is any more significant than another in its ability to
cause periodontal disease. The implication from the non-specific plaque hypothesis is that all
patients must maintain a high standard of oral hygiene to prevent periodontal disease, as all bacteria
are perceived as playing a role. Although the amount of plaque present may correlate well with
disease severity in cross-sectional studies, it correlates poorly in longitudinal studies. This hypothesis
does not consider variations in the dental biofilm that may affect its pathogenicity or, most
importantly, host determinants.

Specific plaque hypothesis

Periodontal disease is the result of an infection with a single specific pathogen.

This may help to explain why there are many patients who have considerable plaque deposits but
only a minority suffer from severe destructive periodontitis. The implications from the specific
pathogen hypothesis are that one need only worry about the bacterial pathogen responsible for
periodontal disease, and therefore need only employ procedures that lead to the elimination of this
species and not all other bacterial species. Treatment could specifically target the identified
pathogen as one would do for any other monospecific infection such as tuberculosis or syphilis.

If one assumes that the 'real' pathogen is a strict anaerobe, it may be unnecessary to eliminate all
plaque deposits and sufficient to either eliminate the pathogen or promote the development of a
new community where anaerobes are unable to survive. This may be achieved by simply disrupting
the biofilm and could explain the success that is achieved by root surface debridement. Special-risk
patients might be identified by the presence of the specific pathogen in the oral cavity. This might
lead to treatments targeted at specific bacteria, employing antibiotic chemotherapy once the
antibiotic sensitivities are known, or newer therapeutic measures including vaccinations, or the use
of peptides to prevent bacterial adherence and the ensuing colonisation. However, to date no one
pathogen has been specifically linked to chronic gingivitis or periodontitis. The increased relative risk
of aggressive periodontitis in adolescent Moroccans who have Aggregatibacter
actinomycetemcomitans, particularly the JP2 clone, is the most compelling evidence for a role of a
single species in periodontal disease.

Multiple pathogen hypothesis

Periodontal disease is the result of infection with a relatively small number of interacting bacterial
species.

One major difficulty lies in identifying the possible combinations of pathogens that are important. It
should be appreciated that this current list of periodontopathogens may be superseded once the
results from bacterial culture and isolation using molecular techniques are combined and
reinterpreted. One could, nevertheless, arbitrarily determine antibiotic sensitivities of the top ten
periodontopathogens and then employ these antibiotics to eliminate the organisms.

Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, Treponema denticola,

Fusobacterium nucleatum and Campylobacter spp. are present in diseased sites and have been
implicated in disease progression. However, this in itself does not prove that they are responsible for
tissue damage, and indeed one may argue that these organisms are more likely to be found in
deeper pockets and at the sites with more inflammation simply because they thrive in such
ecological niches.

Gingival Enlargement Classification

1) Inflammatory enlargement
a) Acute
b) Chronic
2) Drug Induced Enlargement
3) Enlargements due to systemic Diseases
a) Conditioned enlargement
- Pregnancy
- Vitamin C
- Plasma cell gingivitis
- Nonspecific conditioned enlargement
b) Systemic diseases conditioned enlargement
- Leukemia
- Granulomatous diseases (Wegener granulomatosis, sarcoidosis)
4) Neoplastic enlargement
- Benign Tumour
- Malignant tumour
5) False enlargement
- Underlying osseous enlargement
- Underlying dental issues

Differential Diagnosis for Localized Gingival Overgrowth

Localized enlargement of gingiva, historically termed as edulis, refers to any solitary/discrete,
pedunculated or sessile swellings of the gingiva with no histologic characterization of a particular
lesion. A corrective term reactive lesion of the gingiva, seems to be more appropriate for this
category of swellings.
Frequent diagnosis in this category is inflammatory rather than neoplastic and may fall in one of the
following group of reactive lesions:
1. Fibrous epulis/peripheral fibroma,
 2. Angiogranuloma/pyogenic granuloma
3. Peripheral giant cell lesion/granuloma.

Fibrous epulis/peripheral fibroma

In adults, this lesion frequently represents as firm, pink, un-inflammed mass, and it seems to grow
from below the free gingival margin/interdental papilla. Most often the lesion is painless. Pain may
be associated due to secondary traumata via brushing, flossing or chewing. Histologically, the
fibroma may show additional focus of calcification (peripheral calcifying fibroma), foci of cementicles
(peripheral cementifying fibroma), or trabeculae of bone (peripheral ossifying fibroma).

Angiogranuloma/pyogenic granuloma
Presents in adults as smooth surfaced mass, often ulcerated and grows from beneath the gingival
margin. These reddish/bluish color mass are highly vascular, compressible and could bleed readily.
Typically they grow rapidly within first few weeks and then slowly. The mass may penetrate
interdentally and present as bilobular (buccal and lingual) mass connected through the col area, but
bone erosion in uncommon. Angiogranuloma which appears during pregnancy are termed as
pregnancy epulis/tumor or granuloma gravidarum.
Histologically, the stratified squamous epithelium is thickened, with prominent rete pegs and some
degree of intracellular and extracellular edema, prominent intercellular bridges and leukocytic
infiltration.

Peripheral giant cell granuloma

They occur particularly in anterior region in young patients or in posterior mouth during mixed
dentition phase and in adults. They are very aggressive lesions with significant growth potential. The
high vascularity of these lesions can be understood by their purplish-red color and tendency to
bleed. They also tend to penetrate interdentally and erosion of adjacent bone along with separation
of adjacent teeth is a common occurrence.

Provisional Diagnosis for this Case (based on Clinical and Radiographical Findings)
Chronic severe generalized periodontitis with a localized overgrowth in relation to upper right central
and lateral incisors.

Chronic Generalized Periodontitis

as abundance of local factors-plaque and calculus, its generalized but some areas (molar
region) are more deeply involved than others.
Severe as pocket depth is more than 5 mm
Age of the patient is above 30-35 years old. (39 y/o)
The OPG also shows that the remaining amount of bone. There is vertical bone loss in the
premolar and molar area and in upper right central, lateral incisors.

Treatment Plan
Phases of Dental therapy:
* Emergency phase
1. Phase I therapy (non-surgical phase)
2. Phase II therapy: Surgical Phase
3. Phase III therapy: Restorative phase
4. Phase IV therapy: maintenance phase
Maintenance phase exists at the end of every phase or before beginning of every phase
Emergency Phase:
1) Drainage of abscess (Periodontal, periapical, pericoronal, gingival)
2) Extraction of tooth with hopeless prognosis ( Grade III mobility, root stumps, grossly decayed
tooth)

Phase 1: scaling and root planning (non surgical approach ) , Education and Motivation of the
patient.
Phase 4: periodic recall ,supportive periodontal therapy ,rechecking gingival condition(pockets,
inflammation )
Phase 2 : : on the gingival enlargement & guided tissue regeneration GTR for interproximal bone
loss between 11 & 12. Placement of dental implants 12
Phase 4 : maintenance phase
Phase 3 : prosthetic therapy IRT 12, fixed orthodontic treatment irt missing 31 (spacing observed )

Formation of Periodontal Pocket Etiology

 Picture taken from periobasic.com

- Initially there is plaque formation and accumulation of gram +ve bacteria in the
supragingival tooth surface. This plaque then extends to the subgingival area.
- Periodontal pocket formation starts with plaque accumulation and its maturation. As the
plaque matures, there is a microbial shift towards gram ve bacteria which is the result of
change in subgingival environment. The Ecological Plaque Hypothesis explains that the
factors responsible for the growth of periodontal pathogens with changing subgingival
environment that is conducive for their growth.
- Virulent factors produced by the bacteria in the plaque stimulates host immune response.
These products include: metabolic acids, bacterial lipopolysaccharides, FMLP, volatile
sulphur compounds, extracellular enzymes and fatty acids.
- In response to this, the junctional epithelium cells produce various pro inflammatory
mediators, like IL8, TNF a, PGE2, IL1a and MMP. Along with this, neuropeptides and
histamine produced by free nerve endings causes vascular effects in that area. These
mediators cause increased vascular permeability.
- The perivascular mast cells produce histamine which causes the endothelium to release IL8,
which in turn causes the polymorphonuclear cell recruitment. Large number of neutrophils
transmigrate into the connective tissue under chemoattractant gradient produced by
bacterial products and host immune cells products.
- These neutrophils rapidly passes through the junctional epithelium, into the gingival sulcus.
They form a variably thick layer over the subgingival plaque.
- Neutrophils covering the plaque surface are viable but not completely functional, they
prevent further extension and spread of bacteria by various anti-bacterial actions like
phagocytosis.
- As the inflammation intensifies, there is degradation of connective tissue and gingival fibers
through collagenases and fibroblast which phagocytize collagen fibers.
- The JE cells proliferates and form finger like projections in the connective tissue, and there is
apical extension of the JE along the root surface. Though it is imporatant to note that this
process require healthy epithelial cells, which is why degradation of epithelial cells at the
 base of the pocket retards pocket formation and the degenerative changes on the lateral wll
of pocket are more severe than the base of the pocket.
- The increasing number of transmigrating neutrophils interferes with epithelial attachment
and when the volume of neutrophils reaches approximately 60% or more of the JE, there is a
disruption of epithelial barrier to create an open communication between the pocket and
the underlying tissue. This ulceration is the second important event in pocket formation.
- And because of the disrupted epithelial barrier, the chemoattractant gradient is hampered
and the neutrophils move randomly in the connective tissue. On the other hand,
microorganisms gain access to the connective tissue and this becomes a battlefield for
bacterial interaction.
- Neutrophils perform phagocytic function, macrophages produces various chemical
medicators which further intensifies inflammatory action; and as this prolongs, antigen
presenting cells activate the T-cell response which further activates B-cell response, and
continues until there is bacterial infiltration.
- In due course of time, the alveolar bone resorption begins, which causes the deepening of
periodontal pocket.
- It is important to note that the healing process is continuous throughout. If the bacterial
insult is overcomed and stopped, the JE is again formed and the destruction of connective
tissue stops.

The Significance of Non-Surgical Periodontal Therapy in Management of this

Periodontal Patient
Based on this trigger, the treatment given is phase 1 therapy which means etiotropic phase or non
surgical periodontal phase. The objective is to alter or eliminate the microbial etiology and factors
that contribute to the periodontal diseases to the greatest extent possible, therefore halting the
progression of disease and returning the dentition to a state of healthy and comfort.

During phase 1 therapy, the treatment includes the initiation of a comprehensive daily plaque
control regimen, thorough plaque and calculus removing, correction of defective restorations and
treatment of carious lesions. In this trigger, plaque control instructions are given to the patient as
proper oral hygiene measures. Scaling and root planning given to the patient indicates the removal
of supragingival and subgingival calculus for the patient to create a plaque and calculus free zone to
the teeth. In addition, non surgical periodontal therapy also provides an opportunity for the dentist
to evaluate tissue response and patient motivation about periodontal care, both are crucial
elements to the overall success of treatment.

The last step in phase 1 therapy is to reevaluate the condition of the tissue. After scaling and root
debridement, the periodontal tissue requires approximately 4 weeks to heal sufficiently to be
probed accurately. Patients also need the opportunity to improve their plaque control skills to both
reduce inflammation and adopt new habits.

During review, periodontal tissues are probed, and all related anatomic conditions are carefully
evaluated to determine if any further treatment like periodontal therapy is indicated to the patient.

Various types of biopsies with their indications.

Fine needle aspiration biopsy
In fine needle aspiration biopsy (FNAB), small amount of tissue from the suspicious area is aspirated
using a very thin needle attached to a syringe. This tissue is then looked at under a microscope. The
needle used for FNAB is thinner than the ones used for blood tests.
If the area to be biopsied can be felt, the doctor locates the lump or suspicious area and guides the
needle there. If the lump cant be felt, ultrasound might be used to watch the needle on a screen as
it moves toward and into the mass. (This is called an ultrasound-guided biopsy.) Or, the doctor may
use a method called stereotactic needle biopsy to guide the needle.

Core needle biopsy

A core needle biopsy (CNB) is much like an FNAB. A slightly larger, hollow needle is used to withdraw
small cylinders (or cores) of tissue from the abnormal area. A CNB is most often done in the health
care providers office with local anesthesia. The needle is put in 3 to 6 times to get the samples, or
cores. This takes longer than an FNAB, but its more likely to give a clear result because more tissue
is taken to be checked. A CNB can cause some bruising, but usually doesnt leave scars.
The provider doing the CNB usually places the needle in the abnormal area using ultrasound or x-
rays to guide the needle into the right place. If the area is easily felt, the biopsy needle may be
guided into the tumor while feeling (palpating) the lump.

Stereotactic core needle biopsy

A stereotactic core needle biopsy uses x-ray equipment and a computer to analyze pictures of the
lesion. The computer then pinpoints exactly where in the abnormal area the needle tip needs to go.
This is often done to biopsy suspicious microcalcifications (tiny calcium deposits) when a tumor cant
be felt or seen on ultrasound.

Vacuum-assisted core biopsy

Vacuum-assisted biopsies can be done with special biopsy systems. For these procedures, the skin is
numbed and a small cut (less than inch) is made. A hollow probe is put in through the cut and
guided into the abnormal area of breast tissue using x-rays, ultrasound, or MRI. Tissue is then pulled
into the probe through a hole in its side, and a rotating knife inside the probe cuts the tissue sample
from the rest of the breast.
These methods allow multiple tissue samples to be removed through one small opening. They are
also able to remove more tissue than a standard core biopsy. Vacuum-assisted core biopsies are
done in outpatient settings. No stitches are needed, and theres usually very little scarring.

Surgical (open) biopsy

Most health care providers will first try to figure out the cause of a lesion by doing a needle biopsy,
but in some cases a surgical biopsy may be needed. A surgical biopsy is done by cutting the lesion to
take out all or part of the lump so it can be looked at under a microscope. This may also be called an
open biopsy.

There are 2 types of surgical biopsies:

- Incisional biopsy removes only part of the suspicious area, enough to make a diagnosis.
- Excisional biopsy removes the entire tumor or abnormal area, with or without trying to take out an
edge of normal tissue (it depends on the reason for the excisional biopsy).

In rare cases, a surgical biopsy can be done in the providers office, but its more often done in the
hospitals outpatient department under local anesthesia.

A surgical biopsy is more involved than a fine needle aspiration or a core needle biopsy. Stitches are
often needed, and it will leave a scar.

Management of Persistent Localized Overgrowth after Non-Surgical Periodontal

Therapy.
The first line management of gingival overgrowth is improved oral hygiene, ensuring that the
irritative plaque is removed from around the necks of the teeth and gums.
Situations in which the chronic inflammatory gingival enlargement include significant fibrotic
components that do not respond to and undergo shrinkage when exposed to scaling and root
planing are treated with surgical removal of the excess tissue, most often with a procedure known as
gingivectomy or in this scenario given, excisional biopsy is sufficient.
Improved oral hygiene and plaque control is still important to help reduce any inflammatory
component that may be contributing to the overgrowth.

Antiinfective therapy
An antiinfective agent is a chemotherapeutic agent that acts by reducing the number of bacteria
present. It can be administered locally or orally, many of these agents can be found in the gingival
crevicular fluid, purpose is to decrease the number of bacteria present in the diseased periodontal
pocket.
Some guidelines for antiinfective therapy: It is used as an adjunct to mechanical therapy. The
antibiotics are selected based on the patients medical and dental status, current medications and
results of microbial analysis, if performed.
Examples of antibiotics used to treat periodontal disease: Amoxicillin, Augmentin, Minocycline,
Doxycycline, Tetracycline, Ciprofloxacin, Azithromycin, Metronidazole.
Local delivery agents: Locally delivered antimicrobial agents are available as adjuncts to scaling and
root planning and as aids in the control of bacterial growth on barrier membranes. When placed into
periodontal pockets, they reduce subgingival microflora, probing depths and clinical signs of
inflammation. Eg: subgingival chlorhexidine, tetracycline containing fibres, subgingival doxycycline.

Host modulation
Host modulation is an adjunct to SRP and periodontal surgery, its purpose is to modify or reduce
destructive aspects of the host response so that the immune-inflammatory response to plaque is
less damaging to the periodontal tissues.
Systemically administered agents: Nonsteroidal anti-inflammatory drugs (NSAIDs), bisphosphonates,
Sub-antimicrobial-dose doxycycline (Periostat)
Locally administered agents: topical NSAIDs, enamel matrix proteins, growth factors and bone
morphogenic proteins.
Periodontal Surgery (Phase 2 Periodontal Therapy)
Methods of pocket therapy:
- New attachment techniques:
Offer the ideal result because they eliminate pocket depth by reuniting the gingiva to tooth
at a position coronal to the bottom of the periodontal pocket. New attachment is usually
associated with filling in of bone and regeneration of periodontal ligament and cementum.
- Removal of pocket wall:
Most common method. Wall consist of soft tissue and may also include bone in the case of
intrabony pockets. Can be removed by the following:
- Retraction or shrinkage, in which SRP resolve the inflammatory process and the
gingiva shrinks, reducing the pocket depth.
- Surgical removal performed by gingivectomy technique or by means of an
undisplaced flap.
- Apical displacement with an apically displaced flap.
- Removal of the tooth side of the pocket:
Accompanied by tooth extraction or by partial tooth extraction (hemisection or root resection).

- Pocket reduction surgery:

Resective (gingivectomy, apically displaced flap and undisplaced flap with or without
osseous support)
Regenerative (flaps with grafts, membranes etc.)

Significance of Maintenance Phase of Periodontal Therapy for this patient.

The maintenance phase of periodontal treatment starts immediately after the completion of phase I
therapy. While the patient is in the maintenance phase, the necessary surgical and restorative
procedures are performed.

There are 3 parts in the maintenance program:

1. Examination and evaluation of the patients current oral health - The dentist primarily looks
for changes that have occurred since the last evaluation. This includes evaluation of oral
hygiene status, any pocket depth changes, gingival changes and mobility changes.
2. Necessary maintenance treatment and oral hygiene reinforcement - The required scaling
and root planing are performed, followed by an oral prophylaxis. Irrigation with
antimicrobial agents or placement of site specific antimicrobial devices is performed in
maintenance patient with remaining pockets.
3. Scheduling the patient for the next recall appointment and any additional periodontal
treatment.

Recurrence of periodontal disease can occur if there is inadequate plaque control due to patients
improper oral hygiene measures or failure to comply with recommended SPT schedules. A failing
case has the following clinical and radiographic features:
1. Increasing depth of sulci, leading to the recurrence of pocket formation.
2. Recurring inflammation revealed by gingival changes and bleeding of the sulcus on probing.
3. Gradual increases in tooth mobility.
4. Gradual increases in bone loss, as determined by radiographs.

In conclusion, the long term preservation of the dentition is closely associated with the frequency
and quality of recall maintenance.
Oral Hygiene Instructions
Brushing
- Brush twice a day, last thing at night
Saliva flow decreases at night, tongue action decreases at night
- Brush for at least 2 minutes each time
- Use fluoride toothpaste, regardless of the brand
- Brushing technique: Modified Bass
- Bristles are directed apically at 45 degree (up for maxillary teeth, down for
mandibular) to the long axis of tooth.
- Bristles are pressed gently so that it enters the sulcus and embrasures.
- Vibrate the brush back and forth with short strokes
- Roll the brushes towards the occlusal surface after cervical area is cleaned.
- Change toothbrush after 3months, or when bristles start to flare

Flossing
- Type I embrasure: Dental floss
- Type II embrasure: Interproximal brush
- Type III embrasure: Uniturf brushes
Mouthwash: Use once a day on occasion besides brushing
Denture care Instructions:
- Remove and rinse dentures after eating.
- Handle your dentures carefully.
- Clean your mouth after removing your dentures.
- Brush your dentures at least daily with proper denture brushes.
- Soak dentures overnight.
- Rinse dentures before putting them back in your mouth, especially if using a denture-
soaking solution.

Advice given to the patient to avoid esthetic embarrassment resulting from losing
anterior tooth.
Immediate denture can be advised to the patient to avoid esthetic embarrassment resulting from
losing anterior tooth and it should be worn until the previous extraction socket has healed
completely (6 - 8 weeks) and the definite care is ready to be provided by the dentist.

Immediate denture main steps include:

1. A primary impression is made before extraction.
2. A stone cast is produced.
3. Knock off the anterior tooth to be extracted and remove 1mm of stone from crestal area to
allow for expected resorption.
4. Choose the correct size, shape and shade of anterior tooth and arrange it on the cast.
5. Waxing, flasking and processing the denture.
6. Insert the denture and check for its proper fitting. Make selective grinding to eliminate any
occlusal prematurities.

Advantages:
1. Restore patients esthetic appearance temporarily.
2. Maintenance of space to prevent undesirable migration and extrusion of adjacent or
opposing teeth.
Disadvantages:
1. Limit evaluation of trial denture.
2. Increased patient visits and treatment cost.
3. The immediate denture may jeopardize the integrity of adjacent teeth and the health of
supporting tissue if worn for extended periods without supportive care.

A cast partial denture, a fixed prosthesis or an implant can be suggested to the patient as definite
treatment options to replace the missing anterior tooth.

Possible treatment options that can be offered to the patient.

If you have lost one or more of your natural teeth, it is important to determine the best way to
replace them as soon as possible. Replacing missing teeth will not only help restore your smile and
self-confidence, but also minimize the negative effects that tooth loss can have on your gums,
jawbone and remaining teeth such as: shifting of the teeth, difficulty speaking properly, shift in
occlusion (bite) and increased risk of tooth decay and periodontal disease.

Fixed Partial Denture :

A fixed bridge is permanently cemented into place and can only removed by your dentist. It consists
of one or more false teeth called pontics (one for each missing tooth) in the middle and one or
more anchoring crowns called abutment teeth on either side .The pontics (made from porcelain,
gold, zirconia, alloys etc.) fill in the gap while the abutment teeth are secured to the natural teeth
adjacent to the gap, holding the bridge in place.

To connect the bridge to the neighboring natural teeth, the natural teeth must be shaved/filed down
in order to provide space for the crowns to correctly align with opposing teeth and enough surface
area to enable a strong bond/connection. The natural teeth must be relatively healthy (structurally
sound and free from decay) for this to work. The biggest downside to this process is that it is
irreversible. Once the natural teeth are modified, they cannot be used as regular teeth ever again.

Removable Partial Denture:

A removable partial denture is a prosthesis that sits into the edentulous spaces, and require only
minimal tooth preparation, sometimes none at all, which is the first difference between it and the
bridge. As the name suggests, it is removable, and that is the second difference. The clinical
procedure to fabricate the removable partial denture also differs from fabricating a bridge. A
removable partial denture needs more visits as after tooth preparation is done, an impression needs
to be taken and then the patient has to come back for the bite registration and try in procedure, and
only then, can the patient get the removable partial denture.

Difference between Bridge and Removable Partial Denture.

As a bridge does not use clasps for retention, as do a removable partial denture, it is more aesthetic.
A bridge can also mimic a tooths shade exactly from the incisal tip to the cervical region, which an
acrylic teeth used to set onto the removal partial denture cannot.
However, a bridge is not able to replace too many missing teeth, unlike removable partial denture
which is able to replace any amount of missing teeth. The maximum amount of missing posterior
teeth that can be supported by the bridge are two, and the maximum amount of anterior teeth are
four. This is because the bridge relies on the abutment teeth for retention, and if the bridge is used
to replace too many missing teeth, the forces applied on the abutment will be too great, which will
inevitably lead to loosening of the abutment teeth. However, for the removable partial denture, it
can also derive its retention from clasps, abutment teeth, and the alveolar bone, therefore, less
forces will be put on the abutment teeth.

The cost of both the prosthesis is also different, with the bridge being more expensive.

Implants :

A dental implant is an artificial tooth root (or post) made of titanium that connects to the jawbone
and supports a crown. After being inserted into the jawbone via a short surgical procedure, the post
must osseointegrate (fuse) with the jawbone so it is firmly anchored in position. Once the
osseointegration process is complete (which can take anywhere from 3-6 months), an abutment is
attached to the post. The abutment protrudes above the gum line and provides the surface that the
dental crown is screwed or cemented onto.

Bridges
Benefits:
1. A very natural look. They can be used to improve the color and shape of the teeth being
replaced or covered up. Modern porcelain is extremely sophisticated and a skilled dental
technician can fabricate a bridge that will closely mimic the natural translucencies and
multiple shades found in natural teeth.
2. Straightforward procedure. They are a very common solution to tooth loss and a routine
procedure for many dentists.
3. Affordability. A traditional bridge is around $700 $1,500 per unit. A more detailed outline
of the costs can be found below.
4. Low risk. If a bridge fails, crowns and pontics can be replaced relatively quickly and
painlessly.
5. Fast. The entire process can usually be completed in a few weeks.
Drawbacks
1. Damaging natural teeth. Preparation involves removing a considerable amount of tooth
structure from adjacent teeth. Once this is done, these teeth can never again be used as
regular teeth and must always be crowned.
2. Increased risk of cavities and decay. Removing some of the structure of a tooth increases
the risk of it decaying and the need for a root canal treatment in the future.
3. They need to be replaced periodically typically every 5-7 years.

Implants vs Bridges Comparison

Implant Bridge

How Long They Last 15+ years 5-7 years

Insurance Coverage Rarely covered Covered by most plans

Long-Term Dental Health Little to no gum/bone loss Some bone/gum loss

Oral Hygiene Brush & floss like normal Need special floss & brush

Appearance Best possible aesthetics Very natural looking

Procedure Duration Multiple visits over 3-6 months 2-3 visits over a few weeks

Insurance coverage
Bridges are covered by most dental insurance plans, so you should be able to reclaim a considerable
percentage of the cost. Implants on the other hand are rarely covered by dental insurance. However,
you may be able to claim at least part of the cost of the crown.

How long they last

Well-maintained implants will last for many years and typically for a patient who is 45 years or older,
they are for life. The crown needs to be replaced every 10-15 years due to normal wear and tear, but
the implant itself is permanent barring any uncontrollable circumstances such as accidents and
diseases. Bridges typically need to be replaced periodically (every 5-7 years), but they can last up to
10+ years by practicing excellent oral hygiene.

Long-term oral health

Bone and gum tissue loss will occur under a bridge where the tooth was missing/extracted, which
can have a destabilizing effect on adjacent teeth. An implant on the other hand simulates a natural
tooth root by stimulating the surrounding area with the forces produced by chewing, which
preserves the bone and gums.

Oral hygiene
A special type of floss and possibly other dental hygiene tools are required to clean underneath the
pontics of a bridge and keep the area free from plaque. An implant also requires excellent oral
hygiene, but can be brushed and flossed as if it were an ordinary tooth.

Appearance
Modern bridges look very natural, but as bone and gum tissue are lost over time, gaps can open up
underneath the pontics. An implant provides the highest quality aesthetic results. The crown
emerges from your gums in exactly the same way as a natural tooth.

Procedure duration
Start to finish, bridges are completed in two or three visits over the span of a few weeks. Implants
require multiple visits over the course of 3-6 months and additional procedures such as bone grafts
and sinus lifts are required in some cases.

Treatment Plan Sequence that can be offered for the Patient to replace the Missing
Anterior Teeth
Emergency:
Excision and biopsy of gingival overgrowth

Treatment:
- SRP (esp for pocket depth >4mm)
- Immediate denture fabrication
- Extraction of 12
- Prosthodontic options: 3 unit bridge, implants OR RPD (2-6months)
- Orthodontic evaluation for spacing in mandibular anteriors, and replacement of 31

Maintenance:
OHI & denture care; Recall patient for follow up.

Various types of FPDs that can be offered to the patient to replace Lateral Incisors.
Anterior teeth replacement is all about esthetic because its the first thing people notice when you
smile .we have few options of FPD that can be suggested to the patient to replace the missing lateral
incisor.

Implants:
Can only be given after guided tissue regeneration, and the amount of bone is enough to allow
implants to be carried out.
it will be the best in terms of patient's psychological security and esthetic is the best, but the
cost will be much higher than the other treatment options.
Conventional FPD
Most commonly used .
Fabrication of the fixed partial denture ,which takes support from abutments .the abutments
should be able to support the fpd .

Resin bonded FPD

Resin bonded prosthesis: A prosthesis that is luted to tooth structures primarily enamel which has
been etched to provide mechanical retention for the resin cement.
Advantages -
Minimal removal of tooth structure.
Non-invasive to dentin
Minimal potential for pulpal trauma.
Tissue tolerant because of supragingival margins without gingival irritation.
Esthetically more appealing since only lingual surface of anterior teeth are covered
Simplified impression procedures
Disadvantages -
Reduced restoration longevity
Good alignment of teeth are needed
Usually restricted to single tooth replacement
Types Of Resin Bonded Fixed Partial Denture Designs
1) Rochette FPD
- Bonding through mechanical retention
- The metal retainer had flared perforation so that the bonding material gets locked
mechanically.
2) Maryland FPD
- Although this design has been reported to be stronger, it is more technique sensitive
because the retainers may not be properly etched or may be contaminated before
cementation.
3) Cast mesh FPD
 - nylon mesh is placed on the tissue surface of the retainer wax pattern .drawbacks include :
the nylon mesh may not adapt well to the cast during pattern fabrication.
4)Fungs
-It is of lower cost compared to custom made resin bonded bridges.
-Can be given to patient in a single appointment

Fiber Reinforced Composite Resin FPD

Consists of a fiber reinforced substructure
Veneered with composite material
Increased flexural strength , fracture resistance & increased tensile strength

Design for the immediate RPD for the scenario of the maxillary arch after 12 is
missing.
Since it is not a permanent denture, use acrylic resin base for the denture, which is the most
common types used in removable partial denture.

Advantages:
ability to reline the base as the supporting tissues change
 esthetically superior to metal bases
ease of repair
Disadvantages:
o dimensional stability less than metal bases
o lower strength than metal - long spans
o porous - hygiene
o low thermal conductivity

Denture Bases
1. Use broad tissue base support. Maximizing the denture base coverage provides greater stress
distribution and resistance to displacement by lateral forces. However, the denture base should not
be overextended so that it is displaced during functional movements. If this occurs the
overextension will cause greater rotational forces to be placed on the denture and the abutment
teeth.
2. Distal extension bases should be extended to maxillary tuberosities as these structures provide
comfort and a peripheral seal for retention.

Porcelain tooth tooth form, shape, size.

Check for the overjet, overbite, occlusal plane.

Flange
. Tooth supported partial dentures (Class III and IV) need not necessarily be extended maximally,
since most of the support for these dentures comes from the teeth. Maxillary distal extension
denture bases should terminate in the hamular notches.
Definition. The notch or fissure formed at the junction of the maxilla and the hamular process of the
sphenoid bone, just beyond the distal end of the alveolar process.
Tooth supported rpd sufficient retention, but also can add two clasps over the premolars region if
stronger retention is needed.

Grading and causes of tooth mobility

Millers Classification of tooth mobility :
Grade I : Slightly more than normal ( < 1mm )
Grade II : Moderately more than normal ( >1mm )
Grade III : Severe mobility faciolingually and/or mesiodistally, combined with vertical displacement

Increased mobility is caused by one or more of the following factors :

1. Loss of tooth support ( bone loss ) ]
- Amount of mobility depends on the severity and distribution of bone loss at individual root
surface , length and shape of roots and the root size compared with that of the crown
- eg . a tooth with short tapered roots is more likely to loosen than one with normal size or
bulbous roots with the same amount of bone loss

2. Trauma from occlusion

- Eg. parafunctional habits like bruxism and clenching
- Mobility produced by trauma from occlusion occurs initially as a result of resorption of the
cortical layer of bone, leading to reduced fiber support, and finally widened periodontal
space

3. Extension of inflammation
- From gingiva or from periapex into the PDL results in changes that lead to increased mobility
 - Spread of inflammation from acute periapical abcess

4. Periodontal surgery
- Temporarily increases tooth mobility immediately after the intervention and only for a short
period

5. Pregnancy and sometimes menstrual cycle or use of hormonal contraceptives

( unrelated to periodontal disease and occurs presumably because of physiochemical
Changes in periodontal tissues )

6. Pathologic process of the jaws that destroy the alveolar bone and/or roots of teeth
- Eg. osteomyelitis and tumors of the jaw

Conclusion:
The provisional diagnosis for this case is Chronic Generalized Periodontitis with Localized
Gingival Enlargement, which is caused by various factors, one factor being the patient has
poor oral hygiene maintenance.

Treatment plan that was holistically made, involving many different specialties of oral
medicine, periodontics, oral surgery, community oral health, prosthodontics and also
orthodontics.

Patients concerns and choice of treatment should be taken seriously, especially regarding
tooth/ teeth in the esthetic zone.
It is also important for a dentist to have a holistic approach towards each case present in
order to be able to provide the best possible treatment for the patient.

Reference:
Carranza, F. A., Newman, M. G., Takei, H. H., & Klokkevold, P. R. (2006). Carranza's clinical
periodontology. St. Louis, MO: Saunders Elsevier.

Muller, H. (2005). Periodontology: The essentials. Stuttgart: Thieme.

, L. T. (2014). Prosthodontics. Philadelphia: Elsevier.

Garcia

http://periobasics.com/periodontal-
pocket.html#Mechanism%20of%20periodontal%20pocket%20formation:

http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/forw
omenfacingabreastbiopsy/breast-biopsy-biopsy-types

http://www.juniordentist.com/types-of-tooth-brushing-techniques.html

http://www.mayoclinic.org/diseases-conditions/cancer/in-depth/biopsy/art-20043922

http://www.aaom.com/index.php%3Foption%3Dcom_content%26view%3Darticle%26id%3D
132:gingival-enlargement%26catid%3D22:patient-condition-information%26Itemid%3D120