Each patient underwent a comprehensive dental and periodontal
examination. Periodontal charting included documentation of probing
depths, recessions, clinical attachment levels, bleeding on
probing, tooth mobility, furcation involvement, and plaque scores.
Periodontitis was diagnosed in the presence of more than 4 sites
with clinical attachment loss exceeding 4 mm, radiographic evidence
of alveolar bone loss, and bleeding on probing. Impressions for
diagnostic casts were taken and a panoramic radiograph was
obtained. Casts were mounted on a semi-adjustable articulator after
face-bow transfer and check-bite registration. An occlusal analysis
was performed, diagnostic wax-ups were prepared on the articulated
casts, and restorative treatment needs determined. Once the
restorative and periodontal treatment plans were established,
radiographic and surgical guides were fabricated to facilitate
implant placement. Table 1 shows the patient treatment plan and
Standard medication for all cases included diclofenac (Voltaren;
Novartis Pharma, Nürnberg, Germany), a nonsteroidal
antiinflammatory drug, 100 mg once a day for 4 days; clindamycin
(Ratiopharm, Ulm/Donautal, Germany), a systemic antibiotic, 600 mg
once a day for 6 days; and 0.1% chlorhexidine rinses (Chlorhexamed
Fluid, GlaxoSmithKline, Bühl, Germany) twice a day. Medication was
administered starting 1 day before surgery.
An intersulcular incision extending to the first adjacent tooth on
each side was placed and a full-thickness flap was elevated.
Implant sites were prepared at 875 rpm using a 16:1 hand piece
(Nouvag AG, Goldbach, Switzerland) and a microcomputer-controlled
surgical micro motor (micro-dispenser model 7/8000, Nouvag).
Implants were inserted and tightened to a torque of 35 N with a
hand ratchet (model 046.119/046.049; Straumann).
The surgical site was covered with a resorbable bilayer membrane
(BioGide, Geistlich Biomaterials, Wolhusen, Switzerland).
If necessary, sinus augmentation was performed following a
previously described protocol.26 A 1:1 mixture of bovine allograft
(0.25-1 mm, 0.25 g; BioOss spongiosa, Geistlich Biomaterials) and
autogenous corticocancellous bone (harvested from the retromolar or
chin area) was used as the graft material. The access window was
covered with a resorbable barrier membrane (BioGide, Geistlich
Biomaterials). The membrane was fixated with absorbable pins (Resor
Pins, Geistlich Biomaterials).
Patients were instructed to avoid wearing any removable dentures
for the first 2 weeks postoperatively. Postoperative follow-up
visits were scheduled at 1, 4, and 7 weeks.
Implant placement was performed 4 to 6 months after the sinus
augmentation surgery or simultaneously with the augmentation if the
residual alveolar crest height exceeded 4 mm.
Supportive periodontal therapy was performed every 4 months. At
each appointment, pocket depth (PD), clinical attachment level
(AL), bleeding on probing (BOP), and plaque accumulation (PI) were
recorded at 4 sites of each implant.
AL was defined as the distance in mm between the deepest point of
the peri-implant area and the smooth neck section of the implant.
Measurements were obtained by the use of a periodontal probe
(KM0805, Hu-Friedy, Leimen, Germany).
Removal of soft and hard deposits around the implants and natural
teeth, as well as irrigation of the peri-implant area with 0.1%
chlorhexidine (GlaxoSmithKline), was performed at each visit; oral
hygiene instructions were also given.
A 50-year-old man presented in the office for a complete oral
rehabilitation. Clinical and radiographic evaluation revealed that
none of the remaining teeth were salvageable for either periodontal
or restorative reasons. Therefore, the treatment plan included the
extraction of all remaining teeth; fabrication of a complete
maxillary denture; and an implant retained, supported complete
denture for the mandible, using telescopic crowns as attachments.
After the extraction of all remaining teeth, provisional complete
dentures were delivered. Five months later, 6 ITI implants were
placed in the mandible. Four months later a complete maxillary
denture was delivered. An implant-supported complete mandibular
denture using telescopic crowns as attachments was fabricated at
the same time.
The 53-year-old woman was referred for periodontal and implant
treatment by her general dentist. In the maxilla, only tooth No. 6
was remaining. This tooth was nonsalvageable.
Tooth No. 6 was extracted, and scaling and root planing was
performed in the mandibular dentition. The periodontal condition
appeared stable after the initial treatment phase. No further
periodontal treatment other than regular supportive therapy was
Four months after tooth extraction, a bilateral sinus augmentation
procedure was performed. After a healing period of 8 months, 8 ITI
implants were placed in the maxilla. Six months after insertion,
the implants were loaded with a telescopic crown retained removable
denture. The denture was designed with a free palate
A 53-year-old woman presented in the office for a full mouth
reconstruction. Clinical and radiographic examination revealed that
none of the remaining teeth were salvageable.
It was decided to extract all the remaining teeth and to place
implant retained overdentures.
Four months after extraction, sinus augmentation was performed
bilaterally and 6 ITI implants each were placed in the maxilla and
After a healing period of 6 months, implant retained overdentures,
using telescopic crowns as attachments, were delivered. The
maxillary overdenture was designed with a free palate
A 62-year-old man presented for an implant-supported full mouth
reconstruction. All remaining teeth had to be extracted and
provisional full dentures were delivered.
Six months later, 2 ITI implants were placed in the maxilla, and 6
ITI implants were placed in the mandible.
Five months later, a telescopic crown–supported, palate-free
complete maxillary denture and a telescopic crown-supported
mandibular overdenture were delivered.
A 52-year-old woman presented for periodontal treatment und a
subsequent full mouth reconstruction.
Generalized radiographic horizontal bone loss was present in the
mandible reaching 50% of the root length. The bone loss around
teeth No. 18, 23, 26, and 31 extended to the apices. Generalized
horizontal bone loss was present in the maxilla reaching 65% of the
Probing depths ranged between 6 and 9 mm. Teeth No. 18 and 31 had
clinical furcation involvement Class III.
All maxillary teeth presented with Class III mobility, spontaneous
bleeding, and gingival sensitivity upon touch.
The patient was diagnosed with chronic periodontitis.
All maxillary teeth and teeth No. 18, 23, 26, and 31 were
extracted. The areas of teeth No. 20, 21, 22, 27, 28, and 29 were
treated with access periodontal surgery. A provisional maxillary
denture was delivered. Fixed partial dentures were placed on teeth
No. 20, 21, 22, 27, 28, and 29.
A temporary complete denture was designed for the maxilla. Six
months after extractions and periodontal surgery, 4 ITI implants
were placed in the mandible, and 6 ITI implants were placed in the
maxilla. The number of implants was limited to 6 since the patient
preferred not to undergo sinus augmentations.
Six months after implant placement, an implant-supported horse
shoe-shaped complete maxillary denture with telescopic crowns as
abutments was delivered. Cemented crowns were placed on the
A 50-year-old man presented to the practice reporting spontaneous
bleeding and mobility on all teeth.
Initial periodontal treatment consisting of scaling and root
planing and oral hygiene instruction had been performed 5 years
earlier (March 1996). The patient did not finish this treatment
phase and refused the suggested surgical treatment and supportive
periodontal therapy. He opted to return to his general dentist for
Clinical examination showed severely increased probing pocket
depth, bleeding and suppuration on probing, and mobility on all
teeth (Figure 1a and b). Radiographic analysis revealed bone loss
of more than 70% on all teeth.
The condition was diagnosed as a generalized severe periodontitis.
All teeth of the remaining dentition had a poor long-term
prognosis; therefore, it was decided to extract all teeth.
The extractions were performed during the first treatment phase
except for tooth No. 27. A cyst in that area was removed. Tooth No.
27 was kept to increase the retention of the provisional denture
and scheduled for extraction later. Bony defects were augmented
with demineralized bovine bone (BioOss spongiosa, 0.25-1 mm, 0.25
g; Geistlich Biomaterials) and covered with a 25 × 25 mm resorbable
bilayer membrane (Bio-Gide, Geistlich Biomaterials) .
An intermediate denture supported by tooth No. 27 was delivered.
After 3 months, the area was reopened and implants were inserted.
At the same time, tooth No. 27 was extracted and the socket was
Three months after insertion, the implants were uncovered and the
telescopic crowns and the final denture delivered.
To allow for the insertion of implants in the maxilla, a bilateral
sinus-augmentation was performed. Seven months after augmentation,
8 ITI implants were inserted.
Implant No. 8 was mobile 5 weeks after placement and had to be
removed. The site was rinsed with sterile saline solution and
covered with a 20 × 30 mm nonresorbable membrane (Cytoplast
Regentex GBR-200, Oraltronics). The membrane was removed after 1
A telescopic crown supported free palate (horseshoe-shaped) final
overdenture was delivered at the 9-month point
A 38-year-old woman presented in the office for a regular dental
examination. Clinical evaluation revealed severely increased
probing pocket depth. Radiographic signs of horizontal and vertical
bone loss up to two-thirds of the root length were present . The
maxillary molars had Class III furcation involvement. All teeth in
the maxilla had a poor prognosis.
The patient was informed of the etiology of her periodontal
The maxillary teeth were extracted 2 weeks after the initial
examination and an intermediate denture in the maxilla was
delivered during the same appointment.
Oral hygiene instructions were given and prophylactic cleanings
were performed repeatedly for the remaining teeth until an adequate
level of plaque control could be achieved.
Bilateral sinus augmentation was performed 2 months after the
extraction of the maxillary teeth.
At the 6-month point (ie, 4 months after the sinus augmentation), 7
ITI implants were inserted into the maxilla.
The maxillary implants were uncovered after a 3-month healing
period (ie, at the 9-month point) and an implant-retained, free
palate complete denture with telescopic crowns as abutments was