KEY WORDS Learning objectives author

Periodontitis, dental implants,
peri-implantitis
• Through understanding the limitations
of dental implants in patients with
periodontitis, it is hoped the reader
will develop the knowledge to
help their patients achieve more
successful outcomes
Rajiv M. Patel BDS, MClinDent
(Perio.), MFDS RCS (Eng),
MPerio RCS (Ed)
Specialist in Periodontics, Private Specialist
Referral Practice, UK Dental Specialists,
St. Albans, UK

Rajiv M. Patel
Prim Dent J. 2019;8(4):54-61

Dental implants for patients

with periodontitis
ABSTRACT
This article provides a narrative review of the use of dental implants in patients
with periodontitis. Using clinical examples where possible, consideration is given
to the survival and success of implants, peri-implantitis, comparison of
periodontally compromised teeth to implants and to treatment planning to help
achieve favourable outcomes.

The challenges associated with restoring an edentulous arch or partially dentate

dentition with implants where significant alveolar atrophy has occurred can be
considerable. Compromised outcomes may be commonplace.

Dental implant treatment is more likely to be successful for those patients who attain
and maintain excellent plaque control. Professional support should focus on managing
underlying periodontitis prior to commencing implant therapy and providing long
term, regular supportive periodontal care upon completion of treatment.

Figure 1: Drifted and over erupted
teeth visible when speaking
and smiling for patient PT
M
odern humans emerged
from Africa approximately
200,000 years ago. We
have evolved with microbial
species inhabiting the mouth and indeed
the entire alimentary canal. For large
numbers of people, the inflammatory
response induced by the accumulation of
a biofilm adjacent to the gingival margins
precipitates the loss of the supporting
bone of the teeth: periodontitis.
Perhaps an unintended consequence of
improvements in medicine and extended
life expectancy is a prolonged exposure
to and experience of periodontitis for
those who are susceptible. The result
is a greater potential for tooth loss.
In contrast, endosseous implants have
been with us for only a few decades.
They have transformed the potential for
replacing missing teeth. But does this
modern technology offer a comprehensive
solution to the challenges created by tooth
loss and associated alveolar atrophy
resulting from exposure to periodontitis?
Can the insertion of a titanium screw
into bone in any way overcome the
host response to plaque bacteria?
This article will review the use of dental
implants in patients with periodontitis,
using clinical examples where possible.
Consideration will be given to the
survival and success of implants, peri-
implantitis, comparison of periodontally
compromised teeth to implants and
to treatment planning to help achieve
favourable outcomes.
A case in point is patient PT. PT presented
as a new patient complaining of a loose
implant bridge that kept falling out. He
was sure that a stronger cement would
fix the problem. Dental implant treatment
had been carried out approximately
seven years prior to presentation with
allegedly no follow up care. Medically,

54 p r i m a r y d e n ta l j o u r n a l
2a
Figure 2a: Poor plaque control and loss of periodontal attachment
clearly visible. 2b: Loss of supporting peri-implant tissues
PT suffered with a poorly controlled type
2 diabetes mellitus and hypertension.
A brief glance at PT’s teeth and smile
during our initial conversation revealed
drifted and over erupted teeth, suggesting
a history of periodontitis (Figure 1).
Examination revealed widespread severe
periodontal attachment loss, poor plaque
control and overtly inflamed periodontal
tissues. A dental implant supported fixed
bridge was found to be present replacing
lower anterior teeth. Loss of supporting
tissues had also occurred at the implants
(Figures 2a and 2b).
When asked to demonstrate how loose
the bridge had become, PT was able to
pluck the bridge out of the mouth with
the dental implants still attached. (Figures
3a and 3b).
Clearly, the description, ‘a loose bridge’
was an understatement of the nature of
the problem. What, if anything, can be
learnt from the failure of these implants?
The features inherent in this case
provide a guide to the causes of failure.
Through understanding these causes,
it is hoped that the reader will develop
the knowledge to help their patients
achieve more successful outcomes.
Periodontitis
Several recent review studies and meta-
analyses have shown that patients with
a history of periodontitis, over a long
term, show greater probing depths,
greater bone loss and higher incidence
of peri-implantitis than periodontally
healthy patients.1-4 The most recent of the
Vol. 8 No. 4 winter 2019/20
2b
reviews by Sgolastra et al., 20154 looked
at prospective longitudinal studies and
found strong evidence that periodontitis is
a risk factor for implant loss. This finding
corroborated previous evidence from
Oslo University, Norway.5 In the analysis
by Koldsland et al., 20075 examining
the outcomes of implants placed between
1990 and 2005 they found that overall,
few implants were lost. However, the
implants that were lost, were associated
with patients with periodontitis. Implant
failure rates on a patient level were 25%
in patients with a history of periodontitis
compared to just 3.8% for periodontally
healthy patients. Other studies have
shown failure rates on an implant level
to be approximately double in
periodontitis patients.6-8
These differences in survival may not
be evident at an early stage. Karoussis
et al., 20039 noted that a five-year
follow up was not enough to evaluate the
differences between different groups of
patients. Signs of peri-implant bone loss
were often not seen before this time.
3a
Figure 3a: Soft tissue lined implant
‘sockets’ following the manual removal
of the implant bridge. 3b: Significant
accumulation of plaque and calculus
on the implants and implant bridge
A number of longitudinal studies have
shown the potential differences in
peri-implant bone loss. In their ten-year
retrospective study, Matarasso et al.,
2010,10 noted significantly greater bone
loss at implants supporting single unit
crowns in periodontally compromised
patients. Their study population was
limited to non-smokers, without metabolic
disorders and to those who maintained
excellent plaque control. Bone loss had
occurred irrespective of the dental implant
brand used (Straumann or NobelBiocare).
A ten-year prospective study showed
that clinically the percentage of
implants with at least one site, which
presented a probing depth > 6mm,
was respectively 1.7% for periodontally
healthy patients, 15.9% for patients
with moderate periodontitis and 27.2%
for severe periodontitis.11 Once again,
the authors noted that the difference
between periodontally healthy and
periodontally compromised patients was
negligible during the first five years. The
patients with a history of periodontitis
were deemed to be at greater risk of
developing peri-implant disease. Rocuzzo
et al., 201211 therefore conclude: ‘the
approach for multiple preventive dental
extractions and implant placement, based
3b
55
 Dental implants for patients
with periodontitis
on the assumption the implants perform
better than teeth, should be followed with
extreme caution’. As PT demonstrated
above, once bone loss commences, it
can progress at an alarming rate which,
in his case, led to the loss of his dental
implants within seven years. The studies
highlighted above do not make a direct
comparison between the survival of
periodontally compromised teeth and
dental implants in periodontal patients.
They do, though, show the higher risk
of biological complications.
Even if periodontal treatment has been
carried out prior to implant therapy,
Pjetursson et al., 201212 suggest that
having residual periodontal pockets >
5mm increases the risk for losing peri-
implant bone. In their study of 70 patients
treated for periodontitis, patients showing
signs of peri-implantitis experienced
recurrence of periodontitis; those without
periodontitis did not. For those who
developed peri-implantitis, there was an
average of just four periodontal probing
depths > 5mm at baseline. Those who
didn’t, had an average approximately
two periodontal pockets > 5mm. In
fact, Daubert et al., 201513 found that
severe periodontitis at follow‐up was the
strongest indicator for peri-implantitis of
all variables examined, presenting with
an unadjusted risk ratio of seven. Derks et
al., 201614 in their nine-year follow up of
implants placed in a Swedish population
reported an odds ratio of four for patients
with existing periodontitis. Indeed, the
evidence-based review of peri-implantitis
by Schwarz et al., 201815 developed
during the 2017 World Workshop on
Classification of Periodontal and Peri-
implant Diseases, concludes: ‘there is
strong evidence from longitudinal and
cross‐sectional studies that a history of
periodontitis constitutes a risk factor/
indicator for peri-implantitis’.
56
Given the fallibility of dental implants
in periodontal patients, it would seem
prudent to understand how natural teeth
may survive. Without this knowledge,
the deliberation of whether or not to
extract teeth and replace them with dental
implants will be flawed. The classical
study by Hirschfeld and Wasserman
197816 reviewed tooth loss in 600
treated periodontal patients with a mean
follow up of 22 years (minimum of 15
years). Those familiar with the study
often recall upper molars being the
most commonly lost teeth. Their complex
root anatomy, presence of furcations
and location within the mouth may all
contribute to their more frequent demise.
Nevertheless, during the 22-year follow
up period, only 460 furcation involved
teeth were lost out of 1,464. That
equates to approximately 70% survival
for molar teeth at 22 years for patients
who, by definition, must have had their
periodontal care provided during the
1950s and 1960s. Surely the profession
should be able to achieve at least a
similarly successful outcome 60 to 70
years later? Other long-term follow up
studies of patients treated for periodontitis
also demonstrate very good survival rates
for teeth. The 30-year follow up of 250
periodontal patients who maintained
excellent plaque control and took part in
a maintenance programme revealed only
nine teeth were lost due to progressive
periodontitis.17 The key to success here
is likely to be the maintenance of
excellent plaque control and regular
professional supportive care. But once
again, maxillary molars were the most
commonly lost teeth.
This does not mean that periodontally
compromised maxillary molars need
to be preferentially extracted in favour
of dental implants. Upper molar teeth
with at least 50% bone loss affecting
one root have been shown to have a
favourable ten-year survival rate.18 The
data presented by Ross and Thompson
197818 demonstrated that with relatively
simple periodontal treatment, soft tissue
surgery, no osseous surgery or root
resections (which should not be too taxing
for dentists carrying out implant surgery)
88% of the 387 maxillary molars survived
during a mean follow up period of ten
years. Of the 46 teeth that were lost,
25 of them had been present between
six and 18 years.
Fugazzotto, 200119 published data on
the success of 701 root resected molars
in comparison to 1,472 molar positioned
dental implants in private practice. The
cumulative success rates were 96.8% and
97% respectively for root resected teeth
and implants, suggesting that perhaps
periodontally compromised teeth could be
as successful as dental implants. However,
it should be noted that the success rate for
the root resected molars reduced to 75%
where the tooth was a terminal abutment.
In this scenario, an implant may be more
successful.
More recent evidence from Schmidlin
et al., 201020 presented a retrospective
analysis of the complication rates for
single crowns and dental implants in 64
periodontal patients. A comparison of the
biological and technical complications
was assessed after a mean follow up of
ten years. A single crown placed on vital
teeth had the best chance of remaining
free from complications (89.3%). Crowns
placed on endodontically treated teeth
fared a little worse (85.8%). Crowns
with a post and core were at greater
risk of experiencing complications
(75.9% chance of remaining free from
complications). Single crowns on implants
fared the worst with only a 66.2% chance
of remaining free from complications.
The European Association of
Osseointegration consensus statement
2015 on the economic evaluation of
implant supported prostheses21 indicates
that for a 50-year-old patient with a molar
tooth with a class 1 furcation defect over
a 30-year period, scaling and root planing
was more effective and cost effective
than an implant-supported single crown
(estimated using provider’s fees from the
German private insurance fee schedule).
The presentation of the evidence
above is not intended as an argument
against the use of dental implants in
p r i m a r y d e n ta l j o u r n a l
Periodontics for
improved patient care

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 Dental implants for patients
with periodontitis
patients with periodontitis, but as
a statement of limitations. When
faced with the dilemma of whether to
maintain a periodontally compromised
tooth or to consider extraction and
replacement with an implant, it would
not be unreasonable to treat and
maintain a tooth that is functional and
asymptomatic. After all, what is the
purpose of the profession if, at its core,
it is not to help maintain our patients
with a fixed, comfortable functioning
dentition? If dental implants may only
last a finite period of time, the longer
we are able to maintain the natural
teeth, the later in life the patients may
require rehabilitation with dental
implants and the older the patients will
be when the implants fail. Ultimately, the
patients will have enjoyed the benefits of
a fixed dentition for a greater period of
their lives, hopefully avoiding the need
for removable prostheses – something
we all surely wish for ourselves.
Plaque control and
supportive therapy
Patient PT’s underlying risk of biological
implant complications seem to have
been compounded by the apparent lack
of any follow up or supportive care.
Supportive therapy has been defined
as professional plaque control and
selective sub gingival scaling at sites
showing clinical signs of inflammation
during recall visits.22 The purpose of
this treatment is to maintain peri-implant
health. When considering a recall
protocol, a number of factors should be
considered: previous periodontal history,
location of the soft tissues, implant
location and prosthesis design.
58
The effects of supportive care have been
demonstrated by Costa et al., 2012.23
In their study, 80 patients diagnosed
with peri-implant mucositis at baseline
were divided into two groups: those who
had preventive maintenance therapy
over a five-year period and those that
did not. The findings were stark. For
patients who complied with maintenance
therapy, 18% went on to develop peri-
implantitis. Conversely, 43.9% of patients
who did not comply with maintenance
therapy developed peri-implantitis. Other
longitudinal studies confirm that a lack
of supportive care is associated with a
higher frequency of peri-implantitis .11,12,24
The positive effects of supportive therapy
for implants in patients with periodontitis
have been presented by Meyle et al.,
2014.25 Their ten-year follow up of
non-smoker patients with a history of
periodontitis found that across the cohort,
the mean radiographic bone loss was
less than 1mm. However, on a patient
level, the prevalence of peri-implantitis
was 30%. Implant success (not survival)
at ten years was relatively low at 76.2%.
Given the evidence, supportive therapy
must be considered an important factor
in improving the chances of long-term
success. A lack of supportive therapy
increases the risk of peri-implantitis.
It would therefore seem imperative to
‘educate’ patients to consider long term
supportive therapy as part of their implant
treatment, beyond implant placement and
delivery of the restoration.
Treatment planning:
implant positioning,
number of implants and
prosthesis design
Once the decision has been taken to
replace teeth with dental implants,
consideration must be given to the design
of the prosthesis, the number of implants
required and their location. It can be
difficult to match patient expectations or
achieve ideal outcomes. Patients may
attend a clinic asking for implants, but
they do not request them with the sole
purpose of having titanium screws placed
in their jaws. What is often inherent in
their request is a desire for fixed teeth,
that look natural, or worse, make them
look like they used to do; and they
want a “permanent” solution.
PT had three implants placed in the
anterior mandible to replace five of
the lower anterior teeth. Two of the
implants were in close proximity to each
other under narrow lower incisors. Had
sufficient space been left to allow access
for plaque control? In this instance, fewer
implants may well have improved access
for plaque control, but in doing so,
would the risk for mechanical
complications rise? Personal experience
would suggest that management of
mechanical complications may be
difficult, but they tend to be more
successful than trying to re-grow peri-
implant bone or even arrest bone loss.
Implant position should be determined
by the proposed location of the new teeth
being in the ideal position with ideal
form, providing good function. A loss
of hard and soft tissues may result in an
inability to place an implant in the correct
3D implant position. A consequence
of this may be the placement of dental
implants that are too deep, located too
far buccally or palatally, or placement
of implants of inappropriate diameters.
The corollary of this is likely to be a
difficulty in achieving ideal aesthetics or
ideal loading characteristics. Therefore,
compromises may have to be made.
Where significant bone loss has
occurred, local anatomical features
may prove to be a greater hindrance
in allowing implant placement. The
proximity to the maxillary sinuses and
the inferior alveolar nerve and mental
foramen in the mandible will become
more apparent. Clinically, this may
necessitate significant hard and soft
tissue augmentation to facilitate ideal
implant positioning, or an acceptance
of sub-optimal implant angulations and
increased distance from the head of
the implant to the occlusal plane.
This may in turn dictate the method of
implant prosthesis retention. Cemented
p r i m a r y d e n ta l j o u r n a l
4a
Figure 4a: Demonstrates the deep placement of the implant in the upper left first molar site. 4b: Working cast showing
the palatal positioning of the implant. 4c: The potential plaque accumulation under the buccal ‘overhang’
restorations may further increase
the risk for developing biological
complications. Work carried out by
Linkevicius et al., 201326 showed
that cementation of restorations could
result in the extrusion of excess cement
into the peri-implant mucosa. In fact,
their prospective study examining 53
cemented implant restorations found
excess cement present in the peri-implant
tissues and the surface of the crown
or abutment in every single case. The
amount of excess cement was greater
the deeper the crown margins and
radiographic assessment was shown to
be an unreliable method of assessing
if excess cement had been removed.
The concern is that excess cement may
act as a foreign body. An inflammatory
response may be provoked that results
in peri-implantitis. Cement remnants
may provide a rough surface for micro-
organisms to colonise leading
to peri-implant mucositis and possibly
peri-implantitis. Presence of excess
cement was also found to be associated
with signs of peri-implant disease in as
many as 85% of cases27 and 81% of
cases.28
Screw retained restorations may be
preferable, however they do not
completely absolve themselves of risk.
Incorrect positioning of the implant may
still create restorations with large un-
cleansable overhangs. Deep placement
may create a deep pocket and a large
subgingival environment impairing
Vol. 8 No. 4 winter 2019/20
4b
Figure 5: Suboptimal implant placement
resulting in restoration with a mesial
‘overhang’. Peri-implant bone loss has
subsequently occurred beneath the
overhanging portion of the restoration
proper plaque control. Though not in
a patient with periodontitis, the implant
location in Figures 4a-4c demonstrates
the potential for creating restorations
that are difficult to maintain.
The positioning of the implant in
Figure 5 resulted in a restoration that
had a significant mesial overhang which
the patient reported as difficult to clean
under. Bone loss perhaps was then an
inevitability.
Where significant attachment loss has
occurred and multiple teeth require
replacement, thought should be given
as to whether a fixed or removable
prosthesis may be preferable in the long
4c
term. It has already been demonstrated
that plaque control (both professional
and home care) is crucial to reducing
the risk for peri-implant bone loss.
Indeed, plaque control, or a lack of,
is likely to be a significant factor for a
patient that has lost many of their teeth
due to their periodontitis. If a patient
has struggled to maintain adequate
plaque control with their natural
dentition, will they perform better
with complex long span or full arch
implant bridges? The loss of significant
amounts of alveolar ridge height may
necessitate the replacement of the soft
tissues with some form of a prosthetic
flange to prevent the prosthetic teeth
from having an unnaturally long
appearance. The transition line from
the edge of the flange to natural soft
tissue may be placed deep in the
sulcus as to avoid creating an aesthetic
eyesore. This, though, may make it
very difficult to maintain excellent
plaque control.
59
 Dental implants for patients
with periodontitis

Figures 6a-6c demonstrate the
debris found on the fit surface of
the bridge (or fixed denture), the
abutment surfaces and the peri-implant
mucosa. Note, however, the excellent
plaque control and gingival health the
patient was maintaining in the lower
arch. This is a patient capable of
maintaining plaque control to a good
standard but hindered in the upper
arch thanks to the design of
the prosthesis.
An alternative approach would be to
consider the use of implant supported over
dentures. Dentures provide an easy way of
accommodating the loss of hard and soft
tissues to create a good aesthetic outcome.
More importantly though, access for plaque
control and maintenance of healthy peri-
implant tissues is greatly improved. The
McGill consensus statement 200229 reported
patients are significantly more satisfied with
implant supported overdentures compared
to conventional overdentures. Patients
experience more stable dentures, greater
ease when chewing, greater comfort and are
able to speak more easily. Work by Fillion et
al., 201330 demonstrated that dental implants
have the ability to improve oral health related
quality of life measures, regardless of the
fixed or removable nature of the prosthesis.
Following a full assessment and lengthy
discussion with PT, a decision was made to
extract the remaining teeth and replacement
with upper and lower complete implant

6a 6b 6c

Figure 6a: Extra-oral. 6b: Intra-oral. 6c: Occlusal views of the full upper arch fixed implant bridge

6d 6e

Figure 6d: Appearance of the

underlying peri-implant tissues.
6e: The fitting surface of the
bridge following removal after
12 months in function

references
1 Safii SH, Palmer RM, Wilson RF.
Risk of implant failure and marginal
bone loss in subjects with a history
of periodontitis: a systematic review
and meta-analysis. Clin Implant
Dent Relat Res. 2010;12(3):165-74.
2 Ramanauskaite A, Baseviciene N,
Wang HL, Tözüm TF. Effect of history
of periodontitis on implant success:
meta-analysis and systematic review. 7 Evian CI, Emling R, Rosenberg
Implant Dent. 2014;23(6):687-96
3 Chrcanovic BR, Albrektsson T,
Wennerberg A. Periodontally
compromised vs. periodontally
healthy patients and dental implants:
a systematic review and meta-analysis.
J Dent. 2014;42(12):1509-27.
4 Sgolastra F, Petrucci A, Severino M,
et al. Periodontitis, implant loss and
peri-implantitis. A meta-analysis. Clin
Oral Implants Res. 2015;26(4):e8-16.
5 Koldsland OC, Scheie AA, Aass
AM. Prevalence of implant loss and
the influence of associated factors.
J Periodontol. 2009;80(7):1069-75.
6 Brocard D, Barthet P, Baysse E, et
al. A multicenter report on 1,022
consecutively placed ITI implants:
a 7-year longitudinal study. Int J Oral
Maxillofac Implants. 2000;15(5):
691-700.
ES, et al. Retrospective analysis of
implant survival and the influence of
periodontal disease and immediate
placement on long-term results.
Int J Oral Maxillofac Implants.
2004;19(3):393-8.
8 Wagenberg B, Froum SJ. A
retrospective study of 1925
consecutively placed immediate
implants from 1988 to 2004.
Int J Oral Maxillofac Implants.
2006;21(1):71-80.
9 Karoussis IK, Salvi GE, Heitz-Mayfield
LJ, et al. Long-term implant prognosis
in patients with and without a history
of chronic periodontitis: a 10-year
prospective cohort study of the ITI
Dental Implant System. Clin Oral
Implants Res. 2003;14(3):329-39.
10 Matarasso S, Rasperini G, Iorio
Siciliano V, et al. A 10-year
retrospective analysis of radiographic
bone-level changes of implants
supporting single-unit crowns in
periodontally compromised vs.
periodontally healthy patients.
Clin Oral Implants Res. 2010;21(9):
898-903.
11 Roccuzzo M, Bonino F, Aglietta M,
Dalmasso P. Ten-year results of a three
arms prospective cohort study on
implants in periodontally compromised
patients. Part 2: clinical results.
Clin Oral Implants Res. 2012;23(4):
389-95.
12 Pjetursson BE, Helbling C, Weber
HP, et al. Peri-implantitis susceptibility
as it relates to periodontal therapy
and supportive care. Clin Oral
Implants Res. 2012;23(7):888-94.
13 Daubert DM, Weinstein BF, Bordin S,
et al. Prevalence and predictive factors
for peri‐implant disease and implant
failure: a cross‐sectional analysis.
J Periodontol. 2015;86:337-347.
14 Derks J, Schaller D, Håkansson J,
et al. Effectiveness of implant therapy
analyzed in a Swedish population:
prevalence of peri‐implantitis.
J Dent Res. 2016;95:43-49.
15 Schwarz F, Derks J, Monje A, Wang
HL. Peri-implantitis. J Periodontol.
2018;89 Suppl 1:S267-S290.
16 Hirschfeld L, Wasserman B.

60 p r i m a r y d e n ta l j o u r n a l
supported overdentures. For this patient,
this allowed him to achieve a good aesthetic
outcome and good function with minimally
invasive surgery and, importantly for him,
at a relatively modest financial cost.
The ease of access to the locator abutments
has allowed PT to maintain optimal plaque
control and as a result, the peri-implant
mucosa has remained healthy.
The trade-off for the patient is the acceptance
of removable prostheses. Despite having
markedly improved retention and stability
compared to conventional dentures, the
removable nature of the prostheses may
make it unpalatable for some patients. For
these patients, the compromise they elect to
live with is the risk of developing peri-implant
diseases and the resulting consequences
if optimal plaque control cannot be
maintained.
Summary
Patients with a history of periodontitis
seeking dental implants for the replacement
of teeth must be made aware of the likely
finite nature of treatment and the potential
pitfalls prior to commencing on an often long
and expensive journey to dental rehabilitation.
Often it is not the implants that fail, but
the human body that fails to respond to a
microbial challenge without causing bone
loss. Given the profession’s inability to alter
the inflammatory response, the planning and
execution of dental implant treatment must
pay attention to the only realistic method
of preventing or reducing the risk of
inducing a damaging inflammatory
response: plaque control.
The prosthesis design, method of retention,
positioning and number of implants must
all be considered with the patient’s and the
professional’s ability to maintain adequate
plaque control. A failure to do so risks loss
of the implants.
The challenges associated with restoring an
edentulous arch or partially dentate dentition
with implants where significant alveolar
atrophy has occurred, can be considerable.
Compromised outcomes may be common
place. Understanding the challenges and
managing patient expectations through
honesty are an important part of implant
treatment for this group of patients.
Ultimately, treatment is more likely to be
successful for those patients who attain
and maintain excellent plaque control.
Professional support should focus on
managing underlying periodontitis prior to
commencing implant therapy, and providing
long term, regular supportive periodontal
care upon completion of treatment.

7a 7b 7c

Figure 7a: Extra-oral view of the upper and lower implant supported complete overdentures in situ.
7b: Demonstration of the patient maintaining adequate plaque control at the locator abutments in the maxilla,
and 7c: in the mandible for patient PT. (Dentures constructed by Dr Zulaikha Burki, Specialist in Prosthodontics)

A long-term survey of tooth loss in
600 treated periodontal patients.
J Periodontol. 1978;49(5):225-37.
17 Axelsson P, Nyström B, Lindhe J. The
long-term effect of a plaque control
program on tooth mortality, caries and
periodontal disease in adults. Results
after 30 years of maintenance. J Clin
Periodontol. 2004;31(9):749-57.
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