Naoshi Sato

Periodontics & Restorative

MaintenanceA Clinical Atlas

London, Berlin, Chicago, Tokyo, Barcelona, Beijing, Istanbul, Milan,Moscow, New Delhi, Paris, Prague, So Paulo, Seoul and Warsaw

PrefaceThis book discusses changes in the periodontium, problems occurring during the peri-odontal maintenance phase and their solutions using a case study approach. The under-lying concept is based on my conviction that maintenance is crucial for the long-term suc-cess of periodontal therapy. The objective is to give the reader guidance in selecting theappropriate treatment and maintenance methods needed for long-term periodontal andprosthetic success.

While writing this book, I reviewed the outcome of periodontal therapy in mypatient population. The findings strengthened my conviction that flexible treatment plan-ning and systematic professional care are crucial to the long-term success of periodontaltherapy. Successful periodontal therapy requires teamwork across different dental special-ties, particularly periodontology and prosthetics. The relevant methods for restoration andpreservation of periodontal health (surgical and nonsurgical modalities, restorative-prosthetic treatment with occlusal therapy, etc.) must be given due consideration whencarrying out such treatment.

In order to meet the goal of consistently providing high-quality care for theirpatients, dentists must continuously increase their treatment standards and thus must bewilling to update their skills and knowledge on a daily basis. Even after complex andsophisticated techniques have been learned, it is not possible to apply them successfullywithout proper knowledge of their indications and the timing of their performance. Thelack of adequate follow-up and aftercare likewise leads to treatment failure. Providinghigh-quality treatment is a mission that dentists can rightfully be proud of. Even in this agewhere new developments are continually being introduced in the field of dentistry, highquality does not mean that the treatment must always be innovative.

A dentist can easily lose sight of what is important in the constant flood of infor-mation and commercial trends. Vast amounts of information are easily accessible today.Still, we must try to judge new research findings and treatment approaches openly andobjectively. Objectivity can be distorted by our personal preferences.

The introduction of regenerative therapy and implants has led to major advancesin surgery in general and periodontal surgery in particular, e.g., gingivoplastic surgery.Continuous improvement of ones clinical skills based on scientific developments is animportant aspect of modern dental practice. Interest in new treatment methods and con-tinuous learning are crucial to raising the quality of periodontal treatment services. Inmany cases, treatment results for a new method are published without a comprehensiveevaluation of the new method, after too short a follow-up period, and before long-termfollow-up data become available. Many new methods and materials are quickly aban-doned. Therefore, critical judgment and due caution are required, particularly when con-sidering the use of a new treatment method.

In order to achieve long-term and predictable results of periodontal therapy, theclinician must use methods with a long history of proven efficacy in clinical trials.Adherence to this rule ensures that the treatment will be safe and effective. The compe-tence of clinicians depends, among other things, on their ability to consistently performthe safest and most reliable methods in daily practice. In many cases, clinicians tend toneglect treatments based on solid evidence in favor of novel methods that are more lucra-tive. Guided tissue regeneration, enamel matrix protein derivative application and othermethods of periodontal tissue regeneration as well as plastic periodontal surgery tech-niques of peri-implant tissue improvement used by many dentists today are based onsound principles of periodontal surgery.

Accurate assessment of the outcome of treatment requires careful aftercare andproper follow-up. This makes it possible to establish a specific, long-term and meaningful

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treatment plan for the individual patient. Clinicians must be positive and open-minded indaily practice in order to objectively analyze their treatment results and to accurately eval-uate failures.

The long-term success of periodontal therapy depends mainly on the type andquality of aftercare. The outcome of treatment is not determined by patient compliancealone. Maintenance therapy encompasses all aspects of individual supervision and conti-nued treatment of patients at risk of periodontal disease. This work requires extensiveknowledge of the diagnosis and treatment of periodontal diseases. Another importantgoal is to create a healthy periodontal environment that is easy to maintain. Therapeuticcompromises can lead to complex problems during the maintenance phase. As the indivi-dual maintenance plan varies depending on age-related, mental and physical factors, thepresence or absence of general diseases, and social, familial and job-related factors, a flex-ible approach is required. In any case, a healthy mouth provides a good quality of life.

All of the clinical periodontal and related endodontic restorative-prosthetic, implan-tological and occlusal cases presented in this book are patients that I have personally treatedand maintained. Selected long-term outcomes are presented at the end of each chapter.Numerous intraoral clinical photographs and radiographs with detailed commentary areused to explain the periodontal changes that occurred over the course of time. Additionalreferences to relevant maintenance therapy literature are also cited. Essential terminology isexplained in an easily comprehensible manner in the form of a glossary. Historical facts sur-rounding the use of these terms are included where applicable.

In recent years, I had the opportunity to publish the books Clinical Applicationsand Techniques of Periodontology and Prosthodontics (1992), Periodontal Surgery: AClinical Atlas (1997), and Peri-implant Soft Tissue Management (2001). PeriodontalSurgery: A Clinical Atlas [Translation of the Japanese Title] was first translated into Englishand later into German, Spanish, French, Italian, Korean and Portuguese. The English editi-on of Periodontal Surgery: A Clinical Atlas (2000) became a bestseller and is highly regar-ded, which was a great honor for me. At the same time, it made me realize what a greatresponsibility I have for the contents of my book.

I would like to thank Mr. Ikko Sasaki of Quintessence Publishing Co. Ltd. for giving me theopportunity to publish this book, and Mr. Hidetoshi Akimoto and Ms. Sanae Omiya ofEditorial House Aki for doing all of the editorial work. I am grateful to my revered teacherProf. Dr. Kazuyuki Ueno, Emeritus Professor at the Iwate University Department ofDentistry, and Dr. Haruhiko Abe, Director of the Institute of Total Prosthetics.

Thanks also to Drs. Norimasa Endo, Hitoshi Shirahama and Yoshiro Hattori for theirvaluable comments and continuous encouragement during the preparation of this book,Mr. Etsuo Sekiya for dental laboratory work, and my dental practice staff for good team-work.

Last but not least, I would like to thank my wife Akiko, my son Kimihiko, and mydaughter Yuka. This book is dedicated to my late father Keisuke and to my mother Yoko.

Naoshi Sato

Preface

VI

Contents

Chapter IMaintenance Therapy A Vital Part of Periodontal Therapy. . . . . . . . . . . . . . . 1

1 Maintenance Therapy as Part of Periodontal Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Effective Maintenance Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Occlusal Stability during the Maintenance Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 Reevaluation during the Maintenance Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Attachment Loss during the Maintenance Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456 Pocket Management during the Maintenance Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Case I-A Smoker with recurrent periodontal breakdown due to irregular maintenance . . . . . . . . . . . . . . . . . . . . . . . 53Case I-B Monitoring after conservative therapy and minimally invasive furcation treatment . . . . . . . . . . . . . . . . . . . 58Case I-C Maintenance therapy of strategically important teeth in a patient with few remaining teeth . . . . . . . . . . . 65Case I-D Partial denture design in a patient with few remaining teeth and little periodontal support . . . . . . . . . . . 71Case I-E Treatment and maintenance of a periodontitis patient with secondary occlusal trauma:

Initial therapy followed by prosthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Case I-F Problem abutments and maintenance therapy in a periodontal-prosthetic patient

with multiple tooth loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Case I-G Treatment and long-term management of a deep infrabony defect in the posterior region . . . . . . . . . . . . 91Case I-H Maintenance therapy with residual risk factors remaining after active therapy. . . . . . . . . . . . . . . . . . . . . . . 97Case I-I Occlusal management of a partially edentulous patient with advanced periodontitis. . . . . . . . .