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C r o s s - a r c h i m p l a n t - s u p p o r t e d f i x e d r e s t o r a t i o n Introduction Endosseous dental implants have been widely used to aid the support of restorations replacing missing teeth. This has been widely reported in the literature dating back to the early 1960s.1, 2 Implants have added predictable treatment options for patients, clinicians and dental tech- nicians.3, 4 Nevertheless, technical and biological complications may occur either at an early stage, owing to failed integration during healing, or later, regarded as loss of integration and stabil- ity after healing and during functional loading.5 Smoking, low bone density, irradiation, infection, relative overload, previous periodontitis and parafunctional habits, such as bruxism, are some of the described risk factors that may lead to implant failure.5, 6 In the case of parafunctional habits, in a systematic review, it was noted that treated patients with periodontitis may experi- ence more implant loss and biological compli- cations compared with nonperiodontitis patients with implants.4 During the first year of function, a certain amount of physiological marginal bone loss is often observed around a dental implant, and this probably reflects remodeling/adapta- tion after surgery7 and during loading;8 thereaf- ter, minimal further bone loss has been annually observed.6, 9 As a consequence, the prerequisites for implant success are marginal bone loss of up to 1.0 mm within the first year of implant load- ing and successive annual mean marginal bone loss of 0.2 mm during the follow-up period.9, 10 Continuous bone loss with clinical signs of infec- tion, such as bleeding and suppuration, is referred to as periimplantitis, irrespective of the sequence of events.11 Depending on the defini- tion used, the prevalence of progressive bone loss/periimplantitis in long-term studies has been reported to range from 7.7 to 39.7%.12 Peri- odontally healthy patients and patients with chronic adult periodontitis show no difference in periimplant variables and implant survival rate, but patients with generalized aggressive periodontitis have greater periimplant pathol- ogy, more marginal bone loss and a lower implant survival rate.13 Furthermore, it is of inter- est to note that the impact of a history of peri- odontitis on early implant loss was found to be negligible in patients that have been treated with supportive periodontal therapy.14 However, in the long term, periimplantitis was detected more than twice as frequently in periodontally com- promised than in periodontally healthy sub- jects.13, 15 Furthermore, based on clinical experience, it has been noted that bruxers are a high-risk category regarding successful implant outcomes and this has been reported in the literature.15 Studies have reported more frequent technical compli- cations, including implant loss, in bruxers.16 This case report describes the 13-year man- agement of a patient with generalized aggressive periodontitis and bruxism treated using Bråne- mark TiUnite implants (Nobel Biocare, Yorba Linda, Calif., U.S.) with machined collars. In the upper jaw, a cross-arch implant-supported fixed restoration was delivered. In the lower jaw, an implant-supported fixed partial prosthesis was provided, retaining some natural dentition, which increased the risk of a periodontal reservoir. Case report A 57-year-old woman with a history of general- ized aggressive periodontitis presented to our clinic for a periodontal consult and treatment in 2003. Despite an overall full-mouth root planing, multiple surgeries and antibiotics, the patient continued to exhibit progressive bone loss. Two years after the initial consult, a comprehensive clinical, radiographic and study cast evaluation found that the remaining dentition showed recur- rent abscesses with progressive bone loss due to chronic periodontal disease (Fig. 1). Furthermore, the case was complicated by pathological tooth mobility, furcation involvement at the maxillary molars, occlusal instability and parafunctional habits, including bruxism. Various treatment options were discussed with the patient, including maxillary and man- dibular conventional removable complete den- tures, as well as implant-supported overdenture or implant-supported fixed restorations. The patient’s chief desire was to replace her existing teeth with implant-supported fixed restorations without conventional removable complete den- tures or removable prostheses. After detailed consultation, the extraction of all of the remain- ing maxillary dentition and its replacement with dental implants were suggested. The patient understood and agreed to the treatment plan and was informed about the higher risk of implant failure owing to her periodontal disease and brux- ism, especially if some natural teeth were retained. The standard outcome in these cases is up to 98.05% at the 10-year follow-up,17 but owing to the pre-existing periodontal disease and bruxism, the success rate was expected to be Journal of Oral Science & Rehabilitation Volume 3 | Issue 3/2017 49