Dr Yevgeni Viktorov
Comprehensive treatment of a patient with generalized aggressive periodontitis: A 7-year follow-up
Generalized aggressive periodontitis (gAP) is a rare type of disease. Rapid attachment loss, bone destruction, early tooth loss in relatively young patients makes the dental attendance of this patient-group to a challenge and live time commitment for a dentist/periodontologist. This case presents the treatment of a patient with gAP involving conservative and regenerative periodontal approaches to create a stable base for further implantological treatment and finally esthetic improvement of the typical “periodontal smile”. Stable results ten years after the first consultation emphasize the role of the supportive periodontal treatment (SPT) as a crucial part of the periodontal care.
A 29-year-old female patient presented 2008 to our clinic with the chief complaints of an unaesthetic smile, permanent debonding of the maryland bridge in the maxillary anterior are and gingival bleeding. She had a history of prior periodontal treatment with poor success. The patient had no systemic disorders and did not smoke. She was an insurance employee and was married.
Starting with the diagnostic part of the treatment, a panoramic radiograph, intra- and extra-oral photographs were taken and periodontal charting was performed.
The patient presented an almost complete dentition. Main intraoral findings were partly insufficient restorations made of different dental materials, poor periodontal conditions with deep, bleeding and suppurating pockets (BOP Index 37%) and clinical attachment loss. The esthetic view was dominated by periodontal tissue loss in the anterior areas with resulting gingival recessions and black triangles and was accompanied by an insufficient resin-bonded fixed partial denture (maryland bridge) replacing the missing maxillary left lateral incisor. Based on this clinical information, the patient was diagnosed with general aggressive periodontitis.
Primary objective of our treatment was to improve the prognosis of the periodontally compromised teeth by establishing stable, inflammation-free and easily maintainable periodontal conditions prior to any further (reconstructive) therapies. Secondary objective was to replace the missing maxillary incisor with a more esthetic and durable solution in conjunction with the overall improvement of the patient’s overall smile.
Our treatment plan and first steps were:
Three months after conservative periodontal treatment (SRP supported by systemic antibiotics), improvement of the probing depth and clinical attachment loss was achieved. This allowed us to reduce the number of sites that required periodontal surgery down to two (distal of the maxillary left second premolar and mesial of the mandibular right second molar).
Based on the favorable conditions of the patient and the periodontal site (perfect patient compliance, non smoker, systemically healthy, deep but isolated vertical bone defects) we decided for a regenerative surgical approach as the best treatment option.
The surgery was performed using the modified papilla preservation technique. Both three-wall infra-osseous defects were treated with enamel matrix protein alone. Good blood clot stabilization and avoidance of soft tissue collapse was achieved by wound adaptation and primary closure. The type and location of the incision (bone supported, out of defect, no vertical release) as well as an appropriate suture (internal mattress and single interrupted sutures) according to the defect anatomy are important factors for success.
Reduction of probing depth and gain of clinical attachment could be obtained by surgical and regenerative periodontal treatment and maintained over 9 years.
The situation was maintained with periodontal supportive therapy for which the patient was scheduled every three months according to her risk profile.
After having achieved the primary objective, we decided to go for the next goal and turn our attention to the reconstruction of the missing lateral incisor and address the overall esthetic demands.
Due to the high bone deficiency on the implant site, we decided to choose a two step approach for implantation.
The first step was the augmentation of the ridge using a GBR technique. A xenograft material and resorbable collagen membrane were used for lateral augmentation. Light perforation of the cortical bone was performed to accelerate angiogenesis, then the xenograft material was packed laterally to augment the defect area.
A tight, tension free primary flap closure was achieved through split flap preparation and internal periost suture.
Six months later during implantation, a wide ridge could be found.
A proper implant could be placed in a right prosthetic position.
The second stage surgery was performed minimally invasive and a soft tissue augmentation with a small connective tissue graft from the tuberosity was performed.
One month later, the esthetic treatment could be started. The changes to the shape of the teeth were performed with indirect adhesive cemented Emax restorations. The teeth were prepared for veneers and a screw retained provisional crown was placed on the implant to condition the soft tissue.
Seven years ago, when the preparations were performed, we pursued an approach that would use a coronal path of insertion of the veneers. However, this resulted in a very invasive preparation. Nowadays, according to more recent minimally invasive concepts, we perform a much less invasive preparation by utilizing a vestibular path of insertion.
Ten years after the first visit and 7 years after finalization of the “active” treatment, the patient is in supportive periodontal therapy for 2 to 4 times a year (in this period she had two children and had not always time for her teeth) Nonetheless, she still has stable periodontal conditions.
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