Dr Mitsuhiro Iwata
TITLE: Interdisciplinary Therapy for Severe Periodontitis with Advanced Pathological Tooth Migration: A Case Report
INTRODUCTION: This is to report the treatment outcome of a patient with severe periodontitis and occlusal trauma induced by pathological tooth migration which were comprehensively treated through periodontal regenerative and implant therapies and multibracket appliances.
CASE PRESENTATION: A 63-year-old female presented with the chief complaint of upper front teeth mobility. Almost all of her teeth, including molars, had significant tooth mobility, deep periodontal pockets, and infrabony defects. All teeth, including molars, had mesial inclination and showed advanced pathological tooth migration. After initial periodontal therapy, periodontal regenerative therapy in all molar regions were performed. The comprehensive orthodontic treatment using anchor screws was subsequently carried out to make all teeth upright. After completing the orthodontic therapy, staged GBR was applied and two implants were placed in the upper anterior region. Then, definitive surgeries were performed for molar regions before placing the final prostheses. These treatments improved the level of alveolar bone, and high cleansability was achieved due to the reductions of probing depth. Stable occlusion was established with anterior guidance. A favorable periodontal condition has been maintained postoperatively.
CONCLUSION: A comprehensive and interdisciplinary treatment enables stable occlusion, establishment of periodontal tissue with high cleansability, as well as esthetic appearance, even in patients with severe periodontitis and malocclusion.
Fig.1 A generally healthy, non-smoking, 63-year-old woman visited our clinic with a complaint about upper front teeth mobility. Both the mandibular and maxilla anterior teeth were flaring-out without anterior guidance.
Fig.2 Significant alveolar bone loss was observed at the upper anterior teeth.
Fig.3 Almost all of her teeth, including molars, had infra bony defects. Periodontal
pockets were extremely deep with some of them reaching up to 10mm. Teeth mobility was significant. 77% of the pockets were deeper than 4 mm, and 24% were deeper than 7 mm. Red: Bleeding on probing (BOP). Yellow: Pus discharge. The diagnosis was generalized severe chronic periodontitis and occlusal trauma involving pathological tooth migration.
Fig.4 The lateral view of the intercuspal position. All teeth, including molars, had mesial inclination and showed advanced pathological tooth migration.
Fig.5 There were no occlusal contacts on the working side during lateral movement.
Fig.6 The balancing contact was recognized on the non-working side.
Fig.7 The occlusal view of the upper and lower jaws. The lower anterior teeth were flaring out. Oral hygiene was poor and severe gingival inflammation was recognized at almost all teeth
Fig.8 Cephalometric analysis showed Skeletal Class II and Bi-maxillary protrusion.
Fig.9 According to our conventional treatment plan, all first premolars of the maxillomandibular would have been extracted and the anterior teeth would have been retracted to improve the bi-maxillary protrusion. However, it was necessary for us to shorten the treatment period as much as possible, because of the patient’s age (64). So, indeed, we proceeded with the following treatment plan. At first, regenerative therapies in all molar regions were implemented. Following that, comprehensive orthodontic therapy using anchor screws was performed to make all teeth upright. Then, all teeth were retracted to their backward positions. After completing the orthodontic therapy, GBR to the anterior region was applied and two implants were placed. For the molar regions, definitive surgeries were performed in order to gain the physiological alveolar bone and the shallow gingival sulci. And then, prosthodontic treatment was conducted.
Fig.10 As Class II furcation-involvement was confirmed in the lower right molar region, regenerative therapy was performed by using Emdogain (EMD), bone filler and non-resorbable membrane.
Fig.11 Infrabony defects were recognized in all upper right molars. EMD and bone filler were used to perform regenerative therapy. Regenerative therapy for other molars was also carried out using EMD and bone filler.
Fig. 12 6 months after regenerative therapy, orthodontic therapy at the mandible was initiated. 0.022-inches slot preadjusted edgewise appliances were placed, and then leveling and alignment with nickel-titanium archwires were started. Following this, up-righting of all teeth was performed using anchor screws placed in the wisdom-teeth region.
Fig. 13 Similarly, all of the maxillary teeth were retracted using anchor screws placed in the molar region.
Fig. 14 After approximately 6 months from regenerative therapies, all mandibular teeth were up-righted and retracted backwards. Then all maxillary teeth were also retracted backwards, considering that the vertical dimension of occlusion was able to be controlled as much as possible.
Fig. 15 The relationship between the anchor screws and lower molars before and after orthodontics. The lower molars have moved in the direction of the anchor screws by about 5 mm.
Fig. 16 The white arrows show the positions in which the anchor screws were placed before orthodontic therapy. The molars moved backwards by half of the width of the molars.
Fig. 17 The status of debonding. The entire course of orthodontic therapy was completed in less than two years.
Fig. 18 Regarding the anterior region, not only the interdental papillae but also the alveolar bone was severely lost, resulting in a serious esthetic problem.
Fig. 19 The first treatment was horizontal and vertical GBR using a non-resorbable membrane and bone filler.
Fig.20 6 months later, alveolar bone morphology was still not sufficient in the cervical area (white arrow).Therefore, additional GBR was again performed when implants were placed. Titanium bone screws were inserted in the cervical area to obtain appropriate alveolar bone morphology.
Fig. 21 Additional GBR were performed when the implants were placed using titanium bone screws, bone filler and the resorvable membrane.
Fig, 22 Appropriate alveolar bone morphology gained after GBR and implant placement (white arrows).
Fig. 23 Soft tissue augmentation was performed using connective tissue (CT) grafting and CT with epithelium.
Fig. 24 For the molar region, all molars were divided into 4 groups, and then definitive surgeries were performed group by group. In the lower right molars infrabony defects were filled with osteoid tissues. Then, in order to gain physiological bone morphology and shallow gingival sulci, osseous surgery and apically positioned flap were performed.
Fig. 25 In the upper right molars, similarly, infrabony defects were filled with osteoid tissues. Then, for the same purpose, definitive surgeries were performed.
Fig. 26 After the surgeries, we confirmed the occlusion, esthetic appearance and cleansability by provisional restoration.
Fig. 27 Final restorations were delivered. The occlusal relationship have been stable. Esthetics, as well as cleansability and a stable occlusal relationship, have all been realized perfectly.
Fig. 28 Appropriate anterior guidance was confirmed and occlusal trauma to the periodontal tissue was greatly reduced.
Fig. 29 By performing appropriate site development, hard and soft tissue around the implants were reconstructed, and esthetics was dramatically improved.
Fig. 30 Most of the periodontal pockets were within 3 mm, and BOP points decreased considerably. Teeth mobility was not noticed and all restorative work was delivered as a single restoration. The bones around the natural teeth could gain physiological morphology.
Fig. 31 Post-treatment cephalometric evaluation still showed Class II jaw-base relationship and a slight increase of vertical dimension of occlusion. The inclination of the lower incisor was changed appropriately and an acceptable interincisal relationship was also maintained.
Fig. 32 Complete series of peri-apical Xrays 2 years after treatment. Bone around the teeth and implants was very stable. Tooth mobility has not been noticed and the periodontal tissues have been well maintained.
