Dr Izabella Tomera-Niekowal
First stage of periodontal treatment of a vertical infrabony defect associated with mucogingival deformities related to trauma during orthodontic treatment.
Case Description
A 17 year old patient was referred by the orthodontist for a periodontal treatment.
The main complaint was the chronic gingival inflammation and discomfort in the area of maxillary central incisors.
The patient reported also some bleeding when brushing.
Medical History
Good general health, nonsmoker.
Dental history
The Patient experienced trauma of teeth 51,61 at age of 4.
He started orthodontic treatment at the age of 8 with a diagnosis: mandibular retrognathism, crowding in both arches, impacted permanent central incisors and impacted supernumerary teeth in upper jaw.
Orthodontic treatment involved the treatment of a basic defect , introducing impacted teeth into the dental arch. For that reason impacted supernumerary teeth were surgically extracted and impacted teeth 11, 21 were exposed. The patient received removable orthodontic appliance for 2 years but the treatment was not effective. For that reason patient underwent a second surgical exposing of teeth 11, 21 with the placement of a fixed orthodontic appliance. During this procedure space for the teeth was reconstructed and teeth 11, 21 was introduced to the arch and finally proper placement.At the last stage of orthodontic treatment patient underwent trauma of maxillary incisores with partial dislocation of tooth 21. Up to our best knowledge tooth remained immobilized by orthodontic appliance for 1 month and after that time active orthodontic treatment was continued. Since that time patient remained under general dentist control for the vitality of teeth 12, 11, 21, 22.After finishing orthodontic treatment patient extracted teeth 38,48.
The last dental visit was 2 months before the patient came to the periodontal office. Fixed orthodontic appliances were removed and the patient received removable retention appliances. At that time he also had a visit at a general dentist office in order to control the vitality of teeth 12, 11, 21, 22. The patient had a regular dental follow-up every 6 months most of time and in the last year every month at general dentist office.
Periodontal Examination
-Mean probing depth=2,6; Mean Attachment Level=2,6; FMPS=42%; FMBS=29%
-Deepest PPD according to tooth 21 -6mm on the distal buccal aspect, 5 mm on the palatal aspect
-Dental plaque induced mild chronic gingivitis.
-Gingival recession of teeth 11, 21.
-Lack of keratinized gingiva in the area of teeth 11, 21.
-Aberrant upper lip frenum- Class III according to Placek Classification.
-Grade II mobility of tooth 21 according to Miller Classification.
Radiographic examination
Periapical radiograph made before fixed orthodontic appliances removal showed a vertical bone defect at distal aspect of tooth 21.
For the purpose of possible vertical root fracture diagnosis a sectional CBCT was done.
The CBCT examination presented a vertical infrabony defect at distal aspect and circumferential defect at palatal aspect of tooth 21. Lack of buccal bone according to teeth 11, 21. No symptoms of vertical root fracture could be observed.
Plaque control history
Manual toothbrushing, horizontal technique twice a day.
Diagnosis
-Condition after orthodontic and surgical treatment, vestibular position of teeth 21. Condition after trauma in maxillary incisor region.
-Vertical infrabony defect at the distal aspect of tooth 21 extending to the buccal aspect and also circumferentially to the palatal aspect. Associated with mucogingival deformities and uncertain endodonthic condition of teeth 12, 11, 21, 22.
Prognosis
According to the multifactorial condition and to the possible further long-term complications – questionable.
Treatment plan
- Evaluation of endodontic condition of teeth 12, 11, 21, 22, endodontic treatment if needed.
-The endodontic evaluation was made at the general dentist office and confirmed the vitality of teeth 12, 22 .Teeth 11, 21 were found nonvital and underwent endodontic treatment.
- Hygienic phase
– Motivation and instruction in oral hygiene.
- Infection control
– Periodontal ultrasonic debridement was performed.
- Periodontal reevaluation
– Periodontal chart reveals a reduction in probing pocket depth and reduced number of sites with bleeding on probing.
– FMPS=14%, FMBS=6%
- Maxillary labial frenectomy.
-The rationale to perform labial frenectomy prior to further surgical treatment was to eliminate negative pull syndrome and tension to the thin, delicate alveolar mucosa covering teeth 11, 21 during soft tissue augmentation procedure.
- Splinting of teeth 12, 11, 21, 22.
-Before soft tissue augmentation to provide soft tissue graft stability.
-The fiber splint was placed on the buccal aspect of teeth 12, 11, 21, 22.
- Soft tissue periodontal plastic surgery in the area of teeth 11, 21 to provide better quality of soft tissue for the reason of further periodontal regeneraton.
Considering the unfavorable anatomical conditones of the maxillary anterior area as a consequence of previous treatments and trauma in the past, there was not enough vascular bed to perform FGG. Augmentation of alveolar mucosa with the use of SCTG from the posterior palate and enamel matrix derivative in modified coronally advanced tunnel (MACT) aproach was performed. The main goal was to provide better soft tissue quality and quantity for the reason of infrabony defect regeneration and to achieve better conditions for proper oral hygiene control.
Further steps
- Regeneration of infrabony defect of tooth 21.
- Orthodontic treatment to obtain the correct position of tooth 21 in the dental arch in relation to the adjacent teeth with occlusal adjustment if no further post trauma complications (like for example root resorbtion) appear.
Conclussion
This approach is not a standard chronic periodontitis treatment. This method is rather a treatment of choice of posttraumatic lesion when a connective scar tissue may be expected.
First visit at periodontal office.
Situation before orthodontic treatment
Situation at the end of orthodontic treatment.
Initial situation: gingival recesion of teeth 11 and 21, lack of kreatinized gingiva in the area of teeth 11 and 21, aberrant upper lip frenum.
Occlusal view.
CBCT
CBCT
Frenectomy, straight after surgery and one week after surgery.
One month after frenectomy.
Splinting of teeth 12,11,21,22
Soft tissue augmentation – incision.
Soft tissue augmentation – tunnel preparation
Connective tissue graft
Soft tissue augmentation – placing CTG in to the tunel.
One week after augmentiation
Two weeks after augmentation.
One month after augmentation
Two months after augmentation
Three months after augmentation.
Six months after augmentation.
Results at sixth months.
Before and after.
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