Perio Contest 2018/ 11 April 2018/

Case 29 | Perio Contest 2018 | Switzerland

Dr Oliver Laugisch

Therapy of a generalized chronic periodontitis

Dr. med. dent. Oliver Laugisch,
Department of Periodontology, University of Bern, Switzerland

Anamnesis:
Social anamnesis and chief complaint
Mrs. M.A. is 67 years old, married and retired. The patient was referred to the Department of Periodontology. Her chief complaint was the treatment of her periodontitis with maximal preservation of teeth and instauration of an adequate chewing function.

Medical history
Since 2007 the patient has an artificial hip joint. Otherwise the patient is medical healthy and has no medication requirements. She is a former smoker and till quitting smoking in 2000 the patient smoked 20 cigarettes per day.

Dental history
Mrs. M.A. keeps yearly appointments for control and tooth-cleanings at her family dentist. At time of diagnostics she suffered from food-impaction, tooth migration and enhanced tooth-mobility.

Diagnostics:

Extra oral:
Without pathological incidents

Intra oral:
Amalgam tattoo in region tooth 47

Dental findings:
The patient has a sufficient treated dentition. Tooth 27 was extracted in 2002 due to an endodontic mistreatment. At time of diagnostics all teeth beside the sufficient endodontically treated tooth 24 were vital (CO2-testing). Wear-facets could be diagnosed at front-teeth and premolars (Fig.1 + Fig.2).

Intraoral photos at time of diagnostics

Periodontal findings:
Probing pocket depth (PPD) up to maximal 12mm could be seen in all quadrants. Teeth 17, 26, 37, 36 und 46 had furcation involvement degree I. An enhanced mobility was found on teeth 15, 14, 41 and 45 (degree I) and on teeth 21, 25 and 34 (degree II). Initial oral-hygiene-indices represented a plaque-index (PI) of 44% and a bleeding on probing (BOP) of 43% of sites (Fig. 3).

Periodontal status at time of diagnostics

Radiographic findings:
The radiographic status showed a generalized horizontal bone-loss with localized vertical components. Shadows in terms of subgingival calculus could be found at teeth 21, 34, 44 und 45 (Fig. 4).

X-rays at time of diagnosis

Diagnosis:

Advanced generalized chronic periodontitis with furcation-involvement [1].

Treatment plan:

Systemic phase:
Consultation of her general practitioner and her orthopedic specialist with regard to an antibiotic coverage of her hip-joint prosthesis.

Hygienic phase:
Oral-hygiene-instructions and –motivations followed by deep-scaling and root-planing in all four quadrants under local anesthesia and if necessary under antibiotics coverage are planned.

Surgical phase:
Periodontal surgery including regenerative procedures of localized vertical bony defects in all four quadrants.

Maintenance:
Visits at the dental hygienist in a 3-month interval are indicated.

Prosthetic phase:
If teeth 21 and 34 should be extracted, these gaps need to be preserved. As teeth 21 and 22 are not parallel to each other, the use of a bridge needs to be discussed due to risk of vitality-loss. Furthermore lack of bone region 21 and 34 should be considered when an implantation is focused. Therefore a bonded bridge or implant region 21 and a conventional bridge or implant region 34 is indicated.

Treatment sequence:

Systemic phase:
No precautions are necessary. An antibiotic coverage of her hip joint prosthesis is not necessary.

Hygienic phase:
Oral-hygiene-instructions and –motivations up to a plaque index below 20% took place before starting with scaling and root-planing. The patient was guided to an index of 2% and 1%. Tooth 21 needed to be extracted due to a periodontal abscess with vitality loss and a worsening of its mobility up to degree III (Fig. 5). Deep Scaling was performed under local anesthesia and a “Vallplast®” provisional was handed out. Oral hygiene indices showed a PI of 7% and a BOP of 9%. All pockets ≥ 4mm received additional instrumentation.

Periodontal abscess region tooth 21 and indicated therapy

Surgical phase (Fig. 6):

Surgical treatment in all quadrants

– Surgery teeth 33-35: 1. A splint mesial and distal of tooth 34 after acid-etch-technique with composite was added. 2. Simplified-Papilla-Preservation Flap (SPPF) [2], Removing of granulation tissue, scaling and root-planing, conditioning of the root with EDTA for 2 minutes and application of an enamel-matrix- derivative in combination with bovine bone substitute in the 2- and 3-wall bony- defects. Tight closure with “Gottlow-Laurell” sutures [3].
– Surgery teeth 43-46: Splint, SPPF, Removing of granulation tissue, scaling and root-planing, conditioning of the root and application of an enamel-matrix- derivative in combination with bovine bone substitute in the 2- and 3-wall bony- defects. Tight closure with “Gottlow-Laurell” sutures.

– Surgery teeth 25-26: Splint, SPPF, Removing of granulation tissue, scaling and root-planing, conditioning of the root and application of an enamel-matrix- derivative in combination with bovine bone substitute in the 2- and 3-wall bony- defects. Tight closure with “Gottlow-Laurell” sutures.
– Surgery teeth 14-16: Splint, SPPF, Removing of granulation tissue, scaling and root-planing, conditioning of the root and application of an enamel-matrix- derivative in combination with bovine bone substitute in the 2- and 3-wall bony- defects. Tight closure with “Gottlow-Laurell” sutures.Reevaluation after surgery showed improvement of periodontal conditions (Fig. 7 + Fig. 8). Tooth mobility decreased to physiological. Only 4 sites with a PPD up to 4mm max. Oral-hygiene indices represented a PI 5% and BOP 4% (Fig. 9).
X-rays of treated teeth after periodontal regenerative surgery
Intraoral photos after treatment
Maintenance:
Periodontal risk assessment [4] showed a medium risk and the suggested interval for this category was 4-6 months.
Prosthetic phase:
Due to a massive oral-vestibular bone-deficiency region 21 an implantation without extensive augmentation is impossible. Furthermore a risk of loss of vitality is possible when teeth 11 and 22 are prepared for a conventional bridge 11-x-22 as they are not parallel to each other. After an extensive planning and discussion with the patient, we decided to custom-made a resin bonded bridge 11x (Fig. 10).
Periodontal status at time of reevaluation after surgery

Discussion:
This case-presentation shows a therapy of an advanced generalized chronic periodontitis with furcation involvement. After optimizing oral hygiene, all teeth were scaled and root-planed. As there is evidence that remaining pockets ≥ 6mm [5] and vertical bone-defects [6] represent a risk for future attachment-loss, these have been targets in a surgical phase.
The configuration of vertical bony-defects determines regenerative periodontal techniques [7]. Studies indicated that the use of enamel-matrix-derivatives [8] and enamel-matrix derivatives in combination with bovine bone substitute [9] had histologically shown regeneration of periodontal ligament, bone and cementum in humans. To combine these techniques with microsurgical “Papilla-Preservation- Flaps” leads to an additional gain of attachment and ergo more pocket-reduction than “Papilla-Preservation-Flaps” alone [10]. Less mobility if teeth are splinted before regenerative procedures has an additional positive effect [11].
The final x-rays show a remineralization of vertical bony-defects. This could be a sign for regeneration.
At time of reevaluation after surgery only 4 pockets of 4mm remained, PI was 5% and BOP 4%. If the patient still performs good oral hygiene and compliance with maintenance [12] also molars with a furcation degree I have a good long-term prognosis [13].

Custom made resin bonded bridge region 21

References:

Armitage, G.C., Development of a classification system for periodontal diseases and conditions. Ann Periodontol, 1999. 4(1): p. 1-6.
Cortellini, P., G.P. Prato, and M.S. Tonetti, The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent, 1999. 19(6): p. 589-99.
Gottlow, J., et al., Guided tissue regeneration using a bioresorbable matrix barrier. Pract Periodontics Aesthet Dent, 1994. 6(2): p. 71-8; quiz 80.
Lang, N.P. and M.S. Tonetti, Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent, 2003. 1(1): p. 7- 16.
Matuliene, G., et al., Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance. J Clin Periodontol, 2008. 35(8): p. 685-95.
Papapanou, P.N. and J.L. Wennstrom, The angular bony defect as indicator of further alveolar bone loss. J Clin Periodontol, 1991. 18(5): p. 317-22.
Cortellini, P., A. Labriola, and M.S. Tonetti, Regenerative periodontal therapy in intrabony defects: state of the art. Minerva Stomatol, 2007. 56(10): p. 519- 39.
Sculean, A., et al., Healing of human intrabony defects following treatment with enamel matrix proteins or guided tissue regeneration. J Periodontal Res, 1999. 34(6): p. 310-22.
Sculean, A., et al., Five-year clinical and histologic results following treatment of human intrabony defects with an enamel matrix derivative combined with a natural bone mineral. Int J Periodontics Restorative Dent, 2008. 28(2): p. 153- 61.
Tonetti, M.S., et al., Enamel matrix proteins in the regenerative therapy of deep intrabony defects. J Clin Periodontol, 2002. 29(4): p. 317-25.
Cortellini, P. and M.S. Tonetti, Evaluation of the effect of tooth vitality on regenerative outcomes in infrabony defects. J Clin Periodontol, 2001. 28(7): p. 672-9.
Matuliene, G., et al., Significance of Periodontal Risk Assessment in the recurrence of periodontitis and tooth loss. J Clin Periodontol. 37(2): p. 191-9.
Hirschfeld, L. and B. Wasserman, A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol, 1978. 49(5): p. 225-37.

Figures:

Fig. 1: Intraoral photos at time of diagnostics
Fig. 2: Dental status: crowns, fillings, endodontic treatments, as well as vitality (CO2) and percussion positive (P) teeth or teeth with usures (U) or abrasions (A)

Fig. 3: Periodontal status at time of diagnostics
Fig. 4: X-rays at time of diagnosis
Fig. 5: Periodontal abscess region tooth 21 and indicated therapy
Fig. 6: Surgical treatment in all quadrants
Fig. 7: X-rays of treated teeth after periodontal regenerative surgery
Fig. 8: Intraoral photos after treatment
Fig. 9: Periodontal status at time of reevaluation after surgery
Fig. 10: Custom made resin bonded bridge region 21

Tags: Periodontology

Team Zerodonto

We are here in the backstage.Always working for you.Something is priceless, for everything else in the dental world there's Zerodonto!