Perio Contest 2018/ 27 April 2018/

Case 72 | Perio Contest 2018 | Japan

Dr Teppei Tsukiyama

Title: Successful multidisciplinary treatment strategy for patient with severe periodontal disease.

Introduction

It is easy for dentist to make a patient-oriented snapshot treatment plan based on the first impression. However, stepping into a deeper level, it is important to evaluate from all different aspects including history throughout patient’s lifetime. When considering treatment from a lifetime perspective, even patient presented with same clinical conditions, treatment planning becomes diversified depending on multiple factors such as age, motivation, compliance, genetics etc. This 52 y.o. female patient under 15 years’ maintenance care in our practice, desired to improve her dental esthetics. Patient presented with compromised oral condition and didn’t want to have definitive treatment at 15 years ago, and had been maintained in recall visit periodically. In 2012, patient finally decided to receive comprehensive definitive treatment since she became ready mentally, physically, and financially. This clinical report describes a successful interdisciplinary approach for the treatment of severe periodontitis involving an esthetically compromised dentition and high patient demand.

Initial and Final photos at smile

52-year-old female who had been in maintenance program for previous 15 years, presented to us with chief complaint: “I want to remove my black spots on my front teeth.”

History of past dental visits in past 15 years. Since patient wasn’t committed to definitive treatment plan at that time, patient underwent repeated restoration cycle.

Highlight of Phase I therapy along treatment plan sequence.

Intra Oral Photos at initial visit.

Full mouth radiographs before starting the treatment.

Summary of caries and endodontic condition.

Periodontal examination at initial visit.

Periodontal examination after Phase I therapy.

Perio Risk Assessment by OHIS (Oral Health Information Suite) described high periodontal risk.

Occlusal evaluation.

Prognositic assessment for tooth survival by McGuire’s and Zitzmann’s classification.

Parameter changes of periodontal condition along Phase I therapy (left), and Case assessment lists in every aspect for treatment planning (right).

Highlight of Phase II therapy along treatment plan Sequence.

Implant treatment on #36,37. 1st slide. Implant placement with simultaneous GBR was planned 1 year after extraction.

Implant treatment on #36,37. 2nd slide. Combination graft of FDBA/Bio-oss, and non-crosslink collagen membrane were utilized for GBR. Then primary closure was achieved passively with 5-0 nylon sutures. Regenerated bone was confirmed upon flap elevation at stage II procedure.

Implant treatment on #36,37. 3rd slide. Final impression was taken and implant fixed single crowns in the manner of screw retained were delivered.

PA demonstrating the sequence of implant therapy on #36,37.

Procedure of periodontal regenerative therapy on #46,47. 1st slide. 2-3 wall angular bony defects were observed on #46,47.

Procedure of periodontal regenerative therapy on #46,47. 2nd slide. EMD/FDBA was grafted into defect and covered completely with primary closure.

Procedure of periodontal regenerative therapy on #46,47. 3rd slide. In order to remove some residual pocket after regenerative therapy, apically positioned flap was performed. Newly generated hard tissue was confirmed underneath.

PA demonstrating the successfully outcome of regeneration on #46,47.

Preop condition before GTR on #13-21. 1st slide.

Procedure of GTR on #13-21. 2nd slide. Modified papilla preservation technique was utilized to save interproximal soft tissue. GTR was performed with EMD, DFDBA, and d-PTFE membrane for non-space containing defect.

Procedure of GTR on #13-21. 3rd slide. Primary closure was achieved with 6-0 mono filament sutures. Newly formed tissue was observed at the re-entry for membrane removal.