Regenerative periodontal surgery: A bone regeneration is performed on a self-contained bone defect between 2.3 and 2.4

Regenerative periodontal surgery, bone regeneration, self-contained defect, periodontal treatment.

Referral

The patient was attended to at DR. Lluch’s dental clinic (Valencia, Spain).

Patient Complaint

History of presenting complaint: The patient has attended periodontal maintenance for more than ten years. He knows he has had periodontal disease since he was a teenager and visited the dentist approximately every five months. For the past five months, he has noticed that if he presses on the level of the upper left canine, the pus comes out.

The patient had been notified for over five years that he needed to perform resective surgery on most of his posterior teeth because their pockets were more significant than 5 mm. Scaling and root planning without lifting a flap could not be thoroughly cleaned. The patient is super squeamish and only wants to do maintenance every five months.

Social history

Age:46 years old
Occupation: C.E.O.

Medical history

Alcohol intake: He drinks wine every day, eight glasses of wine per week.
Family conditions: Diabetes, alcoholism, depression.

Dental history

Oral hygiene: He brushes his teeth and flosss.
Dental visits: Frequent.
Evaluation:
1. Health
2. Function
3. Aesthetics
The maximum aperture was 37 mm in the anterior zone.

Attitudes towards previous treatment

Highly complicated. The patient needs to meditate every time the anaesthesia is given to perform maintenance with him. So, he reserves about two hours of appointment.

Periodontal treatments

Phase one

1. The first step in therapy is to guide behaviour change by successfully motivating the patient to remove supragingival dental biofilm and risk factor control.
To achieve this first step, it is necessary to do the following:

• Supragingival dental biofilm control and develop skills in dental biofilm removal.
• Interventions to improve the effectiveness of oral hygiene motivation and instructions.
• Adjunctive therapies for gingival inflammation
• Interventions aimed at removing supragingival plaque and calculus, as well as possible plaque-retentive factors that impair oral hygiene practices.
• Risk factor control includes all the behavioural health change interventions eliminating/mitigating the recognised risk factors for periodontitis onset and progression (smoking cessation, improved metabolic control of diabetes, and dietary counselling and weight loss).

I reevaluated the patient after six weeks to continue building motivation and adherence or exploring other alternatives to overcome the barriers.

Treatments

1. Cleaning and applying airflow are carried out.

2. Radiological diagnostic method: Periapical radiographs and orthopantomography were not performed to assess periodontal health. He has claustrophobia and cannot be in a small room with a closed door.

Periapical series

Periapical X-rays

3. Perio chart shows the deep pockets and soft tissue conditions:

A. The probing deep generalised was 4-5 mm.

B. C.A.L. values were more than 5 mm in molars and between 2.3 and 2.4.

D. Bleeding and plaque generalised.

E. Thin biotype.

F. recession in 2.3; 2.4; 3.4; Miller type 1.

G. Generalised periodontal disease stage 3 grade C (Caton et al., 2018).

H. The CPITN code was 1 for the majority of her teeth.

4. The patient was taught the instructions and good brushing and flossing techniques. The use of an electric toothbrush is recommended since, according to Ccahuana-Vasquez et al. (Ccahuana-Vasquez et al., 2019) reduces plaque and gingivitis compared to the manual toothbrush.

5. To control plaque levels in the patients, it was recommended to use some tablets to detect plaque after brushing. Thus, they would know if the plaque is being removed and where they need to brush better.

6. The patient was taught with motivation and education about the harmful effects of tobacco and alcohol on health. It was recommended to visit pages such as the Slutta.no page, created by Helsenorge.no, for more information on quitting smoking. In addition, pinto-Filho et al. 2018(Pinto-Filho et al., 2018) conducted a cross-sectional study about alcohol and tooth loss. They found that Alcohol dependence increased 2.5 times the risk of tooth loss.

7. Every five months, systematic revaluation was recommended to check the periodontal evolution in the supportive periodontal care phase.

Teeth prognosis (Mac Guire 1991)

• 2.3 and 2.4: Their prognosis is uncertain because they have occlusal trauma and an interproximal pocket of more than 11 mm in length.
• 3.6: An uncertain prognosis because he has a more than 7 mm pocket in his distal root.
• 4.7: His prognosis is uncertain since he has a distal pocket of more than 7 mm.
• 1.5: uncertain prognosis, pocket larger than 5 mm distally.
• 1.6: Uncertain prognosis due to his mesial pocket and the fact that he presents grade-two mobility.
• The rest of the teeth have a good prognosis.

 

Photo initial

Diagnosis

1. Generalised periodontal disease stage 3 grade C (Caton et al., 2018).

2. Bone defects at 2.3;2.4; 1.5; 1.6; 3.6, and 3.7.

Periodontal intra-bony defects (also called «vertical» defects) are an anatomical sequela of periodontal disease progression, with a base apical to the inter-dental alveolar crest, surrounded by one, two or three bony walls (Lang, 2000). These defects are associated with a higher risk of progression (Papapanou & Wennstrom, 1991) and, as such, are often considered to require surgical intervention beyond cause-related periodontal therapy.

3. Anterior open bite.

Once phase one was completed, making the patient understand why her gums were bleeding and the importance of controlling the plaque, we began phase two of the treatment.

The second therapy step aims to control (reduce/eliminate) the subgingival biofilm and calculus (subgingival instrumentation).

PHASE TWO

In addition to this, the following interventions may be included:

• Use of adjunctive physical or chemical agents

• Use of adjunctive host-modulating agents (local or systemic)

• Use of adjunctive subgingival locally delivered antimicrobials

• Use of adjunctive systemic antimicrobials(Sanz et al., 2020)

1. Scaling and root planning were performed. The aims of this treatment are:

A.  To reduce bleeding and the level of plaque to £25%.

B.  To reduce the depth level of the pocket under 4 mm plus B.O.P. and any P.P.D. > 6 mm.

C. Keep the horizontal defect less than 2-3 mm in the furcation involved.

D.  To prevent pain or bad smell.

E.   To evaluate other techniques such as regenerative or resective surgery or re-scaling and root planning again if this treatment is not successful in the periodontal revaluation carried out after six weeks.

• The patient was taught with motivation and education about the harmful effects of tobacco and alcohol on health.

It was recommended to visit pages such as the Slutta.no page, created by Helsenorge.no, for more information on quitting smoking. In addition, pinto-Filho et al. 2018(Pinto-Filho et al., 2018) conducted a cross-sectional study about alcohol and tooth loss. They found that Alcohol dependence increased 2.5 times the risk of tooth loss.

3.     Periodontal re-evaluation

The aims of therapy:

No periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm.

If this is not done, in that case, the third step of therapy should be considered. Some specific situations follow directly to phase three, such as tooth mobility with no antagonist.

If the treatment successfully achieves the therapy endpoints, patients should be placed in supportive periodontal care (S.P.C.) programme.(Herrera et al., 2022).

1. After scaling and root planning, indicating the brushing and flossing technique to the patient, the patient was summoned for a review two weeks later.

2. The results were unfavourable; Therapy goals were not achieved.

After explaining the seriousness of the situation many times, the patient understood that if he continued like this, he would eventually lose his teeth. Between 2.3 and 2.4. a fistula began to emerge, through which it squeezed, and pus came out. As her boyfriend told her that he had a terrible taste in his mouth and that she did not want to kiss him, the patient agreed to undergo resective surgery in the second quadrant and regenerative surgery at the level of 2.3 and 2.4 on the self-contained bone defect she had.

 

Phase three

If the endpoints of therapy:

• No periodontal pockets >4 mm with bleeding on probing or deep pockets ≥6 mm have not been achieved. The third therapy step should be implemented(Sanz et al., 2020).

To gain further access to subgingival instrumentation or aim at regenerating or resecting those lesions that add Complexity in managing periodontitis (intra-bony and furcation lesions), it may include the following interventions(Sanz et al., 2020):

• Repeated subgingival instrumentation with or without adjunctive therapies

• Access flap periodontal surgery.

• Resective periodontal surgery.

• Regenerative periodontal surgery:

What is regenerative periodontal surgery?

Regenerative periodontal surgery has two main fields of action: forming new soft tissues and obtaining new hard tissues.
Soft tissues are required when the patient has gingival retractions, lacks keratinized gum, needs more vestibule depth, or requires greater volume.
Periodontal bone regeneration seeks to form a new cementum, alveolar bone and a new periodontal ligament.
Therefore, regenerative periodontal surgery is a set of interventions with autologous materials or xenografts that seek to form dental support tissues such as the gum and alveolar bone.

Can periodontal tissue be regenerated?

«A large body of clinical and histological evidence accumulated over the last 4-5 decades shows how healing following periodontal surgery of infrabony defects can, with the use of biomaterials, be guided towards the formation of de novo cementum, functionally oriented periodontal ligament, new alveolar bone and gingiva» this was suggested by Nibali et al.2021 (Nibali, L., Sultan, D., Arena, C., Pelekos, G., Lin, G. H., & Tonetti, M. (2021).

When there is an indication for surgical interventions, these should be subject to additional patient consent, and specific evaluation of risk factors or medical contraindications should be considered. In addition, the individual response to the third therapy step should be re-assessed (periodontal re-evaluation)(Sanz et al., 2020).

Once it was verified that the previous requirements were met, a regenerative periodontal therapy was designed to perform the following periodontal regenerative procedures:

1. Making a flap without incision, through which a resective surgery would be performed from 24 to 2.7. At a level of 2.3, regenerative surgery would be achieved with enamel matrix proteins and Bio-Oss.

• This surgery was performed under conscious sedation.
• In the other quadrants, it was explained that resective surgery should be performed and regenerative surgery should be performed on some teeth. He responded that until a fistula appeared, nothing would be done.

The protocol followed until this defect’s regeneration follows the guide Mariano Sanz recommended. (Sanz et al., 2020)

Treatment (guided tissue regeneration)

1. An intrasulcular incision is made from 2.2 to 2.7.
2. A cut was made at the level of the periosteum of the vestibular flap to give it more excellent elasticity and better access and visibility.
3. Then, the scaler and Gracey curettes were used.
4. Once the granulation tissue was removed, the peri-set burs were passed to contour the ideal bone shape, but the contour was lower in the cervical than in the interproximal.
5. Once everything is clean, it is rinsed with chlorhexidine and physiological saline.
6. The defect at the interproximal level of 2.3 and 2.4 is self-contained, so it was regenerated with Bio-Ossy bone with Endogain.
7. Once it was verified that everything was compact, it was sutured with a 4.0 suture.
8. It was suggested that we close the space between 2.3 and 2.4 to get a contact point closer to the gum and thus be able to get some papilla, but the patient refused.
9. The occlusion was verified with articulating paper. The 2.3 had a more intense contact point than the anterior teeth, and that contact point was relieved to improve possible bone loss due to occlusal trauma.
10. The patient does not want to hear about orthognathic surgery or braces, so he has yet to be referred to a specialist. He was told that this would be ideal.

Postoperative indications

• The antibiotic during the postoperative period: 500 mg amoxicillin for five days.

25 mg dexketoprofen, three times daily, and chlorhexidine digluconate rinses (0.12%) twice daily for two weeks.

• Sutures were removed two weeks postoperative day.
• Soft toothbrush to brush the operative site. The patient was reinstructed regarding oral hygiene measures in the sixth postoperative week. He was followed once a week for the first postoperative month and again in the third month for information on the operation site and professional plaque removal if needed.

Surgery photos

Re-evaluation

Periodontal re-evaluation

The aims of therapy:

• No periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm.

The previous objectives were met in the second quadrant. However, it should be noted that it has not been probed after regenerative surgery. Therefore, it will wait six months to do it.

Regarding the other quadrants, the patient continues with deep pockets greater than 5 mm in 3.6, 4:7, 1.5 and 1.6.

As mentioned above, he only wants to do a dental cleaning, scaling, and root planning without surgery.

He made an appointment at four months to start phase four of periodontal maintenance.

Phase four

It aims to maintain periodontal stability in all treated periodontitis patients by combining preventive and therapeutic interventions defined in therapy’s first and second steps. It is realised from three to six months after phases one, two or three, depending on the severity of the condition, age, and cooperation.

The must be rechecked risk factors, do the perio chart again.

• Register of dental biofilm.
• P.P.D.
• Furcations invoice exam.
• Mobility.
• X-rays if there are clinic changes or pain.

Scaling and root planning and polish restorations in specific points:

A.  To reduce bleeding and the level of plaque to £25%.

B.  To reduce the depth level of the pocket to under 5 mm.

C.  Keep the horizontal defect under 2-3 mm in the furcation involved.

D.  To prevent pain or bad smell.

If everything is controlled and there are no periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm, the control appointment will be the first year every four months and the second year every six months; This must be agreed upon with the patient, his cooperation, and financial conditions.

1. The patient was continuously motivated and educated on the harmful effects of tobacco and alcohol on health. It was recommended to visit pages such as the Slutta.no page, created by Helsenorge.no, for more information on quitting smoking. In addition, pinto-Filho et al. 2018 (Pinto-Filho et al., 2018) conducted a cross-sectional study about alcohol and tooth loss. They found that Alcohol dependence increased 2.5 times the risk of tooth loss.
2. Systematic revaluation was recommended after four months to recheck the periodontal evolution.

Teeth prognosis (Mac Guire 1991)

• 2.3 and 2.4: Their prognosis is good; even if they have occlusal trauma now, they do not have a deep pocket of more than 4 mm.
• 3.6: Bad prognosis because The pocket depth has increased since the last periapical sampling. It is bothering him, and his mobility is currently in grade 2.
• 4.7: His prognosis is still uncertain since he has a distal pocket of more than 7 mm.
• 1.5: uncertain prognosis, pocket larger than 5 mm distally.
• 1.6: Uncertain prognosis due to his mesial pocket and the fact that he presents grade-two mobility.
• 1.7: It presents a grade 1 distal furcation. Its treatment continues to be resective surgery.
• The rest of the teeth have a good prognosis.

His level of plaque and hygiene improvement has been incredible. However, he still smokes more than ten cigarettes daily.

 

Evolution

It is clear that if periodontal surgery is not done, no matter how much he comes to control and we do scaling and root planning unless it is decided soon, the third quadrant, with its respective molars, will evolve negatively.

 

Overall

In this case, I learned that the frenulum could not only be removed from the buccal with a zetaplasty or with parallel or oval incisions; disinsertion of the fibres from within the flap is a possibility(Sculean and Allen, 2018).

This treatment was made because the recession was minor. However, if it becomes enormous, a total frenectomy must be performed, and in many cases, the chin muscle must be removed to avoid the recurrence of the retraction.