Urgencia dental 24 horas: A patient with periodontal disease and peri-implantitis underwent resective surgery, bone regeneration with autologous block, dental implants, and kasanjian vestibuloplasty.

Khoury technique, periodontal disease, peri-implantitis, kasanjian vestibuloplasty, dental implants, guided bone regeneration, collagen membrane.

Patient Complaint

«I do not want to use the removable prosthesis. I had dental implants, but they failed two years ago. But nobody wants to put on dental implants because they say I do not have the bone. »

History of presenting complaints

The patient tells us that he had had an implant treatment plus regeneration.

A few months ago, he had lost an implant and could no longer use his prosthesis.

His previous doctor told him that He had peri-implantitis and could not put the implants back in, and he recommended a removable appliance.

 Personal information

Age: 46 years old.

Sex: Man.

Single.

Occupation: Electric engineer.

Medical history

Actual diseases: Psoriasis.

Past illnesses: Flue, bilateral pneumonia due to poor healing from a cold.

Allergy: Clavulanic acid.

Family conditions: His mother and aunts suffer from senile dementia; his father died of a heart attack, and his sister has problems with depression.

Alcohol intake: “Social drinker”, one glass of wine daily.

Smoke: The patient Smoked fifteen cigarettes per day.

Dental history

Oral hygiene technique: Need to improve.

Dental visits: Frequent.

Reason for loss of teeth: Due to periodontal disease, the patient commented that he felt that the prosthesis was not very well adapted and that they put too much food in it and could not be cleaned well.

Habits: He has obstructive sleep apnea and is an oral respirator (Suzuki and Tanuma, 2020).

Oral aperture: The maximum aperture was 39 mm in the anterior zone.

 Attitudes Towards Previous Treatment

Good attitude, very cooperative patient.

 Systematic orofacial examination

The face:

Caucasian patient with strong chewing muscles; he has brachyfacial features.

Mouth:

Sufficient saliva and good tongue mobility; the oral mucosa is hydrated.

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 localised 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 assessed periodontal health and CBCT.

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

A. Bleeding and plaque localised in upper posterior molars.

B. The patient has gingival recessions Miller types three and 4 (Pini-Prato, 2011)in lower premolars.

            C. Gingival biotype thin.

            D. Deep pockets in the mandible are 4 mm on average, although 4.4 and 3.3 have a mesial 9 mm; teeth 4.7 and 3.7 have 6 mm of a mesial deep pocket.

 In the maxilla, the average is 4 mm, but teeth 2.6 and 1.6 have 6 mm of deep pocket average, and in 2.7 and 1.7, there is an 8 mm average.

            E. Tooth 1.6 has an involvedfurcation type 2C (Rasperini et al., 2020) according to Rasperini et al. 2020.

            F. Tooth 4.3 has an endodontic-periodontal lesion(G. Caton et al., 2018) with apical focus and grade 3(Aminoshariae et al., 2020) mobility; Teeth 1.7 and 2.7 have grade 2-3 mobility.

            G. Implant 3.2 has peri-implantitis with more than 80% of bone loss.

            H. He presents a lack of keratinised gingiva from 3.3 to 4.3.

I. C.A.L. is in posterior maxilla teeth > 5 mm.

J. Radiography bone loss in posterior maxilla teeth is> 7 mm, anterior 4 mm; in the molar, the mandible is > 4 mm.

4. The patient was taught the instructions and good brushing and flossing techniques. An electric toothbrush is recommended since 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. 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. After three weeks, A systematic revaluation will be done to check the periodontal conditions.

Periapical tooth 4.3

 

  CBCT

Periapical series

 

 

Diagnosis

1. Implant 3.2 shows peri-implantitis with more than 80% of bone loss.

•  Severe periodontitis, molar-incisive distribution, and upper molars have a reserved prognosis due to bone loss and mobility, grade C and stadium 3.

• Tooth 4.3 has an endodontic-periodontal lesion(G. Caton et al., 2018) with apical focus and grade 3 mobility (Aminoshariae et al., 2020).

• Atrophic anterior mandible bone with lack of keratinised gingiva.

• They included wisdom tooth 4.8.

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

Phase two

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

2. 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. 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 after one month

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 favourable; the gingiva was not bloody, and he had a well-controlled plaque.

3. In the lower part, the problem persists with peri-implantitis and with tooth 4.3

4. We had not reduced the pocket depth level under 4 mm plus B.O.P. and any P.P.D. > 6 mm.

We had these pockets in the molars and the anterior area in the maxilla and mandible.

5. The patient had to remove tooth 4.3 and implant 3.2.

6. Perform a resective surgery in both arches and later evaluate a commitment of furcations, pocket depth, Bleeding and dental and aesthetic mobility again.

Once the patient understood that he had lost his teeth due to periodontal disease, smoking and alcohol seriously harmed him, and his plaque and Bleeding.

Teeth prognosis (Mac Guire 1991)

In general, the prognosis of all the teeth was uncertain.

4.4 and 3.3: Due to their pockets of more than 9 mm in the mesial area.

4.7 and 3.7: Uncertain.

1.7 and 2.7: Bad.

2.6 and 1.6: uncertain.

4.3 and implant 3.2: Extraction.

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.

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 reassessed (periodontal re-evaluation)(Sanz et al., 2020).

Once it was verified that the previous requirements were met, a treatment plan was designed to perform the following:

Resective Treatment

1. In this case, as the gums were in good condition, having a good consistency and appearance, it was decided to perform a resective surgery with the flap technique.

• This surgery sought to eliminate the granulation tissue causing the pain while also seeking to improve the bone architecture so that it was not retentive.

• It was carried out in quadrants, waiting an average of two to three weeks before doing the next one. Each time the patient came, the area treated the last time was reviewed.

• An intrasulcular incision was made without vertical discharges.

• The ultrasound removed supragingival calculus and tartar; Gracey curettes were used to eliminate the granulomatous tissue, while the gingiva was rinsed with hydrogen peroxide and chlorhexidine.

• Concerning the 1.6 vestibular furcation, an attempt was made for the patient to be better hygienic; no regenerative therapy was performed as it was considered that none of the patient’s molars had a good prognosis.

• Once granulation tissue has been achieved, the perioset burs achieve proper periodontal bone architecture, reproducing the architecture of a periodontally healthy tooth (Monje et al., 2015), avoiding cracks and surfaces easily colonisable by bacteria. After this, the suture was done.

Post-operatory recommendations

1. Chlorhexidine was applied during the procedure, and maintenance chlorhexidine mouthwash was prescribed for one week, twice daily.

2. Ibuprofen 400 mg, during the first day every 8 hours.

3. Given the possible gingival Bleeding, Cyklokaprom was prescribed to control the Bleeding. It was disposable in blisters; after breaking the blister, it was dropped in a gauze and placed where the Bleeding was.

4. The hygiene kit would have pieces of cotton soaked in salty water.

5. Supplement vitamin D(Ghaly, Hart and Lawrance, 2019) was advised to improve healing and to help with periodontal disease(Machado et al., 2020).

The patient has to improve his interproximal hygiene. A water pick has been recommended if interproximal brushes and dental floss are not to his liking.

The patient is advised to use plaque detectors to check where he needs to improve his hygiene once he has brushed.

The patient must go to phase four.

Once the patient has no generalised bleeding, has a local plaque index, tries to smoke only ten cigarettes a day and does not drink alcohol during the week, the patient is suggested to undergo guided bone regeneration, in which a graft of the branch of the 4.8 wisdom tooth, will be placed as the occlusal wall, and a derma membrane will be placed as the vestibular wall, in the middle there will be autologous bone and xenograft, all this will be fixed with screws and thumbtacks.

After four months, it would be reassessed, and surgery would be performed to restore the fundus of the vestibule and to restore keratinised gums. Once this has been achieved, three dental implants will be placed. After that, we would wait around 3-4 months to start making the fixed prosthesis from 3.2 to 4.3.

Subsequently, the patient will come for evaluation every four months to control and evaluate his reduced periodontium.

 

supportive periodontal care

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(Sanz et al., 2020).

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

• Register of dental biofilm(Baelum and Papapanou, 1996): grade 1.
• Furcations (Rasperini et al., 2020).
• Mobility.
• X-rays if there are clinic changes or pain.
• No periodontal pockets >4 mm with Bleeding on probing or no deep periodontal pockets ≥6 mm; this is the aim.

A.    Biofilm control

Cleaning and air Flow were realised; moreover, instruction and motivation. 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.

• Scaling and root planning focused on Molars.

The aims of this treatment are:

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

B.  To keep the depth level of the pocket under 5 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, if this treatment is unsuccessful in the periodontal revaluation carried out after four months.

Teeth prognosis (Mac Guire 1991)

The upper teeth, in general, have an uncertain prognosis. They have support in a third of their root teeth, such as 1.7, 1.6, 2.6 and 1.6.

The upper premolars have somewhat more osseous support, but their prognosis is uncertain.

The lower teeth responded very well to the resective surgery, and their prognosis has improved. Now it is good.

 For teeth 3.1 and 4.4, it is uncertain. It depends on whether bone regeneration works or not. If it does not work, the most likely thing is that these teeth will be lost.

Treatment to have implants from 3.2 to 4.3

1. The treatment was performed by extracting the implant and the affected tooth and waiting a month and a half for the primary closure of soft tissues.

Subsequently, a block bone graft was removed from the right ramus, drawn with a piezoelectric.

• The graft was fixed upright with micro-screws, filled with autologous bone scraped from the mandibular ramus and covered with a xenograft.

• A derma® membrane was fixed in the buccal area with pins, and after four months, three Klockner essential cone 1.5 implants were placed.

• A connective tissue graft was performed to improve the aesthetics of the tissue with a Kazanjian vestibuloplasty(Ponzoni, Jardim and De Carvalho, 2013).

 

Differential fixed treatments

1. Vertical augmentation with an autologous bone graft, Khoury technique.
2. Vertical augmentation with Gore-Tex membrane, autologous bone and xenograft.
3. Vertical augmentation with a metallic membrane and a mix of autologous bone and xenograft material.
4. Makes a computerised prosthesis that already contains the implants and is fixed to the bone using micro-screws.

Options

Conveniences:

1. It is an effective treatment that works overtime(Palacio García-Ochoa et al., 2020).

•  This treatment let me put on a long implant and get good stability.

• It allowed to improve the patient’s aesthetics and avoid the realisation of a fixed

• Prosthesis with teeth that are too long would affect pronunciation and hygiene.

Inconveniences:

1. Requires more manual skill. If there is any complication in the surgery with manipulating the alveolar dental nerve, I could alter the nerve’s sensitivity (Abayev and Juodzbalys, 2015).

• Intravenous anaesthesia has its risks (Manso et al., 2019). First, the patients cannot help us, which is complicated to work with because the patient is in a deep stage.

• If the regeneration is exposed or goes wrong, we can produce a more extensive defect than we initially had.

Surgery/Treatment details

1. Anaesthesia local: Adrenaline 4%, infiltrative in the buccal zone; lidocaine 2% was used to block the dental alveolar nerve.

This case was realised under intravenous sedation.

• Flap design:

Crestal incision with a buccal discharged on the frenulum and in 35 and 45. A piezoelectric was used to make an incision in the bone to separate the nerve from the cortical bone.

3.Suture 4.0 is resorbable.

4. Safe’s scraper to have the autologous bone in peeling.

5. Three implants for two crowns because he had implants before, which failed. So, the idea was that if one implant failed, he still could have his crowns; the implants used were Klockner Essential cone 1.5® implants (Klockner™, Barcelona, Spain).

Oral medication

1. The patient was premedicated with 300 mg of Clindamycin.

It was administered every 8 hours for seven days, starting two days before.

2. Ibuprofen 400 mg, 3 daily for 3 days.

3.Dexametasone 4 mg, for swelling.

4. Vitamin D Supplement for healing(Machado et al., 2020).

O.P.G. control of regeneration

 C.B.C.T. scan after three months

 X-ray after three months

 Photos of the surgery

 

Periodontal re-evaluation

The aims of therapy:

• No periodontal pockets >4 mm with Bleeding on probing or no deep periodontal pockets ≥6 mm.
  • Achieve bone regeneration, which would allow the placement of dental implants.

Dental implant surgery

For this surgery, an implant key measures the ideal distance to place the implants, thus respecting the papilla’s formation between their crowns.

 

Periapical X-ray with the implants

Photos of implant surgery

It waited four months to place the dental implants. The second phase was done three months later. A vestibuloplasty with a connective tissue graft was performed to obtain buccal sulcus and keratinised tissue with the aesthetic result.

O.P.G. with the implants

 Kazanjian vestibuloplasty plus a connective tissue graft

What is Kazanjian technique for Vestibuloplasty?

The objective of this technique was to gain the bottom of the vestibule and surround the dental implants with a keratinised gum that would make it possible to make the dental crowns as accurate as possible and protect the implant more against peri-implantitis.

To perform this technique, removing the muscle fibres of the mental muscle was necessary if they were left. They would help to recur the surgery. Next, a connective tissue graft from the palate was placed around the implants. Finally, the vestibular flap was sutured to the bottom of the vestibule.

He waited three months to take the impressions to make the fixed prosthesis.

 

Photos with the implants after Kazanjian Vestibuloplasty

Photo baseline vs post-treatment

 

Periodontal re-evaluation after six months of Kazanjian Vestibuloplasty:

1. The aims for this treatment were completed:

A.  The aim was to reduce bleeding and plaque levels to £25%.

B. The pocket’s depth level was not greater than 5mm.

C.   No furcation compromise had more than 2-3 mm of the horizontal defect.

D.  There was no pain or bad smell.

2. The patient has not stopped smoking but has stable teeth.

3. The depth level of the periodontal pockets decreased because the distance from the bone level to the enamel line diminished. This occurred by increasing the size of the clinical crown(Marzadori et al., 2018).

4. The patient must be re-educated in oral hygiene and stop using cigarettes. The patient will be scheduled in six months for periodontal maintenance if necessary.

 

Evolution and prognosis

In this case, the evolution and prognosis are favourable. The patient has lowered his tobacco consumption. Moreover, after adjusting the occlusion and through the respective periodontal maintenance that is performed every six months on the patient, he has not lost any teeth, the molars are still in the mouth, and at the moment, there is no planning to remove them.

 

Overall

In this case, I learned to manage the dental nerve using a piezoelectric device, creating bone incisions that, with chisels, allowed me to displace the cortical bone. In this case, I learned the importance of being patient with soft tissues.

The sound energy that the patient transmitted and his predisposition to achieve a good result were crucial for excellent development.

Thanks to this case, I operated on many more derivatives for this patient and his family. I will be eternally grateful to him for letting me follow up until the end since he had to travel to the hospital to see him and take the control photos for one year.