Treatment of Localized Aggressive Periodontitis Regenerative Periodontal Therapy Offers Alternative to Extraction/Implant Placement Ahmad Soolari, DMD, MS

Inside periodontics peer-reviewed

Treatment of Localized Aggressive Periodontitis Regenerative periodontal therapy offers alternative to extraction/implant placement Ahmad Soolari, DMD, MS

ue to the effect of im- with inconsistent margins, which could be was localized aggressive periodontitis. The plant-related compli- measured from the cementoenamel junc- patient’s medical history was unremarkable, cations, the longevity of tion or from the crest of the alveolar bone but a significant finding was the retention of implants is often ques- to the base of the defect. A periapical ra- primary teeth with premolar impaction on tionable, even when diograph showed angular bone loss on the the lower right side. The patient was later compared with that of distal aspect of tooth No. 24 with an angle referred to an orthodontist for consultation. compromised but suc- of almost 45°. The interproximal space be- The goal of regenerative periodontal cessfully treated natural teeth. This article de- tween tooth No. 24 and tooth No. 23 was the therapy is to improve a tooth’s prognosis by Dscribes a case of severe, localized periodontal only site with severe bone loss throughout regenerating the supporting structures. In disease in which the patient rejected a recom- the patient’s mouth; therefore, the diagnosis this case, the prognosis for tooth No. 24 was mendation to undergo extraction followed by implant placement and restoration in favor of receiving regenerative periodontal therapy to save the natural tooth.

Case Report A 17-year-old female patient presented with bone loss associated with tooth No. 24. A clinical examination and periodontal eval- uation (ie, assessment of mobility, probing depth, bleeding on probing, plaque score, and clinical attachment loss) revealed severe horizontal and vertical bone loss, deep probing depth with bleeding, class II mobility, a fig. 1 widened periodontal ligament, traumatic occlusion, and the formation of a diastema between the teeth (Figure 1 through Figure 4). In addition, there was bone loss of a less- er magnitude associated with tooth No. 23. The radiograph of tooth No. 24 suggested vertical and horizontal bone loss extending to the apical one-third of the root length. This was an isolated deep intrabony defect

Ahmad Soolari, DMD, MS Diplomate American Board of Periodontology fig. 2 Private Practice Gaithersburg, Potomac, and Silver (1.) Pretreatment retracted full-mouth photograph showing localized swelling and lack of pig- Spring, Maryland mentation in the area of teeth Nos. 23 and 24 with a diastema between them. (2.) Pretreat- ment full-mouth series of radiographs showing localized severe bone loss associated with teeth Nos. 23 and 24 along with retained primary teeth on lower right side.

42 inside dentistry | March 2020 | www.insidedentistry.net Inside | Periodontics poor, and in such cases, the current trend in the initial phase of the periodontal therapy Dental). This enabled access to the root and the dental community is to extract the tooth and that a surgical phase would follow. osseous defect in the interproximal area be- and place an implant. However, the patient In advance of the procedure, the patient tween teeth Nos. 23 and 24 via a full-thickness could not afford implants and wanted to re- was premedicated with 250 mgs of metroni- flap that was raised beyond the mucogingival tain her natural tooth for as long as possible. dazole and 500 mgs of amoxicillin 3 times a junction to facilitate the ridge-augmentation Moreover, the longevity of implants does procedure. The flap elevation enabled access not surpass that of compromised but suc- “For cost-effective, to the granulation tissue occupying the defect, cessfully treated natural teeth,1 and biologic and the subsequent removal of the granula- and prosthetic complications are common positive outcomes, tion tissue allowed visualization of the defect, as implant cases age.2 Beyond these consid- periodontists should which measured 5 mm × 8 mm. The lack of erations, the successful placement of an im- adopt a balanced access to the root and osseous defect resulted plant and management of the space between in the destruction of buccal and lingual bone teeth Nos. 23 and 24 would require a greater approach between plates (Figure 5). The teeth were scaled and volume of bone and gingiva; therefore, the placing implants root planed again to remove any remaining existing site was not favorable for implant plaque and calculus. Debridement of all ne- placement. The patient accepted a treat- and employing crotic tissue enabled observation of the bare ment plan that included surgical regenera- regenerative bone with no bleeding. Once debrided, the tive periodontal therapy. osseous defect was filled with a particulate periodontal therapy freeze-dried bone allograft (Cortical Bone, Clinical Treatment in which patients Maxxeus Dental) (Figure 6) and covered Prior to the surgical appointment, scaling are assessed for the with a resorbable membrane (Bio-Gide®, and root planing was performed and occlu- Geistlich Biomaterials) that was trimmed sal adjustments were made. A reevaluation appropriateness and fitted to the interproximal area (Figure of the area 6 weeks after scaling and root of each on a case- 7). The flap was coronally advanced to cover planing revealed moderate improvements in the membrane and was secured into position probing depth, bleeding on probing, and the by-case basis.” with simple interrupted 4-0 sutures (Coated clinical attachment loss. However, a 6-mm VICRYL® [polyglactin 910] Suture, Ethicon). probing depth with bleeding on probing per- After the periodontal surgery, the patient sisted; therefore, regenerative periodontal day for 2 weeks. After anesthesia was achieved, was advised to return in 3-month intervals therapy was planned as an alternative to envelope incisions were made from the dis- for maintenance appointments to prolong tooth extraction and prosthodontic treat- tal aspect of tooth No. 21 to the mesial aspect the improvements achieved during surgery, ment. The patient was made aware that the of tooth No. 25 using a No. 12 scalpel blade which were normal to shallow probing depth, scaling and root planing treatment was only (No. 12 Carbon Steel Scalpel Blades, Benco attachment level gain, and no bleeding on

fig. 3

(3.) Pretreatment close-up view of lower anterior teeth showing open contact, incisal chip, swelling, and lack of pigmentation. (4.) Pretreatment periapical radiograph of mandibular left central incisor (tooth No. 24), showing severe horizontal and vertical bone loss as well as fig. 4 open contact formation with tooth No. 23.

44 inside dentistry | March 2020 | www.insidedentistry.net Inside | Periodontics probing. The patient’s compliance with this photograph of the lower anterior ridge (Figure implant placement, angulation of implants, recommendation was erratic, but this did not 9) demonstrates an improvement in the tis- poorly planned prostheses, loading too negatively affect attachment gain. The patient sue’s color, tone, and texture as well as a lack early, etc) and biological factors (eg, poor was informed that the benefit of periodontal of edema. There was no bleeding on probing, oral hygiene, periodontal disease, systemic treatment, whether surgical or nonsurgical, the probing depth was 3 mm, and there was diseases, smoking, specific microbes caus- can be short-lived without a commitment to no tooth mobility or open contact. ing peri-implantitis) that can affect the suc- regular periodontal maintenance visits. cess of implants, it was noted that approxi- At a 3-year follow-up appointment, radio- Discussion mately 25% to 30% of the adult population graphs were taken, and they demonstrated An advanced surgical reconstruction ap- have overt grinding or clenching bruxism that tooth No. 23 had improved and that proach can yield a favorable long-term prog- and that this could contribute to implant tooth No. 24 was fully functional and had no nosis, maintain natural healthy dentition, failure if the implant-supported prosthesis more mobility, no widened periodontal liga- and overcome the need for a prosthesis.3 has an inadequate occlusal design to ad- ment, and no diastema (Figure 8). In this case, Biological and technical complications can dress bruxism. 5 Poorly designed implant- regenerative periodontal therapy was able to occur in as many as 50% of implants within supported prostheses are not conducive to produce a remarkable regainment of bone (ie, 10 years of placement.4 In a discussion of the patient’s performance of oral hygiene, 8 mm) within 3 years. A 3-year postoperative technical factors (eg, occlusion, improper which can lead to the presence of disease

fig. 5 fig. 6 fig. 7

fig. 8 fig. 9

(5.) Surgical close-up view of a large osseous defect measuring 5 mm × 8 mm, which involved severe bone loss, diastema formation between the teeth, and missing buccal and lingual plate mass that resulted in the formation of two wall defects. (6.) Particulate freeze-dried bone allograft being placed into the osseous defect. (7.) A resorbable membrane being placed prior to suturing. (8.) Three-year posttreatment radiograph of tooth No. 24 exhibiting significant bone formation, regainment of bone previously lost in the horizontal and vertical dimensions, and significant improvement in closure of the diastema between the teeth.(9.) Three-year posttreatment close-up photograph of lower anterior teeth exhibiting improvement in tissue color, tone, and texture (compare with Figure 3) as well as closure of the open contact between teeth Nos. 23 and 24.

46 inside dentistry | March 2020 | www.insidedentistry.net Inside | Periodontics around a dental implant and eventually the bone marrow.8 Second, the risk of devel- The case presented here demonstrates cause peri-implantitis. Poor personal oral oping peri-implantitis is higher among pa- that a tooth with a poor prognosis can be hygiene and periodontal disease are etio- tients who are susceptible to periodontitis,5 retained using appropriate regenerative logic factors for attachment loss around lat- and the treatment of peri-implantitis is not periodontal therapy. Not every tooth with a eral incisors, and these factors can cause the predictable.8 Third, the cost of maintaining poor prognosis can be saved, but advances in same problem and even more harm around implants can be much higher than the cost of regenerative periodontal therapy can some- implant-retained restorations used to re- maintaining natural teeth.10 Fourth, approxi- times enable dentists to avoid tooth extrac- place lateral incisors.3 Because implants are mately 50% of implant cases may experience tion and implant placement, preserving the not completely trouble free, can be expen- biological and technical complications with- natural dentition. sive, and do not necessarily last longer than natural teeth, retaining a patient’s natural References teeth should be the goal whenever possible. “Implant treatment 1. Holm-Pedersen P, Lang NP, Müller F. What are For cost-effective, positive outcomes, perio- outcomes are generally the longevities of teeth and oral implants? Clin Oral dontists should adopt a balanced approach positive, but implants Implants Res. 2007;18(Suppl 3):15-19. between placing implants and employing re- 2. Derks J, Schaller D, Håkansson J, et al. Effectiveness of generative periodontal therapy in which pa- do occasionally fail, implant therapy analyzed in a Swedish population: prev- tients are assessed for the appropriateness and this can occur due alence of peri-implantitis. J Dent Res. 2016;95(1):43-49. of each on a case-by-case basis. Successful 3. Kamil W, Al Bayati L, Hussin AS, Hassan H. Recon regenerative periodontal therapy requires to a variety of reasons, struction of advanced bone defect associated with access to the root and osseous defect to including metal severely compromised maxillary anterior teeth in enable proper diagnosis and debridement. allergies, occlusal issues, aggressive periodontitis: a case report. J Med Case Rep. Reynolds and colleagues suggested that suc- 2015;9:211. doi: 10.1186/s13256-015-0677-6. cessful outcomes could be expected after previous periodontal 4. Lang NP, Berglundh T, Heitz-Mayfield LJ, et al. early intervention for intrabony defects with disease, oral hygiene, Consensus statements and recommended clinical pro- regenerative approaches.6 Regenerative ma- cedures regarding implant survival and complications. terials such as freeze-dried bone allografts, diet, systemic disease, Int J Oral Maxillofac Implants. 2004;19(Suppl):150-154. barrier membranes, and growth factors are smoking, inadequate 5. Christensen GJ. Why are implants failing? placed at the site to potentiate the formation Dentaltown website. https://www.dentaltown.com/ of new cementum, bone, and a functional bone, or microbial magazine/article/7757/why-are-implants-failing. periodontal ligament during the healing colonization.” Published October 2019. Accessed January 9, 2020. process. Prior to finalizing any treatment 6. Reynolds MA, Kao RT , Camargo PM, et al. Periodontal plan, periodontists should consider the risk regeneration - intrabony defects: a consensus report of disease progression and subsequent tooth from the AAP Regeneration Workshop. J Periodontol. loss as well as which option (ie, implant in 10 years.4 And finally, compromised but 2015;86(2 Suppl):S105-S107. placement versus preservation of natural successfully treated natural teeth last longer 7. Donos N, Laurell L, Mardas N. Hierarchical decisions teeth) is likely to result in a better prognosis than implants.1 Implant treatment outcomes on teeth vs. implants in the periodontitis-susceptible with fewer complications, is preferred by are generally positive, but implants do oc- patient: the modern dilemma. Periodontol 2000. 2012; the patient, and is economically justifiable.7 casionally fail, and this can occur due to a 59(1):89-110. The longevity of implants and of compro- variety of reasons, including metal aller- 8. Lindhe J, Berglundh T, Ericsson I, et al. Experimental mised but successfully treated natural teeth gies, occlusal issues, previous periodontal breakdown of peri-implant and periodontal tissues. A should also be considered before finalizing disease, oral hygiene, diet, systemic disease, study in the beagle dog. Clin Oral Implants Res. 1992; a treatment plan. Several factors must be smoking, inadequate bone, or microbial col- 3(1):9-16. taken into account. First, the tissues around onization.5 Another issue that merits consid- 9. Lindhe J, Meyle J, Group D of European Workshop implants may be more susceptible to plaque- eration is the expertise of the practitioner. A on Periodontology. Peri-implant diseases: consensus associated infections than the tissues around comparison of implant treatments rendered report of the sixth European workshop on periodon- natural teeth.8 In a study involving beagle by different types of practitioners found tology. J Clin Periodontol. 2008;35(8 Suppl):282-285. dogs, plaque was allowed to accumulate that the survival rate of implants placed 10. Fardal Ø, Grytten J. A comparison of teeth and im- around natural teeth and dental implants by inexperienced practitioners was 73.0% plants during maintenance therapy in terms of the num- to induce periodontal disease. The results whereas the survival rate of implants placed ber of disease-free years and costs -- an in vivo internal from the clinical and histological examina- by implant specialists was 95.5%.11 To aid in control study. J Clin Periodontol. 2013;40(6):645-651. tions revealed that tissue destruction was the decision of whether or not to extract a 11. Setzer FC, Kim S. Comparison of long-term survival more pronounced at the implant sites than tooth and place an implant, Pjetursson and of implants and endodontically treated teeth. J Dent at the sites of the natural teeth. The extent Heimisdottir offer a system to classify teeth Res. 2014;93(1):19-26. and severity of hard- and soft-tissue break- as secure, doubtful, or irrational to treat.12 12. Pjetursson BE, Heimisdottir K. Dental implants down was greater around the implants than Overall, dentists should attempt to retain - are they better than natural teeth? Eur J Oral Sci. the natural teeth, and it even extended into natural teeth whenever possible. 2018;126(Suppl 1):81-87.

48 inside dentistry | March 2020 | www.insidedentistry.net