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Ridge Preservation in a Case of Severe Periodontitis

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Ridge Preservation in a Case of Severe Periodontitis CONTINUING EDUCATION Ridge preservation in a case of severe periodontitis Drs. Roberto Rossi, Ulf Nannmark, Andrea Pilloni, and Nino Squadrito, CDT, demonstrate how to preserve and condition the soft tissue with a combined approach eriodontal disease is often responsible for Pthe loss of attachment around teeth and Educational aims and objectives therefore a major cause of ridge deficiency This article aims to present a case of advanced periodontitis treated with implants and after the teeth are extracted. The world has a ridge preservation technique to help preserve and improve the soft tissue. become more and more aware of esthetics in dentistry, and any procedure aimed to Expected outcomes Implant Practice US subscribers can answer the CE questions on page XX to preserve the hard and soft tissue becomes earn 2 hours of CE from reading this article. Correctly answering the questions will useful to satisfy the needs of increasingly demonstrate the reader can: demanding patients. • Identify a technique for approaching implant treatment in severe periodontitis This article will present a case of in order to minimize the collapse of the soft and hard tissue and thus try to preserve the natural esthetics. advanced periodontitis treated with a ridge • Review the biology of tooth extractions, wound healing, and residual ridge modeling. preservation technique and later planned • See how this technique with the materials used limited contour changes after tooth extraction and and finalized with the use of guided implant preserved facial keratinized gingiva. surgery, immediate loading, and thus, soft • Realize the differences in the pattern of bone resorption in periodontitis and non-periodontitis subjects. • Recognize that the combination of presurgical computed planning and immediate loading might lead to tissue conditioning in order to minimize the excellent soft tissue conditioning and minimal surgical traumatism for the hard and soft tissue. effects of the disease. • Realize the importance of the relationship between the height of the interproximal bone peak and the teeth’s contact point to emphasize the importance of maintenance or reconstruction of the bone to The literature support the soft tissue. Tooth loss in many cases is one of the primary causes of alveolar bone remodeling residual ridges in which the quantity of bone showed a better preservation of facial kera- and loss. Schropp and colleagues showed tissue continuously decreases. The authors tinized gingiva when compared to control the changes in the soft and hard tissues after suggested that any potential regulatory factor sites. Also, grafted sites allowed the place- teeth extraction in clinical and radiographic of residual ridge resorption should have ment of longer implants and wider implants prospective study (2003). an adverse effect either on the increased when compared to non-grafted sites. The tissue changes after removal of catabolic activity by osteoclasts or on the In 2008, Allegrini and colleagues a premolar or a molar in 46 patients were decreased anabolic activity by osteoblasts. reviewed the literature on socket preserva- evaluated over a period of 12 months by A recent study by Barone and colleagues tion and concluded that the maintenance of measuring study casts, linear radiographic described the tissue changes of extraction the alveolar bone after extraction depends on analysis, and subtraction radiography. Their sockets with a comparison of spontaneous a careful surgical procedure and the use of a results showed that the major changes healing versus a ridge preservation technique biomaterial capable of maintaining the prior occurred during 1 year after extraction. with secondary soft tissue healing (2013). space, which is helpful in bone tissue healing. Jahangiri and colleagues reviewed The study group was treated with careful In 2012, Lindhe and colleagues evaluated the understanding of the biology of tooth extraction and insertion of corticocancellous an important factor: changes in the pattern of extraction, wound healing, and residual porcine bone and a collagen membrane, bone resorption in periodontitis and non-peri- ridge remodeling (1988). Defects in socket while the control sites received only sutures odontitis subjects. The paper was to discuss matrix formation or cellular activity will lead to stabilize the blood clot. Test sites showed the tissue of the fully healed extraction sites in to stalled healing. The review of residual a vertical bone remodeling of 0.3 ± 0.76 mm, patients who had lost teeth as a result of peri- ridge remodeling describes the long-term 1.1 ± 0.96 mm, 0.9 ± 0.98 mm at the mesial, odontal disease or from other causes. This result of tooth extraction and formation of buccal, and distal sites, while the control study indicated that the edentulous posterior group showed a remodeling of 1 ± 0.7 mm, maxilla was comprised of 58% lamellar bone, 2.1 ± 0.6 mm and 1 ± 0.8 mm at the same 15% woven bone, 7% osteoid, and 10% Roberto Rossi, DDS, MScD, is in private practice in Genova, Italy. sites. Horizontal changes were 3.6 ± 0.72 bone marrow. More than 50% was mineral- Ulf Nannmark, DDS, PhD, is an associate professor in the mm in the control sites and 1.6 ± 0.55 mm ized bone. Also, Vignoletti and colleagues Department of Oral and Maxillofacial Surgery at the Sahlgrenska in the study group. presented a systematic review of the surgical Academy, University of Gothenburg, in Sweden. This study concluded that alveolar ridge protocols for ridge preservation after tooth Andrea Pilloni, DDS, MScD, is the chairman of the Department of preservation technique performed with extraction (2012). Periodontology at the Sapienza University of Rome in Rome, Italy. collagenated porcine bone graft and a Fourteen publications on PubMed, Nino Squadrito, CDT, is head of the Golden Smile Laboratory in resorbable membrane was able to limit the Embase, and the Cochrane Central Register Genova, Italy. contour changes after tooth extraction. of Controlled Trials (CENTRAL) were evalu- Another important issue was that test sites ated, each looking at randomized controlled 36 Implant practice Volume 8 Number 5 CONTINUING EDUCATION Figure 1: Initial picture of a case of severe periodontitis Figure 2: Occlusal view of the teeth Figure 3: Radiograph showing advanced bone loss clinical trials and prospective cohort studies with a follow-up of at least 3 months reporting on changes on both the hard and soft tissue (height and width) of the alveolar process (mm or %) after tooth extraction (up to February 2012). Data from nine of these 14 studies were grouped in the meta-analysis. The results showed a statistically significant greater ridge reduction in bone height for Figure 4: Careful extractions trying to preserve the soft Figure 5: The sockets were cleaned, disinfected, and grafted control groups as compared to test groups tissue with collagenated porcine bone graft and a significant greater reduction in bone width for control groups. soft tissue conditioning and minimal surgical shows pockets up to 12 mm on the first The authors concluded that the potential traumatism for the hard and soft tissue, and bicuspid, 8 mm on the distal of the second benefit of socket preservation therapies is this could be helpful in the maintenance and/ bicuspid, and 9 mm and 10 mm on the demonstrated in less vertical and horizontal or development of interproximal papille. mesial and distal of the first molar. The teeth resorption of the alveolar bone crest. The were healthy and did not have any cavities scientific evidence does not provide clear Case presentation (Figures 2-3). Bone loss was reaching around guidelines in regard to the type of biomaterial, A 32-year-old female patient presented the apex of the roots of the first bicuspid or surgical procedure, although a significant with signs of severe periodontitis, a perio- and the first molar, and the mobility was 2+. positive effect of the flapped surgery was dontal probing depth of more than 6 mm, Local anesthesia is first administered with a observed. After the ridge preservation has bleeding on probing, and periodontal computerized controlled device (Single Tooth been performed, a study suggested a protocol screening and recording (PSR) of four in the Anesthesia, STA™, Milestone Scientific, Inc.) for planning and treating such cases with molar areas. The area in the first quadrant with articaine with epinephrine 1:200.000. guided implant surgery (Rossi, et al., 2010). was elected to be treated with extractions Once the teeth and the surrounding soft The authors showed how the combina- and simultaneous bone grafting for ridge tissue were anesthetized, the teeth were tion of presurgical computed planning and preservation (Figure 1). separated from the gingiva with a microblade immediate loading might lead to excellent The periapical radiograph of the quadrant and later extracted (Figure 4). The granulation Volume 8 Number 5 Implant practice 37 CONTINUING EDUCATION tissue on the extraction sockets was care- and integration of the bone grafts allowed preservation technique. To further enhance fully curetted, and the sockets were first irri- the placement of three implants of 5 mm the chance for soft tissue conditioning, only gated with chlorhexidine and later grafted diameter (Figures 10-13). a small core of connective tissue and epi- with corticocancellous collagenated porcine The surgical guide was created using thelium was removed with a tissue punch bone graft (Figure 5) (mp3, Osteobiol®). computer technology and verified prior to prior to implant insertion (Figures 14-16). The periapical radiograph shows the the surgical appointment. On the day of At the time of surgery, three biopsies attempt to completely fill up the residual surgery, the protocol calls for stabilization of were taken from the previously grafted sites, sockets (Figure 6). The simultaneous appli- the surgical guide on the residual teeth but and histomorphometric analysis showed cation of a removable partial denture (Figures with some flow composite on the upper right new vital bone in place of the graft previously 7-8) with ovatic pontics had the goals of, first, canine.
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