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 , 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). 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

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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 (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 , 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 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

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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 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. The width of the crest was main- placed. Figure 19 shows the entire biopsy at sealing the grafted sockets and, second, tained after extractions and with a ridge X4 magnification; bone trabeculae can be supporting the soft tissue in an attempt to preserve a scalloped gingival architecture. The re-evaluation at 8 months (Figure 9) shows how the temporary denture helped guide the healing, protecting the bone grafts and also maintaining the natural scalloped architecture. At this point, the case was studied with a navigation system (OsstemGuide™, Hiossen Osstem), and the treatment plan was to place three dental implants in place of the roots of the teeth previously removed. The case Figure 8: The temporary removable partial denture was analysis shows how the ridge preservation designed to protect the grafts and to support the soft tissue with ovatic pontics

Figure 6: The X-ray shows the grafted sockets in an attempt Figure 7: Temporary removable partial denture Figure 9: Eight months after extraction, the clinical situation to preserve the interproximal bony peaks shows the ridge preservation

Figures 10, 11, and 12: The case was studied using OsstemGuide Navigation system

Figure 13: Panorex view of the project

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Figure 14: The healed ridge; volumes were maintained Figure 15: View of the surgical guide Figure 16: View of the ridge after removal of cores of epi- despite the advanced bone loss thelium and connective tissue

Figure 17: Implants in place Figure 18: Peri-implant tissue post surgery Figures 19-20: Histology of the grafted sites showing healthy live bone seen in almost all parts of the section, but the right upper corner, a small piece of bio- also remnants of the biomaterial. The middle meterial is totally surrounded by bone. No part of the section consists of soft tissue, a signs of inflammation can be seen in the soft combination of mostly yellow bone marrow or hard tissue (Figures 19-20). with small islands of red marrow (hematoxylin- The surgical trauma was very minimal, eosin staining). and the possibility to install a temporary Figure 20 shows part of the previous bridge on the implants on the same day section at a higher magnification (X20). further enhanced the chances of conditioning The bone tissue is well organized and well the peri-implant soft tissue (Figure 21). The supplied by blood vessels. In the upper post-surgical X-ray shows the precision and left, a part of biomaterial can still be seen the perfect abutment to implant connec- in between the bone and the soft tissue. In tion. Six months later in a follow-up visit, the Figure 21: Temporary crowns for immediate loading

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temporary bridge was removed to reveal Conclusion the ridge preservation and the soft tissue Esthetics are becoming more and more conditioning. At this time, three individual important in modern dentistry, and the crowns were fabricated and delivered to preservation of the soft and hard tissue is replace the missing teeth and showing excel- one of the primary goals. Any time we ran lent color, shape, and soft-tissue integration into cases of advanced or aggressive perio- (Figures 24-27). The radiograph taken a year dontitis where the bone loss and the PSR and a half after teeth extraction shows the was four, we noticed a severe collapse of amount of regeneration and the sustained the soft tissue as a consequence of the . advanced bone loss. Figure 22: X-ray of the temporary crowns in place

Figure 23: Soft tissue conditioning after 6 months loading Figure 24: Final restoration with individual crowns

Figure 25: Crowns on master cast buccal view Figure 26: Lingual view

Figures 27A and 27B: Final restoration in place showing health interproximal soft tissue at time of delivery and 6 months later

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Modern periodontal and implant litera- areas from baseline, and the use of imme- ture became very aware of this problem, and diate crowns with proper anatomical shapes many different techniques have been intro- will help conditioning the peri-implant soft ... any procedure aimed to duced to solve and minimize this problem tissue after also supporting its maturation preserve the hard and soft tissue (Jahangiri, et al., 1988; Allegrini, et al., 2008; (Rossi, et al., 2012). Lindhe, et al., 2012; Vignoletti, et al., 2012; Since dentistry is moving forward into becomes useful to satisfy the Ladsberg and Bichacho, 1994; Kutkut, esthetics, a protocol that will help restore Andreana, and Monaco, 2012). the hard tissue in cases of aggressive perio- needs of increasingly Many different authors have presented dontitis will also help in the preservation and demanding patients. similar protocols with different bio- improvement of the soft tissue, giving clini- materials, from autogenous bone, to cians a new therapeutic option. IP allografts, to synthetic and xenografts, but all of these procedures, despite using different materials, share a similar goal of minimizing the collapse of the soft and hard tissue and thus trying to preserve the natural esthetics (Horowitz, Holtzclaw, and Rosen, 2012; Horvath, et al., 2013; Scheyer, Schupbach, and McGuire, 2012; Pagni, et al., 2012; Cardaropoli, et al., 2012; Hämmerle, et al., 2012). The relationship between the height of the interproximal bone peak and the teeth’s contact point has been well described in the literature (Nordland and Tarnow, 1988); therefore, the maintenance or reconstruc- tion of the bone in that area becomes of paramount importance in supporting the soft tissue and, thus, esthetics. A combi- nation of ridge preservation techniques with subsequent guided implant surgery will reduce the surgical trauma to the soft tissue, help condition the interproximal Figure 28: X-ray of the final restorations showing integration and regeneration of the previously diseased bone

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