Clinical Sheet

Dental Surgery Clinical Sheet PERIODONTAL REGENERATION ON TWO TEETH AFFECTED BY A SEVERE PERIODONTAL DISEASE Use of an equine origin granular graft in combination with an amelogenin gel. In subjects most at risk, the inflammatory response to bacterial colonization of gingival pockets may give rise to periodontitis, a destructive process that leads to the loss of some of the bone and connective tissue, as well as to apical migration of junctional epithelium. Starting from typical symptoms of gingivitis, characterized by redness, swelling and bleeding tendency, over time one observes a significant change in the biofilm species, where A. actinomycetemcomitans start becoming predominant, as well as red complex bacteria and, to a lesser extent, those of the orange complex. The progress of periodontitis is not constant over time and may vary from person to person, however in its aggressive forms it often eventually leads to the loss of the affected members. Causal therapy eliminates the microbial biofilm and the inflammatory condition caused by it, Francesco Bellucci Private practitioner but the tissue defects will not be able to repair spontaneously. Hence the clinical need to have Avellino, Italy recourse to regeneration procedures that include the alveolar process, to achieve preservation [email protected] of the members originally involved in the pathology for the longest time possible. Within this framework, using a graft that may be remodeled by osteoclasts and that is very easy to handle may be a significant aid in achieving long-term clinical success. The use of amelogenin-based gels may be just as useful due to their action on the periodontal ligament. Materials The case illustrated here entailed using a Bioteck antigens from the equine tissue of origin through equine bone substitute consisting of a 1:1 mixture the exclusive enzymatic process Zymo-Teck. of cancellous and cortical granules, sized 0.5-1 Zymo-Teck does not alter the native structure mm (Osteoxenon, OX31) in combination with an of bone collagen whose quaternary structure is amelogenin-based gel (Emdogain, Straumann). therefore found in the graft. The presence of native Emdogain is a protein-based gel, having a long collagen is one of the factors that allow the graft history of clinical use1, that helps preserving the to be recognized and remodelable by osteoclasts, tooth promoting regeneration of the hard and soft allowing it to be physiologically remodeled thus periodontal tissues that were lost to periodontitis. leading to the formation of a significant amount of The bone graft is obtained by removing the new bone tissue. 1. Matarasso M. et al. Enamel matrix derivative and bone grafts for periodontal regeneration of intrabony defects. A systematic review and meta-analysis. Clin Oral Investig, 19(7), 1581-1593 (2015). Fig. 1 - Initial periapical X-ray, bone resorption is Fig. 2 – Tooth 1.5 presents significant probing Fig. 3 – Detail of the periapical defect involving particularly severe at the apex of tooth 1.5, and depth (10 mm). tooth 1.5. also involves tooth 1.4. Fig. 4 – Palatal aspect of the lesions on both Fig. 5 – Grafting the particulate, palatal view. Fig. 6 – Suture at the end of the regeneration teeth 1.4 and 1.5. procedure. PERIODONTAL REGENERATION ON TWO TEETH AFFECTED BY A SEVERE PERIODONTAL DISEASE Use of an equine origin granular graft in combination with an amelogenin gel. Surgery The patient presented with conspicuous mobility incision was performed distally to 1.5. of member 1.5. Upon the first visit, adult chronic periodontitis was diagnosed, which had never been After exposing and cleaning the defect, using both treated before and had caused the loss of some piezoelectric and manual instruments, root surfaces teeth and the presence of pockets larger than 5 mm were treated with EDTA-based gel. After that, a in various sectors of the mouth. The X-ray showed pedunculated flap was prepared on the palate side of two infra-osseous defects on teeth 1.4 and 1.5. Tooth tooth 1.5 to promote subsequent graft stabilization. 1.5, although mobile and presenting a significant The graft was prepared by mixing the bone granules apical defect, appeared to still adequately respond with the amelogenin gel. The root surfaces were to sensitivity tests. The tooth was splinted and the spread with amelogenic gel before performing the patient undertook causal therapy. graft; the bone mixture prepared beforehand was then applied. The flaps were sutured with horizontal After 40 days, the distal probing depth was 9 mm internal mattress stitches then interrupted stitches. for member 1.4 and 10 mm for 1.5 (with 11 mm attachment loss for 1.4 and 14 mm for 1.5). It was At the one-year follow-up, good healing was observed therefore decided to perform regenerative surgery on 1.4, and filling of the infra-osseous portion in aimed at tooth preservation after root canal position 1.5. treatment of 1.5. For the purpose of regeneration, a flap was opened around tooth 1.4 with the simplified After 3 years, the X-ray showed that the situation papilla preservation technique, whereas a crest had improved and tissue levels were stable. Fig. 7 – Clinical appearance (top) and X-ray Fig. 8 – Clinical appearance (top) and X-ray Fig. 9 – Clinical appearance (top) and X-ray follow-up (bottom) one year after the bone follow-up (bottom) two years after the bone follow-up (bottom) three years after the regeneration procedure. regeneration procedure. regeneration procedure: bone levels remain unchanged over time. Visit www.bioteckacademy.com for other clinical sheets and to access the ever up-to-date scientific literature. All trademarks are registered by the respective proprietors DEN_SCH17_EN Rev.20170914.

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