The patient presented with the chief complaint of pain and suppuration on tooth no. 8. He expressed that he had been previously treated for periodontal disease and had undergone bone regeneration surgery. He reported having regular brushing habits and consistent use of dental floss, interproximal brushes, and oral rinses.
The patient does not smoke but drinks a glass of wine daily and takes Lansoprazol for heartburn and reflux. The patient reports no other medical issues.
Extraoral/Facial
TMJ/Mandibular Range of Motion/Muscles of Mastication and Facial Expression
Dental
Periodontal
The patient’s primary objective was to keep tooth no. 8 and eliminate the pain and suppuration around it.
Photographs, panoramic and full mouth intraoral radiographs, diagnostic casts mounted in CR (centric relation), and clinical and periodontal chartings were obtained.
Overall periodontal health would be improved with root planing, scaling and oral hygiene review.
To correct defects around teeth nos. 7 and 8, regenerative surgery was performed using a PTFE-e membrane (GORE-TEXÒ Regenerative Membrane Titanium Reinforced) fixed with two tacks and PTFE sutures. The biomaterial used consisted of autogenous bone harvested from the oblique line of the mandible. The periodontal defect was thoroughly cleaned, reaching almost the apex of tooth no. 8. A connective tissue graft was harvested from the palate and sutured on the buccal and proximal of tooth no. 8 to correct the gingival recession which appeared after the scaling. The PTFE-e membrane and the tacks were removed approximately one year later. During the second surgery, a fistula was detected on the buccal area of the regenerated bone. Tooth no. 8 was diagnosed as necrotic, and endodontic treatment was immediately performed. An additional connective tissue graft was harvested from the palate to compensate for the lack of volume due to buccal bone resorption caused by the fistula.
While tooth no. 8 was being monitored for healing, several hygiene appointments were completed to maintain gingival health.
The orthodontic treatment started one year later to correct the malposition in the anterior segment. This treatment lasted one year. During this time composite restorations of teeth nos. 21 & 28 were completed and tooth no. 17 was extracted to help maintain the periodontal health of tooth no. 18.
Before restoring the anterior segment, intraoral bleaching was done. After the wax-up and mock-up was performed to assess esthetics and function, teeth nos. 6-11 were restored with feldspathic veneers.
The treatment was finalized with a night guard to protect the restorations.
Periodontal maintenance was performed periodically, however several maintenance appointments were missed by the patient. In 2015, a periodontal defect was detected in the distal of tooth no. 31. A GTR procedure was performed and tooth no. 32 was extracted to avoid food impaction and to improve the long-term prognosis of tooth no. 31.
In 2016, resective periodontal surgeries on teeth nos. 2, 3, 14 & 15 were completed to reduce the depth of periodontal pockets, facilitating hygiene.
In 2021, a regenerative periodontal surgery was completed with Endogain and MinerOss 0,5 for teeth nos. 13 & 14.
Regular oral hygiene, restorative and orthodontic maintenance recall appointments continue.
Treating this patient early in my career proved to be lengthy and quite challenging. Even with more years of experience under my belt, I believe that this would still be difficult and perplexing for most clinicians.
In retrospect, I would probably not change my approach to this case. I spoke to the patient honestly and explained the anatomy of the bone defect affecting both teeth nos. 7 and 8. I explained that the most straightforward option would be to extract tooth no. 8 but that vertical bone regeneration would be almost impossible due to the lack of a bone peak on the mesial of tooth no. 7. Orthodontic extrusion would be then needed to reposition the bone peak coronally, but the 6 mm periodontal bone defect would force us to extrude tooth no. 7 too much and he would end up requiring endodontic treatment and crown lengthening on at least the distal of the tooth. All of that would compromise the crown-to-root ratio of tooth no. 7 and as a result, its long-term predictability. So, we discarded that option.
Extracting both teeth nos. 7 and 8 (observing the coronal peaks on both sides of the defect) would have been a very aggressive approach for this young patient, involving multiple surgeries and a high “esthetic” risk. Uncertain papilla levels and volume and the patient’s “gummy” smile would cloud the predictability of the outcome.
It was decided to proceed with GTR of the 0-wall periodontal defect even knowing the high risks of a possible membrane exposure. The main reason to start with this was that we always had the other two options in case of failure. I used a CTG to allow for better membrane coverage and to correct the mild gingival recession present after the initial scaling. This was successful, but after removing the PTF-e membrane during the second stage surgery, it was evident that the large periodontal defect had compromised the pulp’s vitality. We completed the endodontic treatment during the same appointment and harvested another CTG to compensate for the lack of buccal bone volume.
Additional periodontal defects were treated over the subsequent years in part because the patient was less than compliant with recall appointments.
Even though there were some setbacks during treatment, the patient was happy with the final result. After 15 years, the treatment continues, the patient’s intraoral condition has improved, and the long-term prognosis of the teeth has changed for the better.
