Background information
Patient:
Male, 34 years old, referred to the practice for periodontal therapy.
First examination: January 2002.
Chief compliants: Inflammation, recurrent abscesses, pain, migration and hypermobility of tooth 11,
bad breath. The patient was concerned with function, aesthetics, and preservation of teeth.
Anamnesis: Good general health, family history of periodontitis, never smoker, never treated for
periodontitis.
Fig. 4 The baseline radiograph shows the presence
of a deep and wide intrabony defect involving the
mesial and also the distal side of tooth 11.
Fig. 5 Pre-operatory slide showing the 11 mm mesial
pocket. Local anesthesia has been delivered on the
buccal and lingual area.
Fig. 6 A modified papilla preservation incision has
been performed between teeth 11 and 21 (wide interdental space), while a simplified papilla preservation flap has been preferred between teeth 12 and
11 (narrow interdental space) 9,10,11.
Fig. 7 The flap design involves tooth 12 (distal
angle) through tooth 21 (distal angle). After elevation
of a full thickness buccal and lingual flap, a deep
(10 mm) and wide 1-wall intrabony defect associated to tooth 11 is evident 1,2,12,13.
Fig. 8 After careful debridement and root planing, a
bio-resorbable collagen barrier membrane (Geistlich
Bio-Gide®) has been adapted and positioned around
tooth 11 14.
Fig. 9 A deproteinized bovine bone mineral (Geistlich
Bio-Oss®) is implanted to fill the intrabony defect
and support the collagen barrier membrane. The use
of a combined approach (barrier and filler) has been
chosen in this case to support the gingival tissues in
the presence of a non-supportive wide 1-wall intrabony defect 13,14,15,16,17.
Fig. 10 After membrane adaptation, a split thickness incision has been performed on the buccal flap
associated with a vertical releasing incision distal to
tooth 12 to increase flap mobility and allow primary
closure.
Fig. 11 Primary closure of the flap has been achieved with multilayer internal mattress sutures. The
interdental space between 11 and 21 has been closed
with 3 levels of sutures 12,18.
Fig. 12 Post-operatory radiograph, showing the intrabony defect filled by the implanted material.
Fig. 13 Primary closure maintained after 1 week, at
suture removal.
Periodontal examination: Severe generalized gingival inflammation associated with the presence
of large deposits of plaque and calculus, migration of tooth 11, purulence associated to tooth 11 and
41. Bad breath. Full mouth plaque score: 99%. Full mouth bleeding score: 100%. Presenting with
108 sites with probing depth ≥5 mm.
Fig. 14 Re-evaluation at 1 year. The tooth 11 has spontaneously realigned, no gingival recession has occurred, and the mobility is completely resolved. A 4 mm
residual probing depth is evident, along with a 7 mm
attachment level gain as compared to baseline with a
good preservation of the interdental soft tissues 14,19.
Fig. 15 The 1-year radiograph shows the resolution
of the intrabony component of the defect.
Fig. 16 Re-evaluation after 6-years. The tooth 11 is
completely and spontaneously realigned. The patient
refers good comfort and function and is fully satisfied with aesthtics 20,21,22.
Fig. 17 Radiograph taken 6-years after regeneration,
showing the stability of the defect resolution.
Diagnosis: Chronic generalized severe periodontal disease in a patient with family history for periodontitis and presence of large deposits of plaque and calculus.
Initial treatment plan: Cause related periodontal therapy, including motivation and instructions for
home care, professional supra-gingival debridement and sub-gingival root planing. Re-evaluation
for potential additional therapy.
Treatment objectives: Gain periodontal health, preserve teeth, improve function and aesthetics.
Re-evaluation: 1 month after completion of cause-related therapy the patient reported the complete
resolution of bad breath, resolution of inflammation and purulence, resolution of pain, lower
mobility associated to tooth 11. Tooth 11 appeared also slightly repositioned with respect to baseline
migration. Full mouth plaque score: 17%. Full mouth bleeding score: 10%. Presenting now with
13 sites with residual probing depth ≥5 mm. Residual pockets were associated to teeth 16-17 and
tooth 11. Radiographic examination showed the presence of a deep intrabony defect associated
with tooth 11 1,2,3,4,5.
Surgical treatment plan: Flap surgery teeth 16-17; periodontal regeneration tooth 11.
2. Aims of the therapy
> Aims of periodontal regeneration tooth 11: At re-evaluation, tooth 11 presented with residual pockets
of 11 mm at the mesial side, 9 mm at the palatal side, and 7 mm at the distal side, associated with a
deep and wide intrabony defect. Soft tissues were well preserved and represented by a consistent
amount of thick attached gingiva. Periodontal regeneration was planned to reduce probing depth
by increasing bone and attachment in order to avoid gingival recession and to reduce tooth hypermobility. Overall aims, therefore, were resolution of pockets, aesthetic preservation and function
improvements6,7,8.
3. Surgical procedure
Fig. 1 Baseline photograph: evidence of severe
gingival inflammation, associated with plaque and
calculus accumulation, and migration of tooth 11.
Fig. 2 Re-evaluation photograph: resolution of the
gingival inflammation. Tooth 11 slightly repositioned
(partial spontaneous resolution of the pathological
migration).
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Fig. 3 Tooth 11 after cause-related therapy presenting with a slight residual migration and no gingival
recession. The gingiva is thick and the interdental
papillae well preserved.
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