Case Report. Received: 05 th August 2014 Accepted: 03 rd November 2014 Conflicts of Interest: None Source of Support: Nil.

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1 Received: 05 th August 2014 Accepted: 03 rd Novemer 2014 Conflicts of Interest: None Source of Support: Nil Cse Report From Hopeless to Good Prognosis: Journey of Filing Tooth Surh Gupt 1, Jeevnnd Deshmukh 2, Rich Khtri 3, Viny Kumr Kulkrni 4, B Krthik 5 Contriutors: 1 Reder, Deprtment of Periodontology, Rishi Rj College of Dentl Sciences & Reserch Centre, Bhopl, Mdhy Prdesh, Indi; 2 Professor & Hed, Deprtment of Periodontology, Rishi Rj College of Dentl Sciences & Reserch Centre, Bhopl, Mdhy Prdesh, Indi; 3 Postgrdute Student, Deprtment of Periodontology, Rishi Rj College of Dentl Sciences & Reserch Centre, Bhopl, Mdhy Prdesh, Indi; 4 Professor, Deprtment of Pedodontics, Modern Dentl College & Reserch Centre, Indore, Mdhy Prdesh, Indi; 5 Senoir Lecturer, Deprtment of Orl Pthology, Rishi Rj College of Dentl Sciences & Reserch Centre, Bhopl, Mdhy Prdesh, Indi. Correspondence: Dr. Deshmukh J. Deprtment of Periodontology, Rishi Rj College of Dentl Sciences & Reserch Centre, Gndhingr, Bhopl , Mdhy Prdesh, Indi. Phone: Emil: jeevndeshmukh@gmil.com How to cite the rticle: Gupt S, Deshmukh J, Khtri R, Kulkrni VK, Krthik. From hopeless to good prognosis: Journey of filing tooth. J Int Orl Helth 2015;7(2): Astrct: Chronic periodontitis, long with ssocited clinicl fi ndings such s pthologic tooth migrtion, distem, functionl nd esthetic errtions, poses n immense chllenge to dentl professionl. These fi ndings convert clinicl decision mking into dunting tsk nd dversely ffect the prognosis nd the tretment pln for the presenting clinicl prolem. An interdisciplinry pproch imed t restoring functionl nd esthetic needs of the ffected individul within the limittions of such compromised clinicl scenrio my e vile lterntive to ny rdicl tretment cusing loss of nturl tooth structure such s extrction. This rticle reports the usefulness of the interdisciplinry route for mnging n otherwise hopeless clinicl sitution of chronic periodontitis complicted with extreme moility nd pthologic tooth migrtion, which resulted in compromised function nd esthetics. Key Words: Chronic periodontitis, hydroxyptite, pthologic tooth migrtion, pltelet-rich fi rin, pltelet-rich fi rin memrne Introduction Chronic periodontitis is one of the myrid chllenges fced y professionl in dentl prctice. It presents s n infectious disese resulting in inflmmtion within the supporting tissues of the teeth, progressive ttchment loss, nd one loss. 1 The predicment of the clinicin is compounded y secondry fctors coupled with chronic periodontitis such s pthologic tooth migrtion, 2 distem, functionl nd esthetic errtions. These fi ndings dversely ff ect the prognosis nd the tretment plnned nd push it down from good or fir towrds poor or hopeless, leding to n eventul loss of nturl tooth structure. An interdisciplinry pproch imed t restoring functionl nd esthetic needs of the ff ected individul within the limittions of the compromised clinicl scenrio my e vile lterntive to rdicl tretment such s extrction. This rticle reports the usefulness of the interdisciplinry route for mnging n otherwise hopeless clinicl sitution of chronic periodontitis complicted with extreme moility nd pthologic tooth migrtion, which resulted in compromised function nd esthetics. Cse Report A 26-yer old mle individul cme to visit the Deprtment of Periodontology, Rishi Rj College of Dentl Sciences, Bhopl with the chief complint of loosening of tooth in the front region of the upper rch, ssocited with swelling nd leeding from the gums since 1 yer. He reported diffi culty in chewing from the ffected re, often ssocited with discomfort nd less thn cceptle frontl ppernce. The individul ws otherwise norml with no reported medicl nomlies. Upon dentl exmintion, orl cvity presented with poor orl hygiene (Figure 1). There ws n undnce of clculus nd stins on the teeth, especilly in the nterior region. There ws generlized exudtion present long with generlized erythemtous gingiv. Tooth numer 21 presented with erythemtous nd enlrged gingivl tissue which ws frile in nture, nd there ws extrusion long with Grde III moility. A midline distem ws ssocited with tooth numer 11 nd 21. There were generlized periodontl pockets, with 21 presenting with 10 mm deep periodontl pocket nd overll nterior region ppered enlrged. Upon exmintion, 21 ws found to e vitl. Anterior deep ite ws lso evident. Considering the fctors infl uencing individul tooth prognosis, tooth numer 21 ppered to hve questionle to hopeless prognosis. A provisionl dignosis of chronic generlized periodontitis with inflmmtory gingivl enlrgement in the nterior region ws mde. Upon investigtion, n orthopntomogrph (OPG) ws tken, which confi rmed the dignosis of chronic generlized periodontitis. An intr-orl peripicl rdiogrph (IOPA) ws dvised for tooth numer 21 region, which susequently reveled n extruded tooth (21) long with dvnced one loss in the interdentl region, especilly in 53

2 Figure 1: () Pre-opertive view, () pre-opertive introrl peripicl in reltion to 21. the mesil interdentl region where n ngulr defect could e pprecited (Figure 1). There ws uccl corticl one dehiscence. However, distl interdentl one nd pltl ony component were helthy. Relevnt clinicl prmeters such s proing pocket depth nd clinicl ttchment level were recorded. Routine lood investigtions were performed, which did not revel nything of relevnce. The prognosis for 21 ws determined to e hopeless. Clinicl nd rdiogrphic findings led to n initil tretment pln entiling full mouth fl p surgery long with extrction of 21. The tretment pln ws explined to the ptient. However, the ptient ws insistent upon not scrifi cing the tooth nd desired every possile lterntive for rehilittion of the sme. Eventully, the tretment pln ws modifi ed, keeping in mind the ptient s need for rehilittion without scrifi cing the ffected tooth, nd the presenting clinicl nd rdiogrphic evidence. The tretment pln included components of non-surgicl therpy, regenertive periodontl surgery nd susequent esthetic nd functionl rehilittion, long with re-evlution fter every tretment phse. On the fi rst visit to the deprtment, phse I therpy ws egun. A thorough scling nd root plning ws performed, which ws followed y explining orl hygiene instructions to the ptient. The ptient ws put on recll visits periodiclly (Figure 2). Upon stiliztion of the periodontl condition nd prior to regenertive periodontl surgery, n extr-coronl wire nd composite splint ws fricted to mnge the extreme moility ssocited with 21. Ppill preservtion fl p procedure ws performed in reltion to 11 nd 21. Deridement ws completed. Upon surgicl exposure, comined type of the osseous defect ws evident in reltion to 21 (Figure 3). The one ws intct on the pltl spect. Root iomodifi ction ws performed with tetrcycline (500 mg cpsule opened nd mixed with 10 ml sterile wter). Susequently, hydroxyptite contining one grft (Syogrf- Eucre Phrmceuticls) with prticle size rnging etween μ ws plced in the comined osseous defect (Figure 4). Figure 2: Clinicl view 2 weeks fter scling nd root plning. Figure 3: Ppill preservtion fl p refl ected nd comined osseous defect in reltion to mesiodistl of 21. Figure 4: () After one grft plcement, () pltelet-rich fi rin memrne plced over the one grft The pltelet-rich firin (PRF) memrne ws prepred ccording to the following protocol: 10 ml of intrvenous lood ws withdrwn from the ntecuitl foss into sterile tue vi venipuncture. No nticogulnt ws dded to the tue, nd it ws immeditely centrifuged t 3000 rpm for 10 min. It yielded fi rin clot wedged in etween the top lyer of cellulr plsm nd the ottom lyer of erythrocytes. 3 The fi rin clot ws susequently seprted using sterile tweezers nd scissors nd compressed with glss sl to form fl t memrne. The one grft ws covered with the PRF memrne thus otined (Figure 4), fl p sutured nd periodontl 54

3 dressing plced. Post-opertive mintennce cre included iuprofen-twice dy for 3 dys, moxicillin-thrice dily for 5 dys, soft diet for 2 weeks, to void nterior iting of food for 8 weeks, no rushing in surgicl re for 2 weeks, no intrsulculr rushing for 8 weeks, nd chlorhexidine 0.2% rinse for 2 weeks. On recll visit fter 10 dys, periodontl pck nd sutures were removed, nd post-opertive mintennce cre ws continued t regulr intervls. Clinicl re-evlution t 6 months reveled n improvement in the clinicl prmeters, with moility reduced from Grde III to Grde I. An IOPA reveled signifi cnt one fi ll in reltion to 21 (Figure 5). The splint ws susequently removed (Figure 5). Intentionl root cnl tretment (RCT) in the form of single visit endodontics ws susequently performed on 21. The fi nl step in rehilittion of 21 ws friction of crown, which ws then cemented onto the tooth, thus restoring the function nd esthetic demnds of the ptient within the limittions posed y the initil hopeless prognosis of the clinicl presenttion (Figure 6). Discussion Periodontl therpy is performed with the primry ojectives of gining ccess to the disesed sites, chieving reduction in pocket depth, rresting further disese progression nd fi nlly restoring the periodontl tissues lost due to disese process nd chieving tngile enefi ts in the form of improved esthetics. Figure 5: () Clinicl view fter 6 months, () IOPA in reltion to 21 tken fter 6 months Figure 6: Clinicl view fter complete rehilittion. The ultimte im is to chieve periodontl regenertion vi new ttchment formtion. Regenertion hs een defi ned s the reproduction or reconstitution of lost or injured prt to restore the rchitecture nd function of the periodontium. 2 Regenertion, however, proves to e n elusive gol to chieve, especilly when we encounter compromised clinicl sitution such s one presented in our cse study. The dvnced one loss in reltion to 21, ssocited with extrusion nd Grde III moility rendered the prognosis for ny ttempt t sving the tooth nd restoring the function, s questionle to hopeless. However, the ptient s insistence on not extrcting the tooth led to look t vrious lterntives in such compromised sitution. The fi rst im of stilizing the periodontl condition ws chieved y performing phse I therpy. However, orthodontic intrusion ws not fesile s there ws dvnced one loss with deep ngulr one defect in the interdentl region of 21 s well s uccl corticl plte dehiscence. Therefore, n extrcoronl wire nd composite splint ws fricted. It helped in controlling moility y distriuting the mstictory forces cross multiple reltively helthier teeth. 4 It would lso prevent ny further extrusion of the tooth nd improve mstictory function to certin extent. 4 Pst reserch knowledge suggests tht conventionl open fl p deridement offers only limited potentil towrds recovering the lost periodontl structures. 5 Vrious grfting modlities hve, therefore, een employed for periodontl tissue regenertion such s utogenous 6-7 nd llogenic one grft. 8 However, none of them hs een estlished s gold stndrd in the tretment of introny defects. Ppill preservtion fl p technique 9 long with one grft nd PRF memrne plcement ws considered the tretment of choice in our cse study. Ppill preservtion fl p preserves interdentl soft tissues, helps in mximum protection of the one grft nd the PRF memrne, nd results in estheticlly plesing gingivl contours following the regenertive therpy. Hydroxyptite contining one grft ws used to fill the osseous defect. 10 It contined hydroxyptite crystls with clcium-to-phosphte rtio of The properties tht mde it suitle s one grft were its osteoconductive property, nd excellent tissue comptiility. Along with one grft, PRF memrne ws plced over the grft prticles. PRF is second-genertion pltelet concentrte imed t improving wound heling following surgicl procedures. 3 Since the ptient s own lood is utilized for fricting the memrne, the thret of disese trnsmission or ny foreign ody rections is negted to gret extent. The pltelet-rich lyer ids in grdul relese of growth fctors (GFs) from the pltelet grnules. 11 The growth fctors 55

4 wrrnting specil mention re vsculr endothelium growth fctor (VEGF), pltelet-derived growth fctor (PDGF), fi rolst growth fctor (FGF), insulin-like growth fctor (IGF), nd trnsforming growth fctor-β (TGF-β), to nme few. They ssist in replcing the lost tissue, resurfcing of the wound, nd restoring vsculr integrity. PRF stnds out in comprison to vrious other pltelet concentrtes due to its property of sustined relese of these growth fctors, which gretly ssists the wound heling. 12 Of lte, PRF hs een found to possess n ility to stimulte the growth of osteolsts nd periodontl ligment cells, oth of which re signifi cnt for the regenertion of periodontl defects. Besides, it is nti-infective, nd leds to one mtrix remodeling during the heling phse. PRF hs een successfully utilized to tret different periodontl defects. Severl cse reports hve een pulished which document encourging results fter covering single s well s multiple gingivl recession defects with PRF memrnes. 13 In such cses, 1-yer follow-up showed tht the improvement ws still pprecile. This oservtion hs een corroorted y vrious others in their studies It hs een stted tht PRF could hve nother ppliction s guided tissue regenertion memrne to effectively tret three-wll osseous defects nd Grde II furction defect. 17 Even though our clinicl cse presented with questionle to hopeless prognosis vis-à-vis extreme moility nd one-wll defect, improvement in the clinicl nd rdiogrphic prmeters fter 6 months justifi ed the use of one grft long with PRF memrne. Even though the moility eventully improved from Grde III to Grde I following regenertive therpy, nd rdiogrphic reevlution t 6 months suggested one fi ll, clinicl judgment fvored performing intentionl RCT with 21 followed y prosthetic crown plcement. Intentionl RCT provided resonle nd predictle tretment pproch in this cse where the extruded tooth hd to e drsticlly reduced, nd the vitl pulp would certinly e involved for the prosthetic crown construction. It delivered the dvntge of preventing fl re-ups cused y lekge or loss of the temporry sel tht might e possiility in cse the tretment gets prolonged. Besides, it eliminted the chnces for inter-ppointment microil root cnl contmintion cteril re-growth. The susequent intentionl RCT nd finl crown plcement rought in remrkle improvement in the mstictory function nd gretly enhnced the esthetics within the limited oundries of the therpeutics. Summry nd Conclusion Our cse study highlights the need to postpone decision mking in cse of compromised prognosis for ny tooth, especilly in the esthetic zone. Extrction of such compromised teeth should e delyed till re-evlution following Phse I therpy. One must lwys keep in mind the desires of the ptient while formulting tretment pln for such ffected teeth. We must not ignore the tngile enefi ts one my chieve through interdisciplinry pproch, such s reduction in moility nd improvement in fcil ppernce tht go long wy in wholesome rehilittion of the individul. The present cse study lso underscores the significnce of PRF memrne long with one grfts s resonle nd cost-effective tretment modlity in the mngement of extremely moile teeth. References 1. Flemmig TF. Periodontitis. Ann Periodontol 1999;4(1): Americn Acdemy of Periodontology. Glossry of Periodontl Terms, 3rd ed. Chicgo: Americn Acdemy of Periodontology; Dohn DM, Choukroun J, Diss A, Dohn SL, Dohn AJ, Mouhyi J, et l. Pltelet-rich fi rin (PRF): A secondgenertion pltelet concentrte. Prt I: Technologicl concepts nd evolution. Orl Surg Orl Med Orl Pthol Orl Rdiol Endod 2006;101(3):e Ferencz JL. Splinting. Dent Clin North Am 1987;31(3): Snder L, Krring T. 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