Ridge preservation in a case of severe periodontitis

Transcription

1 Ridge preservation in a case of severe periodontitis Roberto Rossi, Ulf Nannmark, Andrea Pilloni and Nino Squadrito demonstrate how to preserve and condition the soft tissue with a combined approach Periodontal disease is often responsible for the loss of attachment around teeth and therefore a major cause of ridge deficiency after the teeth are extracted. The world has become more and more aware of aesthetics in dentistry and any procedure aimed to preserve the hard and soft tissue becomes useful to satisfy the needs of increasingly demanding patients. This article will present a case of advanced periodontitis treated with a ridge preservation technique and later planned and finalised with the use of guided implant surgery, immediate loading and thus soft tissue conditioning in order to minimise the effects of the disease. The literature In many cases, tooth loss is one of the primary causes of alveolar bone remodeling and loss. Schropp and colleagues showed the changes in the soft and hard tissues after tooth extraction in clinical and radiographic prospective study (2003). Tissue changes after removal of a premolar or a molar were evaluated over a period of 12 months in 46 patients by measuring study casts, linear radiographic analysis and subtraction radiography. Their results showed that the major changes occurred in the first year after extraction. Jahangiri and colleagues reviewed the understanding of the biology of tooth extraction, wound healing and residual ridge remodeling (1988), finding that defects in Roberto Rossi DDS MScD is in private practice in Genova, Italy. Ulf Nannmark DDS PhD is an associate professor in the Department of Oral and Maxillofacial Surgery at the Sahlgrenska Academy, University of Gothenburg, in Sweden. Andrea Pilloni DDS MScD is the chairman of the Department of Periodontology at the University of Roma Sapienza, in Rome, Italy. Nino Squadrito CDT is head of the Golden Smile Laboratory in Genova, Italy. socket matrix formation or cellular activity lead to stalled healing. Their review of residual ridge remodeling described the long-term result of tooth extraction and formation of residual ridges, in which the quantity of bone tissue continuously decreases. The authors suggested that any potential regulatory factor of residual ridge resorption should have an adverse effect either on the increased catabolic activity by osteoclasts or on the decreased anabolic activity by osteoblasts. In a recent study Barone and colleagues described the tissue changes of extraction sockets with a comparison of spontaneous healing versus a ridge preservation technique with secondary soft tissue healing (2013). The study group was treated with careful extraction and insertion of corticocancellous porcine bone and a collagen membrane, while the control sites received only sutures to stabilise the blood clot. Test sites showed a vertical bone remodeling of 0.3 ± 0.76mm, 1.1 ± 0.96mm, 0.9 ± 0.98mm at the mesial, buccal and distal sites, while the control group showed a remodeling of 1 ± 0.7mm, 2.1 ± 0.6mm and 1 ± 0.8mm at the same sites. Horizontal changes were 3.6 ± 0.72mm in the control sites and 1.6 ± 0.55mm in the study group. This study concluded that alveolar ridge preservation techniques performed with collagenated porcine bone grafts and resorbable membranes were able to limit the contour changes after tooth extraction. Another important issue was that test sites showed a better preservation of facial keratinised gingiva when compared to control Educational aims and objectives This article aims to present a case of advanced periodontitis treated with implants and a ridge preservation technique to help preserve and improve the soft tissue. Expected outcomes Correctly answering the questions on page 66, worth one hour of verifiable CPD, will demonstrate that the reader understands a technique for approaching implant treatment in severe periodontitis in order to minimise the collapse of the soft and hard tissue and thus try to preserve the natural aesthetics. sites. Grafted sites also allowed the placement of longer implants and wider implants when compared to non-grafted sites. In 2008, Allegrini and colleagues reviewed the literature on socket preservation and concluded that the maintenance of alveolar bone after extraction depends on careful surgical procedure and the use of a biomaterial capable of maintaining the prior space, and which is helpful in bone tissue healing. In 2012, Lindhe and colleagues evaluated an important factor: changes in the pattern of bone resorption in periodontitis and nonperiodontitis subjects. The paper discussed the tissue of fully healed extraction sites in patients who had lost teeth as a result of periodontal disease or from other causes. This study indicated that the edentulous posterior maxilla was comprised of 58% lamellar bone 15% woven bone, 7% osteoid and 10% bone marrow. More than 50% was mineralised bone. Also, Vignoletti and colleagues presented a systematic review of the surgical protocols for ridge preservation after tooth extraction (2012). Figure 1: Initial picture of a case of severe periodontitis idt July

2 Figure 2: Occlusal view of the teeth Figure 3: Radiograph showing advanced bone loss Figure 4: Careful extractions trying to preserve the soft tissue Figure 5: The sockets were cleaned, disinfected and grafted with collagenated porcine bone graft Figure 6: The X-ray shows the grafted sockets in an attempt to preserve the interproximal bony peaks Figure 7: Temporary removable partial denture Figure 8: The temporary removable partial denture was designed to protect the grafts and to support the soft tissue with ovatic pontics Fourteen publications on Pubmed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were evaluated, each looking at randomised controlled clinical trials and prospective cohort studies with a follow-up of at least three months, reporting on changes to both the hard and soft tissue (height and width) of the alveolar process (mm or %) after tooth extraction (up to February 2012). Data from nine of these 14 studies was grouped in the meta-analysis. The results showed a statistically significant greater ridge reduction in bone height for the control groups compared to test groups and a significant greater reduction in bone width for the control groups. The authors concluded that the potential benefit of socket preservation therapies is demonstrated in less vertical and horizontal resorption of the alveolar bone crest. The scientific evidence does not provide clear guidelines in regards to the type of biomaterial, or surgical procedure, although Figure 9: Eight months after extraction the clinical situation shows the ridge preservation a significant positive effect of the flapped surgery was observed. After ridge preservation has been performed, the study suggested a protocol for planning and treating such cases with guided implant surgery (Rossi et al, 2010). The authors showed how the combination of presurgical computed planning and immediate loading might lead to excellent soft tissue conditioning and minimal surgical traumatism for the hard and soft tissue and this could be helpful in the maintenance and/ or development of interproximal papille. Case presentation A 32-year-old female patient presented with signs of severe periodontitis, a periodontal probing depth of more than 6mm, bleeding on probing and periodontal screening and recording (PSR) of four in the molar areas. The area in the first quadrant was elected to be treated with extractions and simultaneous bone grafting for ridge preservation (Figure 1). The periapical radiograph of the quadrant showed pockets up to 12mm on the first bicuspid, 8mm on the distal of the second bicuspid and 9 and 10mm on the mesial and distal of the first molar. The teeth were healthy and did not have any cavities (Figures 2-3). Bone loss was reaching around the apex of the roots of the first bicuspid and the first molar, and the mobility was 2+. Local anesthesia was first administered with a computerised controlled device (STA Milestone Inc) with articaine with epinephrine 1: Once the teeth and the surrounding soft tissue were anaesthetised, the teeth were separated from the gingiva with a microblade and later extracted (Figure 4). The granulation tissue on the extraction sockets was carefully curetted and the sockets were first irrigated with clorexidine and later grafted with corticocancellous collagenated porcine bone graft (Figure 5) (MP3, Osteobiol). The periapical radiograph shows the attempt to completely fill up the residual sockets (Figure 6). The simultaneous application of a removable partial denture (Figures 7-8) with ovate pontics had the goals of firstly sealing the grafted sockets, and secondly supporting the soft tissue in an attempt to preserve a scalloped gingival architecture. The re-evaluation at eight 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 8 July 2015 idt

3 Figures 10, 11 and 12: The case was studied using the Osstemguide Navigation system Figure 13: Panorex view of the project Figure 14: The healed ridge; volumes were maintained despite the advanced bone loss Figure 15: View of the surgical guide three dental implants in place of the roots of the previously extracted teeth. The case analysis shows how the ridge preservation and integration of the bone grafts allowed the placement of three implants of 5mm diameter (Figures 10-13). The surgical guide was created using computer technology and verified prior to the surgical appointment. On the day of surgery, the protocol called for stabilisation of the surgical guide on the residual teeth with some flow composite on the upper right canine. The width of the crest was maintained after extractions and with a ridge preservation technique. To further enhance the chance for soft tissue conditioning, only a small core of connective tissue and epithelium was removed with a tissue punch prior to implant insertion (Figures 14-16). At the time of surgery three biopsies were taken from the previously grafted sites, and histomorphometric analysis showed new vital bone in place of the graft previously placed. Figure 19 shows the entire biopsy at X4 magnification; bone trabeculae can be seen in almost all parts of the section, Figure 16: View of the ridge after removal of cores of epithelium and connective tissue but also remnants of the biomaterial. The middle part of the section consists of soft tissue, a combination of mostly yellow bone marrow with small islands of red marrow (hematoxylin-eosin staining). Figure 20 shows part of the previous section at a higher magnification (X20). The bone tissue is well organised and well supplied by blood vessels. In the upper left, a part of biomaterial can still be seen in between the bone and the soft tissue. In the right upper corner, a small piece of biometerial is totally surrounded by bone. No signs of inflammation can be seen in the soft or hard Figure 17: Implants in place tissue (Figures 19-20). The surgical trauma was very minimal and the opportunity to install a temporary bridge on the implants on the same day further enhanced the chances of conditioning the peri-implant soft tissue (Figure 21). The post-surgical X-ray shows the precision and a perfect abutment to implant connection. Six months later, at a follow-up visit, the temporary bridge was removed to reveal the ridge preservation and the soft tissue conditioning. At this time, three individual crowns were fabricated and delivered to replace the missing teeth and showing excellent colour, shape and soft tissue integration (Figures 24-27). The radiograph taken a year and a half after teeth extraction shows the amount of regeneration and the sustained osseointegration. Conclusion Aesthetics are becoming more and more important in modern dentistry and the preservation of the soft and hard tissue is one Figure 18: Peri-implant tissue post surgery 10 July 2015 idt

4 Figure 21: Temporary crowns for immediate loading Figures 19 and 20: Histology of the grafted sites showing healthy live bone Figure 22: X-ray of the temporary crowns in place Figure 23: Soft tissue conditioning after six months loading Figure 24: Final restoration with individual crowns Figure 25: Crowns on master cast buccal view Figure 26: Lingual view Figures 27a and b: Final restoration in place showing healthy interproximal soft tissue at time of delivery and six months later 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 reconstruction of the bone in that area becomes of paramount importance in supporting the soft tissue, and thus, aesthetics. A combination of ridge preservation techniques with subsequent guided implant surgery will reduce the surgical trauma to the soft tissue, help condition the interproximal areas from baseline, and the use of immediate crowns with proper anatomical shapes will help conditioning the peri-implant soft tissue after also supporting its maturation (Rossi et al, 2012). Since dentistry is moving forward into aesthetics, a protocol that will help restore the hard tissue in cases of aggressive periodontitis will also help in the preservation of the primary goals. Any time we ran into cases of advanced or aggressive periodontitis where the bone loss and the PSR was four, we noticed a severe collapse of the soft tissue as a consequence of the advanced bone loss. Modern periodontal and implant literature has become very aware of this problem and many different techniques have been introduced to solve and minimise it (Jahangiri et al, 1988; Allegrini et al, 2008; Lindhe et al, 2012; Vignoletti et al, 2012; Ladsberg and Bichacho, 1994; Kutkut, Andreana and Monaco, 2012). Many different authors have presented similar protocols with different biomaterials, from autogenous bone, to allografts, to synthetic and xenografts, but all of these procedures, despite using different materials, share a similar goal of minimising the collapse of the soft and hard tissue and thus trying to preserve the natural aesthetics (Horowitz, Holtzclaw and Rosen, 2012; Horvath et al, 2013; Scheyer, Schupbach and McGuire, 2012; Pagni et al, 2012; Cardaropoli et al, Figure 28: X-ray of the final restorations showing integration and regeneration of the previously diseased bone 12 July 2015 idt

5 and improvement of the soft tissue, giving clinicians a new therapeutic option. idt References Allegrini S Jr, Koening B Jr, Allegrini MR, Yoshimoto M, Gedrange T, Fanghaenel J, Lipski M (2008) Alveolar ridge socket preservation with bone grafting review. Ann Acad Med Stetin. 54(1):70:81 Barone A, Ricci M, Tonelli P, Santini S, Covani U (2013) Tissue changes of extraction sockets in humans: a comparison of spontaneous healing vs. ridge preservation with secondary soft tissue healing. Clin Oral Implants Res. 24(11): Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Cardaropoli G (2012) Socket preservation using bovine bone mineral and collagen membrane: a randomized controlled clinical trial with histologic analysis. Int J Periodontics Restorative Dent. 32(4): Hämmerle CH, Araujo MG, Simion M. Osteology consensus group 2011 (2012) Evidence-based knowledge on the biology and treatment of extraction sockets. Clin Oral Implants Res. 23(5):641 Horowitz R, Holtzclaw D, Rosen PS (2012) A review on alveolar ridge preservation following tooth extraction. J Evid Based Dent Pract. 12(3 Suppl): Horvath A, Mardas N, Mezzomo LA, Needleman IG, Donos N (2013) Alveolar ridge preservation. A systematic review. Clin Oral Investig. 17(2): Jahangiri L, Devlin H, Ting K, Nishimura I (1988) Current perspectives in residual ridger remodeling and its clinical implications: a review. J Prosthet Dent. 80(2): Kutkut A, Andreana S, Monaco E (2012) Esthetic consideration for alveolar socket preservation prior to implant placement: description of a technique and 80-case series report. Gen Dent. 60(6): Ladsberg CJ, Bichacho N (1994) A modified surgical/prosthetic for optimal single implant supported crown. Part I The socket seal surgery. Pract Periodontics Aesthet Dent. 6(2):11-7 Lindhe J, Cecchinato D, Bressan EA, Toia M, Araujo MG, Liljenberg B (2012) The alveolar process of the edentulous maxilla in periodontitis and non-periodontitis subjects. Clin Oral Implants Res. 23(1):5-11 Nordland WP, Tarnow DP (1988) A classification system for loss of papillary height. J Periodontol 69 (10): Pagni G, PellegriniG, Giannobile WV, Rasperini G (2012) Postextraction alveolar ridge preservation: biological basis and treatment. Int J Dent 2012: Rossi R, Morales RS, Frascaria M, Benzi R, Squadrito N (2010) Planning implants in the aesthetic zone using a new implant 3D navigation system. Eur J Esthet Dent. 5(2) Scheyer ET, Schupbach P, McGuire MK (2012) A histologic and clinical evaluation of ridge preservation following grafting with demineralized bone matrix, cancellous bone chips, and resorbable extracellular matrix membrane. Int J Periodontics Restorative Dent. 32(5): Schropp L, Wenzel A, Kostopoulos L, Karring T (2003) Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 23(4): Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M (2012) Surgical protocols for ridge preservation after tooth extraction. Asystematic review. Clin Oral Implants Res. 23 Suppl 5: CM LOC The new anchor 40 o 20 o 20 o idt July