Combined OrthodonticPeriodontal Treatment of an Infrabony Defect A Case

of bringing the tooth upright into a more ideal position and placing an osseous graft into the defect. The case was followed closely for 12 months from initial treatment, 10 months from the time of grafting and was reentered at the fifth postoperative month: Case Presentation

Report

A 50-year-old male was referred to the periodontal department of the Veterans Administration Medical

Center, New York, NY for consultation and

by Gregory Kazandjian, d.d.s.* Irwin Walter Scopp, b.s., d.d.s.* Sigmund Stahl, d.d.s.* Isolated one- or -wall infrabony lesions present a in difficult problem the treatment of periodontal disease. These lesions have been treated either by resective pro-

cedures,1,2 regenerative procedures,3"5 overeruption6

or

extractions. In instances, isolated lesions may very well be associated with tilted teeth such as the mesially inclined mandibular molar with an infrabony pocket at its proximal surface. Because of the orthodontic complications, the therapeutic plan and sequence are usually specific for each case. Recently, Brown7 dealt with mandibular molars which (a) were mesially tilted into adjacent edentulous spaces and (b) had infrabony osseous defects at their mesial proximal surfaces. Bringing these molars into an upright position caused definite changes in the osseous and soft tissue architecture associated with the mesial surface of the teeth. Brown concluded that correcting the axial inclination of the tilted teeth will restore a normal occlusal plane, reduce pocket depth, and alter gingival morphology to a more desirable architecture. Since the newly upright molars would be taken "away" from the infrabony defect, an "eversión" of the soft and hard tissue pocket walls might be created. In line with Brown's work, further questions deserve attention. For example, what are the soft and hard tissue changes on the distal proximal surfaces of such newly upright molars? What changes take place when an infrabony defect exists on a proximal aspect which is opposite to the direction of the inclination and the tooth is brought upright "into" the defect? Similarly, will the prognosis of the upright tooth improve if an autogenous osseous graft is placed in the defect? And if so, should the graft be placed before, during or after the orthodontic procedure? The following is a case report of a distally inclined mandibular left central incisor associated with an infrabony defect at its mesial surface. The treatment consisted some

*

Department

of

Dentistry,

infrabony pocket. Periodontal charting of the mandibular incisor teeth demonstrated interproximal pocketing of 4 to 6 mm. The

left central incisor exhibited a minimum zone of attached gingiva on its facial aspect, and on its mesial aspect it exhibited a pocket depth of 6 mm. The two central incisors exhibited 1 to 4 mm of soft tissue recession and a mobility pattern of 1+ (Figs. 1A and IB). Treatment Plan

The severe pocket depth, vertical bone loss, mucogingival involvement and distal tilt of the left central incisor usually would suggest tooth extraction. However, because of the patient's reluctance to have additional extractions, it was decided to maintain the tooth by combined orthodontic and periodontal therapy.

Sequence

Treatment Treatment of the mandibular anterior segment performed in three phases:

Veterans Administration Medical Cen-

of

was

Moving the left central incisor into an upright position.

Phase 1.

York, NY 10010 and Department of Periodontics, New York University College of Dentistry, New York, NY 10010. ter, New

treatment.

Past medical history was noncontributory. All maxillary molars were missing. In the mandibular arch, all molars were missing except No. 18 and all premolars except No. 21. The patient had never received partial dentures for either arch. Since the case presentation deals with the mandibular anterior teeth, observations will be limited to that segment. Clinical examination of the mandibular anterior teeth showed a rolled and slightly reddish marginal tissue. There was severe bleeding associated with tooth No. 24. Calculus deposits were evident. Distal migration of all mandibular teeth was noted in the left quadrant. In addition the left central incisor was distally tipped and overlapped the left lateral incisor. It was also in slight labial version. Examination of the occlusion revealed an anterior edge-to-edge relationship. The tilted left central incisor contacted the slightly overerupted maxillary left central incisor. The excursive movements exhibited group function, with no interferences. Radiographic examination suggested generalized horizontal bone loss in the mandibular anterior segment. In addition, there was an area of vertical bone loss associated with the mesial aspect of the tilted left central incisor which upon clinical probing proved to be an

479

480

J. Periodontol. 1979

Kazandjian, Scopp, Stahl

September,

Figure 1 A. Preoperative clinical photograph demonstratingpocket depth of 6 mm at the mesial proximal surface of the distally inclined left central incisor. B. Preoperative radiograph demonstrating the infrabony pocket on the mesial proximal aspect of left central incisor. The probe extends 10 mm (from CEJ) into the defect. C. Postorthodontic radiograph demonstrating remodeling and narrowing of the infrabony pocket and the distally displaced root apex and thickening of the periodontal ligament. D. Operative photograph showing exposed roots and bone with a probe within the infrabony defect.

Phase 2. Periodontal surgery and

infrabony pocket.

osseous

grafting of the

Phase 3. Re-entry of the grafted site for final osseous corrections and soft tissue grafting to augment the zone of attached gingiva associated with the facial aspect of the left central incisor. Phase 1

right central and lateral incisors and cuspid were splinted with wire8"10 and acid etched composite material was placed over the wire splint to prevent displacement. This splint was used as anchorage in moving the left central incisor upright. Grassline ligature was used to move the tooth11 and it was changed at weekly intervals. The

This was continued for 7 weeks until the tooth assumed the desired position in the arch, and then it was splinted to the anchor splint. Since the infrabony defect existed on the mesial proximal aspect of the distally tilted tooth, the action of uprighting meant moving the tooth "into" the defect. Several clinical and radiographie changes were noticed as a result of this movement:12 1. Mesial pocket depth had changed from 6 mm to 8

and when this was measured from the CEJ, a loss 2 of to 3 mm of attachment was observed. 2. Definite soft tissue remodeling was observed with each change of the grassline. 3. Distal pocket depth remained at about 3 mm. 4. "Narrowing" and remodeling of the infrabony defect was clearly noted on the radiograph (Fig. 1C). 5. Physiologic responses which occur from orthodontic movement were also noted on the e.g. thickening of the PDL, radiolucent zone at the area of tension, displacement of the root apex distally (Fig. mm

radiographs;12

1C). Phase 2 Two weeks after splinting of the newly upright tooth, the entire anterior segment was treated surgically. The aim of surgery was to (a) decrease pocket depth and (b) augment the bone level of the infrabony pocket associated with the left central incisor. A full thickness flap was raised by means of a modified Widman type incision.13 The surgical site was debrided of all granulomatous tissue. The exposed cementum of the roots was well planed and the osseous morphology visualized. As ex-

Volume 50 Number 9

Combined Treatment

pected, the only osseous deformity present was the infrabony pocket (Fig. ID). An osseous autografi was obtained from the right tuberosity.14 A coagulum-bone-blend as described by Diem, Bowers and Moffitt,15 was placed into the defect which was overfilled (Fig. 2A). The surgical site was then coapted and sutured using 4-0 interrupted silk sutures. The flaps were held in position with finger pressure for 5 minutes. A noneugenol dressing was placed for 2 weeks and changed weekly. An antibiotic (Penicillin) was administered for 15 days. Analgesic medication was prescribed to be taken as needed. The surgical site was observed and photographed at the following intervals: 2,4, 7, 8, 12 weeks and 5 months. Radiographs were also taken at 2 weeks, 2 months and 5 months. At the end of the 5 th postoperative month the following observations were made: 1. All anterior teeth exhibited

a

giva. All pocket depths ranged from

2. 3. There was 5 mm.

postoperative

clinically healthy gin1 to 3

recession

splint remained intact and did not seem to patient's oral hygiene procedures.

impair Mobility was minimal. Focusing attention on the left central incisor and the osseous autografi, further observations were made: 1. Mesial pocket depth had been reduced from 8 mm (at the

5.

end of Phase 1) to 3 mm, and when this was measured from the CEJ, a gain of 4 mm of attachment was

observed.

2. Recession, measured from CEJ to gingival margin, had increased about 2 mm. 3. The overfilled graft material had all "disappeared." 4. Pocket depth on the distal aspect remained at about 3 mm. 5. Radiographically the grafted infrabony site showed considerable remodeling and leveling off of the inter-

proximal septum.

Phase 3

postoperative month a reentry procedure was performed. This was done: (a) to visualize the osseous morphology of the grafted site and perform final At the 5th

mm.

varying

4. The wire

481

from 2 to

Figure 2A. Operative photograph showing placement of the osseous autografi. Note the overfilling of graft material. B. 5-month postoperative radiograph suggesting fill in the osseous defect and leveling off and remodeling of the interproximal bone. The probe extends about 6 mm (from CEJ) to the crest of bone. C. Operative photograph demonstrating the extent of osseous fill and remodeling of the interproximal bone. D. 10-month postoperative photograph of the operative site (1 week after splint removal) showing soft tissue remodeling and an augmented zone of attached gingiva on the facial aspect of left central incisor. E. 10-month postoperative radiograph showing remodeling of the interproximal bone. The attachment level (measured from CEJ) is essentially unchanged.

Kazandjian, Scopp, Stahl corrections, and (b) to lower the frenum attachment and augment the zone of attached gingiva. The surgical procedure was designed to serve two purposes. At the mesiobuccal line angle of the left central

J. Periodontol. 1979

September,

482

incisor a vertical incision was made to bone and was extended into the mucosa. Mesial to this incision a full thickness flap was raised, and distal to the same incision a partial thickness flap was raised and sutured to the periosteum at its base. The full thickness reflection served to denude the bone in order to visualize the architecture of the previously grafted site. The split thickness flap provided a recipient bed for a free gingival The site of the original infrabony defect was examined. It appeared that part of the lesion had filled and the interproximal bony crest had leveled off as part of osseous remodeling. The osseous attachment level, when measured from the bottom of the infrabony pocket to a reference point on the tooth, seemed to have increased by 4 mm (Figs. 2B and 2C). The surgery was continued by repositioning the full thickness flaps and suturing them with 4-0 interproximal silk sutures. No osseous corrective procedure was felt necessary. The periosteal bed received a free gingival which was secured with 5-0 graft from the right plain gut periosteal sutures. The entire area received a noneugenol dressing which was kept for 2 weeks and

graft.16'17

palate18

changed weekly. The patient was followed for 5

months from the time 10 months from the time of grafting. of reentry, or Photographs were taken at 1,2, 3, 5, 7, 9 weeks, 3 months and 5 months postoperatively. Radiographs were taken at 7 weeks and 5 months. The wire splint was removed 1 week prior to the last photograph (Figs. 2D and 2E). At this time the following observations were made and compared to those of Phase 2: a clinically healthy gingiva. All pocket depths remained in the range of 1 to 3 mm.

1. All anterior teeth exhibited

2. 3. There was no further recession. 4. The wire splint remained intact. 5. Mobility of the splint remained minimal. In addition, the following observations the left central incisor:

were

made for

1. There was no further pocket deepening at either the mesial or distal aspect of the tooth. 2. The attachment remained at approximately the same level. 3. There was no further recession. 4. A zone of attached gingiva with a much lower frenum attachment was now present. 5. There was a slight (about 1 mm) relapse of the tooth distally during the 1 week that the splint was removed. 6. Radiographically, the interproximal crest appeared

radiopaque, peared unchanged.

somewhat

more

and the bone level ap-

Summary

presentation involving the combined orthodontic-periodontic treatment of a distally inclined mandibular left central incisor with a mesial infrabony defect is reported. Treatment was performed in three phases: (a) the tooth was moved upright (b) periodontal surgery with osseous grafting of the infrabony defect was then performed; and (c) the operative site was reentered 5 months later. The patient was followed and soft and hard tissue changes were documented for 12 months A case

from time of initiation of treatment. References

1. Ochsenbein, C: Osseous resection in periodontal surgery. J Periodontol 29: 15, 1958. 2. Selipsky, H.: Osseous surgery—How much need we compromise? Dent Clin North Am 20: 79, 1976. 3. Hiatt, W. H., and Schallhorn, R. G.: Human allografts of iliac cancellous bone and marrow in periodontal osseous defects. I. Rationale and methodology. J Periodontol 42: 642, 1971. 4. Froum, S. J., Thaler, R., Scopp, I. W., and Stahl, S. S.: Osseous autografts. I. Clinical responses to bone blend or hip marrow grafts. / Periodontol 46: 515, 1975. 5. Dragoo, M. R., and Sullivan, H. C: A clinical and histologie evaluation of autogenous iliac bone grafts in humans. Part I. Wound healing two to eight months. J Periodontol 44: 599, 1973. 6. Ingber, J. S.: Forced eruption: Part I. A method of treating osseous defects—Rationisolated one and two wall ale and case report. J Periodontal 45: 199, 1974. 7. Brown, I. S.: The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings. J Periodontol 44: 742, 1973. 8. Hall, D. L., and Lindeberg, R. W.: Splinting of mandibular anterior teeth. J Acad Gen Dent 38, 1974. 9. Lemmerman, K.: Rationale for stabilization. J Periodontol 47: 405, 1976. 10. Simring, M., and Posteraro, A. F.: Hazards and shortcomings of splinting. NY State Dent J 30: 19, 1964. 11. Wank, G. S.: The use of grassline ligature in periodontal therapy. Dent Clin North Am 6: 473, 1972. 12. Gryson, J. .: Changes in the periodontal ligament incident to orthodontic therapy. Periodontol Abstr XIII: 14-21, 1965. 13. Ramfjord, S. P., and Nissle, R. R. The modified Widman flap. J Periodontol 45: 601, 1974. 14. Pfeifer, J. S.: The present status of bone grafts in periodontal therapy. Dent Clin North Am 13: 193, 1969. 15. Diem, C. R., Bowers, G. M., and Moffitt, W. C: Bone blending: A technique for osseous implants. J Periodontol 43: 295, 1972. 16. Sullivan, H. C, and Atkins, J. H.: The role of free gingival grafts in periodontal therapy. Dent Clin North Am 13: 133, 1969. 17. Brackett, R. C, and Gargiulo, A. W.: Free gingival grafts in humans. / Periodontol 41: 581, 1970. 18. Pennel, B. M., Tabor, J. C, King, K. O., Towner, J. D„ Fritz, B. D., and Higgason, J. D.: Free masticatory mucosa graft. J Periodontol 40: 162, 1969.

infrabony

Combined orthodontic-periodontal treatment of an infrabony defect. A case report.

Combined OrthodonticPeriodontal Treatment of an Infrabony Defect A Case of bringing the tooth upright into a more ideal position and placing an osseo...
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