A Defect Made Defunct by Giacomo Tarquini, DDS

Categories: Periodontics;
A Defect Made Defunct  

Guided tissue regeneration case study of a periodontal intrabony defect, with a surgical re-entry and clinical evaluation after 5 years


by Giacomo Tarquini, DDS


In predisposed subjects, the formation of a periodontal bacterial biofilm may induce periodontitis, which involves chronic inflammation affecting the hard and soft periodontal tissues. Periodontitis may cause periodontal ligament destruction, alveolar bone resorption and, in the most severe cases, the loss of the affected teeth.1

Loss of alveolar bone support, a characteristic sign of periodontal disease, is generally considered to represent the anatomical sequela to the apical spread of periodontitis.

The persistence of deep pockets after active periodontal therapy has been associated with an increased probability of tooth loss, owing to the possibility that ecological niches (deep pockets and furcation involvement) associated with some osseous lesions may represent site-specific risk factors or indicators for disease progression.

The extent and severity of alveolar bone loss are usually assessed by periodontal probing and radiological examination, namely periapical radiographs; moreover, because of the limited ability to provide a detailed view of three-dimensional anatomical structures, cone-beam computed tomography (CBCT) represents a substantial aid in the diagnosis, treatment planning and assessment of periodontal patients.


Principles of guided tissue regeneration

When teeth have deep pockets and reduced periodontal support, improvement in short- and long-term outcomes may be achieved by carrying out concomitant regenerative interventions.

Because of differences in the healing abilities of different periodontal tissues, regeneration of the periodontium after traditional access flap procedures is difficult to obtain. One of the most important factors that limit the achievement of a predictable regeneration is in fact the downgrowth of junctional epithelium along the denuded root surface.

Guided tissue regeneration (GTR) therapy involves the use of barrier membranes and grafting bone substitutes to allow selective repopulation from the periodontal ligament and alveolar bone while excluding the gingival corium cells that usually repopulate the wound healing site first.

Many clinical studies and systematic reviews (with meta-analyses) have shown that the treatment of one-, two- and three-wall intrabony defects with GTR reduces periodontal probing depth and improves clinical attachment loss when compared with an open-flap debridement approach.


Prognostic factors

Prognostic factors in GTR may be classified in four different categories: patient-related, tooth-related, site-related and surgery-related factors.2

Patient-related: Significant clinical improvements can be expected only in nonsmoker patients with optimal plaque control and reduced levels of periodontal contamination.

Tooth-related: Severe and uncontrolled tooth mobility (Miller Grade II or higher) may impair the regenerative outcomes.

Site-related: Defect morphology plays a major role in healing after periodontal-regenerative treatment of intrabony defects. The depth of the intrabony component of the defect influences the amount of clinical attachment and bone gained, although it has been demonstrated that deep and shallow defects have the same potential for regeneration. In other words, after the treatment of deep defects, we’d expect to achieve linear amounts of attachment gain that are larger in absolute value than those obtained after the treatment of shallow defects, but both deep and shallow defects can express a regenerative potential up to the complete resolution of the intrabony component of the defect.

Another important morphological characteristic of the defect is the width of the intrabony component: the angle that the bony wall of the defect forms with the long axis of the tooth. Wider defects have been associated with reduced amounts of clinical attachment level and bone gain.

It has also been shown that the number of residual bony walls is correlated with the outcomes of various regenerative approaches, but it should be noted that the number of walls and the width of the defect are influential when nonsupportive biomaterials are used.

Nevertheless, the influence of defect anatomy appears to be mitigated, to some extent, when a more stable and long-lasting combination of barrier membrane and bone replacement material is applied.

As far as surgery-related factors, key concept for successful regeneration includes:
  • The presence of space for the formation of the blood clot at the interface between the flap and the root surface, which can be provided by the use of self-supporting membranes and/or graft biomaterials.
  • The stability of the blood clot. (That’s why membranes should be fixed with pins or titanium screws.)
  • The soft-tissue protection of the interdental area, to avoid surgical wound dehiscence and thus bacterial contamination of the underlying membrane. Its incidence could be greatly reduced with the use of access flaps specifically designed to preserve the interdental tissues, such as papilla preservation techniques.
Surgical approach: Papilla preservation techniques

Papilla preservation techniques were developed to achieve and maintain primary closure of the flap and to increase the ability to create space for regeneration in the interdental area. This approach is based on the elevation of full-thickness buccal and lingual flaps, followed by a buccal periosteal incision to increase buccal flap mobility. Vertical releasing incisions are traced when needed.

Flaps are generally coronally positioned on top of barriers, grafts or combinations and are sutured with a double-layer suturing technique to provide stable interdental closure.

The modified papilla preservation technique (MPPT) can be successfully applied in the anterior and premolar region when the interdental space width is ≥2 mm at the most coronal portion of the papilla.3

When interdental sites are narrower (<2 mm) or when we are in molar region, a different papilla preservation procedure has been proposed: the simplified papilla preservation flap (SPPF).4


Materials for regenerative surgery

Regarding materials and products, three different regenerative concepts have been explored: barrier membranes, grafts and wound-healing modifiers, and many combinations of those.

Early studies involved nonresorbable membranes—especially expanded polytetrafluoroethylene (ePTFE) barrier membranes— but the need for a second surgical procedure to remove them, the consequent increase in morbidity and the recognized problems associated with protection of the regenerated tissue following membrane removal have directed most clinicians toward the use of bioabsorbable membranes derived from native or linked collagen fibers, pericardium or poly-D,L-lactide-coglycolide (PLGA).

Because a considerable number of controlled, randomized clinical trials comparing outcomes after application of bioabsorbable and nonresorbable membranes failed to demonstrate clinically significant differences, the use of a bone substitute covered with a resorbable membrane shall be considered capable of allowing for a satisfactory periodontal regeneration.5

Another important issue concerns debridement of intrabony defects and root surface decontamination. Owing to the acoustic microstreaming and the cavitation effect, dedicated ultrasonic inserts demonstrated their efficacy in GTR procedures.6

Moreover, their specific shape is particularly useful when treating deep and narrow intrabony defects.7


Clinical case

After clinical examination and intraoral radiographic assessment (Figs. 1–3), surgery was performed as follows.

Antibiotic prophylaxis before surgery, then every 12 hours for six days, was initiated and the patient was instructed to rinse with 0.2% of chlorhexidine, to be continued for two weeks after surgery. In addition, 220 mg of naproxen sodium was administered one hour before surgery, then twice a day for three days.


Tarquini_Periodontal intrabony defect
Fig. 1: Presurgical defect sounding.
Tarquini_Periodontal intrabony defect
Fig. 2: Presurgical periodontal chart.
Tarquini_Periodontal intrabony defect
Fig. 3: Presurgical periapical radiograph.
 

The surgical area was anesthetized using 40 mg/mL of articaine hydrochloride with epinephrine (1:100,000).

According to the local anatomy, access to the defect was achieved using the modified papilla preservation technique (Fig. 4).

The reactive granulomatous tissue within the intrabony defect was debrided using Gracey curettes (Fig. 5) and root decontamination was carried out using ultrasonic inserts (Fig. 6).


Tarquini_Periodontal intrabony defect
Fig. 4: Access flap according to MPPT surgical protocol.
Tarquini_Periodontal intrabony defect
Fig.5: Reactive tissue debridement with Gracey curettes.
Tarquini_Periodontal intrabony defect
Fig. 6: Root surface decontamination by the means of ultrasonic inserts.
 

The intrabony component of the defect (Fig. 7) was measured by means of a 15-mm periodontal probe (Fig. 8). The defect was grafted with a bone substitute and a 25-by-20-by-0.2-mm collagen membrane was trimmed using sterile scissors, positioned to cover the defect (Fig. 9) then stabilized with titanium pins (Fig. 10).

Tarquini_Periodontal intrabony defect
Fig.7: Clinical aspect of the intrabony defect.
Tarquini_Periodontal intrabony defect
Fig.8: Intrabony component of the defect, measured with a 15mm periodontal probe.
 

Tarquini_Periodontal intrabony defect
Fig.9: Resorbable barrier membrane and bone substitute positioned over the bone defect.
Tarquini_Periodontal intrabony defect
Fig.10: Resorbable barrier membrane secured with a titanium pin.


Full flap closure was achieved, and the flaps were sutured using 5-0 nonresorbable PTFE sutures (Fig. 11).

After suture removal, the patient was followed up with every three months until healing had occurred with no complications or adverse events (Fig. 12).


Tarquini_Periodontal intrabony defect
Fig. 11: Flap is sutured according to MPPT protocol.
Tarquini_Periodontal intrabony defect
Fig. 12: Soft tissue healing.
 

Results

At the final follow-up, the CAL gain was 9 mm and the residual PPD was 3 mm (Fig. 13).

Starting from the 12-month check-up, the CAL was not significantly different from that at the previous visit. Additionally, starting from the 24-month check-up, the mean PPD was not significantly different from that at the previous visit, indicating that bone resorption was absent or limited from that time onward; indeed, as shown in periapical radiograph, the bone defect was completely filled (Fig. 14).


Tarquini_Periodontal intrabony defect
Fig. 13: Postsurgical periodontal chart at 24-month follow-up.
Tarquini_Periodontal intrabony defect
Fig. 14: Postsurgical periapical radiograph at 24-month follow-up.
 

At five years from the surgery, a surgical reentry independent of the intrabony defect previously treated was necessary, due to a second GBR procedure next to the intrabony defect reported here. Such condition required a flap opening involving the intrabony defect and thus allowing its clinical evaluation.

Surgical reentry allowed a clinical evaluation of the previous surgical clinical inspection and revealed that the intrabony defect was repaired and the aspect was that of newly formed mature bone of the patient (Figs. 15 and 16).

Tarquini_Periodontal intrabony defect
Fig. 15: Surgical reentry procedure after 5 years (buccal aspect).
Tarquini_Periodontal intrabony defect
Fig.16: Surgical reentry procedure after 5 years (occlusal aspect).


Conclusions

Many clinical studies and systematic reviews (with meta analyses) have shown that the treatment of periodontal defects by grafting bone substitutes in combination with GTR membranes reduces PPD and improves CAL; furthermore, they showed that the CAL gain was maintained over time thus providing a high percentage of long-term success.

In this specific case, a surgical reentry was performed at a 5-year follow-up and clinically confirmed the reestablishment of the lost periodontal attachment and the complete filling of the bone defect.

Similar clinical feedback is rare in literature and represents important clinical evidence of the success of the intrabony defect healing.8



References
1. Tarquini G. Treatment of intrabony defects using equine-derived bone granules and collagen membranes: A retrospective study with 13-year follow-up. Journal of Contemporary Dental Practice, Volume 21: Issue 9 (September 2020); 970-976
2. Cortellini P, Tonetti M. Focus on intrabony defects: guided tissue regeneration. Periodontology 2000, Vol. 22, 2000, 104–132
3. Cortellini P, Pini Prato G, Tonetti MS. The modified papilla preservation technique with bioresorbable barrier membranes in the treatment of intrabony defects. Case reports. Int J Periodontics Restorative Dent 1996;16:547–559.
4. Cortellini P, Pini Prato G, Tonetti MS. The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent 1999;19:589-599.
5. Tarquini G. Guided Tissue Regeneration (GTR), Cap. 3. In: Tarquini G. “Tecniche di chirurgia parodontale: dalla diagnosi alla terapia” (Textbook), EDRA Editions (September 2017): pag. 164.
6. Tarquini G. Ultrasounds in periodontal surgery: clinical effects. Cap. 1. In: Tarquini G. “Tecniche di chirurgia parodontale: dalla diagnosi alla terapia” (Textbook), EDRA Editions (September 2017): 25-26.
7. Tarquini G. Evaluation of a novel ultrasonic insert in Guided Tissue Regeneration (GTR): a retrospective study” Implants Italy; 1/2019: 24-28
8. L Florès-de-Jacoby 1, A Zimmermann, L Tsalikis Experiences with guided tissue regeneration in the treatment of advanced periodontal disease. A clinical re-entry study. Part I. Vertical, horizontal and horizontal periodontal defects. J Clin Periodontol. 1994 Feb;21(2):113-7.


Author Bio
Giacomo Tarquini Giacomo Tarquini, DDS, graduated with honors in dentistry and dental prosthetics from the Sapienza University of Rome in 1994, and has been practicing dentistry for about 25 years. Today he practices in Rome with particular interest in the disciplines of periodontology and implantology. He is also a consultant, professor, tutor and lecturer for a variety of dental specialties. Along with various articles, Tarquini is the author of the textbook, Techniques of Periodontal Surgery: from Diagnosis to Therapy.
 

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