PHASE I: Preparatory phase
- Education regarding etiology and prevention of periodontal disease.
- Introduction of the treatment plan to the patient.
- Oral hygiene instruction/demonstration
- Supportive periodontal therapy. Scaling root planing.
- Provisional restoration. teeth #8-11
Interim evaluation:
1. Evaluation and reinforcement of patient's oral hygiene.
2. Evaluation of tissue response to Phase 1 periodontal therapy.
PHASE II: Surgical phase
- Pocket elimination surgery in upper right first molar areas with possibility of DB root resection.
- Correction of mucogingival problems in UR and UL first molar areas.
- Extraction of maxillary left central and lateral incisors in conjunction with ridge preservation and possibly ridge augementation procedure.
- Pocket elimination surgery in lower left first molar area.
PHASE III: Restorative Phase
- Fixed Partial Dentures. teeth #7-11
- Fixed Partial Dentures. teeth #14-16
- Occlusal splint to control occlusal factors.
PHASE IV: Maintenance Phase
Periodontal Therapy every three to four months to:- Evaluate Plaque score
- Evaluate Bleeding score
- Evaluate Probing depths
- Evaluate Attachment levels
- Evaluate Mobility
- Evaluate Furcations
- Assist patient with oral health care
- Root planing and polishing as needed
Surgical Phase
- Patient premedicated prior to procedure with 500mg Amoxicillin and 800mg Ibuprofen. Amoxicillin was continued at 500mg three times a day for seven days post operatively. Ibuprofen was continued at one tablet every 4-6 hours as needed for discomfort.
- Patient rinsed with Chlorhexidine mouth rinse for 30 seconds before surgical procedure. Chlorhexidine rinses were continue beginning the day after surgery, at twice a day.
- Local anesthesia provided by 2% Lidocaine 1:100,000 epinephrine initial block supplemented by local infiltration in mandibular areas, or local infiltration only in maxilliary areas.
A. Upper Frontal Sextant
Procedure: Surgical extraction of teeth #9, 10
Ridge preservation/augmentation procedure.
Surgical sextant analysis:
There is adequate amount of soft tissue present for primary closure of the
flap after graft placement and adequate amount of keratinized tissue allowing for
flap manipulation.
The primary goal of this procedure is: Preservation of the alveolar ridge in horizontal and vertical dimension after extraction of teeth #9 and #10.
Possible additional procedure: Augmentation of the alveolar ridge in teeth #9 and #10 area.
The goal of this procedure is to increase the bulk of the alveolar ridge for better esthetic appearance of the FPD.
Teeth 9 and 10 were extracted with preservation of the buccal plate of alveolar ridge. Extraction socket were curetted and crest of the bony ridge degranulated. Polytetrafluroethylene membrane (Gore-Tex) was trimmed to fit to the area between teeth #8 and 11 and inserted between the alveolar ridge and the flap on the palate. A Decalcified Freeze Dried Bone (DFDB) graft was then condensed into the extraction sockets.
Facial flap was released further apically by split dissection to enable suturing of the membrane to the periosteum and to mobilize the flap so that primary closure could be obtained. Gore-Tex material was used for interrupted sutures.
A provisional FPD was inserted immediately and cemented temporarily by Temp Bond. The patient was instructed in the use of a cotton tip soaked in chlorhexidine to maintain optimal oral hygiene in the surgerized area.
Post-Operative Course:
During the first month patient was seen on weekly basis to assess the healing and his ability to perform adequate oral hygiene. Gore-tex sutures were removed in 2 weeks.
In week four the area mesially to tooth #11 showed a small exposure of the membrane approximately 3 mm in diameter. The patient was instructed in the use of cotton applicators with chlorhexidine to specifically clean this region.
The exposure of the membrane never enlarged and was free of exudation. The membrane was removed at 14 weeks.
Stage II: Membrane Removal
Horizontal incisions were performed at the crest of the alveolar ridge and continued as intrasulcular incision around teeth #8 and #11. At the distal facial line angle of teeth #9 and #11, 2 vertical incisions crossed the mucogingival junction to allow for flexibility of the flap. A full/split thickness flap was elevated for the access to the Gore-tex membrane. The membrane appeared firmly attached to the ridge. A #15 scalpel blade was used to help elevate the membrane margin from the regenerated material. There were no signs of the inflammation. After membrane removal a dense material resistant to probing was seen in the area which was unexposed compare to a red velvet-like soft tissue which corresponded to the exposed area. The flap was closed with 5.0 gut suture without tension. The provisional FPD was cemented with Temp Bond and patient was again instructed about oral hygiene. Four weeks were allowed for healing before the secondary surgical procedure.
Secondary Surgical Procedure: Ridge Augmentation
The purpose of this procedure was to further enhance results achieved by the first surgery and therefore further improve the esthetics of planed FPD. The goal was also to reposition the mucogingival junction in a apical direction in order to improve aesthetics.An incision was performed at the crest of the alveolar ridge, extended in a distal direction on both sides approximately 1 mm from tooth #8 and #11 and ended as a vertical incision in the distal facial line angle of teeth #8 and #11 after crossing the mucogingival junction to allow flap manipulation. A full/Split thickness flap was elevated. A connective tissue graft was harvested from the palate in the manner which preserved the epithelial band at the margin of the graft.
The connective tissue graft was sutured to the periosteum with 5.0 gut sutures using interrupted and horizontal mattress sutures. The edges of the buccal and palatal flaps were approximated and sutured to the epithelial band of the graft leaving the epithelium exposed. This resulted in an apical positioning of the mucogingival junction.
The temporary bridge was cemented with Temp Bond and the patient reinstructed in oral hygiene. Starting one week after the procedure, acrylic was added repeatedly in small amounts to the apical portion of the pontics in order to create an illusion of interdental papillae.
Surgical sextant Analysis:
Adequate zone of keratinized tissue, except for minimal amount over the facial of the tooth #3.
Procedure: Pocket reduction osseous surgery with possible distal buccal root resection. The goal of this procedure is:
- assess #3 for prognosis
- access distal buccal and palatal root surfaces for debridement and elimination of expected grade III furcation by root resection which will lead to cleansible topography
- reduced probing depths and ease of maintenance
Vertical releasing incision D tooth #4 to allow adequate access.
Palatal: Sulcular incision to reserve gingival tissue for adequate closure.
The surgical site was completely debrided of granulation tissue using surgical curettes.
The root surfaces were carefully instrumented with sharp curettes, ultrasonic instrumentation and finishing burrs. Surgical site was assessed and buccal and distobuccal furcations evaluated.
Initial plan for distal buccal root resection was not used due to fusion of distal buccal and palatal roots.
Decalcified freeze dried bone (DFDB) material was condensed into the buccal furcation and the three wall vertical distopalatal defect.
A piece of connective tissue obtained by thinning of the palatal flap was used to cover the graft material and secured by 5.0 gut suture around the tooth.
A combination of interrupted and mattress/sling sutures were completed using 4.0 silk. Dry Foil and Coe Pak periodontal dressing were placed.
-
1 week
- Dressing and sutures were removed. Wound was debrided gently with sterile saline. Granulation tissue with fibrin clot and remnants of the connective tissue graft covered the area. Patient received the instructions in the use of cotton tip soaked in chlorhexidine for plaque control.
2 weeks - Healing was progressing well. Granulation tissue covered the area.
3 weeks - Healing was progressing well and patient demonstrated his ability to perform adequate oral hygiene.
- In following weeks patient was seen on weekly basis and after re-epitelization occurred, the use of an interproximal brush and ultra soft brush was demonstrated.
6 months - Pink, firm gingiva, slight erythematous margin on mesiopalatal only, which exhibits no bleeding on probing. Radiographs show increased radio-opacity around molar area. Clinical parameters indicate decrease in probing depth recession and clinical attachment gain and recession.
12 months - Secondary surgical procedure: connective tissue graft and re-entry
- The goal of the procedures was to increase the amount of keratinized tissue facial to 3 and assess the healing of the grafted site.
The goal of the procedures was to increase the amount of keratinized tissue facial to tooth #3 and to assess the healing of the previously grafted bone site.
Sulcular and vertical incisions were performed and a full thickness palatal flap was elevated. A connective tissue graft was obtained by thinning of the palatal flap. The previously grafted palatal site exhibited fill of the three wall bony lesion with material resembling bone. This material appeared hard upon probing. There was an area of softer tissue directly adjacent to the tooth, which allowed penetration of the probe to approximately 1-1,5 mm. 4.0 silk interrupted suture was used to close the flap.
Subsequently, a split thickness flap was elevated on the facial at apically positioned and sutured at the base by a suture with 5.0 gut.
A connective tissue graft was sutured to the periosteum apically to the recession and partially covering the root. Surgicell, Dry Foil and Coe Pak surgical dressing were used to protect the facial surgical site. Dressing with attached Dry foil were removed in one week. Healing progressed within normal limits. Revascularization of the graft had started. The site was gently cleansed with sterile saline and patient was instructed in the use of a ultra soft tooth brush and interproximal brush.
D. Upper Left Sextant
Procedure: Strip Gingival GraftThe primary goal of this surgical procedure was to increase the zone of keratinized tissue on the facial gingiva of tooth #14 and to increase the vestibular depth. Tooth #14 will be restored following healing of this surgery.
Surgical sextant analysis
There is inadequate vestibular depth in this area and minimal amount of keratinized tissue on the facial of tooth #14. There is adequate thickness of palatal tissue to harvest a strip gingival graft. A tracing incision approximately 1.5 mm from gingival crest outlined the coronal margin of the split thickness flap. The flap was apically positioned and sutured at the base by a suture with 5.0 gut. A narrow strip gingival graft containing the full thickness of the palate and was further split into 3 strips which were added to the recipient site. Surgicell, Dry Foil and Coe Pak surgical dressing were used to protect the facial surgical site. Surgicell was also inserted to the donor site and secured by the horizontal mattress sutures. CoePak covered the area to diminish patients discomfort.
Healing
The dressings with attached Dry foil were removed in one week. Healing progressed well within normal limits. Re-vascularization of the graft had started. The site was gently cleansed with sterile saline and patient was instructed in the use of an ultra soft tooth brush and interproximal brush.