- Systemic Management: None
- Emergency Phase:
Endodontic Consultation #18
Root Canal Therapy #18 - Initial Therapy
- Patient Education of the Etiology & Pathogenesis of Periodontal Disease
- Oral Hygiene Instruction; Demonstration of the Use of Toothbrush, Rubber Tip, Dental Floss and Proxy Brush.
- Scaling and Root Planning with Anesthetic
- Caries Control #18 & 2
- Correction of Restorative Etiological Factor; Overhang Mesial #3; Overhang Mesial # 8 and Open Contact #19-20
- Occlusal Adjustment
- Evaluation:
- Evaluation and Reinforcement of Patientís Oral Hygiene
- b. Evaluation of Tissue Response to Phase I Perio Therapy
- Surgical and Restorative Plan:
- Phase II, Surgical Plan:
- Pocket Reduction Surgery URQ (#2-6)
- Pocket Reduction Surgery LRQ (#28-31)
- Pocket Reduction Surgery ULQ (#12-15)
- Pocket Reduction Surgery LLQ with possible bone regeneration at the apical third (#18-21)
- Pocket Reduction Surgery Lower Anterior
- Non Surgical Pocket Reduction Upper Anterior
- Restorative Plan:
- Fixed Partial Denture #13-15
- Single Unite Crown #18
- Bonded Restorative Treatment to close part of the black triangle
- Phase II, Surgical Plan:
- Maintenance Phase:
- Supportive Periodontal Treatment (SPT) every 3 months
- Restorative Evaluation every 6 months
Periodontal Surgical Treatment URQ (#2-6)
- Purpose of the surgery: Pocket reduction and root surface debridement.
- Goal of the surgery: Primarily to correct osseous defects and to provide a more harmonious bony contour; direct access to the root surfaces.
- Surgical procedure: Topical anesthetic.
- Infiltration anesthesia: 4x 1.8 ml carpule 2% Lidocaine 1:100,000 Epinephrine
- Probing and bone sounding revealed bone defect interproximally with no furcal involvement.
- Buccal incision: Minimal scalloping 1 to 1.5 mm, reverse bevel incision
- Palatal incision: Reveres bevel scalloping 2-3 mm; horizontal incision between #6-7 to get access to root surfaces yet minimizing esthetic compromise
- Distal wedge incision: triangular distal wedge about 3 mm extending 6 mm distally
- Full thickness flap elevation
- Soft tissue degranulation
- Examination of bone morphology revealed interproximal osseous defect between #2-3 and #3-4 classified as class I crater (less than 2-3 mm deep); Intact Furcation with thick bony housing on buccal and palatal
- Osseous recontouring: Palatal approach to reduce the interproximal defects. Osteoplasty was done to thin the bony housing.
- Ostoectomy was done to scallop and provide positive architecture but maintain the furcation intact.
- Scaling and root planing performed after osseous resection.
- Suture: 4-0 silk with FS-2 needle. Continuous sling anchored with horizontal mattress. Distal wedge was closed with close back anchor and single interrupted suture was used to close the papilla between #6-7.
- 5 minute pressure was applied. Post operative instructions were given to the patient.
- Rx: Ibuprofen 800 mg, 30 tab, 1 q8h; Amoxicillin 500 mg, 30 caps; 1 q6h . Warm salt water rinse 2-3 times a day.
- Post operative 1 week: Healing very good; secondary healing interproximal #2-3; Instructed patient on using proxybrush and rubber tip.
- Post operative 3 weeks: Healing uneventful; tissue appears firm and pink; Need to improve oral hygiene.
- Probing depth after 6 months revealed a residual depth of 4 mm palatal interproximal # 2-3 and no bleeding on probing.
- Oral hygiene has been re-enforced.
Periodontal Surgical Treatment LRQ (#28-31)
- Purpose of surgery: Pocket reduction and root surface debridement.
- Goal of the surgery: Primarily to correct osseous defects; provide a more harmonious bony contour and direct access to the root surfaces.
- Surgical procedure: Topical anesthetic.
- Inferior alveolar block along with lingual and buccal anesthesia: 3x 1.8 ml carpule 2% Lidocaine;1:100,000 Epinephrine.
- Probing and bone sounding revealed bone defect interproximally with no furcal involvement.
- Buccal incision: Sulcular to preserve attached gingiva.
- Lingual incision: Reverse bevel scalloping 2 mm.
- Distal wedge incision: triangular distal wedge about 3 mm extending 5-6 mm distally.
- Envelope flap without any vertical incision.
- Full thickness flap elevation.
- Soft tissue degranualtion
- Examination of bone morphology revealed lingual interproximal osseous defect between # 29-30 and # 30-31 classified as class I crater (less than 2-3 mm deep). Thick bony ledges on lingual. Intact furcations.
- Osseous recontouring: lingual approach was used to reduce the interproximal lesion, ramping lingually. Osteoplasty was done to thin the bony housing and sluice the interproximals.
- Scallop osteoctomy was done at the root surfaces to provide a positive architecture and maintain the furcation intact.
- Scaling and root planning performed after osseous resection.
- Suture: 4-0 silk with FS-2 needle. Continuous sling anchored; distal wedge was closed with close back anchor.
- 5 minutes pressure was applied. Post operative instructions were given to the patient.
- Rx: Ibuprofen 800 mg, 30 tab, 1 q8h; Amoxicillin 500 mg, 30 caps; 1 q6h . Warm salt water rinse 2-3 times a day.
- Post operative 1 week: Healing very good; Instructed patient on using proxybrush and rubber tip.
- Post operative 3 weeks: Healing uneventful; tissue appears firm and pink; very good healing.
- Probing depth after 6 months revealed a residual depth of 4 mm lingual interproximal #30& 31 and no bleeding on probing.
- Oral hygiene has been re-enforced.
Periodontal Surgical Treatment LLQ (#18-21)
- Purpose of the surgery: Pocket reduction and bone regeneration with root debridement
- Goal of surgery: Primarily to correct osseous defects; regenerate apical third of defect; direct access to root surfaces.
- Surgical procedure: Topical anesthetic.
- Inferior alveolar block along with lingual and buccal anesthesia: 3x 1.8 ml carpule 2% Lidocaine;1:100,000 Epinephrine.
- Probing and bone sounding revealed bone defect interproximally with no furcal involvement.
- Buccal incision: Reverse bevel incision; scalloping 2-3 mm around #18,19,20 with sulcular incision around tooth #21 to preserve attached gingiva. Preserving the papilla between #19-20 for the regeneration purposes.
- Lingual incision: Reverse bevel incision; scalloping 2-3 mm around #18,19,20 with sulcular incision around tooth #21 to preserve attached gingiva.
- Distal wedge incision: triangular distal wedge about 3 mm extending 5-6 mm distally.
- Full thickness flap elevation.
- Soft tissue degranulaion.
- Examination of root morphology revealed mesial concavity on mesial root #19: a difficult area for patient to maintain clean. Examination of bone morphology revealed interproximal osseous defect between #18-19 and #19-20 classified as class I and class II crater respectively. ( class II crater = less than 4-6 mm deep)
- Osseous recontouring: Lingual approach was used to reduce the interproximal bony defect (1-2 wall defect) and the osseous coagulum was collected for bone graft of the apical third.
- Osteoplasty and osteoctomy was done to thin out the bony ledges and sluice the defect interproximally.
- Positive architecture can not be achieved without endangering the furcation and osseous level on tooth #20. Decision was made to maintain a flat to negative architecture rather than opening up the furcations.
- Scaling and root planing was performed after osseous resection.
- The osseous coagulum accumulated at time of osteoplasty and osteoctomy was used to graft the apical third of defect which had a three wall defect.
- Suture: 4-0 silk with FS-2 needle. Continuous sling anchored; distal wedge was closed with close back anchor.
- 5 minutes pressure was applied. Post operative instructions were given to the patient.
- Rx: Ibuprofen 800 mg, 30 tab, 1 q8h; Amoxicillin 500 mg, 30 caps; 1 q6h . Warm salt water rinse 2-3 times a day.
- Post operative 1 week: Healing very good; tissue appears firm and pink. Instructed patient on using proxybrush and rubber tip.
- Post operative 3 weeks: Healing uneventful; tissue appears firm and pink; very good healing. Must improve plaque control; some inflammation on buccal #18; Oral hygiene was re-enforced.
- Probing depth after 6 months revealed a residual depth of 5 mm lingual interproximal #19 and 4mm interproximal # 18 & 19 with no bleeding on probing.
- Oral hygiene has been re-enforced.
Alternative Treatment Plan:
If patient was not happy with the anterior esthetic:
Option 1: Anterior veneer to match # 8& 9
Option 2: Orthodontic forced eruption of tooth #8 followed by single unite implant #8