CASE OF THE MONTH

Submitted by: Dr. Cecil White Jr.

HISTORY• 32 year-old female; Medical history within normal

limits.• OMFS performed LeFort I osteotomy in maxilla

(w/BSSO in mandible). • The mesial root of #6 was cut, and developed a

persistent radiolucent area; no pain involved.• #6 developed draining fistula w/no response to

electric pulp tester. Subsequent pain upon mastication, 6 months later, prompted non-surgical endo to #6.

• Referral to periodontist, 54 months following original orthognathic surgery.

CLINICAL EXAM

• 10 mm probing depth (PD) at mesial of #6, and 7 mm PD at distal of #7.

• Miller’s Class I mobility of #6 and #7.• #6 displayed purulence and bleeding upon

probing.• Radiographs displayed radiolucent area at

mesial of #6, with partial loss of root structure in apical 1/3rd of tooth.

TREATMENT PLAN

• Phase I:– Scaling/root planing (SRP) of area performed.– Reevaluation at 8 weeks following SRP revealed

persistent problem, with no improvement in probing depth/clinical attachment levels.

• Phase II:– Open flap debridement to assess lesion/defect

Pre-operative presentation- Facial surface

Pre-operative presentation- Palatal surface

Pre-operative radiograph

INTRA-OPERATIVE FINDINGS

• Combination 1- and 2-wall intrabony defect, extending from the mesial surface, to the distopalatal line angle of #6.

• Vertical dimension of the defect ranged from 4-6 mm.

• A 5 mm x 2 mm segment of gutta-percha was exposed, starting 4 mm apical to the CEJ.

POTENTIAL TREATMENT OPTIONS• Application of Enamel Matrix Derivative (EMD)

to defect and root surface of #6, closure.• Extract tooth #6, immediate implant to #6, bone

graft/barrier, closure.• Glass ionomer cement to root surface defect, root

surface conditioning with tetracycline (TCN), bone graft/TCN/barrier, closure.

• Extract teeth #6 and #7, bone graft/barrier, closure; subsequent implant placement.

• Extract #6, bone graft/barrier; subsequent placement of Fixed Bridge (#4 - #8).

CHOSEN TREATMENT OPTION

Glass ionomer cement to root surface defect, root surface

conditioning with tetracycline (TCN), bone graft/TCN/barrier,

closure.

DFDBA graft/tetracycline combination placed into defect, following root surface conditioning with tetracycline and glass ionomer cement repair of root surface defect.

Placement of expanded-polytetraethylene(e-PTFE) barrier

Primary closure

6 weeks following barrier placement - Facial

6 weeks following barrier placement - Palatal

Barrier removal at 6 weeks, with “regenerative” soft tissue present

Re-entry of #6 area at 24 months following original open flap/root repair/bone graft procedure (i.e. “original” surgery)

Restoration at 30 months following “original” surgery/6 months following “re-entry” procedure - Facial

Restoration at 30 months following “original” surgery/6 months following “re-entry” procedure - Palatal

Post-operative radiograph at 24 months post-operative

PRE-SURGERY POST-SURGERY/RESTORATIVE

PRE-SURGERY 24 MONTH POST-SURGERY

SUMMARY• PROBLEM

– Chronic periodontal lesion, with root surface defect, caused by errant section of root surface during orthognathic surgery procedure.

• TREATMENT – Situation was treated with open flap debridement,

repair of root surface defect with glass ionomer cement, root surface conditioning with tetracycline, combination DFDBA/tetracycline (4:1 ratio), and placement of e-PTFE barrier.

• OUTCOME– 1 to 3 mm probing depths, no mobility, and no

bleeding on probing to sites #6 and #7.