Periodontal Surgery Involving Modified Widman Flap Procedure and Connective Tissue Graft for

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Posted at the Institutional Resources for Unique Collection and Academic Archives at Tokyo Dental College, Available from http://ir.tdc.ac.jp/

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Periodontal Surgery Involving Modified Widman Flap Procedure and Connective Tissue Graft for

Generalized Aggressive Periodontitis: A Case Report Author(s) Imamura, K; Okamura, Y; Matsumoto, Y; Mashimo, Y;

Tomita, S; Sugito, H; Saito, A

Journal Bulletin of Tokyo Dental College, 57(4): 259‑268 URL http://hdl.handle.net/10130/5821

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Periodontal Surgery Involving Modified Widman Flap Procedure and Connective Tissue Graft for Generalized Aggressive Periodontitis: A Case Report

Kentaro Imamura¹⁾, Yuri Okamura¹⁾, Yasugi Matsumoto²⁾, Yuko Mashimo¹⁾, Sachiyo Tomita¹⁾, Hiroki Sugito³⁾ and Atsushi Saito¹⁾

1) Department of Periodontology, Tokyo Dental College, 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan

2) Matsumoto Dental Clinic,

8-3 Minamikasuga-machi, Oita-shi, Oita 870-0815, Japan

3) Department of Endodontics and Clinical Cariology, Tokyo Dental College, 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan

Received 9 March, 2016/Accepted for publication 4 April, 2016

Abstract

We report a case of generalized aggressive periodontitis (AgP) requiring periodontal treatment including flap surgery and ridge augmentation. The patient was a 39-year-old woman who presented with the chief complaint of pus discharge from tooth #36. No other obvious signs of gingival inflammation were observed. Periodontal examination revealed multiple sites with a probing depth of ≥10 mm. Radiography showed pro- nounced bone defects in the maxillary incisors and molar region. Real-time PCR was used to detect Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythia in subgingival plaque; all 3 pathogens were found. Based on a clinical diagnosis of generalized AgP, periodontal therapy was initiated, which resulted in an improvement in clinical and microbiological parameters. A modified Widman flap procedure was then performed on sites with residual periodontal pockets. Next, a connective tissue graft was performed for ridge augmentation at #22, which had shown evidence of ridge resorption.

Postoperative reevaluation revealed a reduction in probing depth and an improvement in marginal bone levels. Oral function was then restored using a fixed bridge prosthesis and maintenance therapy initiated. The periodontal condition has remained stable over a 2.5-year period. In the present case of AgP, surgical intervention reduced periodontal pockets and periodontal pathogens and improved the architecture of both the hard and soft tissues, allowing subsequent care of the periodontium to be performed efficiently by the patient.

Key words: Aggressive periodontitis — Initial periodontal therapy — Microbiological testing — Modified Widman procedure — Connective tissue graft

Case Report doi:10.2209/tdcpublication.2016-1700

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Bull Tokyo Dent Coll (2016) 57(4): 259–268

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Introduction

The common features of aggressive periodontitis (AgP) are: 1) the patient is other- wise clinically healthy; 2) rapid attachment loss and bone destruction; and 3) familial aggregation⁹⁾. Some studies have suggested that pathogens such as Aggregatibacter actino- mycetemcomitans and, to a lesser extent, Porphy- romonas gingivalis are involved in the patho- genesis and progression of AgP^9,25). In addition to microbial pathogens, genetic polymor- phisms may also play a role in the development of this disease, with complex interaction taking place with other genetic and environ- mental factors¹²⁾. It is therefore critical to take such risk factors into consideration when planning treatment for AgP; and any such plan will have to involve both the removal of the cause-related factors together with stabili- zation of occlusion²²⁾. One important and common goal of periodontal treatment is to reestablish a healthy periodontium that can be properly maintained by patient self-care.

Here, we report a case of AgP requiring periodontal treatment including flap surgery and alveolar ridge augmentation using a connective tissue graft.

Case Presentation

Written informed consent was obtained from the patient for inclusion in this report.

1. Oral history

In February 2011, a 39-year-old woman was referred to us at the Department of Conserva- tive Dentistry at the Tokyo Dental College Chiba Hospital by her local dentist with the chief complaint of pus discharge from tooth

#36.

She reported noticing mobility in #36 more than 10 years earlier, and had occasionally experienced swelling in the surrounding gin- giva. In 2000, she also noticed increased mobility in #21 together with labial inclination of other front teeth. Tooth #21 had been extracted due to a trauma injury in 2008. She had not

sought regular dental check-ups. In 2011, she experienced pain in #36, and her dentist referred her to our clinic for the potential extraction of the tooth together with a comprehensive periodontal examination.

2. Clinical assessment and diagnosis

The patient was systemically healthy and a non-smoker. Her father used a removable partial denture, but the reason for tooth extraction was unknown.

Figure 1 shows an oral view obtained at her first visit (baseline). A total of 26 teeth were present. Generally, although no marked evidence of gingival inflammation was present, discharge of pus from the periodontal pocket was observed in #36. The front teeth showed labial inclination. Her dental arch was V-shaped, and she presented open bite. No fremitus was observed in centric occlusion.

Working movement to the right involved #13 and 16, while that to the left involved #23 and 33; no balancing contact was observed.

Although tongue crenulations (scalloped borders) were observed, the patient was unaware of any tongue habits.

The results of the baseline periodontal examination are shown in Fig. 2. Mean probing depth (PD) was 3.9 mm, with a maximum value of 12 mm. Forty-nine out of 156 sites (31%) had a PD of ≥4 mm and 20 sites (13%) a PD of ≥7 mm. The level of plaque control as assessed by the O’Leary plaque control record (PCR)¹⁵⁾ was 58%. She brushed her teeth twice a day, but her interest level toward oral health appeared to be low.

Radiographic examination at baseline (Fig.

3) revealed angular bony defects in #16, 22, 25, 26, 36, 37, and 46. Periapical radiolucency at #16 suggested a perio-endo lesion. How- ever, the result of electric pulp testing was positive. Tooth #16 had degree 1 furcation involvement in the distal area, while that in

#36 was degree 2 in the buccal area.

Microbiological assessment of subgingival plaque was carried out as described previ- ously²⁴⁾. A sample of subgingival plaque was obtained from the site with the deepest PD (bucco-mesial site in #36). After carefully

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removing the supragingival plaque with steril- ized cotton pellets, two sterile paper points were inserted into the deepest area of the pocket for 30 sec. The sample was then imme- diately transferred into a tube supplied in a

commercial kit (Saliva-Check Lab, GC, Tokyo, Japan) and sent to a microbiological testing laboratory (GC Oral Check Center, Tokyo, Japan) for real-time PCR analysis of A. actino- mycetemcomitans, P. gingivalis and Tannerella

【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　

【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　字下げなし　斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシは -（ハイフン）に F50：tohaba の文字スタイルをかけて作成

Fig.　1　Oral view at baseline (Feb. 2011)

Fig.　2　Periodontal examination at baseline

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forsythia. The results of the microbiological assessment are shown in Fig. 4. Total bacterial counts (copies) were 1.5×10⁷. The number of copies (proportions within the total bacterial counts) for A. actinomycetemcomitans, P.

gingivalis and T. forsythia were 7.7×10³ (0.05%), 2.4×10⁶ (16%), and 9.5×10⁴ (0.6%), respectively.

A clinical diagnosis of generalized AgP was made according to the classification of the American Academy of Periodontology^1,9). 3. Prognosis and treatment planning 1) Prognosis

Due to the presence of furcation involvement and tooth motility, the prognosis for #36

was determined to be ‘hopeless’ and that for

#16 ‘poor’. Due to the presence of deep intrabony defects, the prognosis for #26 and 27 was ‘poor’. Because of its single-root mor- phology and absence of mobility, the prognosis for #22 was ‘guarded’.

2) Treatment planning

The following treatment plan was explained to the patient and informed consent obtained.

(1) Initial periodontal therapy

This comprised oral hygiene instruction, quadrant scaling and root planing (SRP), extraction of #36, control of potential tongue thrusting, endodontic treatment, and placement of provisional restorations (#16, 11–22, 35, and 36).

Fig.　3　Radiographic view at baseline

Fig.　4　Change in microbiological findings (real-time PCR) in #36 Values (copies) are shown in log scale. IP: initial periodontal therapy, A. a.: Aggregatibacter actinomycetemcomitans, P. g.: Porphyromonas gingivalis, T. f.: Tannerella forsythia.

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(2) Reevaluation

Periodontal and microbiological examinations (3) Periodontal surgery

Modified Widman flap procedure for sites with a PD of ≥4 mm

(4) Reevaluation

Periodontal and microbiological examinations (5) Treatment for recovery of oral function (6) Supportive periodontal therapy or maintenance

Clinical Procedures and Outcomes A detailed outline of the treatment process is shown in Table 1.

1) Initial periodontal therapy

After establishing the appropriate level of plaque control, quadrant-based SRP was performed. Behavioral cognitive therapy was used to reduce habitual tongue thrusting. It had been decided initially to extract #36 as the prognosis was ‘hopeless’. However, this plan was later abandoned in favor of saving the distal root. Therefore, hemisection of the

mesial root was performed at this stage. The reevaluation revealed a decrease to 13 and 4%

for sites with a PD of ≥4 and ≥7 mm, respectively. The 3 periodontal pathogens targeted were no longer detected (Fig. 4).

2) Periodontal surgery

A Widman flap procedure was selected for sites with residual periodontal pockets (Figs.

5A–D). Here, a bone defect exceeding the root apex was found in #16 intraoperatively, necessitating subsequent trisection of the palatal root. Flap surgery was also performed on #46 and 47. A provisional restoration (1-unit bridge type) was placed on #16–23.

These surgical interventions resulted in a reduction in periodontal pockets and an improvement in the marginal bone levels.

Tooth #22 was extracted because it fre- quently showed acute symptoms during initial periodontal therapy, which indicated that it would be unsuitable as an abutment tooth for the planned prosthesis. A class III ridge defor- mity according to the Seibert classification became apparent at 6 months after extrac-

Table　1　Treatment process Baseline Initial periodontal therapy February 2011 ∙ Oral hygiene instruction

∙ Scaling and root planing

∙ Behavioral cognitive therapy

∙ Hemisection (#36) September 2011 (Reevaluation)

Surgical periodontal therapy

∙ Modified Widman flap procedure (#26, 27, 15, 16, 46, 47)

∙ Placement of temporary restoration (#16-23) April 2013 ∙ Trisection (#16), Extraction (#22)

∙ Connective tissue graft (#22) (Reevaluation)

Treatment for recovery of oral function

∙ Fixed bridge prosthesis (#35, 36, 16-23) July 2013-present (Reevaluation)

Maintenance

∙ Oral hygiene instruction

∙ Professional tooth cleaning

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tion¹⁸⁾. Therefore, ridge augmentation was performed using a connective tissue graft (Figs. 5E–H), the tissue for which was har- vested from the left palatal area.

3) Treatment for recovery of oral function Postoperative reevaluation revealed no sites with a PD of ≥4 mm and an improvement in marginal bone levels. A pulpectomy had to be performed on #12 and 15 due to postoperative hypersensitivity and problems with abutment parallelism. Subsequently, final prostheses were placed on #35, 36, and 16–23 (fixed bridge). Group function was tested after placement of a provisional restoration to clarify occlusal contact. No problems were identified with occlusal guidance, so this was adopted in the final restorations as well.

4) Maintenance therapy

After reevaluation, maintenance therapy was initiated. Oral photographs, the results of periodontal examination, and radiographs at 2.5 years of maintenance are shown in Figs.

6–8. So far, the condition of the periodontium has remained stable.

Discussion

On presenting at our clinic, the patient was 39 years old, and had initially noticed mobility in the front teeth more than 10 years earlier, indicating that periodontal breakdown had started when she was in her early 20’s. Peri-

odontal destruction was observed around a total of 13 teeth, and involved more than two teeth other than first molars or incisors, lead- ing to a clinical diagnosis of generalized AgP^1,9). The PCR score was 58%, which was somewhat higher than the mean score of 49%

observed in patients visiting our hospital¹⁷⁾. The main etiologies other than plaque were calculus, parafunction, and malocclusion, and the treatment plan was focused on early removal of those factors.

Evaluation of initial periodontal therapy according to predetermined criteria for suc- cessful non-surgical therapy⁷⁾ revealed that it had been incomplete. Therefore, the deci- sion was taken to perform a modified Wid- man flap procedure to further reduce residual periodontal pockets.

An increase in bone resorption and attachment loss on reevaluation necessitated extraction of #22. A slight decrease in the vertical dimension of occlusion due to the placement of provisional restorations in the molar region may have induced occlusal trauma to the tooth. The extraction of #22 resulted in alveolar ridge resorption, which had the potential to compromise plaque control around the pontic area after placement of the final prosthesis. Furthermore, this also posed a risk in terms of compromised esthetics. Therefore, ridge augmentation was performed using a connective tissue graft. Inlay graft technique^19,20) was selected in order to increase the

Fig.　5　Periodontal surgery

During modified Widman flap procedure for #26, 27 (A, B) and #15, 16 (C, D). Connective tissue graft for

#22 site (E-G). 4 months after connective tissue graft (H).

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dimensions of both the horizontal and vertical soft tissues without affecting the muco-gingival junction. Ridge augmentation yielded favorable soft tissue architecture for the pontic placement.

The prognosis for #16 was ‘poor’, and trisection of the palatal root was performed

here. It has been reported that the 10-year survival rate after root resective therapy in molars with furcation involvement was 93%, and that periapical lesion was the most preva- lent cause for tooth loss²⁾. In the present case, root canal treatment for #16 was performed under a rubber dam to minimize the risk of

Fig.　6　Oral view at 2.5 years during maintenance

Fig.　7　Periodontal examination at 2.5 years during maintenance

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root canal infection. No hypermobility was observed in #16, and cleansability was tested with a provisional restoration. The tooth was then included in the periodontal prosthesis.

Microbiological involvement has been reported in the development of AgP for over 30 years, with A. actinomycetemcomitans being identified as the prime suspect^14,21). However, the diagnostic value of microbiologic tests in discriminating certain forms of periodontitis has been questioned^8,11,13). Nevertheless, monitoring specific periodontal pathogens is still believed to be important in periodontal ther-

apy^5,6,24). In previous reports from our depart-

ment, AgP was successfully treated with¹⁶⁾ or without adjunctive antimicrobial therapy²³⁾. In the present case, no antimicrobial therapy was implemented prior to periodontal surgery, and no A. actinomycetemcomitans, P. gingi- valis, or T. forsythia was detected after. Peri- odontal pathogens have been reported to re- emerge, triggering recurrence of periodontitis³⁾. Cugini et al.⁴⁾ reported that regular periodontal maintenance yielded favorable results microbiologically, indicating the importance of continued monitoring for periodontal pathogens.

There were limitations in the microbiological assessment in this case report. First, sampling was performed at only one site, which cannot therefore be taken to offer a represen-

tative subgingival microbiological profile of the whole mouth. Second, the initial sampling site, the bucco-mesial area of the mesial root of #36, had to be changed to the bucco-mesial area of the distal root, due to extraction of the mesial root. Currently, however, a pooled method is favored at our clinic, obtaining samples from multiple sites but excluding those where the prognosis is hopeless.

The patient’s level of plaque control was good (PCR <20%) at the start of maintenance therapy. Surgical intervention improved the architecture of both the hard and soft tissues, allowing the condition of the periodontium to subsequently be maintained efficiently by the patient. The risk at the maintenance phase was determined to be low according to the Periodontal Risk Assess- ment¹⁰⁾. However, a marked change was observed in occlusal contact and guidance after therapy. Given this situation and patient preference, the recall interval was set at 3 months. So far, the periodontal condition has remained stable, and monitoring is scheduled to continue.

Acknowledgements

We would like to thank the dental hygien- ists of the Tokyo Dental College Chiba and

Fig.　8　Radiographic view at 2.5 years during maintenance Imamura K et al.

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Suidobashi Hospitals for their collaboration in providing periodontal care.

A part of this report was presented at the 300th Meeting of the Tokyo Dental College Society (Tokyo, October 17, 2015).

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Correspondence:

Dr. Atsushi Saito

Department of Periodontology, Tokyo Dental College,

2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan E-mail: [email protected] Imamura K et al.

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