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Table of Contents
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 59-64

Successful stabilization of periodontal disease and preprosthetic implant site preparation using autogenous mandibular symphysis block bone grafting in aggressive periodontitis


Faculty of Dentistry, Melaka - Manipal Medical College, Jalan Batu Hampar, Bukit Baru, Melaka, Malaysia

Date of Web Publication24-May-2012

Correspondence Address:
Nettemu Sunil Kumar
Assistant Professor, Faculty of Dentistry, Melaka - Manipal Medical College, Jalan Batu Hampar, Bukit Baru, 75150 Melaka
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.96579

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   Abstract 

Aggressive periodontitis is the disease affecting the periodontium, leading to rapid attachment and alveolar bone loss in an otherwise systemically healthy individual. The rate of periodontal connective tissue and alveolar bone breakdown is further influenced by hereditary, genetic, and familial compounding factors. This case report highlights the sequential treatment strategy employed to achieve an esthetic and functioning dentition for an aggressive periodontitis patient, involving stabilization of the periodontal condition and preprosthetic site preparation by horizontal ridge augmentation using autogenous mandibular block bone grafting procedure.

Keywords: Aggressive periodontitis, autogenous bone, mandibular symphysis, patient co-operation


How to cite this article:
Sowmya N, Kumar NS. Successful stabilization of periodontal disease and preprosthetic implant site preparation using autogenous mandibular symphysis block bone grafting in aggressive periodontitis. J Dent Implant 2012;2:59-64

How to cite this URL:
Sowmya N, Kumar NS. Successful stabilization of periodontal disease and preprosthetic implant site preparation using autogenous mandibular symphysis block bone grafting in aggressive periodontitis. J Dent Implant [serial online] 2012 [cited 2018 Jul 22];2:59-64. Available from: http://www.jdionline.org/text.asp?2012/2/1/59/96579


   Introduction Top


Aggressive periodontitis poses a great challenge to clinicians with regards to periodontal treatment and prosthetic rehabilitation, mainly due to multiple complicating factors including the hasty rate of disease progression, compromised remaining dentition, superimposing hereditary and genetic influences, and the refractory nature of the disease. Providing an esthetic and functioning dentition for such a patient involves meticulous treatment planning with sequential periodontal treatment and preprosthetic preparation of site to achieve fine quality and quantity of bone prior to prosthetic therapy involving dental implant placement. The preprosthetic implant site preparation is the most important, but most often overlooked procedure in implant dentistry. This case report elaborates a well-structured treatment plan for a patient with aggressive periodontitis, involving the stabilization of periodontal condition and preparation of implantation site by horizontal ridge augmentation using autogenous mandibular block bone grafting.


   Case Report Top


A 33-year-old male patient reported to the Department of Periodontology and Oral Implantology with multiple chief complaints. The patient expressed esthetic concern over the missing teeth in relation to upper front teeth region. The patient had also started noticing a sudden increase in the spaces between the teeth and tilting and migration of few teeth since past 1 year. The patient also experienced severe bad breath during this period. However, the primary concern of the patient was the unesthetic appearance while smiling, due to the missing anterior teeth. The medical and personal histories of the patient were non-contributory. The past dental history painted a mixed picture about the patient's nature of visits to the dental office. The patient expressed extreme concern about his deteriorating dental condition, but at the same time, due to work commitments, always failed to maintain dental appointments. As a result, intraoral examination revealed a tooth preparation for crown placement done in relation to upper right central incisor, but the patient had not fulfilled further dental visits and had not completed the crown placement procedure. Also, he had extracted the upper front teeth by himself after experiencing increased teeth mobility in relation to upper right lateral and upper left central incisors [Figure 1]. Intraoral examination revealed the presence of minimal plaque and calculus deposits, and apparently healthy appearance of gingiva, but periodontal probing revealed the presence of generalized deep periodontal pockets and Grade I mobility of all the teeth. Pathological migration involving rotation and tilting of few teeth were also noticed. Radiographic examination including full mouth intraoral periapical radiographs and orthopantamogram [Figure 2] revealed generalized moderate horizontal as well as few areas of angular bone loss patterns. A tailor-made treatment plan to suit this patient was formulated. Taking into consideration the patient's nature, prior to commencement of treatment, he was given detailed counseling on the importance of oral health, the need for sequential treatment planning involving periodontal, preprosthetic, and prosthetic treatment components, and the significance of the maintenance phase of treatment and recall visits to the dental office. Informed consent was obtained from the patient.
Figure 1: Preoperative intraoral view

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Figure 2: Preoperative radiograph

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Treatment plan was primarily aimed at stabilization of the periodontal condition.

Phase I therapy included thorough supragingival and subgingival scaling, root planing and polishing, and providing instructions on oral hygiene. An adjunctive systemic antibiotic therapy was initiated with 100 mg/ day doxycycline for 14 days. Four weeks later, reprobing of periodontal pockets and reassessment of oral hygiene was done. Phase II periodontal therapy was initiated and periodontal flap surgery was performed in relation to all the teeth, with placement of bovine particulate xenograft (Bio-Oss, Geistlich Pharmaceuticals, Wolhausen, Switzerland) and sterile bioresorbable collagen membranes (Healiguide, Advanced Biotech Products, Chennai, India) in relation to teeth with favorable intrabony defects. At the time of the third month review visit, intraoral examination revealed a stable periodontal condition, with minimal probing pocket depths and adequate oral hygiene maintenance. Taking into consideration the personal and functional demands of the patient, implant therapy was included in the treatment plan. Bone mapping was carried out at the sites of missing upper right lateral and upper left central incisors. The next surgical treatment phase involved preprosthetic horizontal ridge augmentation using autogenous block bone grafts harvested from the mandibular symphysis region, in relation to these regions, in order to achieve adequate bone volume and quality for providing support to the future prostheses.

Surgical procedure

The surgical sites were anesthetized by local administration of 2% lignocaine hydrochloride (LOX, Neon Labortories Ltd., Mumbai, India) with 1:200,000 adrenaline. At the recipient site in relation to upper anterior region, mucoperiosteal flaps were elevated using a crevicular incision on the labial and palatal aspects, along with mesial and distal vertical releasing incisions on the labial aspect, and the horizontal deficiency defect was exposed [Figure 3]. The mobility of the flaps was then tested to ensure that primary closure of the site can be obtained through tension-free suturing. Using a William's graduated periodontal probe (Hu-Friedy, Chicago, USA), measurements of length and width of grafting sites were obtained.
Figure 3: Recipient site at the maxillary anterior region

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Harvest of autogenous corticocancellous block bone grafts from mandibular symphyseal region

Access to the surgical site was obtained using a vestibular incision apical to the roots of the lower anterior teeth; flap was mobilized with careful periosteal separation and relieved to expose sufficient mandibular symphyseal bone [Figure 4]. Autogenous corticocancellous block bone grafts, each measuring approximately 3 × 2.5 cm, were harvested using straight fissure steel burs (Hager and Meisenger GmbH, Dusseldorf, Germany) [Figure 5] and [Figure 6] and immediately placed inside dappen dish containing isotonic saline solution [Figure 7]. The bone blocks were harvested with special care to avoid jeopardizing vital anatomic structures. Decortication holes were then placed at the recipient bed using 1-mm-diameter drill (KLS Martin, Florida, USA) [Figure 8]. This step ensured initiation of osteogenesis, speedy and adequate blood supply to the area to obtain rapid blood clot formation, and accumulation of a reservoir of endogenous bone-formative elements. [1],[2],[3],[4] The soft cancellous layer of the block grafts was trimmed and placed flush against the recipient defect, while the cortical side of the graft provided an ideal surface for rigid fixation. With a lag screw technique, the block grafts were compressed and rigidly fixed to the recipient surface with miniscrews (KLS Martin; 1.5 mm in diameter and 7 mm in length) to prevent any rotational movements of the grafted blocks. The screws were advanced until the gap between the head of the screws and the cortical surface of the grafts was closed [Figure 9]. The donor site was packed carefully with xenograft particulate bovine bone graft material (Bio-Oss, Geistlich Pharmaceuticals), following which the flaps at the recipient and donor sites were sutured using an absorbable suture material (4-0 Vicryl, Ethicon, Inc., Johnson and Johnson, Somerville, NJ, USA).
Figure 4: Donor site at the mandibular symphysis region exposed to harvest autogenousblock bone grafts

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Figure 5: Outline of the graft block on the left side of the mandibular symphysis midline

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Figure 6: Outline of the graft block on the right side of the mandibular symphysis midline

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Figure 7: Harvested autogenous block bone grafts placed in sterile isotonic saline solution

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Figure 8: Decortication holes placed at the recipient site

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Figure 9: Autogenous block bone grafts secured tightly in position at the recipient site

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Postoperative care

A prescription of betamethasone and systemic antibiotic therapy of 100 mg/day doxycycline for 10 days was given. The patient was advised to use warm saline rinses for the first 2 weeks to promote wound healing process, followed by the use of 0.12% chlorhexidine gluconate (Peridex, Zila Pharmaceuticals, Phoenix, AZ, USA) to facilitate adequate plaque control. [5]

The surgical sites were checked every 2 weeks for a period of 2 months. There was very minimal postoperative discomfort experienced by the patient and no postoperative complications were reported. Following 6 months of healing period, the patient was recalled for surgical removal of the fixation screws and implant placement at the augmented sites. The patient, however, expressed lack of interest in undergoing implant placement and further dental treatment citing employment commitments and busy work schedule as reason. Access flap was raised in the upper anterior region and the fixation screws were removed; the augmented sites exhibited successful integration of the harvested block bone grafts to the recipient bed [6] [Figure 10] and [Figure 11]. A temporary prosthetic bridge was placed in the upper anterior region for esthetic purpose. The patient failed to report to the dental office for further appointments.
Figure 10: Proper integration of the augmented bone graft to the recipient site observed during screw removal second surgery after healing period

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Figure 11: Proper integration of the augmented bone graft to the recipient site observed during screw removal second surgery after healing period

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   Discussion Top


The use of dental implants as part of oral rehabilitation has become a common treatment modality that is reliable in the long term. [7],[8],[9],[10] Since the late 1980s, numerous study results have been published on the oral rehabilitation of partially edentulous patients with implants. [10],[11],[12],[13],[14] The question of whether the positive results published to date can also be applied to periodontally diseased patients with a compromised remaining dentition is yet to be adequately clarified. Implant placement at any given edentulous site is a relatively easy procedure, but preprosthetic site preparation to create an ideal bone bed for receiving and stabilizing the implant to achieve complete osseointegration is of utmost importance. In most cases, this concept of achieving good quantity and quality of bone at the edentulous site is often overlooked. In this case report, an organized sequential treatment plan was executed, involving the stabilization of periodontal condition and successful preparation of the implantation site by horizontal ridge augmentation using autogenous mandibular block bone grafting. Autogenous bone grafts are considered as "gold standard" and predictable regeneration is achievable due to its potential osteogenic property. Further, it has been shown that in the facial skeleton, membranous bone, such as that harvested from the mandible, undergoes less resorption than endochondral bone. [15],[16] And, if the graft volume is sufficient for the planned reconstruction, mandibular bone is the ideal choice. [17],[18] Intraoral block bone grafting is a predictable operation with a high success rate for long-span augmentation up to complete jaw augmentation or extensive bone reconstruction of the maxillary alveolar ridge. [19] Autogenous bone grafting using blocks of bone obtained intraorally or extraorally are widely considered the best approach to augment deficient alveolar ridges. [17],[20],[21] Mandibular block autografts for maxillary and mandibular ridge augmentation are predictable and offer many advantages. [22] These grafts are primarily cortical in nature, exhibit minimal resorption, and tend to incorporate exceptionally well with recipient bone within a short time frame. They also maintain post-implant placement bone volume and retain the radiographic density to the augmented site. [21] The results of a 3-year prospective longitudinal study showed that oral rehabilitation can be performed with implants in patients treated for generalized aggressive periodontitis. However, a continuous slight attachment loss and bone loss was reported and the potential for implant placement in these patients needs to be shown in controlled longitudinal studies. [23] Results of a 10-year prospective long-term cohort study concluded that partially edentulous subjects treated for generalized aggressive periodontitis can be rehabilitated successfully with osseointegrated implants; however, the bone and attachment loss at the implant site was higher than in periodontally healthy subjects. [24]


   Conclusion Top


The possibility of continuous attachment loss and bone loss occurring around natural teeth and their prosthetic replacements in regenerated bone cannot be ruled out in patients treated for aggressive periodontitis. Stabilizing the periodontal condition and ensuring patient maintenance and co-operation is mandatory and of utmost importance prior to planning the prosthetic rehabilitation of the dentition involving implant prosthesis. The prognosis for the retention of the teeth and implants is thus open to question and depends on patient's stringent home care and maintenance regime and reporting for regular recall visits.

 
   References Top

1.Lang NP, Hammerle CH, Bragger U, Lehmann B, Nyman SR. Guided tissue regeneration in jaw bone defects prior to implant placement. Clin Oral Implants Res 1994;5:92-7.  Back to cited text no. 1
    
2.Fritz ME, Jeffcoat MK, Reddy M, Koth D, Braswell LD, Malmquist J, et al. Guided bone regeneration of large mandibular defects in a primate model. J Periodontol 2000;71:1484-91.  Back to cited text no. 2
    
3.Rompen EH, Biewer R, Vanheusden A, Zahedi S, Nusgens B. The influence of cortical perforations and space filling with peripheral blood on the kinetics of guided bone regeneration. A comparative histometric study in the rat. Clin Oral Implants Res 1999;10:85-94.  Back to cited text no. 3
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4.Smukler H, Capri D, Landi L. Harvesting bone in the recipient sites for ridge augmentation. Int J Periodontics Restorative Dent 2008;28:411-9.  Back to cited text no. 4
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5.Wang HL, Boyapati L. "PASS" principles for predictable bone regeneration. Implant Dent 2006;15:8-17.  Back to cited text no. 5
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6.Peleg M, Sawatari Y, Marx RN, Santoro J, Cohen J, Bejarano P, et al. Use of corticocancellous allogeneic bone blocks for augmentation of alveolar bone defects. Int J Oral Maxillofac Implants 2010;25:153-62.  Back to cited text no. 6
    
7.Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416.  Back to cited text no. 7
    
8.Albrektson T, Dahl E, Enbom L, Engevall S, Engquist B, Eriksson AR, et al. Osseointegrated oral implants: a Swedish multicenter study of 8139 consecutively inserted Nobelpharma implants. J Periodontol 1988;59:287-96.  Back to cited text no. 8
    
9.Zarb GA, Schmitt A. The longitudinal clinical effectiveness ofosseointegrated dental implants in posterior partially edentulous patients. Int J Prosthodont 1993;6:189-96.  Back to cited text no. 9
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10.Jemt T, Lekholm U, Adell R. Osseointegrated implants in the treatment of partially edentulous patients: a preliminary study on 876 consecutively placed fixtures. Int J Oral Maxillofac Implants 1989;4:211-7.  Back to cited text no. 10
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11.Van Steenberghe D, Lekholm U, Bolender C, Folmer T, Henry P, Herrmann I, et al. The applicability of osseointegrated oral implants in the rehabilitation of partial edentulism: A prospective mulitcenter study on 558 fixtures. Int J Oral Maxillofac Implants 1990;5:272-81.  Back to cited text no. 11
    
12.Naert I, Quirynen M, van Steenberghe D, Darius P. A six-year prosthodontic study of 509 consecutively inserted implants for the treatment of partial edentulism. J Prosthet Dent 1992;67:236-45.  Back to cited text no. 12
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13.Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke N, Hirt HP, et al. Long-term evaluation of non-submerged ITI implants (I). 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res1997;8:161-72.  Back to cited text no. 13
    
14.Lekholm U, Gunne J, Henry P, Higuchi K, Lindén U, Bergström C, et al. Survival of the Branemark implant in partially edentulous jaws: A 10-year prospective multicenter study. Int J Oral Maxillofac Implants 1999;14:639-45.  Back to cited text no. 14
    
15.Zins JE, Whittacker LA. Membranous versus endochondral bone autografts: Implications for craniofacial reconstruction. Plast Reconstr Surg 1983;72:778-86.  Back to cited text no. 15
    
16.Phillips JH, Rhan BA. Fixation effects on membranous and endochondral onlay bone graft vascularization and bone deposition. Plast Reconstr Surg 1990;85:891-7.  Back to cited text no. 16
    
17.Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 1997;12:767-76.  Back to cited text no. 17
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18.Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis graft for dental implants: A preliminary and procedural report. Int J Oral Maxillofac Implants 1992;7:360-6.  Back to cited text no. 18
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19.Schwartz-Arad D, Levin L. Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges. J Periodontol 2005;76:636-41.  Back to cited text no. 19
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20.Misch CM. Use of the mandibular ramus as a donor site for onlay bone grafting. J Oral Implantol 2000;26:42-9.  Back to cited text no. 20
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21.Misch CE, Dietsch F. Endosteal implants and ileac crest grafts to restore severely resorbed totally edentulous maxillae - A retrospective study. J Oral Implantol 1994;20:100-10.  Back to cited text no. 21
    
22.Michael A. Pikos. Atrophic posterior maxilla and mandible: Alveolar ridge reconstruction with mandibular block autografts. Alpha Omegan 2005;98:34-45.  Back to cited text no. 22
    
23.Mengel R, Flores-de-Jacoby L. Implants in patients treated for generalized aggressive and chronic periodontitis: A 3-year prospective longitudinal study. J Periodontol 2005;76:534-43.  Back to cited text no. 23
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24.Mengel R, Behle M, Flores-de-Jacoby L. Osseointegrated implants in subjects treated for generalized aggressive periodontitis: 10 year results of a prospective, long-term cohort study. J Periodontol 2007;78:2229-37.  Back to cited text no. 24
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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