Clinical attachment level gain and bone regeneration around a glass ionomer restoration on root surface wall of periodontal pocket.

A case describing perio-restorative management of an accidental trauma in the mid portion of root on an upper left canine tooth following an ostectomy surgery is presented here. The traumatized root area was undergoing fast resorption and a chronic periodontal abscess had developed in relation to the lesion. The article illustrates the clinical and radiographic photo series of a periodontal flap surgery done to gain access into a subgingival region for the placement of Glass ionomer restoration on the root and its periodic follow up. The clinical condition of the area suggests 8 mm clinical attachment gain over the restoration and the review radiographs at definite intervals up to 18 months revealed evidence of consistent bone regeneration around the restoration. The article also highlights the various other possibilities, where this restorative material can be effectively used in conjunction with periodontal surgical procedures.

INTRODUCTION

Clinical practice of Periodontology is often associated with interdisciplinary approaches in managing threat to the existence of tooth resulting from iatrogenic dental procedures. Judicial approach employing the precise periodontal procedure and the usage of right restorative material decides the prognosis of such teeth. Such a case is presented here, where a perfect blend of the principles of flap surgery and the biocompatible nature of a restorative material is being effectively utilized beyond its exclusive application and achieving its success.

CASE REPORT

Background

A 21-year-old female patient presented with throbbing pain in relation to upper left canine tooth. The tooth had a history of occasional pain since 1 year and was related to have started following an orthognathic surgery done on upper maxilla. On examination she had pain on vertical and lateral percussions on that tooth. The radiograph of the area revealed a root injury in the middle third of the root and the possibility of endodontic involvement of the area. The distal area of the tooth had a periodontal pocket of 9mm probing depth as seen in Figure 1.

Figure 1

Clinical presentation

The patient was unwilling for extraction of the tooth and its prosthetic rehabilitation. She was referred to do root canal treatment for the immediate management of pain. Her tooth was endodontically treated as shown in Figure 2, and she was relieved of acute symptoms and periodontal pocket became inactive. Although she was supposed to report for the periodontal review, upon relieved from acute symptoms she did not turn up.

Figure 2

Post RCT radiograph

Six months later, the patient reported with a painful periodontal abscess and a draining sinus opening in relation to the periapex of the same tooth. The gingiva in relation to the abscess was edematous and purulent exudation was noticed draining through the periodontal pocket and the sinus opening as well [Figure 3a]. The radiograph showed fast resorption of the root area in the border of lesion with an ample alveolar bone loss surrounding it [Figure 3b].

Figure 3

(a) Periodontal abscess with draining sinus; (b) Pre-op radiograph

The patient still resisted removal of the tooth and insisted on any treatment to restore her natural teeth as long as possible. Modified Widman flap[1] surgery along with restoration of the root lesion with glassionomer cement was proposed and the patient was willing for the treatment. The possibility of treatment failure following root fracture and the recurrence of pocket following non-adaptation of the gingival tissue on the restorative surface were explained to the patient.

In order to control the inflammatory status of the gingiva and to drain the abscess for a firm and less hemorrhagic area for operation, a closed curettage of the pocket followed by subgingival irrigation with 0.12% Chlorhexidine gluconate were performed. She was prescribed a course of antibiotic (Tab. Doxicycline - 100 mg) for 10 days. She was recalled after 14 days, the gingiva appeared more firm, exudation through gingival sulcus stopped, and the sinus opening had disappeared. But the disto-labial area of the canine and its distal surface had 10 and 9 mm of periodontal pocket, respectively.

Surgical procedure

The objectives of the treatment approach were to establish a proper surgical access to the resorbing root area, freshen the lesion, and restore the root region with Glass ionomer cement and the flap has to be adapted over the restoration and root.

Modified Widman flap surgery with a single vertical incision distal to first premolar was performed exposing the bony defect and injured root area. The area was thoroughly debrided [Figure 4a] the injured root surface was prepared with a micro motor to expose fresh dentin to receive restoration. The prepared root surface was restored with Glass ionomer cement (Fuji II) and after its initial setting, the excess cement were planed and smoothened as seen in [Figure 4b]. The flap was adapted back in its previous position and sutured tightly to the teeth. The immediate post-operative clinical and radiographical view of the area is shown in Figure 4c and d, respectively. The patient was prescribed amoxicillin 500 mg and paracetamol 500 mg t.i.d. for next 7 days and the sutures were removed after 10 days.

Figure 4

(a) Intra-op (lesion view); (b) Lesion restored and surface planed; (c) Postop- (clinical view); (d) Immediate post-op radiograph

Follow up observations

The patient was recalled after 6 months for clinical and radiographical evaluation. Clinically, there were no signs of inflammation in the area of surgery and the flap showed a complete adaptation to the root surface [Figure 5a]. Radiograph of the area indicated bone deposition in close proximity to the restoration and the root resorption seems to have not progressed since the restoration [Figure 5b].

Figure 5

6th month post-op - (a) clinical view; (b) radiographic view

The patient was again reviewed after one more year (18 months post operatively) for clinical and radiographical evaluation of the healing. Clinically, the flap exhibited close adaptation with the restoration surface with probing depth of just 1 mm [Figure 6a], indicating an attachment gain of 8 mm. The radiographic view of the area at this time showed considerable bone apposition around the restoration surface and a clear alveolar crestal bone substantiating the clinical findings [Figure 6b]. The aggressive root resorption following the periodontal abscess had completely ceased.

Figure 6

18th month post-op (a) clinical view; (b) radiographic view

DISCUSSION

Usually when root surface deep inside a periodontal pocket needs a restoration, its prognosis was deemed hopeless and the tooth was extracted. But in cases where the patient is adamant in retaining the tooth, exploring the possibilities of a surgery to gain access to the lesion for restoration, utilizing a right restorative material, and achieving an attachment of gingiva over it are the concern of the clinician.

The present case consists of two areas of interest that need discussion, the selection of an appropriate restorative material for the defect and the most predictable surgical technique suiting the present condition. The biocompatible property of glass ionomer cement to be used in subgingival areas has been extensively studied since many years and its therapeutic advantage over other restorative materials is well understood.[23] The glass ionomer cements possess many desirable properties like fluoride release, marginal integrity, and antimicrobial activity.[4-7] This allows it to be placed close to or even under the gingival margin with minimal reaction. Its ability to render an attachment to soft tissue graft has been proved in many studies.[89] But the evidence of bone deposition around the restoration in the present case along with soft tissue clinical attachment gain call out for further investigations of its biocompatible nature. A surgical re-entry to the site along with a histological investigation of the bone restoration interface would be necessary to understand the type of attachment achieved here.

The biggest challenge in perio-restorative management of such lesions is the possible relapse of the pocket due to non-adaptation of the flap over the restoration.

Anyway this situation was effectively managed partly by the properties of glassionomer restorative material and partly by the favourable nature of periodontal defect favouring its optimum healing.

Modified Widman flap surgery was found apt for assisting this restorative preocedure since it could aid in establishing a proper access to the operative site, debriding the area and rendered attachment at a desirable area favouring less recession post-operatively.

Although the period of its follow up is not sufficient enough to recommend this technique to all similar conditions, an attachment gain of 8 mm over a restoration surface and evidence of consistent bone deposition over it without any signs of clinical inflammation are not matters to be ignored.

This restorative material can also be attempted in conjunction with periodontal surgical procedures, in the management of sub-gingival developmental grooves and anomalies, subgingival endodontic perforations, early furcation involvement, favorable root fractures, root apex closures in apicoectomy surgery, clinical crown build up in subgingival area, etc.

CONCLUSION

Periodontal tissues seldom pardon its insult even in the form of mild rough restoration surface in contact with them. This nature of periodontium makes placement and maintenance of restorations a challenge in close proximity to them. The present case demonstrated a rare success of similar conditions taming the situations to its favor by the usage of right material and techniques, arresting root resorption on tooth, and rendering bone regeneration around a restoration surface.

The fast growing and innovative field of dental restorative materials and the advanced procedures in surgical field invariably aim at perfect reconstruction of the lost natural structures. A method of extraction and replacement with a stronger prosthesis might appear to be a relatively risk free approach in long-term management of such teeth. But in situations where a clinician doesn’t think of an option of prosthesis like implants over natural retainable tooth, the real clinical periodontology apply itself.