Multidisciplinary prognostic transition of a molar tooth for long-term survival.

Patients with periodontitis may have one or few teeth with hopeless prognosis, which would have to be extracted before initiation of orthodontic therapy. Periodontal therapy aims to prolong the lifespan of dentition, as preserving natural dentition is always the best treatment option. The decision to retain a tooth is always based on the probability of long-term success of one or more treatment modality. A 17-year-old female patient seeking fixed orthodontic treatment presented with the left mandibular first molar tooth (36) having hopeless periodontal prognosis with advanced primary periodontal and secondary endodontic lesion, grade III mobility, and grade II furcation involvement. Root canal treatment followed by periodontal surgery using a combination of bone graft (allograft) and platelet-rich fibrin membrane resulted in a clinical and radiographic indication of periodontal healing. The tooth (36) was even used for orthodontic anchorage 3-month postsurgically and was maintained for 2 years. Appropriate diagnosis and meticulous multidisciplinary treatment approach can lead to the restoration of health and function of the teeth with severe loss of attachment and bone loss and can even be used for orthodontic anchorage.

INTRODUCTION

The number of patients (both children and adults) receiving orthodontic treatment has increased both in numbers and in percentage over the last few years. Most orthodontic patients are children and adolescents who except in unusual condition generally have a healthy periodontium with the first molar being used as the anchorage tooth during orthodontic therapy. An underlying periodontal problem not only can worsen during orthodontic therapy but also prevent optimum results. It is important to identify periodontal problems before orthodontic treatment and sequentially plan the orthodontic and periodontal therapy to improve the patient's periodontal health.[12] The rationale of periodontal treatment is to prolong the lifespan of periodontally diseased dentition and to preserve the tooth not only in good esthetic and functionally healthy condition but also to restore the lost periodontium.[3] According to McGuire[4] classification of prognosis, teeth with advanced bone loss, severe attachment loss, and mobility is often considered hopeless and is usually extracted. Recently, Martinez-Canut et al.,[5] introduced a prediction model that helps in determining the prognosis of the whole dentition/tooth, based on survival expectancy, and also to assess the accuracy of the prediction of any tooth extracted for periodontal reasons. The aim of the case report was to present a change in periodontal prognosis and survival rate of a mandibular first molar by multidisciplinary approach, which was later, used as orthodontic anchorage.

CASE REPORT

In January 2015, a 17-year-old systemically healthy, nonsmoking female patient seeking treatment of malaligned teeth was referred from the Department of Orthodontics to the Department of Periodontology of the Institute for opinion regarding severe mobility in the lower left back tooth for 2 months. Medical history and family history were noncontributory and the patient got one of her front tooth extracted due to caries 2 years back. On extraoral examination, swelling in the left mandibular area overlying the posterior teeth was observed, and the submandibular lymph nodes were nonpalpable and nontender. On intraoral examination, maxillary anteriors were proclined, mandibular left central incisor (31) was missing, mandibular left lateral incisor (32) was mesially tilted, slight swelling in the mandibular vestibular region, and periodontal abscess was present in relation to the left mandibular first molar tooth (36). Grade III mobility, advanced Grade II lingual furcation involvement, probing depth of 8 mm (mesial, buccal) and 7 mm (distal and lingual), respectively, and clinical attachment loss being 8 mm on mesial and buccal aspects, 6 mm on lingual, and 5 mm on distal surfaces of tooth were recorded. The tooth did not respond to any vitality tests. There was open contact between teeth 35 and 36 resulting in food impaction. Radiograph showed periodontal ligament widening and radiolucency in the furcation area along with a deep infrabony defect on the mesiobuccal root extending to root apex of tooth 36 [Figure 1].

Figure 1

Preoperative view (a) clinical; (b) radiographic

The presence of traumatic bite along with food impaction in between mandibular anteriors and between 35 and 36 leading to angular type of bony destruction involving 36 was seen. Pattern of bone loss, pulpal involvement, and radiographic appearance confirmed the diagnosis of primary periodontal with secondary endodontic lesion due to localized food impaction in 36. Prognosis of the tooth as per McGuire's classification[4] was hopeless and as per Martinez-Canut et al., prediction model, a code of 0.406 was generated with the survival rate being 4–13 years.[5]

Case management

Treatment planning was done after deliberation, knowing that the tooth had advanced periodontal–endodontic lesion and will be used as an orthodontic anchorage tooth. Treatment of such type of defect is usually controversial whether to undergo extraction or root resection/hemisection, but an interdisciplinary attempt was taken to preserve the tooth in total. Patient was explained about the condition and the planned treatment and also informed written consent was obtained from the patient before treatment. After drainage of the periodontal abscess and completion of phase 1 periodontal treatment, the patient was scheduled for endodontic treatment. After 1 month of revaluation of endodontic therapy, Grade III mobility was reduced to Grade I. Thereafter, periodontal surgery was scheduled and the patient was followed up.

Surgical procedure

Using intracrevicular incision, a localized mucoperiosteal flap was elevated. After the flap was reflected, thorough debridement was done and granulation tissue and tissue tags were removed. Demineralized freeze-dried bone allograft (DFDBA) was placed along with platelet-rich fibrin (PRF) membrane in one wall defect present on mesiobuccal root and lingual furcation defect [Figure 2]. Interrupted direct sutures were placed in each interdental space using nonresorbable black silk (4-0) suture.

Figure 2

During surgery (a) presence of one-wall defect in relation to mesial root of left mandibular first molar tooth (36); (b and c) vertical defect and furcation defect filled with demineralized freeze-dried bone allograft and platelet-rich fibrin membrane

Clinical outcome

The patient was recalled at 10 days for suture removal and was further recalled for follow-up at 1, 3, 6, and 9 months and thereafter at 2 years. Orthodontic forces were applied after 3-month postsurgically and tooth 36 was used as one of the anchorage teeth [Figure 3]. Clinical attachment loss of 4-mm mesially and on mesiobuccal aspect was present at 3-month postsurgically, which reduced to 3 mm at 6 months and remained stable at 2-year follow-up visit; and follow-up radiographs also showed good amount of bone fill in tooth 36 [Figures 4 and 5]. Furthermore, as per Martinez-Canut et al., prediction model result, tooth with the present parameters will not be lost.[5]

Figure 3

Orthodontic anchorage taken from left mandibular first molar tooth (36) 3 months postsurgically

Figure 4

Two-year postsurgical healing

Figure 5

Healing as depicted in radiographs (a) preoperative; (b) postendodontic treatment; (c) at 3-month postsurgery; (d) at 6-month postsurgery; (e) at 9-month postsurgery; (f) at 2-year postsurgery

DISCUSSION

Patients with advanced periodontal disease may have specific teeth with hopeless prognosis, which usually undergo extraction before orthodontic treatment.[6] The aim of periodontal treatment is to arrest periodontal disease progression and maintain patients' teeth irrespective of the prognosis. Graetz et al.[7] reported that in both aggressive and chronic periodontitis patients, approximately 80%–88% of questionable and 60%–66% of hopeless teeth survived at the end of 15-year supportive periodontal therapy. Effective treatment of periodontitis is substantially influenced by various risk factors and hence requires identification.[7] High-risk patients presenting a worse scenario and higher probability of tooth loss due to periodontal disease and identification of risk factors leading to individual tooth loss is a foremost research goal in periodontal prognosis.[8]

Conventional prognostic determinants were based on only tooth-related factors. The presence of local factors, systemic factors, environmental and genetic factors must be considered and analyzed as risk factors for disease.[58]

Various factors such as age, severe periodontitis, heavy smoking, bruxism and baseline number of teeth, type of tooth, furcation involvement, probing pocket depth, bone loss, mobility, and crown/root ratio have been studied to determine the prognosis of the whole dentition/tooth, based on survival expectancy. Knowledge of survival expectancy offers guidance for decision-making regarding whether to maintain or to extract periodontally compromised teeth.[58]

Advanced bone loss involving molar at a young age as of our patient could suggest acute episodes with aggressive form of the disease, but there are other factors such as no genetic predisposition/family history, presence of poorly aligned teeth, trauma from occlusion, food impaction as possible contributory factors for her condition.[9] Gould and Picton[10] found higher periodontal index scores in teeth with poorly shaped contacts when compared with teeth with sound proximal contacts. Occlusal discrepancy could be considered as an independent risk factor contributing to periodontal disease.[11]

In this case, in relation to the left mandibular molar, greater loss of attachment and subsequent bone loss due food impaction and due to mesial tilting of mandibular lateral incisor traumatic bite were observed. Jernberg et al.[12] reported greater probing depth and clinical attachment loss for sites with open contacts and food impaction compared with contralateral sites without open contacts or food impaction.

Bone loss leading to pulpal involvement secondarily may occur due to the spread of inflammatory irritants from the periodontal ligament to the pulp through dentinal tubules, apical foramina, accessory and lateral canals. The treatment of primary periodontal with secondary endodontic lesions requires sequential planning of both endodontic and periodontal therapy as discussed in this case report.[131415]

The goal of treating periodontal-endodontic lesion is to eliminate the etiology, complete sealing of the root canal system, followed by resolving the periodontal component of the lesion, facilitating the regeneration of hard and soft tissues, and formation of new attachment apparatus.[16] Lesions involving both periodontal and endodontic pathologies requires careful management. Pulpal pathologies tend to resolve with endodontic therapy, though, endodontic complications, failures; fractures should also be taken care as they may act as a cause of tooth loss alongside periodontal disease progression. The long-term prognosis of such cases is related to the extent of periodontal attachment loss. The success of therapy depends on the ability to regenerate periodontal attachment and to obliterate the defect in case periodontal lesion is advanced with the presence of a multiwalled bony defect.[17]

In our case, endodontic therapy was done initially as the tooth was nonvital due to the spread of periodontal infection till the apex leading to secondary pulpal infection. The patient was followed for 1 month and reduction of pulpal and periapical inflammation with substantial healing was observed both clinically and radiographically, but the presence of primary periodontal component, which led to development of angular bony defect, needed further evaluation, hence, regeneration was attempted.

In our patient, both periodontal and orthodontic interventions were required, but which one to go first? Health of the periodontal tissues is important so that optimal orthodontic treatment outcome can be obtained, while orthodontic therapy improves the overall functional and esthetic rehabilitation of a periodontally compromised dentition.[18] Removal of plaque and plaque retentive factors should be done before the commencement of orthodontic treatment, and in patients with periodontal defects, orthodontic treatment is usually performed before periodontal surgery as it may lead to change in the shape of periodontium and elimination of defects reducing the need for or extent of surgery. In patients with advanced furcation defect, hemisection may be attempted, but if orthodontic intervention is required in such cases, orthodontics should be attempted first, as keeping the tooth intact during the orthodontics simplifies the concentration of tooth movement.[13]

On the other hand, the prudent clinician knows which defect can be improved with orthodontic treatment and which requires multidisciplinary approach. Periodontal evaluation before orthodontic therapy are required where active disease in spite of adequate phase 1 therapy is present, also where vertical defects are present, as movement of teeth may lead to additional loss of connective tissues.[19] Regenerative periodontal therapy is usually implemented before orthodontic treatment (10 days to 4 months) to create favorable preorthodontic conditions in complex clinical scenarios but can be done postorthodontic therapy as well depending on the case.[18]

The sequence of periodontal and orthodontic treatment should be evaluated after mutual consultation between periodontist and orthodontist.

Orthodontic treatment may be started, if the result of periodontal therapy is stable 2–6 months after periodontal surgery for periodontal tissue remodeling, restoration of health, and evaluation of patient's compliance.[18]

In our case, periodontal treatment was done before orthodontic therapy, as control of inflammation was required during the orthodontic process and also maintenance of health of bone around teeth was mandatory, as the tooth was to be used as an orthodontic anchorage tooth.

A variety of regenerative materials have been used in periodontal surgeries. DFDBA along with PRF was chosen as regenerative material in our case with one wall defect being present on mesiobuccal root and furcation defect present lingually in 36. DFDBA has been widely used in periodontal therapy, as it is both osteoinductive and osteoconductive. In various animal experiments, Urist reported that DFDBA being osteoinductive could stimulate the formation of new bone.[20] It maintains the space for tissues to form and osteoconductive property of the graft may act as scaffold for the growth of mineralized tissue, but various researchers have reported differences in osteoinductive property of DFDBA wherein few, donor bone has shown no activity at all and had thus acted as source of Type I collagen only.[21] These confines of DFDBA have let to the search of a regenerative material with similar regenerative abilities and minimum disadvantages in terms of antigenicity and cost. When platelet concentrates were added to DFDBA, a more predictable result was obtained.[22]

PRF, a second-generation platelet concentrate that was introduced by Choukroun et al. in 2001,[23] has also shown optimistic and promising results. It is a fibrin matrix concentrate enriched with platelets and growth factors that stimulate tissue regeneration and healing. It leads to faster angiogenesis, promotes wound healing, and formation of more resistant connective tissue. It enhances bone formation by stimulation of alkaline phosphatase activity, production of osteoprotegerin, differentiation of osteoblasts, and increasing the RUNX2 expression.[24] Moreover, the cost factor and risk of disease transmission is less due to PRF being an autologous material.[2225]

Varughese et al.[26] reported greater attachment gain and bone fill with osseograft along with PRF membrane and GTR in treatment of perio-endo lesion. Similarly, Bansal and Bharti[22] reported significant improvement in pocket depth and clinical attachment level gain in intrabony defects with DFDBA and PRF. In the present case report, PRF membrane combined with bone graft, resulted in clinically successful resolution of defect after 6-month follow-up period maintained up to 2-year postoperatively. No postsurgical complications were seen like bleeding, pain, relapse of the condition, or development of any root caries which could act as the limiting factor in the success of the therapy.

Furthermore, during orthodontic treatment, periodic periodontal examination is a must which requires professional cleaning and examination of periodontal tissues. The follow-up visit interval varies for individual patient from 8 to 12 weeks to 6 months, and it should be determined considering all the risk factors for periodontal disease and the planned orthodontic movements. If the patient fails to comply with oral hygiene maintenance, orthodontic treatment should be modified.[1819]

In the present case, the patient is a 17-year-old young compliant female and was followed up at 1, 3, 6, and 9 months and thereafter at 2 years, wherein scaling and adequate oral hygiene reinforcement was done. This was done as control of inflammation reduces the chances of orthodontic forces to become detrimental to tissues. Furthermore, our protocol of continuous monitoring and assessment of periodontal condition; adequate maintenance and periodic reinforcement of oral hygiene instructions; and motivation helped us to restrict any acute flare-ups during the treatment, with the patient's compliance playing an important role.

CONCLUSION

The benefits of integrating periodontics, endodontics, and orthodontics in patients with deep periodontal defects requiring orthodontic tooth movement may restore esthetics and functional health of the occlusion while restoring patient's periodontal health.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.