This month's On The Chair is a very interesting case presentation of guided tissue regeneration around the mesal defect of a lower first molar using bioactive glass (Biogran) as the regenerative material with additional protection with a cut section of Resolut membrane.

GUIDED TISSUE REGENERATION AROUND A LOCALISED PERIODONTAL DEFECT

Initial Presentation

A 38 year old patient presented with the complaint of recurrent swelling in gums accompanied with a dull ache over the last couple of years. On detailed examination she was diagnosed as a case of rapidly progressive periodontitis.

A very unique feature of this case was the very highly localised nature of periodontal disease. Clinical examination showed deep pockets of 8 to 9 mm with pururlent exudation adjacent to almost absolutely healthy areas with little or no inflammation and geingival crevices of 1 to 2 mm only. An OPG was taken to assess the overall damage and multiple periodontal lesions were noted spread across the maxilla and the mandible.

The medical history of the patient was not siginficant. The patient used standard oral hygiene measures of cleaning the teeth twice a day with a locally available toothbrush and paste. Plaque levels were not very high and not much of supragingival calculus could be observed. However, all areas with deep lesions had extensive subgingival calculus. The patient has a total of 28 teeth and after a detailed periodontal charting was done the following scores were obtained. The mean recession score was 1 mm and the mean pocket depth was 4 mm. The largest pocket depth score was observed to be 9 mm. The patient was recommended to undertake a thorough oral prophylaxis followed by surgical intervention to regenerate the lost periodontal apparatuss.

Initial Treatment

A complete oral prophylaxis was carried out. All the discernable supra and subgingival calculus was removed and a thorough root planing was carried out. The patient was then instructed in oral hygiene measures for maintenance. She was then scheduled for surgery. A full mouth flap surgery was performed in one single sitting. Each quadrant was opened up, the infective tissue removed, the bony lesions exposed and selectively only Biogran or Biogran and a covering Resolut membrane was placed around the defects. Since this communication is aimed at presenting a detailed follow up of one of the lesions the rest of the information shall be targetted at the lower right first molar.

The lower right first molar presented a very unique defect on the mesial aspect on the buccal side. The pocket scores of the tooth corresponded with the lesions. On raising the full thickness flap, the mesial root was found to be almost totally denuded of bone. Surprisingly the furcation area of the molar was not exposed and had good healthy bone. Infected granulation tissue was found at the lesions site. The granulation tissue was curetted away leaving behind a large U shaped bony defect on the mesial root of the molar. The adjacent premolar showed no defect.

This defect was then filled with Biogran.Biogran is bioactive glass particles manfuactered and sold by Orthovita. These particles range in size from 300 to 355 µm. The material has exceptional handling capabilities and is very easy to place. The entire defect was filled up with Biogran. A small piece of Resolut membrane (resorbable membrane from Gore Tex) was then sectioned and placed over the buccal side of the defect. The flap was then placed over the defect and closed with interrupted sutures.

Post Operative

The patient had no complaints on the following day. There was a mild oedema which subsided by the second day. Good prmiary closure was obtained and maintained till the seventh day when the sutures were removed. The patient was placed on a regimen of Periogard (Chlorhexidine mouthwash from Colgate) for the next 6 weeks. Externally the soft tissue showed excellent healing and there was no complaint of bleeding or purulent exudation subsequently. The patient was maintining the interproximal areas remarkable well. An immediate post op intra oral X-ray was taken which showed the Biogran granules in the defect.

The patient was followed up and a 3 month post op X-ray of the same region was repeated. The Biogran was seen integrating with the adjacent bone. However, the second molar showed signs of further bone damage. This area was not completely handled at the time of the initial surgery. The patient was recommended a reentry into the second molar region to attempt regeneration in lieu of the excellent results obtained in the first molar.

Six Monthly Follow-up and Re-entry

Six and half months after the initial surgery a seoncd surgical procedure was performed to obtain regeneration around the furca and distal defect on the second molar. A full thickness flap was raised to carry out the procedure. Prior to surgery the patient was examined and presented with excellent oral hygine and almost no inflammation except in the lower right second molar.

An IOPA was taken for the lower first molar which showed excellent regeneration of the periodontal apparatuss in the mesial defect. The flap was extended to the second premolar and the area of the the origical defect on the first molar showed almost a complete bone fill and regeneration. This is very clearly visualised in the clinical picture available.

Conclusion

This case has presented with multiple lesions all of which have healed with varying amounts of regeneration of the periodontal structures. The lesion on the lower first molar has been emphasised upon due its very uniqe nature of being a very deep and narrow defect. The lesion had extensive purulent exudation and was barely 3 mm away from almost totally healthy tissue around the same tooth. Such lesions, if repaired and regenerated will go a very long way in having an excellent prognosis. Biogran with its ability to induce excellent bone formation, aided with the Resolut membrane to prevent Connective Tissue infiltration works excellently in aiding good regeneration. What remains to be followed up is the status of the second molar six months from now. A good bone fill in the region will ensure a good and healty prognosis for all her teeth.

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