CASE OF THE MONTH Submitted by: Dr. Cecil White Jr.

HISTORY 32 year-old female; Medical history within normal limits. 32 year-old female; Medical history within normal limits. OMFS performed LeFort I osteotomy in maxilla (w/BSSO in mandible). OMFS performed LeFort I osteotomy in maxilla (w/BSSO in mandible). The mesial root of #6 was cut, and developed a persistent radiolucent area; no pain involved. The mesial root of #6 was cut, and developed a persistent radiolucent area; no pain involved. #6 developed draining fistula w/no response to electric pulp tester. Subsequent pain upon mastication, 6 months later, prompted non-surgical endo to #6. #6 developed draining fistula w/no response to electric pulp tester. Subsequent pain upon mastication, 6 months later, prompted non-surgical endo to #6. Referral to periodontist, 54 months following original orthognathic surgery. Referral to periodontist, 54 months following original orthognathic surgery.

CLINICAL EXAM 10 mm probing depth (PD) at mesial of #6, and 7 mm PD at distal of #7. 10 mm probing depth (PD) at mesial of #6, and 7 mm PD at distal of #7. Miller’s Class I mobility of #6 and #7. Miller’s Class I mobility of #6 and #7. #6 displayed purulence and bleeding upon probing. #6 displayed purulence and bleeding upon probing. Radiographs displayed radiolucent area at mesial of #6, with partial loss of root structure in apical 1/3 rd of tooth. Radiographs displayed radiolucent area at mesial of #6, with partial loss of root structure in apical 1/3 rd of tooth.

TREATMENT PLAN Phase I: Phase I: – Scaling/root planing (SRP) of area performed. – Reevaluation at 8 weeks following SRP revealed persistent problem, with no improvement in probing depth/clinical attachment levels. Phase II: Phase II: – Open flap debridement to assess lesion/defect

Pre-operative presentation- Facial surface

Pre-operative presentation- Palatal surface

Pre-operative radiograph

INTRA-OPERATIVE FINDINGS Combination 1- and 2-wall intrabony defect, extending from the mesial surface, to the distopalatal line angle of #6. Combination 1- and 2-wall intrabony defect, extending from the mesial surface, to the distopalatal line angle of #6. Vertical dimension of the defect ranged from 4-6 mm. Vertical dimension of the defect ranged from 4-6 mm. A 5 mm x 2 mm segment of gutta-percha was exposed, starting 4 mm apical to the CEJ. A 5 mm x 2 mm segment of gutta-percha was exposed, starting 4 mm apical to the CEJ.

POTENTIAL TREATMENT OPTIONS Application of Enamel Matrix Derivative (EMD) to defect and root surface of #6, closure. Application of Enamel Matrix Derivative (EMD) to defect and root surface of #6, closure. Extract tooth #6, immediate implant to #6, bone graft/barrier, closure. Extract tooth #6, immediate implant to #6, bone graft/barrier, closure. Glass ionomer cement to root surface defect, root surface conditioning with tetracycline (TCN), bone graft/TCN/barrier, closure. Glass ionomer cement to root surface defect, root surface conditioning with tetracycline (TCN), bone graft/TCN/barrier, closure. Extract teeth #6 and #7, bone graft/barrier, closure; subsequent implant placement. Extract teeth #6 and #7, bone graft/barrier, closure; subsequent implant placement. Extract #6, bone graft/barrier; subsequent placement of Fixed Bridge (#4 - #8). Extract #6, bone graft/barrier; subsequent placement of Fixed Bridge (#4 - #8).

CHOSEN TREATMENT OPTION Glass ionomer cement to root surface defect, root surface conditioning with tetracycline (TCN), bone graft/TCN/barrier, closure.

DFDBA graft/tetracycline combination placed into defect, following root surface conditioning with tetracycline and glass ionomer cement repair of root surface defect.

Placement of expanded-polytetraethylene(e-PTFE) barrier

Primary closure

6 weeks following barrier placement - Facial

6 weeks following barrier placement - Palatal

Barrier removal at 6 weeks, with “regenerative” soft tissue present

Re-entry of #6 area at 24 months following original open flap/root repair/bone graft procedure (i.e. “original” surgery)

Restoration at 30 months following “original” surgery/6 months following “re-entry” procedure - Facial

Restoration at 30 months following “original” surgery/6 months following “re-entry” procedure - Palatal

Post-operative radiograph at 24 months post-operative

PRE-SURGERY POST-SURGERY/RESTORATIVE PRE-SURGERY POST-SURGERY/RESTORATIVE

PRE-SURGERY 24 MONTH POST-SURGERY PRE-SURGERY 24 MONTH POST-SURGERY

SUMMARY PROBLEM PROBLEM – Chronic periodontal lesion, with root surface defect, caused by errant section of root surface during orthognathic surgery procedure. TREATMENT TREATMENT – Situation was treated with open flap debridement, repair of root surface defect with glass ionomer cement, root surface conditioning with tetracycline, combination DFDBA/tetracycline (4:1 ratio), and placement of e- PTFE barrier. OUTCOME OUTCOME – 1 to 3 mm probing depths, no mobility, and no bleeding on probing to sites #6 and #7.