Interdisciplinary approach for patients with stage-IV periodontitis
“Orthodontic treatment can start shortly after regenerative surgery.” Christina Tietmann | Germany Periodontist, Private Practice for Periodontology Aachen
Karin Jepsen | Germany Priv. Doz., Center for Dental and Oral Medicine University of Bonn Interview conducted by Verena Vermeulen
We discussed two publications documenting treatment of stage IV periodontitis. Both studies were about the combination of regenerative periodontal surgery and orthodontic tooth movement. Is this a valuable combination? Whom does it help? Dr. Tietmann, we are talking about patients with stage IV periodontitis. What characterizes them? Dr. Tietmann: These patients show severe attachment loss and vertical bone loss. The most visible sign of stage IV periodontitis is pathological tooth migration, the typical drifting and flaring of the anterior teeth. You can usually see these patients hiding their smile because they are unhappy about the compromised esthetics. Furthermore, they suffer from functional problems due to the loss of teeth in the posterior region and tooth mobility.
When they come to your office, what is their expectation? Major concern is to keep their own dentition. Due to the esthetic and functional changes they want to get the migrated
teeth realigned and regain esthetics and masticatory function. Very often, pathologic tooth migration of an anterior tooth is the first sign for the patients which makes them seeking – periodontal – treatment. A lot of the patients already had many dental visits and were told their teeth would have to be extracted and would need either implants or removable prostheses.
Implant placement in a patient with a history of severe periodontitis is also not very predictable… That’s true. Periodontal problems must be solved first, before implants can be placed, and still there is a threat of peri-implantitis, because a history of periodontitis is a risk factor for implants. Within the days of periimplantitis it is the major goal to keep the natural dentition as long as possible.
How do you usually treat such patients? It’s a three-step approach. The first step is always to control the infection – antiinfective treatment must be finished before moving on. Second step is periodontal regenerative surgery. This means that I open a flap with minimally invasive surgical techniques to clean the defect and the root and use biomaterials to regenerate the vertical bony defect. It is crucial to stabilize the blood clot during the healing period of regenerative therapy for successful results in mobile teeth. This can be done either by retainers or by implementing the orthodontic appliance before periodontal regenerative surgery starts. And then, the final step is orthodontic treatment. In our retrospective study we started orthodontic tooth movements 3 months postoperatively. Orthodontic counselling has to take place early in the treatment – during anti-infective therapy and before moving on to regenerative therapy. You need to develop a joint vision about the interdisciplinary treatment plan - communication between periodontist und orthodontist is very important in these complex cases.
You published a retrospective study including 48-patients who received periodontal regenerative surgery plus orthodontic treatment, and you had followups up to 4-years.¹ What did you learn? At 1-year we found a mean radiographical bone gain of 4.67 mm (see infographic). Also, the pocket reduction was impressive with 87 % pocket closure. These findings remained stable or even improved
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