Minimally invasive esthetic and functional rehabilitation after systematic periodontal therapy: a case report

Anamnesis: The patient was 45 years old at the time of his first consultation in 2017. He was referred for the treatment of his "progressive periodontitis" and had not undergone previous periodontal therapy. The patient had no general diseases, took no medication and claimed to be a smoker (35 pack years). His main complaints were that he suffered from tooth hypersensitivity, tooth mobility, bleeding gums and pain on biting in the posterior right upper jaw. Clinical findings: Oral inspection revealed generalized soft and localized hard biofilm formation. Teeth 17–26 and 38–47 were present and they responded positively to sensitivity testing and negatively to percussion. The marginal gingiva appeared slightly edematous and swollen. There were generalized probing pocket depths of more than 7 mm and localized values up to 12 mm for teeth 45 and 46. The attachment level was generally above 7 mm and locally up to 13 mm for tooth 14. Grade I–III tooth mobility and grade 1–2 furcation involvement were recorded. Tooth 22 was elongated, rotated and protruded. Panoramic X-ray imaging revealed that the alveolar ridge was located in the apical third of the roots as well as the presence of multiple areas of furcation involvement and periapical translucencies. Diagnosis: – Periodontitis Stage IV, generalized, grade C with modifying risk factor smoking – Endo-periodontal lesion grade 3 at teeth 16 and 17 – Suspected endo-periodontal lesion at teeth 26, 38 and 47 – Suspected occlusal trauma at teeth 22 and 45 – Unharmonious anterior situation (multiple recessions, anterior teeth tipping towards vestibular, protrusion of tooth 22) Therapy: The patient quit smoking until re-evaluation. Teeth with a mobility grade ≥ II were splinted using composite. Root canal treatments of teeth 16, 17 and 26 as well as the functional reduction of teeth 22 and 45 were performed. Tooth 38 was extracted. Subsequently, anti-infective therapy ensued in form of a full-mouth-disinfection with adjuvant antibiotics. After re-evaluation and supportive periodontal therapy (SPT), corrective periodontal surgery of teeth with persisting probing pocket depths ≥ 6mm was performed by means of distal wedge excisions, root amputations and furcation tunneling. Six months after periodontal surgery, the periodontium appeared stable. According to the patient, there were subjective deficiencies due to interdental black triangles, recessions and tooth tipping towards vestibular in the anterior region. Thus, direct shape corrections of teeth 14–24 and 34–44 and closure of the inter-dental gap between teeth 43 and 44 followed. Conclusion: After successful periodontal treatment, functional corrections and direct restorative techniques with composite can be used even for patients with severe periodontal disease in order to achieve minimally invasive and successful treatment outcomes. Keywords: adjuvant antibiotic administration for subgingival instrumentation, direct composite splinting, endo-periodontal lesion, endodontic therapy, esthetics, furcation tunneling, rehabilitation, resective periodontal surgery, root amputation, shape correction, smoking cessation, tooth widening