hopelessness..? turned hopefullness..! – salvaging a molar ... · k : v Çuv} v i}µ vo s}oµu...

BAOJ Dentistry

Ramnath E, et al. BAOJ Dentistry 2019, 5: 15: 053

BAOJ Dentistry, an open access journal Volume 5; Issue 1; 053

Case Report

Hopelessness..? Turned Hopefullness..! – Salvaging a Molar With a Mother’s Touch - Case Report

Ramnath E 1*, Ramakrishnan T2, MejallaM A1, and Vidya Sekhar3 1IIyr Post-graduate student, APDCH, Melmaruvathur, Tamilnadu, India

2Professor & Head, Department of Periodontics, APDCH, Melmaruvathur, Tamilnadu, India 3Reader, Department of Periodontics, APDCH, Melmaruvathur, Tamilnadu, India

*Corresponding Author: Ramnath E, IIyr Post-graduate student, APDCH, Melmaruvathur, Tamilnadu, India

Sub Date: March 10th 2019 , Acc Date: March 22nd 2019, Pub Date: July 10th 2019

Citation: Ramnath E, Ramakrishnan T, Mejalla MA, Vidya Sekhar (2019) Hopelessness..? Turned Hopefullness..! – Salvaging a Molar With a Mother’s Touch - Case Report. BAOJ Dentistry 5: 053

Copyright: © 2019 Ramnath E. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Periodontitis is the inflammatory disease that leads to destruction of the supporting structures of the teeth. The early diagnosis and treatment of periodontitis is always not possible as the periodontitis progress with minimal or no pain. Regenerative medicine is the field that uses exogenous or endogenous stem cells for the regeneration of the lost periodontal tissues. This case report presents about salvaging a molar which was of poor prognosis and at the verge of extraction using Amniotic Membrane as a barrier membrane in the procedure of Guided Tissue Regeneration.

Key Words: Root Resection; Amniotic Membrane; Endo-Perio lesion; Guided Tissue Regeneration

Introduction

Tooth loss may be due to many etiological factors. Periodontitis is the inflammatory condition that may lead to loss of tooth. The amount of bone destruction is based on the severity of the disease. The extensive destruction to alveolar bone surrounding the multi rooted with fraction involvement is treated by Hemi section or Root resection. Resection to the involved root may prevent the need of bridges, abutments, biological stops under removable partial denture free end saddles.[1] Langer et al investigated root resection cases for 10 years after surgery and reported a total failure of 38%.[1] The prognosis of the fraction involved molars can be improved utilizing many regenerative therapies and reconstructive procedures. Cells derived from Amnion have multipotent differential ability. This led use amniotic membrane as a source of stem cells for the regenerative therapy. In 1913, Salbella presented the first clinical report of successful use of amniotic membrane in the treatment of skin ulcerations. Amniotic Membrane is used in dentistry for various purposes. It is been used in treating gingival recessions [2,3]. It is also used in treating furcation defects [4] and as a barrier membrane in regeneration of the intra bony pockets [5]. Since treating a furcation involvement is a complex procedure, it

needs a good source of stem cells for the proliferation of the lost tissue structures. Therefore use of Amniotic membrane serves as a source for stem cells and may serve as an excellentguide in regeneration of the lost tissues.

Structure of Amniotic Membrane

Amniotic membranes develop from extra-embryonic tissue and consist of a maternal component (the deciduas) and fetal component (the chorionic plate) [6]. Chorionic villi holds these two parts and form a connection between the cytotrophoblastic shell of the chorionic sac and the decidua basalis. The amniochorionic membrane forms the outer limits of the sac that encloses the fetus, while the innermost layer of the sac is the Amniotic Membrane. Its thickness is about 10-15 micrometers and made up of two foetal membranes; the inner layer is the amniotic membrane and the outer layer is chorion. There are two types of cells in Amniotic Membrane with embryological origins differing from one another: amnion epithelial cells derived from embryonic ectoderm and amnion mesenchymal cells from embryonic mesoderm.

The ultra structure of Amniotic Membrane reveals to be a transparent,


of 6Citation: Ramnath E, Ramakrishnan T, Mejalla MA, Vidya Sekhar (2019) Hopelessness..? Turned Hopefullness..! – Salvaging a Molar With a Mother’s Touch - Case Report. BAOJ Dentistry 5: 053

thin, avascular composite membrane composed of three major layers: an epithelial layer, a thick basement membrane, and a mesenchyme which is avascular comprising of collagen. Amniotic Membrane has no blood vessels or nerves; instead, the nutrients which are required are supplied by diffusion out of the amniotic fluid and/or from the underlining decidua directly. The amniotic epithelial cell layer consists of a single layer of flat, cuboidal and columnar cells that are in direct contact with the amniotic fluid. It is from this layer that Amniotic Multi Potent Stem Cells (AMSC) are isolated and stored to be used for regenerating tissues. Macrophages and fibroblast-like mesenchymal cells are present in the amniotic mesoderm layer. The appearance of the basement membrane of the amnion is just like the basement membrane found in the gingiva, conjunctiva and other parts of the body.

Types of Amniotic Membrane

Frozen Membrane

Freezing of Amniotic membrane is done by passing through liquid nitrogen at -196°F. The Cooling process makes the membrane bacteriologically pure, immunologically almost inert material and preserves the membrane for an indefinite time. Cryopreservation with dimethyl sulphoxide (DMSO) at -80°C allows retention cells in the Amniotic Membrane at approximately 50% for several months. The several angiogenic growth factors and cytokines are removed during cryopreservation of the Amniotic Membrane. It has been noted that storage of the Amniotic Membrane in glycerol at 4°C results in immediate cell death.

Freeze Dried Irradiated (Lyophilized)

After obtaining the Amniotic membrane from placenta, it is freeze dried at -60°C under vacuum (atmospheric pressure 102) for 48 hours. Then it is irradiated with 2.5 mega rads (25 K Gray) inside a batch type cobalt-60 irradiator. By the method of freeze drying there is sublimation of liquid moisture of membrane to gaseous state without having undergone the intermediate solid stage. By this method the membrane maintains its original size and shape by minimising cell rupture. The freeze dried membrane can be used immediately after soaking it in normal saline for 1 minute.

Properties of Amniotic Membrane

The Multi Potent Stem Cells (MPSC) present in the Amniotic Membrane accelerates the inflammatory phase to phase of proliferation, thus increasing the rate of healing especially in chronic

wounds like periodontitis [4]. The properties of amniotic membrane that accelerates the wound healing are:

• ImmunomodulativeandImmunePrevilage• Anti-Microbial(broadspectrumagainstbacteria,fungi,protozoa

and viruses)• Reductionofpain• Anti-ScarringandAnti-inflammatoryeffects• Tissue repairwith enhanced bone remodeling, osteogenesis and

chondrogenesis.• Acceleratingfibrogenesisandangiogenesis• Increasedextracellularmatrixdeposition• Potentsourceofmesenchymalstemcells

Case Report

A 37 years old patient reported to the Department of Periodontics with a chief complaint of mobile teeth in mouth and wanted to rectify it. The patient had no past medical history but a familial history of complete teeth loss for the patient’s father and grandparents was elicited. On examination the patient had generalised bleeding on probing, increased probing depth greater than 6mm in maxillary and mandibular incisors, premolars and molars. Probing depth in 46 was about 14mm. 46 exhibited a Grade III mobility along with Grade III furcation involvement. Orthopantamograph showed a classical arc shaped bone loss from premolars to molars in first and second quadrants (Figure 1). IOPA of 46 revealed extensive bone loss around mesial and distal roots along with resorption of distal root of 46(Figure 2). The tooth (46) was subjected to vitality test. There was no response on electric pulp testing, indicating the tooth (46) is non-vital. Based on the clinical and radiological findings it was diagnosed as Generalised Aggressive Periodontitis with Endo-Perio lesion in 46. Initial treatment plan was extraction of 46 and followed by phase I therapy. Since the patient was not ready to compromise his tooth, Intial Phase I therapy of Complete Scaling followed by quadrant wise root planing was performed. Phase II therapy of Root canal Therapy in 46 was carried out (Figure 3) and patient was recalled after 4 weeks for review.

After 4 weeks of Phase I and II therapies, clinical examination revealed reduction in bleeding on probing, considerable decrease in the probing depth of maxillary and mandibular central incisors, premolars and molars (except 46). The Grade III mobility of 46 got reduced to Grade I. The probing depth in 46 remained to be 14 mm (Figure 4). The Phase II therapy was planned with Quadrant wise Flap surgery along with resection of distal root in 46 followed by guided tissue regeneration procedure in 46.



Figure 1. OPG Showing arc shaped bone loss in 1st and 2nd quadrants Figure 2. IOPA of 46 shows extensive bone loss around mesial and distal root of 46 and resorption of distal root

Figure 3. Root Canal Therapy Performed in 46 Figure 4. Pre operative Probing depth of about 14mm

Figure 5. Full Thickness mucoperiosteal flap reflected showing osseous defect around distal root of 46

Figure 6A. Resection of the distal root of 46 done



Figure 6B. Resected distal root of 46

Figure 7. Bone Graft (Colocast) placed in the osseous defect

Figure 8. Amniotic Membrane placed over the bone graft in osseous defect Figure 9. Flaps approximated and continuous sling sutures placed

Figure 10. Periodontal dressing given at the surgical site Figure 11. One week post operative image



Figure 12. 3 months postoperative image

Figure 13. 3 Months post operative IOPA of 46 showing bone formation around 46

Figure 14 a&b. Tooth Preparation done and metal ceramic crown cemented in 46

Figure 15 a&b. Pre-operative IOPA of 46, B), 1 year post operative IOPA after placement of metal ceramic crown



References

1. Buhler H (1988) Evaluation of root-resected teeth: Results after 10 years. Journal of Periodontology 59(12): 805-810.

2. Amir A, Shantipriya R, Prasad, Nirjhar B Vimal, SK (2017) “A Comparative Evaluation of Root Coverage in Class I Recession using Amnion Membrane and Prf Membrane: A Case Report”, International Journal of Current Research9 (07): 54899-54901.

3. Chakraborthy S, Sambashivaiah S, Kulal R, Bilchodmath S (2015) Amnion and chorion allografts in combination with coronally advanced flap in the treatment of gingival recession: A Clinical study. Journal of clinical and diagnostic research: JCDR 9(9): 98-101.

4. Kothiwale SV, Anuroopa P, Gajiwala AL (2009) A clinical and radiological evaluation of DFDBA with amniotic membrane versus bovine derived xenograft with amniotic membrane in human periodontal grade II furcation defects. Cell and tissue banking 10(4): 317-326.

5. Holtzclaw D, Toscano NJ (2013) Amnion–Chorion Allograft Barrier Used for Guided Tissue Regeneration Treatment of Periodontal Intrabony Defects: A Retrospective Observational Report. Clinical Advances in Periodontics 3 131-137.

6. Bhushan KS, Singh G, Chauhan G, Prakash S (2015) Amniotic membrane & its structure, features and uses in dentistry–a brief review. Int J Adv Res 3(11): 354-360.

7. Carnevale G, Pontoriero R, Di Febo G (1998) Long-term effects of root-resective therapy in furcation-involved molars: A 10-year longitudinal study. Journal of clinical periodontology 25(3): 209-214.

8. Haskell EW, Stanley H, Goldman S (1980) A new approach to vital root resection. Journal of periodontology 51(4): 217-224.

9. Park SY, Shin SY, Yang SM, Kye SB (2009) Factors influencing the outcome of root-resection therapy in molars: A 10-year retrospective study. Journal of periodontology 80(1): 32-40.

10. Yuh DY, Cheng GL, Chien WC, Chung CH, Lin FG, et al. (2013) Factors Affecting Treatment Decisions and Outcomes of Root‐Resected Molars: A Nationwide Study. Journal of periodontology 84(11): 1528-1535.

https://www.ncbi.nlm.nih.gov/pubmed/3066890


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https://www.researchgate.net/publication/267037716_Amnion-Chorion_Allograft_Barrier_Used_for_Guided_Tissue_Regeneration_Treatment_of_Periodontal_Intrabony_Defects_A_Retrospective_Observational_Report




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hopelessness..? turned hopefullness..! – salvaging a molar ... · k : v Çuv} v i}µ vo s}oµu...

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