Running Time: 56 min
Clinical Concepts in Regenerative Periodontal Therapy
Release Date: January 12, 2018Subtitle:
[MUSIC PLAYING] Thank you. Thank you to gIDE to give me this great opportunity to share my knowledge about clinical concepts in regenerative periodontal therapy. And thank you to my personal friend, Sasha Ivanovic, for this kind invitation. It’s a real pleasure to sit with you, and I want to do this concept, and I’d like to start with you with this video. And as you see, this is a young guy. He’s 12 years old. And this guy, 12 years old, comes from Switzerland to my office in Milano, and he has severe periodontal disease. As you can see, he has a very severe pocket depth distal to the central incisor. And there is pus, and there is really a tremendous inflammatory situation with a very severe attachment loss. Thanks god the aesthetic is preserved, the soft tissue is still there. So as we treated this case, I will show you later. Let’s see the diagnostic phase. First of all, we need to probe, because the diagnosis in periodontal disease is done with a problem that, and the attachment loss is the real sign of periodontitis, and not the radiographic analysis. Today, we take too many x-rays, I think. And we need very important, but it’s not on the basis of the radiographic that you diagnose the periodontal disease. Because when you have a natural tooth, even if it’s without outside the bone but with its periodontal attachment, the tooth is healthy and can stay there and could be vital. And so how much bone do we need back to our teeth? Probably, if you take, make a flap on my canine here on the right side, you see it’s very prominent. And probably there is no bone. But there is attachment, so you really don’t need. So the most important thing, if you have lost attachment but you have the soft tissue is to recreate the attachment. Don’t focus too much on the bone when we talk about natural dentition. If we need to place an implant, it’s completely another story. So in this case, as you can see in the periodontal charting, it’s a very severe pocket depth because we have 13, 12. We have 10, 13. There is one, 4 is not actually 4, it’s 14, and 12. And it’s very localized to these two teeth. And the patient, as you have seen, was under orthodontic treatment. So we take the X-rays, and you can see there is a significant bone loss and attachment loss. So the teeth are splintered, because as I showed you in the clinical photo, you see, it’s a double splint. It’s a buccal orthodontic device. And there is a lingual splinting as well, because the attempt of the orthodontist was to intrude the central incisor in this moment. So we did nonsurgical therapy, and we did nonsurgical therapy with very small curettes. We used the mini curettes very gently, focusing on removing not the granulation tissue– not the granulation tissue– but only the biofilm on the root surfaces. Because if you remove the granulation tissue, you will remove a lot of soft tissue, and you will have an aesthetic damage in this case. So we wanted to preserve all the soft tissue in a recreated attachment, just controlling the infection. And the infection, we can control mechanically with, of course, with the sonic devices and ultrasonic devices, with rinses, with peroxide, and chlorhexidine and with the mini curettes and repeating the procedure for one hour in this area and teaching to the patient how to clean. But the patient was already clean. So really, it’s difficult to understand what was the tissue for this disease. Was bacterial, of course, but what started the disease probably the orthodontist did something wrong. We are not sure about that. Anyway, what happened is that no one touched these gums and teeth before. So we were able to remove the inflammation and to kill the bacteria into the soft tissue. We had to add some antibiotics and, in this case, an association of metronidazole and amoxicillin. And as you know from significant literature reviews from Sgolastra 2012, from [INAUDIBLE] 2002, and from Haffajee 2003, we know that in case of aggressive periodontitis of severe pockets, the association of these two types of antibiotics, amoxicillin and metronidazole, implement the results of the nonsurgical therapy. And so this is the result after two months. And as you can see, still we have a little bit of probing depth, but there is no pus, no suppuration anymore. And so probing a little bit deeper with a little bit more force distal to the tooth number 11, as you can see, the probe still goes down a little bit. So I cleaned again, and after two months we checked the patient again. So every two months, we called the patient. So after four months, as you can see, the tissue is still there, and the pocket that is reduced now is 6 millimeters both sides. And we are actually preparing the patient for surgery. But with nonsurgical therapy, there is no pocket depth anymore. We don’t need any surgery, and this is great news for the patient and also for the team. And think, if you are a patient and you have a disease and you need the surgery, but the doctor says you’re completely healed and you don’t need any surgery anymore, I think it’s a great deal. And this is the pocket after six months. Still there is periodontal disease, because according to Claffey and Tonetti, 2005 Journal of Clinical Periodontology, we know that if we have 5 millimeters pocket depth in two different sides of the mouth, we still have periodontal disease. And in this case, we still have periodontal disease. But if it’s your son, what do you do? You do surgery? You just wait, because the tissue is still in the maturation phase and is still in the healing process. So after eight months, the patient looks in this way. And you see, now the probing that is between 4 and 5 millimeters, and the patient is very happy, and we are happy. And I think he doesn’t need any surgery. This is the X-rays at the baseline, and this is the X-rays after one year. As you can see, there is also a significant capture, not only of the attachment, but also radiographical evidence with bone reformation between the teeth and the root. So why is very important to be very gentle with the soft tissue, even when you clean very well but without removing the soft tissue? Because a friend, a colleague, let’s say, he sent to me a patient and said, Giulio, I have a patient with gingival recession. I did very good, significant cleaning on this root, and look what they did. Now, if you lose and you destroy and you remove the granulation tissue and the nonsurgical therapy it’s too aggressive. Now is going to be very complicated to do a surgery. I will show you a technique that we can apply that is the soft tissue technique for a case like this. But it’s more complicated. If you can preserve the soft tissue and just working deep but very gently on the biofilm and preserving the soft tissue and killing the bacteria that are in the soft tissue with the antibiotics, will be much better, also for the surgery after. And the impact of this, the efficacy of this nonsurgical therapy, I want to share with you. These are unpublished data yet, probably when the recording will be available for buying or will be published already. So in this case, just check on PubMed. And we just submitted this paper with the minimally invasive periodontal approach. And we reported 50 consecutive cases of patients that were scheduled for tooth extraction, and we are talking about many teeth involved in this extraction. In the treatment planning of the colleagues, the patient didn’t want and came for a second opinion. They want to save their teeth. So there were 50 patients between 18 and 56 years old and we follow up for 12 years these patients. It’s not just one, two years, three years report, but it’s 12 years. So it’s a long-term data. The patient was diagnosed with severe aggressive or chronic periodontitis, and you see the characteristics of this patient. And in terms of chronic periodontitis or aggressive periodontitis and total of cases. And you see the smokers, male and female, and the mean follow up of these patients. So we treated the aggressive cases and very deep cases, very deep-pocket cases, with full mouth disinfection with antibiotics. So a very strong session of nonsurgical therapy can take also six hours. In my office, this procedure is more expensive for the patient than a flap surgery, because it takes more time and provides a better service to the patient too. They have massive healing with this. So it’s not the session of oral hygiene that in some centers they do mainly for free. This is just 50 minutes hygiene. No, no. This is a serious nonsurgical phase that lasts four or five years average, sometimes also six years. And you control, of course, the mobility of the teeth in these cases, why the teeth move. The teeth move for two reasons– inflammation and trauma from occlusion. So if you control the inflammation, and you control the trauma from occlusion, the teeth will be stable. You don’t need to extract all the teeth that move, because the orthodontist should remove all the teeth, because all my patients, they have periodontal disease and have the teeth that move. So you should, in this case, just control the infection, inflammation, control and check the trauma from occlusion, and the teeth will be stable again. Then probably you will need to extract anyway. But very often, you can save these teeth for a long time. So in cases where we had aggressive periodontitis and severe deep pockets, over 10 millimeters, we used full-mouth disinfection, one stage with antibiotics. In the cases where we had the chronic periodontitis, we did quadrant by quadrant with the [INAUDIBLE] and where 18 patients treated in this way. At the end, in this patient, we did only nine flap surgeries, 51 periodontal regeneration, six mucogingival surgeries, and we placed 38 implants. I love to place implants when I need, but if I save a lot of teeth, I don’t need to place a lot of implants. And I still think it’s the best solution for our patients most of the time. And so 1,326 teeth involved from periodontal disease and planned for extraction were actually saved, because at the end, we extracted only 42 teeth, and 20 were wisdom teeth, and one for caries, one from fractures, and 20 for periodontal reason. And if you see this graphic, I think it’s very interesting to see. In the shallow pocket, 5-6 millimeter in the upper part, and a 7-millimeter pocket and more, so very deep pockets in the lower part of the graphic. And as you can see, the efficacy of the nonsurgical reduction after the first period of time, after the first month, is very important. And this is the effect of the nonsurgical treatment. So the nonsurgical procedure actually reduced significantly the number of pockets sitting in the teeth, because someone else can reduce the number of pockets extracting the teeth. Now, saving the teeth, you can reduce the pockets and control the disease. And then the supportive periodontal therapy that takes place for 12 years, as you can see, gives a lot of work and a lot of effort to maintain the situation. And where is the surgery? The surgery is this, and are never very early, but when it’s needed, when you have the pocket that lasts after a period of healing, a pocket of 6 millimeters or more. So this is indicated to proceed with the surgery– or 5 millimeters or more. And what is interesting with this data is that at the end of the study, we decided to have feedback from our patients. So we sent it, and we asked what’s the impact for you on the treatment that you received? Unfortunately, this lady is not one of my typical patients, and my colleague and coworker [INAUDIBLE] prepared for me the slides. And we sent at home this questionnaire, and the questionnaire of 50 patients. We were glad that 27 of these patients sent back the questionnaire in anonymous way and so we can have a feedback. And the question was, why did you seek treatment in the first place? It was for tooth mobility, 16, and bleeding gums. This was the leading reason. And when we asked was the treatment painful, they say no. Was the treatment time adequate? They say yes, average. And was the cost of the treatment adequate? Yes, average. And this is the patient perception. And are you happy with the delivered treatment? Look at the answer. They are very happy. And did your delivered treatment comply with your expectations? Absolutely, yes. And did the delivered treatment comply with your needs? They said this is very strong yes from the patient. So they felt that they were treated in a proper way. And this is the best business card you can have around in your area, because these patients are the ones that will send you other patients and will continue the circle. And of course, all these patients were selected for tooth extraction. So this treatment plan is not similar to the previous that they received. But let’s go to the last question. Should you go back in time, would you choose this treatment again? It’s a strong yes. And how would you rate the cost of the treatment? It’s like average, cheap. So they are able to spend a little bit more for this treatment. It’s very stupid to pay a lot of money to receive a lot of treatment. I prefer to pay money to be healthy rather than to have more impairment in my body. So I’m talking about patients like her. She’s a local politician. As you can see, this is some dentist didn’t even diagnose the periodontal disease in this case. They just diagnosed like watching the situation. And they don’t want to put the effort even to treat this patient. And let’s see together. Look at the periodontal charting of this patient. And this patient, the first part– this is the original, as you can see. And look at the tooth number 47, for example, with a pocket depth of 7, 6, 7, 6. And she already has gingival recession. Unfortunately, we cannot save the tooth number 24, 25, 26, 27. Those teeth will need to be extracted, and you will understand when you will see the X-rays. But the other teeth we can save. So we will just need to control the infection and to control the trauma from occlusion. And after three months, as you can see, there is a significant answer. Also, this patient has been treated with a session of full-mouth disinfection with the antibiotics. And you see written by my hygienist, implant [INAUDIBLE]. So this area, it’s implants. And this is the same patient after eight years. Where I placed the implants, now still there is the periodontal charting. Why? Because you need to probe the implants, because you will never lose an implant because you probe. You will lose an implant because you don’t probe. So you need to check. And also in the lower jaw, you see that teeth number 35 and 36, they were missing before. We placed two additional implants to stabilize the occlusion on the left. We stabilize the occlusion in the right side also, making a new bridge in the upper jaw. And I go to the X-rays. As you can see, these were the baseline X-rays. As you can see, there was a significant bone loss. But who cares? As long as you get the attachment, and you can maintain the teeth stable, you can work with these natural, vital teeth in this case. This is the same patient eight years after the treatment. We placed implants in the upper and two implants in the lower left jaw. We stabilized the occlusion over there. We remade the bridge, maintaining the teeth vital in the right side in the upper jaw. So the occlusion was stable. We did orthodontic. So we replaced the incisor in the proper position, and we stabilized with a splint. And so this is the maintenance of this patient during the maintenance phase. You see the patient at the baseline and eight years after. I don’t want to say this is an extreme case, if you want, but this can be done and can be maintained for years. Because this type of patient, when they understand how to work with you and how to keep clean, that you have to go through this anyway, even if you choose to extract the teeth and place implants, you have to teach the patient how to keep clean. They cannot leave with the dirty mouth, even if they select for another therapy. So very important is to wait the proper amount of time after the nonsurgical treatment and to do the re-evaluation never before four weeks, and the major changes happen between one and three months. But the biometric parameters continue to improve for over six months. And the healing and maturation can take one here and even more than that. And does this periodontal generation, in case we do periodontal generation, last for a long period of time? Yes, it does, because there is evidence from Cortellini and Tonetti, from Tony [INAUDIBLE] and other colleagues, and also this work that the Robinson Periodontal Regeneration Award from the American Academy of Periodontology in Los Angeles, here in Los Angeles, because in this moment we are in Los Angeles, in 2012. And the question was, it is possible to maintain long-term teeth that received periodontal regeneration. So with severe pockets. And we follow 120 patients together with Silvestri Maurizio for 15 years. And as you can see, we were able to maintain not only the teeth but also the attachment. And the pocket reduction and the CAL gain that we achieved in one year– you follow the red line, after one year– was preserved and maintained over the 15 years, as you can see, in a predictable way. And what’s the problem? The problem of the patients that were smoking. You can see the red line is the line of the patient that smokes. And the problem is not at three years, four years, five years, but after seven years or more, like in marriage I would say. But it is never an early failure, but it’s a little bit late failure. So today, if I have a patient that smokes, I don’t want to say I don’t do surgery, but I show this data. I say, look, if you continue to smoke, you have to know that you will be part– your success rate will be lower than if you quit smoking immediately. We had many patients in my office that quit smoking with the right and proper motivation. And when we perform periodontal regeneration and to have a good healing in general is very important to have this component. We prepared this graphic with this pyramid in this paper, Basic Elements For Wound Repair that we published in this important paper that you can see. And we need to have cells. We need to have a scaffold matrices. We must have molecular mediators. We need to have blood supply. Blood supply is the key. Without the blood supply, the oxygen, the healing cannot take place. But everything needs to be very stable. And this is true for both– for the bone healing and for the soft tissue healing too. That’s why it’s very important and technically sensitive to stabilize the graft. This is for everything– for implants, for perio. We need to stabilize both the bone graft, the membrane. Everything needs to be stable. And the soft tissue management should be done in a way that everything is stable. And the teeth, if we have teeth, need to be stable, because if the teeth move and we do surgery on movable teeth, forget it. You won’t have a stable wound. So everything should be very stable. And the provisional restoration in case of implants, for example, the provisional restoration shouldn’t move the regenerating area. They should be away from that area. And the patient should be informed how to behave in order to achieve a good healing. So the wound stability really plays a very important role. And important, and this is part of the maturation, and we are starting to go into the details, is the prevalence of complications. Because we had several biomaterials and several techniques to try to achieve periodontal regeneration and to promote periodontal regeneration. But as you can see in these cases, we had also some failures. And with some material and some techniques, we had more failures. So improving over the years the technique, I was part of all these papers except for the one of Giovanni Zucchelli in 2002. But all the others with Silvestri and since, I was one of the centers that did provide the clinical cases. And you see, using amelogenin, which is a gel [INAUDIBLE], you have very little complication. Using a graft and, in general, membranes we had more complication, exposure, and infections that are very difficult to handle and to manage. And [INAUDIBLE] has to grow and to try to define better surgical techniques to try to avoid this problem and to use the biomaterials in the proper way. And this paper, because all the randomized control clinical trials and data are very focused on using biomaterials that are very good sponsors, are important. They support the study. But no one will support a study on surgical techniques, right? But we need to understand if a technique is more predictable than another one. And so in this review, Philippe Graziani concluded that the clinical performance may change according to the type of surgical flap used. This is very important. We can do– depends, the healing– I would say the healing may depend on how you cut it and suture the gingiva rather than how you use the biomaterial and in which way. So the type of flap is very important. And to be precise in the type of flap, we need to use loupes. We need to use a microscope or loupes. And it’s been described in 2001 already from Journal of Periodontology from Cortellini and Tonetti that they had the better performance in the procedure when they were using small instruments and high magnification. When you work with high magnification, the surgery is much more precise, and I want to add also you need to have also a light on the glasses. And you will work in a very nice way, and you can control, like in this way, your procedure. And it’s also a lot of fun to do these things. And so nowadays, if we go in the case of the surgical technique, when you have acceptable aesthetics, you don’t need to coronally advance the flap, to displace the flap more coronally. My suggestion today, my technique– my best technique– is the single-flap approach or the modified MIS, described by my friends Leonardo Trombelli and Sandra Cortellini. They are two different techniques. But let’s say very similar, both as a concept that you don’t need to displace the interdental papilla. There is in the drawing in the left, as you can see, there is just an incision in the buccal aspect of the papilla. It can be perpendicular, as drawn here, or a little bit sliced. If it’s a little bit sliced, gives more vascularity, more vessels, and more connective tissue from the two edges of the wound that will allow the better healing. And then you just make buccal into circle of incision not near the two teeth so you can just elevate the buccal part of the papilla without touching interdental. Why this? Because if you don’t touch the interdental aspect of the papilla, you just clean underneath, you leave intact the vascularity and the blood supply that comes from apical to coronal, supported by the periodontal ligament. These type of vessels you don’t have, for example, in implants but you have with the natural dentition. And this is why you have a very nice, beautiful papilla between teeth, and it’s very difficult to have beautiful papillae between implants, because you have less blood supply that comes from apical to coronal. So the vessels not only come from buccal and palatal but also from apical to coronal. So you just reflect the papilla and you’re clean. In case you can not clean completely the defect with this approach, you can always elevate the interdental papilla, as described first from the great Harry Takei and then modified by Cortellini. You can do that in a minimum way. You don’t need to make always the verticals. You need to try to avoid to involve the mucogingival line. As you stay in keratinized tissue and you open as minimum as you can, but you should be able to clean properly, this is fine. And this is better, because the wound will be much more stable. More you extend your flap, more your flap is big, and more will be difficult to have a very stable clot. And you can extend, of course, flap mesial and distal. And we can see a short video, for example, that show us the incision. You see, I like to do in diagonal. This is a 15C. You can you also use the smaller blades. I like to use the 15C actually, because I like the point– the tip– of the blade that we have. Very gently, you can elevate. In this case, I have a pretty used instrument. I’m sorry. I have wonderful kits now from Hu-Friedy, and I modified the kit because now I use very thin instrument– very small instruments– and so we have just set a new kit of instruments on that that help us to clean properly. For example, this is an instrument that usually is for restorative dentistry. It’s usually not in periodontal kits. But in my periodontal kit it’s there. And help to granulate the defect. You see, you need to be very gentle with the elevator and not pull the tissue. At the end of the procedure, the tissues should be pink and not bluish. You don’t put any tension when you retract your flap. And now that everything has been cleaned, and the root surface decontaminated, with a Prolene 6.0 suture, we can perform a [INAUDIBLE] suture, entering apical from buccal, going at the base of the papilla in the lingual aspect and coming back, as you can see. And then we will be able to go again. Until now, this is basically an internal mattress suture. But now we go one more time in the interdental space, and we engage the loop– the lingual loop– and we come back. Now we can wash. Why I like to perform the suturing before placing the graft, because now you can wash. You can clean. Everything is perfect. You can condition the root surface with the EDTA. Should be for two minutes. Honestly, I never wait two minutes. During surgery, two minutes for me, it’s like 20 minutes. It’s a very long time. And then I prepare the biomaterial. I use most of the time a combination of BioOss and Emdogain, because if you do this very small type of procedure, you cannot use the barrier, the membrane. And so you need to add to the BioOss the amelogenin. That will stop the apical migration of the epithelium. And you fix and you stabilize your suture in a proper way, and you can tell everything it’s very stable and very nice. And you will have a good healing after this type of procedure. And it’s everything very controlled. And about the biomaterials, I want to make a long story very short. But there are these two literature reviews that are already pretty old now– it’s 2008. As you can see from Trombelli-Farina, this review on behalf of the European Academy of Periodontology– or Federation of Periodontology, sorry– the conclusion says that the use of the graft associated to Emdogain seems to increase the results. And also this review from Tu and coworkers from London, published in 2010 on JCP, Journal of Clinical Periodontology, this is a meta analysis and says that the group with the association of Emdogain and BioOss gives the best results. And so there is strong evidence to recommend these biomaterials together with this minimally invasive procedure. And together with Leonardo Trombelli, Leonardo Trombelli’s group from the University of Ferrara, we explored this single-flap approach, and we tried to see in which case we were using amelogenin alone, Emdogain alone, or a mix of Emdogain and BioOss. And we realized actually that in case of we had a three-wall defect, we were using Emdogain. In case of one-wall defect or two-wall defect, we would use a combination of the biomaterials. And then we wanted to see, and we noticed that there was gingival recession when we were doing single-flap approach in case of periodontal interosseous defect, in case of thin biotype type. And as you can see in these cases– we published this paper in Journal of Periodontology in 2015– and as you can see in this case, we changed the prognosis of the teeth. But you see there is a significant gingival recession as a result. And the recessions are both buccal and interproximally as well. And so this tells us another idea, and we try to investigate. And we say, OK, if the biotype is thin or we don’t have bone, we can apply another technique. So how do we assess the biotype of the patient? There is available on the market– this is from Hu-Friedy. This periodontal biotype probe is a Colorvue probe and has been designed from me, I have to say, together with Tiziano Testori. And it’s very interesting, because you can set– if you see in transparency all the tip of the probe’s color– the white, the green, and the blue– that is going to be a thin biotype. If you don’t see the white, but you see the green and the blue, it’s a medium biotype. And in case you don’t see the white, don’t see the green, but you see the blue, it’s a thick biotype. If you don’t see any, it’s a very thick biotype. So this is a very nice and predictable way. We address the study at ACDA University in Amsterdam. It’s going to be published soon. And it’s very reproducible by different clinicians. And in the same patient, reproducing the same procedure several times, the results, it’s always the same. So it’s very consistent as a way to assess the biotype. We know that assess the biotype with other technique is not so predictable. And in case we have a thin biotype today, we graft. We apply all the procedures that you have seen before, but plus we add a connective tissue graft or a soft tissue substitute. We have a study that we are running also using a collagen matrix in these cases. And we published this data. The data published are with the connective tissue graft. And it’s been published in the issue of April of the Journal of Periodontology, and we treated 30 patients. At the end of the results is that if you add the connective tissue graft to the regenerative treatment, as we have seen before, the [INAUDIBLE] and the accessibility of the single-flap [INAUDIBLE] may support the stability of the gingival profile. So this is a full tool that allowed to have a more stable coronal gingival margin over the time. And I want explore with you a little bit more complicated technique that we may have. For example, because we may need, like in a case like this, we have thick biotype in this case. So we don’t need to place the connective tissue graft. But we definitely need to treat this area. How would you like to treat this area? With tooth distraction, you will extract the lateral. If you extract the lateral, it’s not going to be so easy to place an implant in the proper way, because the implant will be very apical. The bone, as you can see, is very apical, but the attachment of the central is good. The attachment is good on the central but not the bone level. So if you preserve the attachment, it’s fine. If you damage this attachment, it’s a problem. So what you can do here is just improve the attachment also on the lateral. But as you can see, the intrabony defect is not a supportive defect. It’s not a [INAUDIBLE] defect. It’s a very small intrabony defect but deep. It’s small but in an apical position, let’s say. So how to treat this case. It’s very risky, and it’s very aesthetically important, because it’s in between the central and the lateral. So in a case like this, we can apply this procedure. This procedure is called soft tissue wall technique for regenerative treatment of non-contained intrabony defects. And we published on the International Journal of Periodontal Restorative Dentistry in 2013. As you can see, we start with an incision at the base of the mesial and the distal papilla. And we preserve the interdental papilla where there is the defect. Now we can clean the intrabony component. We can de-epithelialize the two papillae and the mesial and distal. We can reflect and make an incision at the base of the periosteum. In this way, we can advance the flap coronally, and we can, as you can see, without any tension, we can stabilize our flap in a coronal position. So this is our flap. Stable. And how do you stabilize this type of flap? You will stabilize with a sling suture around the central incisor and around the lateral incisor. And it’s always important to start away from the weak point, because when you start to suture, it’s where you will add the knot. So you don’t want to have too many knots right in the middle where you have your papilla. So you will start from distal, and you will start from mesial in case of the central incisor. Now, with an internal mattress suture, you will just close the papilla. Now, we created in this way with this technique a coronally advanced flap and a coronally advanced box empty where the clot– because the regeneration occurs thanks to a stable clot– inside, and we can just close with our last suture. And we add the biomaterials, as we described before, and we close our suture. Now, after a period of healing, we can start with the orthodontics. In this case, Christiana [INAUDIBLE], the orthodontist, did the intrusion with the Invisalign technique. As you can see, the tooth reached the position that we wanted. And the prognosis of the tooth has been changed. We moved from 7 millimeter pocket depth to 2 millimeter pocket depth. And it’s very stable for a long period of time and easy to maintain. And this is the X-ray that the editor of the journal asked us to publish together with the paper. All the detail, because nowadays we don’t have much time, so I’m giving you as much as I can, as you can see. But I maybe lose something. But according to Sasha, we are very linked with the groups. We have this group, it’s called iPerio. It’s on iperio.org. It’s a website where we promote these type of courses, where we teach in details these procedures and these techniques. You can just contact us. And I want to start now the last case. This is a significant case, I think. I could just teach on this case. This case will tell you a lot. A patient came in with these panoramics and says, [INAUDIBLE] want to extract all my teeth. And my thinking was, I can understand. And he says, but I want to preserve my teeth. Now, always, when you have cases like this, you must sit down, breathe, and always work as you should. You have to know, all teeth are stable except for the tooth number 37. All the other teeth are very stable. All the teeth are vital except for the number 33. The tooth number 33 is the only one that is necrotic. All the other teeth are vital. And what type of disease you think is this? It’s a cancer? Is it? No. This is just periodontal disease. It’s due to a massive inflammation. Now, when you have a massive inflammation in your lungs, what do you do? Do you remove part of your lungs or you just take antibiotics? That’s what you should do also with teeth. I mean, to extract teeth because of inflammation is something really from the middle-ages. Nowadays, we have antibiotics, thank god, that when used in a proper way, when you have a severe disease, will help you to control the infection. As you control the infection, you can move forward with your treatment plan. So as you can see, there is only the tooth number 37 that has furcation involvement, and he has also the mobility. So it’s a very compromised prognosis. But for the other, let’s move forward. Let’s do the periodontal charting. The periodontal charting is over 15 millimeters in many sites in the lower jaw, I would say. There is pus. So how do you treat a case like this? You take the real X-rays, not the [INAUDIBLE] scan. As you take [INAUDIBLE] scan around natural teeth, you don’t have a lot of information, because there is no bone. Buccal to the teeth, there is no bone. There is attachment. This is what you are looking for, as we were saying before. So with these X-rays, so we can compare the healing phase. And so there is a fistula near the canine as well. So Professor Simone Grandini from Florence treated endodontically very nicely, as you can see. And Francesca– Francesca Pomingi, the hygienist, treated with nonsurgical treatment together with antibiotic, amoxicillin and metronidazole associate. The patient is a super nice patient that cleaned properly. He doesn’t smoke. He doesn’t have diabetes. Doesn’t have any co-factor. So there is a significant recession near the canine, and in general in the sites that were tremendously involved by periodontal disease. But you see, this is an early healing. It is after four months. Leave the tissue heal a little bit more. And after seven months, as you can see, all the teeth are still in the mouth. But there is a significant improvement at the bone level in the lower jaw. And now, after seven months, the probing depth improved and now is 8 millimeters in most of the pockets that before were more than 15. Now we can do the surgery, because there is no more improvement. With the nonsurgical treatment, the maximum you can reach is this. Now, the healing phase is finished, we can improve with our surgical procedure. And which surgical procedure we will apply in these cases? As you can see, in the right side, we have this intrabony defect, significant, deep, but we don’t need to improve the aesthetics or to displace our soft tissue more coronal, right? We need just to see that it’s 8 millimeters, 8 millimeters. We need to reduce the intrabony component, and we need to reduce the pocket. So in a way, the periodontal disease doesn’t progress and doesn’t risk to progress. So it’s enough to do this little incision. With this little incision, we can clean underneath, we apply our biomaterial, and we suture. That’s it. And the same in the distal part, as you can see, and a small incision. Reflect in the buccal part of the flap, cleaning underneath, placing the biomaterial, and closing the suture prepared before, and again close. And also in the upper jaw, you can see there is this problem. We can stabilize. As you can see, we can open this case. We need also to reflect the palatal part of the papilla to be able to clean the furcation involvement of the distal to the tooth number 6. And this is the biomaterial. This is the suture. Again, the [INAUDIBLE] suture. And we are able now to close everything. You see, this is before and after. This is before and after. It’s 8 millimeters and now it’s 3. And this is before and after. Was 6 millimeter and now is 4, 3, 4. And this area is a little bit more demanding. The tooth number 7 has been extracted after seven months. And now we have to treat this area. As you can see, we have 8 millimeter distal to the tooth number 5 and 8 millimeter mesial to the tooth number 6 and distal to the tooth number 6. So what we have here is a bone wall buccal and a bone wall lingual. And we have nothing in the middle. Between the two walls, there is nothing. It’s a crater type of defect, because the root [INAUDIBLE] without the connective tissue. So what’s the flap design here? The teeth are stable, and there is no furcation involvement. This is good. It’s a good prognostic factor. And so we do an incision apical to the papilla in a way that we can overlap the flap on top of the de-epithelialized papilla. And then we stayed buccal. I mean, just in a way that we can just move the papilla a little bit more vertical– vertical position. We don’t need to reflect the lingual flap. We don’t want to reflect the lingual flap. We want to just elevate a little bit the papilla in a way we can clean, and then we would place again in the same position. And then we go intracoronal and we stay distal. Again, not in the middle of the crest, but we stay more buccal. And we keep our scalpel on top of the bone crest– of the buccal bone crest. You see the pocket that is significant. The bone loss is– you see the probe is 50 millimeters probe goes down to the apex. And the tooth number 5 has been treated endodontically because the lesion was more apical to the apex. So we needed to clean the apex of the root apical to the apex of the tooth number 5. So we had to do endo in a preventive way. And so as you can see, we de-epithelialized the papilla. We used the same regenerative biomaterials. We released the periosteum so we can advance the flap. The papilla has been de-epithelialized. And we can advance our flap coronally. In this case, to keep everything as stable as possible, we place also a Bio-Gide membrane on top of the regenerated area. And we advance the flap. Again, to keep the flap coronal, as much coronal as possible, we do as sling suture around the tooth number 5. We enter from mesial. We go into keratinized tissue, into the de-epithelialized papilla. We turn around, we go in a mattress way distally. So we will not have the suture on top of the papilla between the two edges of the flaps. So the flap and the papilla will be able to be closed perfectly. And when you pull this suture to close the knot, there is a risk that the loop can cut the soft tissue. So we place a little bit of resorbable membrane in a way that we don’t put too much tension on our soft tissue. And in this way, we can close our flap. And the Prolene is the internal mattress suture in that area, two regular normal sutures distal to the tooth number 6. As you can see, this is before and this is the healing. The probing depth has been controlled. So let’s see the radiographic history of this patient. This patient arrived in this way. And we were in February 2011. So February 2011, the patient was showing this type of defect. And this is September 2011, after only nonsurgical treatment. Let me go back and forward a couple of times. Look at the bone, for example, near the tooth number 44. Look before and after, and this is only the nonsurgical treatment. And now we did the surgical treatment. This is with the regeneration. And now this is May 2014. And now we can also place an implant where we have lost the tooth. And we can place the implants. And we can just start the maintenance phase with this patient that is coming twice a year. He keeps clean, and he kept going forward for a long period of time. And there is evidence that you can maintain this case for a time. He never had in his life one more time of bleeding sites on probing. Because when you control periodontal disease, you really do. If there is the recurrence of periodontal disease, it’s because you didn’t control completely, and you still have some bacteria and some remaining area of disease in the mouth of the patient. So maintenance is very important. I want to just share with you this case. It’s 1993. She came. I wanted to do implants in this patient, of course. I had my brand-new implant kit. And the patient could afford the procedure, but she said no. I don’t want any implant. I don’t want any surgery. Just clean and stabilize the teeth. So in 1993, this is the patient in 1998. This is the patient 2007. As I usually say, before the crisis, we did the gold retainer splint. After the crisis, we sold it, and we came back to the composite. And this is after, you see, after 20 years. Look at the bone level. It’s improved. It’s better 20 years after than 20 years before, because with teeth, if you don’t extract them, and you control the infection and the mobility, the teeth can stay really there forever. This Still, if I go back, I would try to place the implant in this case, because you feel safer, et cetera. But it’s important to know that this is possible, and this is something that we need to have in our armamentarium and to offer to our patients. With this, I like to underline that if you like the tips on suturing, et cetera, together with Quintessence we developed an app. It’s this one. It’s called the Oral Surgery Suture Trainer. I think it’s very interesting. There are over 20 videos that show you the suturing technique. And if you want, you can, using a scan– for example, use Scan Bot to do that– you can scan this key square, and you can get all my publications and keep them updated. And you can visit us and keep in touch through this website. It’s iperio.org. With this, I like you all, and thank you so much. See you soon.