Case 1

“Talkin’ About re-Generation”

By Neal Lerhman, DDS, MS

A 35 year old male, in good overall health presented for evaluation and treatment of a fistula labial to tooth #8. Upon presentation and examination, patient “C” reports that the area has been waxing and waning for approximately six months duration. Patient also admits to smoking at least 1 pack of cigarettes a day. Clinical evaluation reveals a defect of approximately 12 mm on the mesial aspect of the tooth as well as having a concomitant horizontal component. The tooth tested positive to vitality test and no pain was elicited upon percussion at that time. It is important to note that the tooth had extruded past the adjacent teeth in that time and was now outside of the incisal plane. The options for treatment were as follows.Localized scaling and root planing with or without localized delivery of chemotherapeutic agent. Alternatively, open flap with debridement and possible placement of biologics, and finally, LANAP.

fig 1. pre-op probing defect mesial #8

fig 2. ibid. showing horizontal component

When approaching a situation such as this, one must consider the source of the problem as well as the potential pitfalls of the various treatment options. As the tooth was vital and no apparent breach of the root canal system was noted, the likely source of the lesion was periodontal in nature. Therefore no endodontic treatment was indicated. The problem then becomes, how to approach this without resultant negative esthetic sequelae that are often the result of open procedures in this region. Namely, at worst recession ending up in a “black triangle “ appearance in between the two anterior teeth.

fig 3. immediate post-op LANAP

fig 4. ibid with incisal reduction

After some discussion, LANAP was performed and as no incisions were necessary, the likelihood of recession was minimalized. Incisal adjustment was performed and the case proceeded to heal uneventfully. The case was performed at 3.6 w and 100ms for a total of 320 m-Joules. Oral hygeine instructions and anti-inflammatories were prescribed. No antibiotics were taken during the recovery period., The final healing , as seen on the radiographic comparison in figure 6, shows the extent of the regeneration. (N.B. the incisive foramen, which serves as a landmark for comparison.)

fig 5. 4 yr post-operative photo

fig 6. n.b the incisive foramen on the pre-op and then on the left, at 48 month post op showing complete regeneration

As with all LANAP procedures, it is important to understand and communicate to the patient that the healing process, while more complete, takes more time than with more traditional open procedures. The end result, of course is true regeneration of the lost periodontium. In the case of LANAP, the ability to affect change stems form the ability to maintain the cytoskeletal component of regeneration, the underlying granulation tissue, albeit in a more “aseptic” manner.