|Year : 2021 | Volume
| Issue : 3 | Page : 135-139
Periodontal management of osseous defect due to iatrogenesis as well as foreign body impaction: An unusual case report
Poornima Rajendran1, Mohanapriya Asokachandran2
1 Department of Periodontology, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu, India
2 Private Practitioner, Coimbatore, Tamil Nadu, India
|Date of Submission||14-Jul-2020|
|Date of Decision||09-Jun-2021|
|Date of Acceptance||14-Jun-2021|
|Date of Web Publication||22-Dec-2021|
Dr. Poornima Rajendran
Department of Periodontology, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
During any dental treatment, various instruments, dental materials, and appliances come in contact with the tissues of the oral cavity. Inappropriate handling of these instruments and materials can cause both hard tissue and soft tissue damage. Periodontal destruction due to iatrogenesis and foreign body impaction is not uncommon. The present case report describes an unusual case of iatrogenic periodontal destruction due to restorative overhang as well as impacted restorative material into the interdental region and its management.
Keywords: Foreign body impaction, iatrogenesis, osseous defects, periodontitis
|How to cite this article:|
Rajendran P, Asokachandran M. Periodontal management of osseous defect due to iatrogenesis as well as foreign body impaction: An unusual case report. J Interdiscip Dentistry 2021;11:135-9
|How to cite this URL:|
Rajendran P, Asokachandran M. Periodontal management of osseous defect due to iatrogenesis as well as foreign body impaction: An unusual case report. J Interdiscip Dentistry [serial online] 2021 [cited 2022 Jan 25];11:135-9. Available from: https://www.jidonline.com/text.asp?2021/11/3/135/333341
| Clinical Relevance to Interdisciplinary Dentistry|| |
- The present case report describes an unusual case of dislodged restorative material from a Class II cavity that caused severe periodontal destruction
- Multidisciplinary approach was carried out, where a periodontist performed flap surgery to remove the foreign body as well as granulation tissue and the dental practitioner restored the Class II cavity
- The importance of “Primum non nocere-To do no harm” and matrix band and wedge placement during Class II restorations is highlighted.
| Introduction|| |
Iatrogenesis is a term used to describe a harmful effect as a result of medical or dental treatment. It is a common, but preventable hazard of treatment. In dental practice, iatrogenic treatment can produce injury either on the tooth or on the periodontium or both. Various dental and periodontal procedures involve use of high-speed rotary instruments, sharp hand instruments, dental materials that are foreign to the human body, and appliances for prosthodontic and orthodontic treatments. Incongruous use of these materials, instruments, and appliances may result in traumatic periodontal lesions.
Black in 1912 first described the relationship of iatrogenesis and periodontal destruction where the restorations with defective gingival margins lay a foundation for plaque accumulation and thus cause periodontal disease. Encroachment of the interdental region by an overhanging restoration or a foreign body leads to mechanical irritation as well as plaque retention, resulting in periodontal tissue destruction.
The present article describes an unusual case of iatrogenic periodontal tissue destruction due to restorative overhang as well as impacted restorative materials within the interdental space and its sequential management.
| Case Report|| |
A 36-year-old systemically healthy male patient reported with a chief complaint of pain in relation to the maxillary left molar region. The pain was continuous but dull aching in nature. The patient also reported of food lodgment and dentinal hypersensitivity on consuming cold foods in the same region. On clinical examination, the maxillary left first molar (#26 as per the FDI tooth numbering system) revealed Class II dental caries involving the mesial aspect of the tooth [Figure 1]. Periodontal examination with William's periodontal probe showed the presence of score 2 bleeding on probing (BOP) (modified sulcular bleeding index), score 2 gingival index (GI), and probing pocket depth (PPD) of 7 mm in the mesiobuccal aspect of #26. Intraoral periapical radiograph by long-cone paralleling technique exposed a well-defined radiopaque object within the interdental space between #25 and #26 [Figure 2]. Detailed dental history revealed that the patient had undergone dental restorative procedure for the caries in relation to #26 before 2 years and the restoration fractured 6 months back while chewing food. This suggested a provisional diagnosis of localized chronic severe periodontitis. The periodontal destruction was the result of foreign body impaction of the dislodged overhanging restoration.
|Figure 2: Intraoral periapical radiograph in relation to #25 and #26 revealing foreign body impacted within the interproximal space|
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Following the diagnosis, a treatment plan involving nonsurgical and surgical periodontal therapy was devised. The patient was explained about the procedures and written informed consent was obtained. The nonsurgical periodontal therapy comprising supragingival and subgingival scaling was performed during the initial visit. Occlusal evaluation showed the presence of plunger cusp in relation to mesiobuccal cusp of #46. This prompted the need for occlusal correction that was performed on the same visit. The patient was recalled after 3 days for surgical removal of the foreign body and periodontal therapy for the osseous defect incurred, due to the impacted restorative material.
On the scheduled appointment for surgical therapy, local anesthesia was achieved and full-thickness mucoperiosteal flap was reflected with Bard Parker blade no. 15. The flap reflection revealed the dental restorative material embedded well within the interdental space [Figure 3]. Granulation tissue surrounding the material was debrided, and the foreign body was removed [Figure 4]. Following the removal of the foreign body, the extent of alveolar bone loss was assessed. The osseous defect between #25 and #26 was diagnosed to be a one-walled defect with only 4 mm of palatal wall remaining in the region and complete loss of buccal, mesial, and distal walls. Therefore, open flap debridement was done, the root surfaces were planned, and the osseous defect was leveled by osteotomy procedure. The flaps were then approximated and figure of eight sutures was placed in relation to #25 and #26 [[Figure 5] and [Figure 6], respectively]. Postoperative instructions included modified Bass brushing technique, analgesics (ibuprofen 400 mg twice a day for three days), and chlorhexidine 0.2% mouthrinse (10 ml twice a day for 2 weeks). The patient was recalled after 1 week for suture removal and after 1 month for restoration of the Class II cavity. On the restorative recall visit, direct composite restoration of the Class II cavity was done after achieving proper proximal contact with the adjacent tooth using matrix band and wedge [Figure 7].
|Figure 3: Restorative material as the foreign body observed after mucoperiosteal flap reflection in between #25 and #26|
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|Figure 4: Restorative foreign body material after removal from the interproximal space|
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|Figure 5: One-walled osseous defect noted after complete debridement of the region in relation to distal aspect of #25 and mesial aspect of #26|
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|Figure 6: Approximation of the flap and suturing done in relation to #25, #26 and #27|
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|Figure 7: Postoperative intraoral periapical radiograph revealing the extent of bone loss and #26 after final restoration|
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The patient showed uneventful healing on the periodontal recall visit [Figure 8]. The postoperative intraoral periapical radiograph revealed the extent of alveolar bone loss [Figure 7]. The 3 months and 6 months of follow-up visits suggested a significant reduction in both BOP and GI from score 2 to 1. PPD was reduced from 7 to 4 mm.
|Figure 8: Complete healing noted in relation to #25, #26 during the 6 months of recall visit|
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| Discussion|| |
The greatest challenges encountered during the restoration of posterior Class II cavities are reconstruction of the proximal surface and establishment of ideal contact area with the adjacent teeth. Bryan in 1927 suggested that dental restorations serve two very important purposes; restoration of carious teeth to health as well as protection of the supporting structures from injury. Failure to achieve this will result in food impaction, difficulty in employing interproximal plaque control measures and thereby resulting in periodontal disease.
Infringement of the interdental space by an overhanging restoration has the following effects:
- Local irritation of the periodontal structures
- Retention of plaque and calculus
- Inaccessibility for mechanical plaque control in the interdental area
- Alteration in the periodontal microflora.
Various epidemiological as well as experimental studies have frequently documented the above mentioned findings in iatrogenically induced periodontal diseases. The common iatrogenically induced periodontal lesions are due to apical dislodgment of restorative material, traumatically introduced dental materials, and instruments such as endodontic files, excessive orthodontic force application, overhanging restorative margins, and roughness of the restorative surface.,
Restorations with substandard margins and dislodged restorations within the interproximal space have an imperative role in the etiology of periodontal destruction. Than et al. in 1981 evaluated the quality of restorations in 240 extracted teeth that were restored. The results suggested that nearly 60% of the teeth had overhangs. Such faulty restorations not only expedited plaque accumulation but also lead to increase in the proportion of anaerobic species. Waerhaug in 1960 postulated that the gingival inflammation in sites with overhangs was due to excessive plaque accumulation and inadequate plaque control rather than mechanical irritation. Lang et al. in 1983 assessed the plaque samples taken from beneath the restorative overhangs. It was found that the altered microflora resembled the microflora observed in chronic adult periodontitis, with increased levels of black-pigmented bacteriods. These black-pigmented bacteriods are proved to be the prime etiologic organisms for periodontal tissue destruction.
Katge et al. in 2013 and Azodo et al. in 2016 suggested that dental restorative materials and instruments are possible iatrogenic foreign bodies that can be implanted traumatically, iatrogenically, or unintentionally within the soft and hard tissues of the oral cavity.,
Subgingival margin placement of the restoration and not any other property of the restorative material are responsible for deleterious effects on periodontal health. However, when these restorative materials get impacted within the periodontal structures, it will elicit foreign body reaction. Moreover, both overhanging restoration and foreign body impaction within the interdental area will result in violation of the biologic width. Gargiulo et al. in 1961 suggested that infringement of this biologic width due to the above-mentioned reasons result in gingival inflammation, pocket formation, and alveolar bone loss.
In the present case report, the restoration of the Class II caries was improper as well as excessive amount of material had been used when compared to the actual size of the carious lesion. On assessing the extent of alveolar bone destruction, the biologic width violation has definitely occurred at the time of restoration. Moreover, when excessive occlusal force was applied upon the tooth, the restoration dislodged and got implanted within the interproximal space. This led to foreign body reaction, resulting in hastened bone loss. Removal of such foreign bodies is obligatory because it might cause secondary infection with abscess/fistula formation and granulomatous tissue reaction.
Since the osseous defect formed due to foreign body impaction was a one-walled defect in the present case, periodontal regenerative procedure was not an option. Therefore, complete debridement of the defect and osseous re-contouring of sharp bony edges were performed. Following this, the flaps were approximated and sutured.
Mokeem in 2007 reported a significant reduction in clinical parameters such as PPD, GI after removal of restorative overhangs. This is in accordance with the present study where the clinical parameters revealed considerable reduction after the removal of the foreign body and complete debridement of the granulation tissue, when compared to the preoperative values.
Therefore, it is vital that, foreign body impaction or overhanging restorations, symptomatic or asymptomatic, both have to be eliminated to preserve the remaining periodontal tissues.
| Conclusion|| |
Class II restorative therapy should always be done after the placement of matrix band and wedge and after achieving proper proximal contact without any overhangs or high points. It is always preferred that the proximal surfaces of these restorations are polished smooth to facilitate oral hygiene measures and to prevent plaque accumulation. In case of overhanging restorations or if these restorations dislodge into the interproximal area, it will result in irreversible destruction of both the soft and hard tissues of the periodontium. Therefore, it is mandatory that dental procedures should not only be focused on mechanical specifications but also on biological prerequisites.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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