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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 135-139

Periodontal management of osseous defect due to iatrogenesis as well as foreign body impaction: An unusual case report

1 Department of Periodontology, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu, India
2 Private Practitioner, Coimbatore, Tamil Nadu, India

Date of Submission14-Jul-2020
Date of Decision09-Jun-2021
Date of Acceptance14-Jun-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Poornima Rajendran
Department of Periodontology, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_63_20

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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 Top

  • 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 Top

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.[1]

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.[2] 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 Top

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 1: Preoperative image of the Class II cavity in relation to #26

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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 Top

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.[3] 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:[4]

  • 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.[5] 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.[6],[7]

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.[8] Such faulty restorations not only expedited plaque accumulation but also lead to increase in the proportion of anaerobic species.[9] 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.[10] 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.[9] These black-pigmented bacteriods are proved to be the prime etiologic organisms for periodontal tissue destruction.[11]

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.[12],[13]

Subgingival margin placement of the restoration and not any other property of the restorative material are responsible for deleterious effects on periodontal health.[10] 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.[14]

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.[15]

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.[16] 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 Top

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.

   References Top

Rawal SY, Claman LJ, Kalmar JR, Tatakis DN. Traumatic lesions of the gingiva: A case series. J Periodontol 2004;75:762-9.  Back to cited text no. 1
Black A. Preventive treatment of periodontal diseases. Northwest Dent J 1912;10:60-73.  Back to cited text no. 2
Bryan AW. Some common defects in operative restorations contributing to the injury of the supporting structures. J Am Dent Assoc (1922) 1927;14:1486-9.  Back to cited text no. 3
Millar B, Blake K. The influence of overhanging restoration margins on interproximal alveolar bone levels in general dental practice. Br Dent J 2019;227:223-7.  Back to cited text no. 4
Boteva E, Karayasheva D, Peycheva K. Frequency of iatrogenic changes caused from overhang restorations. Acta Med Bulg 2015;42:30-5.  Back to cited text no. 5
Waerhaug J. Effect of rough surfaces upon gingival tissue. J Dent Res 1956;35:323-5.  Back to cited text no. 6
Sumanth KN, Boaz K, Shetty NY. Glass embedded in labial mucosa for 20 years. Indian J Dent Res 2008;19:160-1.  Back to cited text no. 7
[PUBMED]  [Full text]  
Than A, Duguid R, McKendrick AJ. Relationship between restorations and the level of the periodontal attachment. J Clin Periodontol 1982;9:193-202.  Back to cited text no. 8
Lang NP, Kiel RA, Anderhalden K. Clinical and microbiological effects of subgingival restorations with overhanging or clinically perfect margins. J Clin Periodontol 1983;10:563-78.  Back to cited text no. 9
Waerhaug J. Histologic considerations which govern where the margins of restorations should be located in relation to the gingiva. Dent Clin North Am 1960;4:161.  Back to cited text no. 10
Newman MG, Takei HH, Klokkevold PR. Carranza's Clinical Periodontology. 12th ed. St. Louis, MI: Elsevier; 2015.  Back to cited text no. 11
Katge F, Mithiborwala S, Pammi T. Incidental radiographic discovery of a screw in a primary molar: An unusual case report in a 6 year old child. Case Rep Dent 2013;2013:296425.  Back to cited text no. 12
Azodo CC, Erhabor P, Chukwumah NM, Ogordi P. Intraoral foreign body: A case report and review of literature. Indian J Multidiscip Dent 2015;5:97.  Back to cited text no. 13
  [Full text]  
Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol 1961;32:261-7.  Back to cited text no. 14
Romanos GE, Bernimoulin JP, Marggraf E. The double lateral bridging flap for coverage of denuded root surface: Longitudinal study and clinical evaluation after 5 to 8 years. J Periodontol 1993;64:683-8.  Back to cited text no. 15
Mokeem SA. The impacts of amalgam overhang removal on periodontal parameters and gingival crevicular fluid volume. Pak Oral Dent J 2007;27:17-22.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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