Treatment of Intrabony Defect using Xenograft and Collagen membrane-A Case Report with Clinico-radiographic Evidence

Periodontal regenerative procedures attempt to increase the periodontal attachment, bone level and reduce pocket depth in order to improve the immediate and long-term clinical results of periodontally compromised teeth. Guided Tissue Regeneration (GTR) membrane and bone graft materials or their combination has been used for reconstruction of periodontal apparatus. After reflecting a full-thickness flap, thorough debridement and root planing were accomplished in the present case. A bioabsorbable collagen membrane was placed over the xenograft filled defect to treat an intrabony defect. The one-year-follow up showed improvement in clinical parameters with radiographic evidence of bone fill.


INTRODUCTION
Periodontitis is an infectious disease leading to destruction of the tooth-attachment apparatus. 1eeth with deep pockets associated with deep intrabony defects represent a frequent sequel of periodontitis and are considered a clinical challenge. 2,3uided tissue regeneration(GTR) is a technique where placing a mechanical barrier prevents the apical migration of the gingival epithelium allowing periodontal ligament and bone tissue to selectively repopulate the root surface. 3The combined use of bone graft and regenerative membrane resulted in greater pocket-depth reduction, clinical attachment level gain compared with the implantation of bone graft alone. 2

CASE REPORT
A 37-year-old male reported to the Department of Periodontology and Oral Implantology, BP Koirala Institute of Health Sciences, Dharan with a chief complaint of pain in his upper and lower right and left Dr. Victory Thapa, 1 Dr. Sajeev Shrestha, 2 Dr. Khushbu Adhikari, 2 Dr. Suresh Bhandari  back teeth region of the jaw for two years.He had a noncontributory family and medical history.Periodontal examination revealed periodontal pockets ranging from 6 to 10 mm in multiple teeth with generalized deposits present (Figure 1).Orthopantomogram and Intra-oral periapical radiographs (IOPA) revealed generalised horizontal bone loss with vertical bony defects in relation to teeth 26,36,43,46 (according to two-digit tooth numbering system, Figure 2).A provisional diagnosis of generalised periodontitis stage III grade C was made.In Phase I therapy, scaling, and root planing (SRP) was done and was re-evaluated after four weeks.On reevaluation, there was a probing pocket depth of seven millimetre each on the distobuccal surface (Figure 5) and on the lingual surface of tooth 46 (according to two-digit tooth numbering system, Figure 6).
The clinical situation, treatment approach and the type of material to be used were explained to the patient, and consent was obtained for the surgery.
Right inferior alveolar nerve block was given with local anaesthesia 2% lidocaine 1:200000 epinephrine and crevicular incision was made using 12D number surgical blade from mesial surface of right mandibular second premolar to mesial surface of second molar region.Full thickness mucoperiosteal flap was raised, to expose the underlying bone using periosteal elevator.All granulation tissue was removed from the defects and teeth were thoroughly scaled and root planed with Gracey curettes.
After debridement a combined defect was present with three wall defects apically and one wall defect coronally on distal surface of tooth 46 (according to two-digit tooth numbering system, Figure 7) The graft material (Bio-Oss size 0.25 to 1 mm) was moistened in sterile saline before placement into the defect.Following grafting, a bioabsorbable collagen membrane, Bio-Gide  was cut according to the morphology of the defect using a template.
The membrane was carried to the defect site and adapted over the entire defect to cover two to three millimetres of the surrounding alveolar bone and to ensure the stability of the graft material (Figure 8).
Neither sutures nor pins were used for membrane stabilization.Finally, the mucoperiosteal flaps were repositioned coronally (to prevent membrane exposure) and were approximated from buccal to lingual surface using interrupted sutures (3-0 silk suture) (Figure 9).Post-operative care consisted of rinsing with 0.2% chlorhexidine digluconate solution twice a day for two weeks.

DISCUSSION:
A periodontal defect within the bone that is encircled by one, two, or three bony walls is known as an intrabony defect. 4Angular defects with at least two bony walls on either side provide lateral sources for periodontal ligament cell growth and may thus heal more predictably than intrabony lesions with only one wall , we also anticipated in the present case. 4o-Oss is a deproteinized bovine-derived xenograft that is prepared by protein extraction of bovine bone and resembles human cancellous bone with osteoconductive properties.A porcinederived bilayer collagen membrane (Bio-Gide) has been proven to be a promising option in Guided Tissue Regeneration because of its slow absorbable property and its ability to enhance periodontal tissue regeneration. 9ing GTR membrane and graft material to treat deep intrabony defects is one of the most reliable strategies that could result in considerable clinical advantages in terms of clinical attachment and bone growth, as well as a reduction in pocket depth. 6In the present case, a biocompatible barrier membrane was surgically placed over the graft filled defect to prevent migration of the epithelial periodontal tissues into the defects allowing time for bone and
Further he was instructed not to smoke and to apply ice intermittently during the first day on the face over the operated area and was summoned back after one week for suture removal.Post-operative examination and cleaning of surgical site with chlorhexidine was done at two weeks, followed by supragingival scaling every month for upto six months.Neither probing nor subgingival instrumentation was performed during the first 6 months after the surgery.Thapa et al: Treatment of Intrabony Defect using Xenograft and Collagen membrane-A Case Report with Clinico-radiographic Evidence

Figure 7 :
Figure 7: Measurement of intrabony defect buccal and lingual view after debridement.

Figure 8 :
Figure 8: Placement of graft and membrane in the defect.

Figure 11 :
Figure 11: Post treatment radiograph after one year.

Figure 10 : 7 and
Figure 10: Buccal and lingual view after one-year-followup (Reduction in pocket depth).