Periodontal Regeneration in Esthetic Zone. Advice?

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Posted on By Valeria Zamberlin In Periodontics

Any advise is welcome! This 50 years old lady has a severe periodontal disease. HOW WOULD YOU MANAGE this central incisor (tooth#8)? It has probing depth 8mm mesial, 6mm vestibulo-mesial, 6 mm palatal mesial. There is no probing depth on the other aspects of the tooth or other anterior superior teeth.Now we are in basic periodontal therapy and hygiene. Esthetic demands are huge!

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GTR perio regeneration followed by ortho extrusion as needed to alter papilla height. Endo and crown may be required to maximize esthetics. But please also do not forget to diagnose the entire mouth which has several areas of acute periodontal breakdown. Dr. Salama


Hi, looks like she suffers from aggressive perio molars included ...
maybe consider treating the disease prior to symptoms. Good luck


Hi Valeria,

This is severe periodontitis without obvious inflammatory signs and symptoms, judging from your Pan.

It's a possibility there is an unexpectedly virulent bacteriological expression in the context of serious systemic conditions, such as hyperglycemia or some autoimmune manifestation.

This patient with a lovely smile is at the precipice of losing her lower front teeth as well as some molars.

Whatever the treatment plan is, it should include bacteriologic testing for periodontal pathogens. Actinobacillus actinomycetemcomitans, Treponema, P. Gingivalis, etc., are culprits to look for.

Perhaps even suggest a blood test. One-fourth of diabetes in North America is undiagnosed. Ten percent of the population are prediabetic. These hyperglycemic conditions are closely linked to severe periodontitis.

It's just possible this multi-profession approach to the diagnosis of periodontal disease will save lives, besides saving teeth.

Valeria, this patient needs help.

Best of luck,


John Chao, D.D.S.
Inventor of the Pinhole Surgical Technique
Research Associate Professor, Buffalo, SUNY
Adjunct Assistant Professor, USC


John; Thank you. So well said. This is a severe perio case that may have systemic manifestations well beyond the singular area of concern described here. This case should be seen by a periodontist for sure in my opinion. regards Dr. Salama


Hello and Happy New Year.
Thank you very much for each one of the comments.
I am periodontist, I have already done everything you´ve said about taking care of the patient. She is systemically healthy. She has an advanced chronic periodontitis which was never treated nor diagnosed in her 50 years. She has lost left inferior molar, other pockets had been trated with a fair response. She is now in the evaluation and complementary treatment options, one of them being this central incisor.
My question was specifically oriented to de central incisor, because of the periodontal issue and esthetic compromise. . I will actualize probing depth next week. But the main issue here is the papilla. Hoping that the level won´nt change a lot as the hight is mantained with the neighbour insertion level, I would like to regenerate the deffect.
The question is where would you place horizontal incisions, protect or not papilla, do vertical realising incisions and where..go minimally invasive...
Have a grate 2018! Best regards!


Valeria I would look into Cortellini's M-MIST approach which is a minimally invasive micro flap design. This would give you a safe way to approach your flap design to minimize changes to the esthetics. Hope this helps. Regards Naheed


I double Naheed's comment. You may consider to preserve the papilla with minimal extension of the flap to mesial and distal with no vertical incision. Despite all your efforts with regeneration you most likely will not improve the papilla that much but at least you can attempt to improve the bone support filling the infra bony defect, and who knows sometimes miracle happens...
Good luck,


I have learned that despite minimal invasive approach, aesthetic results are not predictable. For this reason I chose a VISTA approach in a very similar situation. There is not evidence behind...but may be the way to go
Best regards


Something similar I was thinking tunneling papilla coming from distal of the lateral..I will check your link carefully. Thanks a lot for all the comments!


I think that surgery will make things worse unless the lifting would be from canine to canine in order to improve the smile line and consequently have esthetic smile.regeneration of that papila in surgical way seems to have low chances ! What class of mobility the pt has?


360 Imaging