Fig. 1a  Initial panoramic radiograph of a 62-year old female patient suffering from generalized moderate to ultimately severe aggressive periodontitis (type III B periodontal disease). Note that tooth # 28 is horizontally completely impacted with a direct communication to the oral cavity (see also Figs. 2b, 4a, 4b). Furthermore, tooth # 37 is vital exhibiting a circumferential periapical radiolucency. In addition, generalized shortened and pointed root shapes could be diagnosed indicating a type III periodontal disease.

Fig. 3a  Positive microbiological analysis (clusters type 4 and 5) at multiple sampling sites at the beginning of the treatment utilizing a ribonucleic acid test (RNA hybridization; IAI PadoTest 4·5®) using a standard approach searching for specific periodonto- / implantopathogens (Aggregatibacter actinomycetemcomitans [A.a.] / Bacteroides forsythus [B.f.] / Porphyromonas gingivalis [P.g.] / Treponema denticola [T.d.]).

Fig. 4a  Horizontal cross section of the initial Cone-Beam Computer Tomogram (CBCT; NewTom® 3G) indicating the close vicinity of the horizontally displaced and completely impacted upper left wisdom tooth (28) to the second upper left molar (27). Note that it is a crucial requirement to remove such teeth on patients suffering from aggressive periodontal disease (type III) with a bacteriological communication (periodontal pocket depth ≥ 4 mm; see also Fig. 2b) to the oral cavity (anaerobic, Gram-negative niche / periodonto- / implantopathogens). Such a removal should take place during periodontitis treatment and prior to implant placement to prevent from bacteriological (re)colonization of endosseous implants.

Fig. 5a  Intermediate periapical radiograph of the upper four vital incisors 12-22 six months after completion of periodontal surgery (open flap debridement). Note the significant gain of alveolar bone especially around the upper central incisors (11, 21; see also Fig. 2a) including a fine line of compact bone formation at the crestal bone level indicating healthy and stable periodontal structures over time. Furthermore, the upper diastema mediale had been closed spontaneously already after the completion of the initial periodontal preparation (supra- and subgingival debridement). Prior to periodontal surgery, a composite splint of the upper four incisal teeth (12-22) was carried out to help temporarily immobilize increased tooth mobility which is a crucial factor of both remodeling of periodontal connective hard (bone) and soft tissues.

Fig. 6a  Preoperative analysis of a newly developed periodontal / periimplant microscopic plastic surgical procedure (connective tissue graft [CTG] technique) at the upper incisors (12-22) showing the palatal CTG donor as well as the anterior CTG recipient site.  For hemostasis, better wound healing as well as patient comfort reasons, a palatal thermoformed guard was provided after completion of the soft tissue surgery.

Fig. 7a  Final Cone Beam Computer Tomographic analysis (CBCT; KaVo / Gendex® 3D) about 3 years after anterior periodontal plastic surgery as well as about 4 years after periodontal open flap debridement. In the meantime, a Soft Tissue Level Implant (Straumann®) could be placed and restored with a porcelain-fused-to-metal crown due to an endodontic failure (acute pulpitis / complete root canal sclerosis despite microscopic ultrasonic preparation) in the first upper right molar region (16) and in a combination with an internal sinuslift procedure via a bovine xenograft (Bio-Oss® Spongiosa) and porcine enamel matrix derivatives (Emdogain®). In addition, full ceramic veneers could be inserted at the two central upper incisors (11, 21; Creation®). Finally, tooth 37 could be removed and the socket preserved utilizing a bovine bone xenograft (Bio-Oss® Spongiosa) in combination with enamel matrix derivatives (Emdogain®) and a porcine collagen membrane (Bio-Gide®). Last but not least, a Soft Tissue Level Implant (Straumann®) was placed in combination with a porcelain-fused-to-metal crown. Note the perfect overall compact bone formation after such a healing period indicating long-term healthy periodontal / periimplant tissues over time.

Fig. 8a  Schematic drawing of three different Bone Level Implants with a Titanium-Plasma-Spray (TPS) coating (left), a machined titanium surface (center), and a Hydroxyapatite (HA) sprayed coating at the beginning of the study. The purpose of this split-mouth animal study was to evaluate if implants are equally susceptible to ligature-induced periimplantitis, and to find out the best methods to monitor periimplant health as well as disease.

Fig. 9a  Final periapical radiograph of the upper four vital incisors 12-22 about 1 year after insertion of full ceramic veneers (11, 21; Creation®) and 3 years after anterior periodontal plastic surgery as well as about 4 years after periodontal open flap debridement. Note stable periodontal hard tissues over time when compared to six months after completion of the periodontal open flap debridement procedure (see Fig. 5a). In addition, no recurrence occurred in terms of tooth migration in the anterior segment even without any means of splinting. This indicates that periodontal regeneration successfully took place with an excellent prognosis long-term. Note that such a long-term result only can be achieved if a maintenance care program is installed with a specialist recall interval (Dental Hygienist / Periodontist) of 3 months, since such an aggressive flora may form again right after 12 weeks.

Fig. 10a  Final clinical long-term result with a stable periodontal, functional as well as esthetic outcome based upon a 3-month recall interval in a Specialist Dental Practice (Dental Hygienist / Periodontist). Note the nice integration of the full ceramic veneers of the two central incisors (11, 21) in combination with a natural soft tissue periodontal architecture on this ‘gummy smile’ patient.

Abb. 11a  Final Cone Beam Computer Tomographic analysis (CBCT; KaVo / Gendex® 3D) in the oro-facial plane of the left second lower molar (37) almost 3 years after socket preservation (Bio-Oss® / Emdogain® / Bio-Gide®) and about 2 years after Soft Tissue Level Implant placement (Straumann®). Note the newly formed and functionally oriented trabecular compact bone aiming at the thread tips of the Soft Tissue Level Implant thus functionally preserving both the buccal and lingual alveolar bone long-term as well as a continuous compact crestal bone layer indicating an optimal hard tissue integration over time. In addition, the 3-D Guided Implant Surgery analysis prior to implant placement allowed for a perfect protection of the most (!) vulnerable neuro-vascular bundle (submandibular artery / vein / nerve) in the lingual mouth floor region, which seems to be a crucial requirement in today’s implant therapy.

Abb. 12a  Patients with a diagnosis of aggressive periodontitis / periimplantitis (periodontal disease type III) have about a 90% chance that their partners also test positive for the classic periodontopathogens / implantopathogens due to the infective (not inflammatory) nature of such a disease (‘Kissing Disease’). Consequently, the partner of the female patient as described above revealed massive total bacterial loads of these classic germs, and consequently, also was treated immediately and completely healed after a period of another 16 months. Positive microbiological analysis (clusters type 4 and 5) at the beginning of the treatment at multiple evaluation sites utilizing a ribonucleic acid test (RNA hybridization; IAI PadoTest 4·5®) using a standard approach searching for specific periodonto- / implantopathogens (Aggregatibacter actinomycetemcomitans [A.a.] / Bacteroides forsythus [B.f.] / Porphyromonas gingivalis [P.g.] / Treponema denticola [T.d.]).