Clinical context and challenges of grade III mobility

The management of severe periodontal bone loss associated with class III mobility represents a clinical challenge where the prognosis for tooth preservation is traditionally considered unfavorable. Faced with extensive destruction of the periodontal ligament, often exacerbated by a history of dental trauma or chronic inflammation, the functional integrity of the teeth is severely compromised. The practitioner must then decide between extraction and a complex interdisciplinary strategy aimed at stabilizing the dental units while restoring periodontal support.

Objective and hypothesis of the interdisciplinary approach

This case report documents the therapeutic management of mandibular central incisors presenting terminal mobility and localized vertical bone loss. The objective is to demonstrate the efficacy of a rigorous sequential protocol integrating endodontic treatment, non-surgical periodontal debridement, mechanical stabilization via fiberglass splinting, and regenerative surgery using enamel matrix derivative (EMD).

The study is based on the hypothesis that the neutralization of micromovements through splinting, combined with the biological potential of EMD to stimulate cementum and alveolar bone formation, significantly improves short-term clinical support, thus allowing for the prolonged retention of teeth initially deemed hopeless.

Interdisciplinary therapeutic protocol

This clinical case report documents the management of a 30-year-old female patient (smoker, 10 cigarettes/day) presenting with generalized periodontitis stage III, grade C. The intervention specifically targets the mandibular incisors (31 and 41) affected by grade III mobility and localized vertical bone loss.

The experimental protocol was structured around four sequential steps:

• Endodontic phase: Root canal treatment of teeth 31 and 41 aimed at eliminating any intraradicular inflammatory component suspected by the apical widening of the periodontal ligament.
• Initial periodontal therapy: Scaling and root planing. At inclusion, the mean clinical attachment level (CAL) was 4.4 mm, the mean probing depth (PD) was 3.9 mm (6-7 mm pockets in the posterior), with bleeding on probing (BOP) of 82% and a plaque index of 75%.
• Mechanical stabilization: Placement of a fiberglass splint bonded with composite to neutralize micromovements.
• Regenerative surgery: Elevation of an intrasulcular flap, debridement of the bone defect and application of enamel matrix derivatives (EMD) on the prepared root surfaces, followed by primary closure with sutures.

Le suivi postopératoire a été réalisé à 3 mois, incluant une réévaluation des paramètres parodontaux cliniques et une analyse radiographique périapicale comparative pour évaluer le gain de support osseux localisé.

Results of interdisciplinary management

The initial evaluation revealed advanced periodontal destruction, particularly localized at the mandibular incisors (31 and 41). The baseline clinical parameters showed generalized inflammation and a critical loss of structural support.

After a 3-month follow-up period following the regenerative procedure using enamel matrix derivatives (EMD) and stabilization with a glass fiber splint, the following observations were reported:

• Dental stability: A marked reduction in mobility was clinically observed compared to the initial grade III status.
• Periodontal health: The clinical outcome is considered favorable, with clinical attachment gain and a reduction in probing depths across all treated sites.
• Inflammation control: A clear improvement in gingival status and a decrease in local inflammation were noted in the anterior mandibular region.

The 3-month follow-up radiographic examination confirms these clinical improvements by revealing an increase in bone level in the mandibular incisor sector. This early improvement in local bone support suggests a positive response to periodontal regeneration procedures combined with mechanical stabilization.

Analysis of the therapeutic strategy

The results of this clinical case demonstrate that the combination of mechanical stabilization and biological stimulation by EMD can reverse a poor prognosis. The major interest here lies in the sequence: the splinting neutralized deleterious micromovements, thus allowing the clot and enamel matrix derivatives to initiate the regeneration of the periodontal ligament and alveolar bone. The endodontic approach, although initial vitality was positive, secured the site by eliminating the risks of endo-periodontal communication during the critical healing phase.

Limits and risk factors

The 3-month clinical follow-up constitutes the main limitation of this study; long-term stability remains to be confirmed by prolonged monitoring. Furthermore, the patient's persistent smoking remains a limiting factor for the long-term sustainability of attachment gains. Finally, the history of direct trauma makes this case specific: the occlusal component could be more pronounced than in classic chronic periodontology, making the generalization of these results to all vertical defects delicate.

Clinical implications

For the practitioner, this report confirms that splinting does not hinder regeneration, but is rather a prerequisite in the presence of significant mobility. EMD remains a biomaterial of choice for stimulating cementum and bone formation, provided that local inflammation is perfectly controlled beforehand.

Summary of results

The combined approach associating endodontic treatment, fiber-reinforced splint stabilization, and regenerative surgery (EMD) allowed for the stabilization of mandibular incisors with an initially poor prognosis (Grade III mobility). At 3 months, the study reports a major reduction in clinical mobility, improved attachment levels, and early radiographic bone gain, confirming the viability of this interdisciplinary strategy.

In concrete terms, for the practitioner:

• Splinting is a prerequisite: the glass fiber splint neutralizes micromovements, creating the stable environment essential for the biological efficacy of the enamel matrix derivative.
• Priority to endo-periodontal sanitation: in the face of apical bone destruction, prior endodontic treatment eliminates the internal inflammatory focus before any attempt at tissue regeneration.
• The patient at the heart of success: the radical transition in hygiene (plaque index from 75% to 0% in this case) remains the determining factor for transforming a doomed tooth into a lasting clinical success.

Technical Lexicon of the Study

Grade III Mobility: Severe degree of dental mobility characterized by horizontal movement greater than 2 mm and/or vertical mobility (intrusion/extrusion).

Enamel Matrix Derivatives (EMD): Biomaterial (often based on amelogenins) used to stimulate the regeneration of the tooth's supporting tissues by mimicking natural dental development.

Glass fiber splint: Bonded splinting device used to stabilize several teeth to reduce mechanical stress and promote periodontal healing.

Clinical Attachment Level (CAL): Distance measured between the cemento-enamel junction and the bottom of the periodontal pocket, a key indicator of the severity of periodontology.

Widening of the periodontal ligament space: Radiographic sign of occlusal overload, trauma, or advanced periodontal inflammation, reflecting a loss of dental stability.

Intrasulcular flap: Surgical incision technique following the gingival sulcus, preserving maximum tissue to allow primary closure over regenerated defects.

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