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68 Cards in this Set
- Front
- Back
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Root surface debridement |
The removal of deposits (plaque, calculus) and a thin layer of cementum bound endotoxin from the root surface. Smooth surface. BLIND - Ultrasonic instrumentation - Hand instrument - Irrigation with saline |
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Limitations of “closed” RSD |
Progressive and aggressive breakdown. Persistent acute episodes (eg. perio abscess). Deep complex bone defects – difficultieswith adequate debridement. Severe hyperplasia or tissue deformity. Pathology e.g. epulides. |
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Aims of periodontal surgery |
- Gain access to root surface for effective debridement - Visualisation of bone defects - Improvement in tissue contour - Reduction in pocketing (probeble pocket depth) - Removal of chronologically inflamed tissue - Encourage regeneration of lost periodontal support - Removal of hyperplastic gingival tissue - Crown lengthening |
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Indications for Surgery |
Gingiectomy: - Hyperplasia - False pockets - Adequates attached gingiva Replaced flap: - Deep persistent bleeding (supperating) pockets Apically repositioned flap: - Pocket elimination - Crown lengthening - Unsuccessful gingivally encroaching restoration |
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Considerations beforesurgery |
- Has non-surgical therapy been undertaken and reviewed at an appropiate interval? - Is pt suitable - medically, emotionally - Do they understand procedure (consent, limitation, complications, aesthetic effect)? - Does pathology warrant surgery - Is oral hygiene adequate - Has restorative strategy been considered |
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Surgical techniques |
Excisional e.g. gingivectomy - Flap - replacement (reattachment) e.g. original and modified Widman flaps - Flap repositional e.g. lateral, apical, coronal - Mucogingival procedures e.g. grafts |
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Gingivectomy |
Stages Local anaesthetic Incisions Removal of excised gingival tissue Scaling Removal of granulation tissue Haemostasis Periodontal dressing |
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Flap procedures – stages |
Local anaesthetic Incisions (use of relieving incisions) Raise flap Curettage RSD Irrigation Sutures (pack for ARF) |
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Access |
- Root surface debridement and granulation tissueremoval. - Root surface treatment and application oftherapeutic agents if appropriate. - Odontoplasty - Root division/amputation - Osteoplasty - Ostectomy - Placement of GTR / graft materials |
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Flap management |
- Raising flaps - Relieving incisions - Replacement of flap |
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Curettage |
to currttage or not? Methods of curettage |
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Types of sutures |
• Interrupted • Suspensory • Continuous |
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Modified Widman Flap |
- Incision 1mm buccally from gingival margin perserving interdental papillae - Flap raised exposing only a few mm of bone - Intracrevicular/horizontal incisions to release pocket lining - Careful curettage of bone - Debridement of root surface - Replace flaps to cover interdental bone and suture |
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Signs of success – flap surgery |
- Decrease in inflammation - Less bleeding on probing - Decrease in pocket depth - Increase in attachment - Eliminate pus - No increase in mobility - Improvement of tissue contour - Stablisation of tissue contour - Stabilisation of bone levels |
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Evidence |
Sytematic review of the effects of surgical debridement for the treatment of chronic perio - Both effective treatments in trems of attachment gain and reduction in gingival inflammation - Greater pocket depth reduction and clinical attachment gain in deeper pockets with open flap debridement |
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apicallyrepositioned flap |
Indications Pocket elimination Crown lengthening Disadvantages Roots exposed – sensitivity and increasedrisk of caries Poor aesthetics Stages: 1) Incisions: - Iabially: inverse bevelincisions - Palatally: gingivectomy - Relieving incisions maybe necessary 2) Raising flap, curettage & RSD - Raise a flap labially beyondthe mucogingival junction - Curettage of pocket lining - Root surface cleaning - Reposition apically 3) Repositioningapically - Raising the flapbeyond the MGJ - Moving the flap in anapical direction 4) Suturing and securing theflap apically - Sling sutures tied labially - Pack to cover the palatalgingivectomy and securethe flap apically 5) Post-operative care andhealing Healing with pocket elimination Root surface exposed |
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Frenectomy |
- Occasionally indicated in patients with a prominent labial frenumattached to interdental papilla - non-surgical vs surgicalmanagement Outline of procedure: - Incision around frenum - Lip incision and undermining of edges to facilitate suturing - Lip wound sutured - Coe-pack dressing over gingival wound |
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Free gingival graft |
Example illustrated: patient with localised recession, lack ofattached gingival tissues and prominent frenal attachment Stages: - Removal of frenum and preparation of wound to receive graft - Tissue removed from palate - Acrylic palate made pre-operatively to hold coe-pack overpalatal wound - Recipient site has gingival graft sutured in place |
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Indications for the surgical management of localized gingival recession |
- Continued inflammation - Progressive breakdown - Aesthetics - Frenal pull - Pocketing beyond MGJ - Some situations when advancedrestorative procedures are planned |
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Techniques of the surgicalmanagement of localized gingivalrecession |
Laterally repositioned flap Coronally repositioned flap Free gingival graft followed by coronallyrepositioned flap Guided tissue regeneration Connective tissue graft |
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Pre-operative assessment |
- Is surgical treatment warranted? - Is recession stable following monitoring? - Medical and social assessment - Tooth vitality - Radiographic examination - Informed consent and clinical records |
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Laterally repositioned flap |
Overview of procedure: Incisions made around the recession defect and along the gingivalmargin of the adjacent donor tissue. A releasing incision is made to release the donor tissue adjacentto the site to be treated. A part full and part split-thickness flap is raised and rotatedlaterally over the defect being treated. |
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Coronally repositioned flap |
A full-thickness mucoperiosteal flap is raised into the base of thebuccal sulcus in relation to the teeth being treated. The flap is then moved in a coronal direction to cover the recessiondefect(s). Interdental sutures and a periodontal dressing hold it in placeduring healing. The procedure may be preceded by a free gingival graft if there isinsufficient attached gingival tissue. |
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Guided tissue regeneration |
A GTR membrane is placed during a surgical procedure. Examples illustrated: Gingival recession treated with a non-resorbable (e-PTFE)membrane Gingival recession treated using a titanium reinforced nonresorbablemembrane Gingival recession treated with a resorbable membrane |
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Connective tissue graft |
Overview: Horizontal incision made through the base of interdental papilla andaround teeth being treated, into ginigival crevice buccally. Relieving incisions are made. A split thickness flap is raised. A flap is raised in the palate and connective tissue with an epithelialborder is dissected out. The wound is closed using sutures and the graft transferred andsutured to the recipient site. The recipient site flap is replaced covering as much of the connectivetissue graft as possible by coronal repositioning . |
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Evidence base for surgical procedures |
Periodontal plastic surgery for treatment of localized gingivalrecessions: a systematic review - Guided tissue regeneration, free gingival graft, connective tissuegraft and coronally advanced flap are effective in reducinggingival recessions with an improvement in attachment levels.No single procedure superior, however connective tissue graftwas statistically significantly more effective than guided tissueregeneration in recession reduction. Cochrane Database Syst Rev. 2009 Root coverage procedures for the treatment of localised recession-typedefects. CONCLUSIONS:Subepithelial connective tissue grafts, coronally advanced flap alone orassociated with other biomaterial and guided tissue regeneration may be usedas root coverage procedures for the treatment of localised recession-typedefects. In cases where both root coverage and gain in the keratinized tissueare expected, the use of subepithelial connective tissue grafts seems to bemore adequate. Randomised controlled clinical trials are necessary to identifypossible factors associated with the prognosis of each PPS procedure. Thepotential impact of bias on these outcomes is unclear. Evidence-based periodontal plastic surgery. II. An individual data metaanalysisfor evaluating factors in achieving complete root coverage. CONCLUSIONS:SCTGs, matrix grafts, and EMD were superior to CAF in achievingcomplete root coverage, but SCTGs showed the best predictability. Theimpossibility of inclusion of all identified RCTs should be taken intoconsideration when interpreting the present findings. |
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Influence Of Occlusal Trauma OnThe Periodontium |
Definition: “ Trauma from occlusion is used to describepathological alterations or adaptive changeswhich develop in the periodontium as a result ofexcessive occlusal stresses.” Excessive occlusal load occurs due to: • An increase in the occlusal load (1°) • A decrease in capacity of the tooth supportingtissues to absorb stress (2°) i.e: There are two types of traumatic occlusion. • Primary occlusal trauma • Secondary occlusal trauma (i.e. secondary toperiodontal tissue loss) |
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Aetiology |
1. It can occur where an individual tooth or a group ofteeth are in premature contact 2. It may occur where there is ‘parafunction’, eg:Bruxism, Clenching 3. It may occur in conjunction with loss or migrationof premolar and molar teeth with anaccompanying, gradually developing spread ofanterior teeth of the maxilla. Following periodontal tissue loss NORMAL forces are nolonger tolerated, but may also : 1. involve an individual tooth or a group of teeth whichare in premature contact 2. occur where there is ‘parafunction’, eg: Bruxism,Clenching 3. occur in conjunction with loss or migration ofpremolar and molar teeth with an accompanying,gradually developing spread of anterior teeth of themaxilla. |
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Excessive occlusal forces can affect othertissues such as: |
• TMJ • Masticatory muscles • Pulp tissue |
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Clinical Signs And Symptoms |
• Tooth Mobility • Fremitus • Tooth Migration (dependent on tension and pressuresites) • Pain • Wear Facets |
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Excessive Occlusal Stress |
• It is difficult to define these stresses innumerical terms • There are four causes: 1. Parafunctional Activity 2. Dental Treatment 3. Occlusal Disharmony 4. Destruction of periodontal tissue by disease |
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Parafunctional Activity |
There are several forms of parafunctionalactivity, these include: – Clenching – Grinding – With/Without Foreign body • Can also be associated with Psychologicalfactors, e.g. Anxiety, Fear and Frustration Bruxism: • Habitual in a large proportion of the population. • Imposes a load of >20kg over a 2.5s period • This excessive force causes ‘flow’ within theviscoelastic periodontal ligament and distortionof alveolar bone, from which tissues are slow torecover • Can lead to impairment of the protective reflex Effects of Bruxism: • In a healthy periodontium the tissues are able toadapt so there is no lasting damage • In pre-existing inflammatory to moderateperiodontal disease the reactions are similar tothat of a healthy periodontium • In advanced periodontitis the rate of diseaseprogression may be accelerated |
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Parafunctional Activity: Diagnosis andTreatment |
Diagnosis – Advanced attrition and wear facets formed only inextreme positions of the mandible – Increased tooth mobility, unrelated to state of disease – Presence of widened PDL spaces – Hypertonicity of muscles of mastication – TMJ discomfort Treatment – Make patient aware – Remove occlusal disharmonies |
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Effects of Dental Treatment |
• Poorly designed partial dentures • Orthodontic Treatment • Contoured Cusps On Restorations • Missing Teeth |
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Occlusal Disharmony |
• Definition: Tooth contacts which interfere withsmooth closing movement along any pathwayinto intercuspal positions • Malocclusion does not mean disharmony • After tooth extraction, adjacent teeth maydrift and tip and opposing teeth mayovererupt • This tilt may lead to greater plaque retention |
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Occlusal Adjustment |
Can be via: – Selective Grinding – Restorations – Orthodontics Objectives of selective grinding 1. Direct Occlusal forces along the long axis of toothand reduce lateral forces 2. Distribute force over as many teeth as possible 3. Eliminate occlusal disharmony4. Achieve a ‘Balanced Occlusion’ |
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Secondary Occlusal Trauma |
• Trauma caused by excessive stresses on teethwith an underlying periodontal condition • The diseased tissue is unable to adapt as well ashealthy tissue |
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Influences Of Occlusal Trauma |
• Widens the periodontal ligament in healthyand diseased periodontium • Periodontitis exacerbated; increasedattachment loss & bone loss which also occursmore rapidly • Gingival recession & tooth mobility inevitable |
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Management |
• The stabilisation and preservation of mobileteeth is the primary aim of treatment • This can be achieved through the use ofsplinting and treatment of any Periodontaldisease |
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Splinting |
Indications - To stabilise teeth with increased mobility that havenot responded to occlusal adjustment & periodontaltreatment - To prevent tipping or drifting of teeth & theovereruption of unopposed teeth - To stabilise teeth after ortho - To stabilise teeth following acute trauma Advantages - Shares load among teeth to prevent unwantedextraction of mobile teeth(eg. prior to periodontal therapy) - Bring teeth into function Disadvantages - Increases plaque retention factors - May overload adjacent teeth The Requirements - Incorporate as many firm teeth around thearch - Hold teeth rigid - Not interfere with occlusion - Must not irritate surrounding soft tiss |
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Splinting – The Types |
- Fixed or removable - Etch retained composite with or withoutreinforcement -TEMPORARY / PERMANENT - Extracoronal cemented restorations or screwretained onto copings -PERMANENT / SEMI-PERMANENT - Hybrids Temporary Splints • In place for less than two months • Prevent mobility on unstable teeth during thehealing phase of a regenerative periodontalprocedure Semi-Permanent & Permanent Splints • PermanentNon-reversible device to stabilise teeth withstable attachment loss • Semi-PermanentUsed prior & post- periodontal surgery if teethare compromised |
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Summary |
• There are two types of traumatic occlusions &two classifications • Caused by excessive occlusal stresses • They widen the PDL causing mobility • Splinting is not a definitive treatment • The underlying periodontal disease must betreated |
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Post Surgical Management |
General post-operative care • Give general advice, preferably written, on what toexpect – some pain, swelling etc. (See advice sheet for flap and gingivectomy procedures) • Oral hygiene advice: Clean adjacent teeth gently. Avoid surgery area. No interdental cleaning. Chlorhexidine mouthwash 0.2% (flap) Clean rest of mouth as usual Return in one week One week later • Removal of pack or sutures. • Rubber cup polish. • Cleaning advice: Gentle brushing, soft brush, gums will bleed. Interdental cleaning gently. Continue mouthwash (another week – beware staining, mucosalirritation, parotid problems, altered taste) Treat any sensitivity – sensitive toothpaste orvarnish. • See again at 1 month and 3 months. |
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Healing |
• After flap surgery – primary intention.Long junctional epithelium. • After gingivectomy – secondaryintention. |
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Primary Intention |
Replaced Flap • Fibrin and clot between tooth and flap. • Organisation & replacement by granulation tissue. • Epithelium grows down from gingival margin. • Long junctional forms. This takes about 6 weeks. • The deep of any vertical bone defect fills in. The alveolar crestresorbs. • Over time the healed tissue shrinks and more crown isexposed. • These changes are maximal at 3 months but occur up to aboutsix months. |
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Secondary Intention |
Gingivectomy: • Initial fibrin cover over wound under pack • Growth of epithelium from retained islets in wound andmargins of area. • Initial epithelialisation takes up to 2 weeks - it may benecessary to repack after 1 week. • Following healing the gingiva regrows to a certainextent, and the gingival level moves coronally. • These changes occur up to about six months. |
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Signs of success – flap surgery |
• Decrease in inflammation • Less bleeding on probing • Decrease in pocket depth • Increase in attachment • Eliminate pus • No increase in mobility • Improvement of tissue contour • Stabilisation of bone levels Expected results Shallow non bleeding pocket with clinicalattachment gain & bone gain. Complications: 1) During: Pain, excessive bleeding, apex exposed,damage to flap 2) After: Pain, secondary haemorrhage,sensitivity, infection, swelling 3) Long term: Recession, dentine sensitivity, pooraesthetics Disadvantages: - More plaque accumumulation on dentinesurfaces - Recurrence of disease - Recession |
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Review appointments |
• One week • (4-6 weeks OH support) • 3 months (DO NOT PROBE BEFORE THIS) • 6 months (may need to wait before probingwith some regenerative techniques) |
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Variability in treatment outcome |
• Surgical procedure: technique,operatorskills • Patient factors: oral hygiene,smoking &infection control, general condition • Defect-characteristics: defect angle &width amount of loss of attachment &bone |
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GINGIVAL RECESSION |
Recession: - Apical shrinkage of the gingivae beyond the amelo-cementaljunction (measured from the ACJ to gingival margin) - Itmay be localised or generalised - Itis an indicator of past disease – but does not mean that active disease ispresent - Note:Recession also occurs following healing from effective perio.treatment! |
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Gingival recession aetiology |
Predisposingfactors & Precipitatingfactors Predisposing factors: - Lackof bone: -- developmental/acquired for example: Thincortical plates/Prominent roots Dehiscences/Fenestrations/ Prominent roots/ deep overbite Long standing periodontitis Occlusal trauma or excessive ortho. Force maycause dehiscences - Thingingival tissue - Roleof fraenum? Precipitating factors: * All causes of gingival inflammation – provoke recession if predisposing factors present - Plaqueinduced gingival inflammation ie.gingivitis and/or periodontitis - Traumatictoothbrushing - Directrepeated trauma (eg.complete overbite impinging on lower gingivae) - Parafunctionalhabits - Iatrogeniccause eg.ortho. Bands, prostheses - Foodtrauma |
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Miller Classification |
Class I: recession does not extend mucogingival junction, no loss of interdentaltissue/bone Class II: recession to or beyond mgj, no loss of interdental tissues Class III: +interdental tissueloss, not beyond recession Class IV: +interdental lossbeyond recession |
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Problems of recession |
Patient anxiety? – Willmy teeth fall out? – Appearance,crown margins visible? Sensitivity –exposeddentine –Tendermucosa Stagnation area – plaque/calculusleading to: –Continuedbreakdown –Rootcaries |
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Management of recession |
- Explainand reassure - Correctprecipitating factors –atraumatic toothbrushing -- Electric tooth brush -- Useof pen grip –Useof single tufted brush - Thoroughscale and polish - Controlany sensitivity - Fluorideapplication - Monitoraltered OH for 2-3 months - Outlinesurgical options Where indicated: - Aesthetics– e.g. gingival veneer - Restorecarious root surfaces - Surgicaloptions – repositionedflap - Lateral - Coronal –Grafts - Fullthickness (“free gingival”) - Connectivetissue - Dermalmatrix - Mucograf –Biologicals– Emdogain |
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Outcome |
- Stabilisation/controlof breakdown - Residualstagnation areas - Managementof sensitivity – long term - Managementof the exposed root surface to prevent caries - Importanceof review to maintain good standard of homecare Monitor how? - Measurein mm and record from CEJ to top of gingival margin – subject to error - Clinicalphotographs - Studymodels |
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Control of sensitivity |
- Plaquecontrol - Fluoridetoothpastes - Desensitiserseg: -- SupaSeal,Duraphat,Seal&Protect,Cervitec -- Desensitising toothpastes -- Dentine bonding agents |
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Indications for surgery |
- Aesthetics - Continuedsensitivity -- Dentine -- Softtissue – lack of attached gingivae - Progressivebreakdown - Frenalpull - Pocketingbeyond MGJ - Advancedrestorative procedures planned Pre-operative assessment - Is surgical treatment warranted? - Is recession stable following monitoring? - Medical and social assessment - Tooth vitality - Radiographic examination - Informed consent and clinical records |
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options |
gingival veneer Laterally repositioned flap Free gingival graft Coronallyrepositioned flap |
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Surgical treatment of gingivalrecessions using Emdogain |
Results 12 months evaluation - Average root-coverage 73%(60-100) - Clinical attachment gain 58%(50-71) - Patient satisfaction 8.5 (7-10) - Maintaining shallow pockets and amount of keratinized gingiva Conclusion: Coronally repositioned flap in combination withthe application of Emdogain Gel is a predictable treatment procedurefor the achievement of soft tissue root coverage…………and gain of clinicalattachment, while maintaining shallow pockets. |
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Regenerative PeriodontalProcedures |
.... |
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Periodontal Structures |
Interdental papilla Junctional epithelium Free gingiva Attached gingiva Mucogingival junction Alveolar mucosa Root cement Periodontal ligament (0.15-.2mm) - Sharpy's fibres with fibroblasts, osteoblasts and cementoblasts Alveolar Process Cortical bone Central spongiform bone |
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Guided Tissue Regeneration |
• Epithelial tissues developfaster than connective tissues • Membrane forms a barrierwhich prevents the downgrowth of the epithelium • Connective tissue then has achance to develop |
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Bone substitutes |
• Bone xenograft (Bio-Oss) • Hydroxyapatitie (Perio-graf,Alveolagraf) • HTR polymer • Bioactive glasses Bio-Oss 1. Clot stabilization facilitated by Bio-Oss® interconnecting macro andmicropores. 2. Revascularization, migration of osteoblasts (purple) and in-growth ofwoven bone (yellow) is enhanced by Bio-Oss® scaffolding. 3. Lamellar bone and Bio-Oss® are successfully integrated afterapproximately six months. Bio-Oss® is included in the natural physiologicremodeling process (osteoclasts - Blue). Bioglass® Technology: - Under a microscope, a Bioglass® particlewould look very much like a piece of smoothsand. The size of these particles is aboutthat of a grain of ordinary table salt. - Upon introduction of Bioglass® into a defect site, animmediate chemical reaction starts with the bodyfluids which modifies the surface of the Bioglass®making it more attractive to organic molecules. - The modified surface of the Bioglass®particles immediately begins to attract thebody's own "building blocks" for tissueregeneration -- Proteins -- which are alreadypresent in body fluids. - In a continuing chemical reaction occurring over the next fewdays, a "framework" of hydroxyl-carbonate-apatite crystalsforms on the surface of the Bioglass® particles which trapsand bonds these "building blocks" to create a virtual "nursery"for new tissue growth. |
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Enamel Matrix Derivative |
Amelogenin productionand biological action Detail of the period when the root sheathcells (blue) secrete enamel matrixproteins. Following formation of theprotein matrix on the surface of themineralizing dentine, cementoblasts(Red) start producing cementum (Lightblue) which anchors collagen fibers. Enamel Matrix Derivative proeteins -> AMELOGENIN -> Tissue enjineering |
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Sequence of biological action afterapplicationof EmdogainGel during surgery. |
1) Attraction 2) Attachement and proliferation 3) Differentiation 4) Alveolar bone |
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Predictabilty EmdogainGel treatment(Heden et al 1999) |
• 87 % of sites > 2 mm attachment gain • Majority of sites > 4 mm att. gain • Average bone fill 69 % • “Emdogain technique is a predictableway to enhance periodontalregeneration outcome”. |
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Outline surgical procedure |
• Coronally advanced flaps • Root surface conditioning with PrefGel • Application Emdogain • Barricaid periodontal dressing • Maintenance care Results 12 months evaluation: • Average root-coverage 73% (60-100) • Clinical attachment gain 58% (50-71) • Patient satisfaction 8.5 (7-10) • Maintaining shallow pockets and amount ofkeratinized gingiva |
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Conclusion |
Coronally repositioned flap in combination with the applicationof EmdogainGel is a predictable treatment procedure for theachievement of of soft tissue root coverage…………………….and gain of clinical attachment,while maintaining shallow pockets |
