Periodontology Osseous Surgery PDF

Tishk International University Dentistry Faculty Periodontics Department Periodontology OSSEOUS SURGERY Dr. Jafar Naghshbandi D.D.S ; M.S , PhD Diplomate Of The American Board Of Periodontology OBJECTIVES DEFINITION RATIONALE TER...

Tishk International University Dentistry Faculty Periodontics Department Periodontology OSSEOUS SURGERY Dr. Jafar Naghshbandi D.D.S ; M.S , PhD Diplomate Of The American Board Of Periodontology OBJECTIVES DEFINITION RATIONALE TERMINOLOGY OF OSSEOUS SURGERY TYPES OF OSSEOUS SURGERY RESECTIVE OSSEOUS SURGERY RECONSTRUCTIVE OSSEOUS SURGERY RECONSTRUCTIVE SURGICAL TECHNIQUES NONGRAFT-ASSOCIATED NEW ATTACHMENT GTR (GUIDED TISSUE REGENERATION) GTR (GUIDED TISSUE REGENERATION) PROCEDURE GRAFT-ASSOCIATED NEW ATTACHMENT COMBINATION OF BOTH SUMMARY AND KEY POINTS TO NOTE DEFINITION Osseous surgery maybe defined as the procedure by which changes in the alveolar bone can be accomplished to eliminate deformities induced by the periodontal disease or other related factors, such as exostosis and tooth supra- eruption.  RATIONALE It is based on the fact that the discrepancies in levels and shapes of the bone and gingiva predisposes patients to the recurrence of pocket depth post-surgically. Hence, the goal of osseous resective therapy is reshaping the marginal bone to resemble the alveolar process undamaged by periodontal disease. The technique usually involves apically-displaced flaps hence the procedure not only eliminates periodontal pockets but also improves tissue contour to provide a more easily maintainable environment. TERMINOLOGY OF OSSEOUS SURGERY OSSEOUS SURGERY: It is a periodontal surgery involving modification of the bony support of the teeth Procedures used to correct osseous defects have been classified in two groups: OSTEOPLASTY: is a plastic procedure by which nonsupporting bone is reshaped to achieve a physiologic gingival and osseous contour. OSTECTOMY: is the removal of radicular and interradicular supporting bone to eliminate osseous deformities.  Depending on the relative position of the interdental bone to radicular bone, osseous surgery is of following types: 1. Positive architecture—When the radicular bone is apical to the interdental bone. 2. Negative architecture—If the interdental bone is more apical than the radicular bone. 3. Flat architecture—It is the reduction of interdental bone to the same height as radicular bone. 4. Ideal—When the bone is consistently more coronal on the inter-proximal TYPES OF OSSEOUS surface than on the facial and lingual architecture surfaces. TYPES OF OSSEOUS SURGERY Depending on the thoroughness of the osseous reshaping techniques, osseous surgery is of following types: 1. Definitive osseous reshaping—Implies that further reshaping would not improve the overall result. 2. Compromise osseous reshaping—It indicates a bone pattern that cannot be improved without significant osseous removal, that would be detrimental to the overall result. Osseous surgery can also be: 1. Additive—Directed towards restoring the bone to original levels. 2. Subtractive—It is designed to restore the form of the pre-existing alveolar bone to the level existing at the time of surgery or slightly apical to this level. Osseous resective surgery INDICATIONS OF RESECTIVE OSSEOUS SURGERY 1. One-walled angular defects 2.Thick, bony margins 3. Shallow crater formations  CONTRAINDICATIONS OF RESECTIVE OSSEOUS SURGERY 1.Anatomic factors such as close proximity of the roots to the maxillary antrum or the ramus. 2.Age. 3.Systemic health. 4.Improper oral hygiene. 5.High caries index. 6.Extreme root sensitivity. 7.Advanced periodontitis. 8.Unacceptable esthetic result.  RECONSTRUCTIVE OSSEOUS SURGERY Periodontal therapy for treatment of periodontitis involves the elimination of bacterial plaque. When periodontitis is resolved, an anatomic defect remains in the periodontium. This anatomic defect is characterized by reformation of gingival fibers, substantial reduction in inflammation, persistent loss of bone and ligament and the formation of long junctional epithelium. Thus periodontal therapy involves two primary components: 1. Elimination of bacterial plaque 2. Elimination of the anatomic defects produced by periodontitis. There are two primary approaches to eliminating these anatomic defects a. Resective b. Regenerative both treatments are surgical.  RECONSTRUCTIVE OSSEOUS SURGERY Periodontal therapy for treatment of periodontitis involves the elimination of bacterial plaque. When periodontitis is resolved, an anatomic defect remains in the periodontium. This anatomic defect is characterized by: a) Reformation of gingival fibers b) Substantial reduction in inflammation c) Persistent loss of bone and ligament d) The formation of long junctional epithelium  RECONSTRUCTIVE OSSEOUS SURGERY Thus periodontal therapy involves two primary components: 1. Elimination of bacterial plaque 2. Elimination of the anatomic defects produced by periodontitis. There are two primary approaches to eliminating these anatomic defects a. Resective b. Regenerative both treatments are surgical.  Therapeutic bone regeneration approaches uses the principles of osteogenesis, osteoconduction and osteoinduction. Osteogenesis: The direct transfer of vital cells to the area that will regenerate new bone. Osteoconduction: Embraces the principles of providing the space and a substratum for the cellular and biochemical events progressing to bone formation. Osteoinduction: Embodies the principle of converting pluripotential , mesenchymal derived cells along the osteoblasts pathway with subsequent bone formation.  The following reconstructive surgical techniques have been proposed. 01 02 03 Nongraft- Graft- Combination associated associated of both. new new attachment. attachment.  Nongraft-associated New Attachment New attachment can be achieved without the use of grafts in: a. Meticulously treated three-walled defects, (Infrabony defect). b. Perioendodontal abscesses. c. When the destructive procedure has occurred very rapidly, for example, after treatment of pockets which had acute periodontal abscess. Various techniques of nongraft-associated new attachment are: 1. Removal of Junctional and Pocket Epithelium 2. Prevention of Epithelial Migration 3. GTR (Guided Tissue Regeneration)  Removal of Junctional and Pocket Epithelium The methods used to do so include: i. Curettage—Only 50 percent of junctional epithelium and pocket epithelium can be removed. ii. Chemical agents—Mostly used in conjunction with curettage. iii. Ultrasonic methods—It is again not very useful, because of lack of clinicians tactile sense while using these methods. iv. Surgical methods— Excisional new attachment procedure with internal bevel incision (ENAP). Gingivectomy procedure. Modified Widman flap. Coronal displacement of the flap.  Prevention of Epithelial Migration Eliminating junctional and pocket epithelium may not be sufficient because the epithelium from the excised margin may rapidly proliferate apically to become interposed between the healing connective tissue and cementum. GTR (Guided Tissue Regeneration)  GTR (Guided Tissue Regeneration) This concept is based on the assumption that periodontal ligament cells have the potential for regeneration of the attachment apparatus of the tooth. Adaptation of barrier membrane on the defect Flap is positioned coronally and sutured  Evaluation of a new bioresorbable barrier to facilitate guided bone regeneration around exposed implant threads: An experimental study in the monkey MB Hürzeler, RJ Kohal, J Naghshbandl, LF Mota… - International journal of oral and maxillofacial surgery, 1998 Cited by 208  Types of membranes Degradable—Collagen, Polylactic acid, Vycril (polyglactin 910) and Guidor membrane. Nondegradable—They must be removed in three to six weeks time, e.g. Millipore, Teflon membrane, Goretex periodontal material.  Clot Stabilization, Wound Protection and Space Creation The successful results obtained with graft materials, barrier membranes and coronally-displaced flaps have been attributed to the fact that all of these protect the wound and create a space for undisturbed and stable maturation of the clot.  Preparation of the Root Surface (Root Biomodification) Several substances have been used to condition the root surface, for attachment of new connective, tissue fibers. These include citric acid, fibronectin and tetracycline.  Procedure Step I: A full thickness of mucoperiosteal flap should be reflected 2-3 mm beyond the defect. Vertical incision should be given where ever necessary. Step II: Debridement of osseous defect and curettage of the inner surface of the flap. Step III: Root planning followed by root conditioning of the exposed root surfaces should be accomplished. Step IV: Create fresh bleeding at the defect site to allow progenitor cells to progress from bone to the site.  Procedure Step V: The membrane should be trimmed so that it extends 2-3 mm beyond the margins of the defect in all directions. Trimming of the flap should also permit primary tension- free closure of the flap. Step VI: The membrane should be adapted to the site and stabilized with the help of suture or tacks. Step VII: Suture the site with silk suture to obtain tension free primary closure. Dressing may be considered to enhance patient comfort but it should not displace or collapse the graft. Step VIII: Post operative instructions and antibiotics should be given. Step IX: If non-re absorbable membrane is used, it should be removed after 4-6 weeks. A B C D E (a) An adequate bone volume (height and width) is a prerequisite for successful implant treatment. (b) Barrier membrane and bone graft as bone substitute materials are placed to accelerate bone formation. (c) After new bone is formed final prosthesis is fabricated. Initial clinical examination on buccal of #19 with 10 mm Probing depth (PD) The initial radiograph shows deep vertical bone loss on #19 with the presence of calculus.  A wide and deep 2 wall intra-bony defect involved the buccal surface of mesial root of #19.  Graft-associated New Attachment 1.Graft—It is a viable tissue/organ that after removal from donor site is implanted/transplanted within the host tissue, which is then repaired, restored and remodeled. 2. Xenograft or heterograft—The donor of the graft is from a species different from the host. 3. Allograft or homograft—A tissue transfer between individuals of the same species but with non identical genes. 4. Autograft—A tissue transfer from one position to a new position in the same individual. 5. Alloplastic graft—A graft of inert synthetic material which is sometimes called implant material.  Graft-associated New Attachment 6. Osteoinduction—A process by which the graft material is capable of promoting cementogenesis, osteogenesis and new periodontal ligament. 7. Osteoconduction—The graft material acts as a passive matrix, like a trellis or scaffolding for new bone to cover. 8. Contact inhibition—The process by which the graft material prevents apical proliferation of the epithelium. 9. Guided tissue regeneration—An epithelial exclusionary technique that promotes new connective tissue attachment without the use of any implant material.  Intraoral autograft Intraoral cancellous bone marrow chips: It can be obtained from: a. Maxillary tuberosity—It contains good amount of cancellous bone with foci of red marrow and the bone is removed with a cutting rongeur. b. Edentulous areas—The bone is removed with curette. c. Healing sockets—They are allowed to heal for eight to twelve weeks and the apical portion is utilized as donor material.  3.Combination of both 1. Non-graft-associated new attachment 2. Graft-associated new attachment Case report Debridement reveals configuration of infrabony defect Guided tissue regeneration membrane trimmed to size Decalcified freeze-dried bone allograft filled in defect Guided tissue regeneration membrane in position Post-operative view