DENT 800B (PERI 805) Periodontal Surgical Therapy Winter 2025 Lecture 1 PDF

DENT 800B (PERI 805) Periodontal Surgical Therapy Winter 2025  Course Outline ◼ Presenters ◼ Dr. Flores ◼ Dr. Kim ◼ Dr. Kerner ◼ Dr. Sarmast ◼ Dr. Wolfram Some overlap of material/redudency ◼ 9...

DENT 800B (PERI 805) Periodontal Surgical Therapy Winter 2025  Course Outline ◼ Presenters ◼ Dr. Flores ◼ Dr. Kim ◼ Dr. Kerner ◼ Dr. Sarmast ◼ Dr. Wolfram Some overlap of material/redudency ◼ 9 days of lectures ◼ 1 Midterm ◼ 1 Final ◼ One Practical Exercise (per student) ◼ Details are still being developed ◼ Groups,days, time & location ◼ First exercise group during the ~5th week  Course Outline Practical Exercise Two video-demonstrations posted on Canvas “Gingivectomy” & “Modified Widman Flap” MUST be VIEWED prior to each participant’s Typodont Exercise Serve as Instructional guide during the exercise Five-Question Quiz prior to Lab.-session, covering the content of videos ◼ Bring your laptop & typodont with mounted gingiva ◼ We supply the instrument cassette  Course Outline Grading Percentage Allocation ◼ 1. Final Examination ◼ 55% (~40 questions: Comprehensive) ◼ 2. Midterm Examination ◼ 39 % (~35 Questions: Lectures 1-4) ◼ 3. Lab.Quiz (Pertains to material in both Lab.- Videos, day of lab.exercise) ◼ 5% ◼ 4. Course Evaluation ◼ 1% ◼ 5. No Weekly Quizzes  Lecture 1 K. Wolfram Periodontal Wound Healing & Brief Review of Surgical Procedures January 08, 2025  Periodontal Tx-Plan Three Phases ◼ Phase I – Initial Therapy ◼ Non-surgical ◼ Phase II – Corrective Therapy ◼ Surgical ◼ Phase III ◼ Maintenance  Initial Therapy ◼ Tx-plan directed toward micro-organisms ◼ Plaque-control ◼ Oral hygiene instructions ◼ Homecare ◼ Possible antimicrobial therapy ◼ Subgingival irrigation ◼ Scaling & Root planning >  Scaling & Root Planning ◼ Removes deposits ◼ Removes necrotic cementum ◼ Smoothens root surfaces. ◼ Helps to re-establish the biocompatibility of the root surface ◼ Epithelial healing ◼ Connective tissue healing  Study Extraction of Teeth with Severe Periodontitis One Side Other Side SRP NO SRP 1. Soaked in a fibroblast- culture SRP 2. Incubated 3. Stained for fibroblasts No SRP NOT Biocompatible Biocompatible Essential for Wound Healing  Periodontal Wound Healing Histologically Level  Healing Mechanisms Post-SRP & Surgery ◼ Healing by Repair ◼ Reattachment ◼ New Attachment  SRP & Periodontal Surgery Stripping of diseased pocket lining Healing in specific sequence (1-4) SRP Surgery 3 4 >> Speed of Proliferation & Migration of Cells involved 1. Epithelial cells from Oral Epithelium Covers wounds Forms epithelial “attachment” 2. Fibroblasts from adjacent gingival CT Produce collagen >> C.T. of the gingiva Provides density to gingiva 3. Fibroblasts from PDL Periodontal stem cells*** Capable to produce PDL & Cementum 3 4 4. Osteoblasts Produce Bone  Healing by Repair Formation of “Long Junctional Epithelium” ◼ Connective tissue accumulation next to LJE ◼ Reattachment LJE CT-accumulation 3 4 Reattachment  Reattachment ◼ Joining of residual pdl-fibers extending from cementum to bone Bone Cementum ◼ In areas with NO prior perio. destruction ◼ For SRP-cases: Base of the pocket ◼ Little contamination ◼ Vital, residual PDL-components still present ◼ Minimal disturbance of attachment ◼ For Surgery-cases: Freshly exposed areas… adjacent to diseased site  Recap: Healing after Root planning Formation of Long Junctional Epithelium (Repair) ◼*??? Residual Pocket Long JE CT-fibers parallel to root Not PDL-fibers CT-accumulation ?? New attachment ?? Reattachment (Attachment Gain) ``````````````````````Rateitschak,et al  New Attachment ◼ The most desirable form of Periodontal Healing ◼ New PDL ◼ New cementum ◼ New bone ◼ Occurs only on root surfaces WITH prior CAL ◼ Contributes little, if any, attachment-gain after RP ◼ Objective of Regenerative/Reconstructive Surgery  Following Periodontal Wound Healing Following Periodontal Therapy: SRP & Surgery Clinical Level  Probing a Healthy Periodontium Probe stops WITHIN JE Rateitschak,et al Probing a Diseased Periodontium Reasons for Pocket Depth Gingival Edema Ease of probe penetration thru fragile, inflamed tissue CAL & Bone loss Probe stops when contacting healthy PDL-fiber inserted into cementum/bone  Pocket Reduction after SRP ◼ Reduction of Inflammation ◼ Decrease in edema ◼ Gingival Recession ◼ Fibroblast activity restored ◼ Collagen production resumes ◼ Increase in gingival density ◼ Resistance to probing ◼ Tissue tonus is restored ◼ Slight attachment gain ◼ Primarily from re-attachment  Pocket Reduction after SRP Pre-SRP Post-SRP LJE C Density Tight cuff Reattachment Predict Overall Pocket Depth Reduction Based on the ORIGINAL Pocket Depth Original PPD PPD-Reduction attributed to Gingival Recession Based on Original Pocket Depth Original PPD Slight Moderate Severe Projected Change in Attachment Level Gain / Gain / Loss Attachment Level k Original PPD  Scaling & Root Planning Benefits ◼ Favorable treatment results ◼ Disorganizes biofilm ◼ Helps to re-establish a biocompatible root surface ◼ Provides pocket depth reduction ◼ Clinically: Comparatively simple procedure ◼ Minimal hemorrhage ◼ Speedy healing ◼ Few unfavorable painful post-op. episodes ◼ Possible dentinal hypersensitivity ◼ Occasional post-treatment hemorrhage  Scaling & Root Planning Disadvantages ◼ Poor access ◼ Poor visibility ◼ Root surface irregularities ◼ Furcations…root concavities ◼ Reliance on tactile sense for detection ◼ There is always residual calculus after SRP… More with increasing pocket depth Residual Calculus Sample of Studies Residual Calculus RE  Issues after SRP Rationale for Periodontal Surgery ◼ Residual Calculus ◼ Residual deep pockets ◼ Morphological changes of osseous crest ◼ Bone loss ◼ Horizontal ◼ Angular bony defects ◼ Bony craters ◼ Bony ledges >>  Rationale for Periodontal Surgery ◼ Furcation defects ◼ Mucogingival deformities ◼ Lack of KT* ◼ Exposed root surfaces ◼ Esthetics ◼ Sensitivity ◼ Attempt to regenerate new bone * Keratinized Tissue Periodontal Surgery  Objectives Periodontal Surgery To correct….. Surgically…. Any acquired or developmental deviation…. from the “Normal” Both: Soft or hard tissues  Indications Periodontal Surgery ◼ Inaccessible deposits ◼ Presence of residual pockets over 6mm (> 6mm) ◼ Furcation defects: Class II/III associated with PPD >5mm ◼ Management of bone defects ◼ Treatment of Peri-implantitis ◼ Re-establishment of “Biological Width” for crown-preps ◼ Correction of Mucogingival Deformities ◼ Root coverage  Contra-indications Periodontal Surgery ◼ Unfavorable systemic conditions ◼ Anticoagulants…Bisphosphonates ◼ Others > Check Hx ◼ Surgery no longer a solution ◼ Insufficient remaining bone ◼ Bone defect not amenable to surgery ◼ Excessive mobility ◼ Undesirable esthetic consequences ◼ Elongation of the clinical crown ◼ “Black triangle” ◼ Non-compliance with OH ◼ Continued high PS Pre-Surgical Considerations  Systemic Risk Factors ◼Recent major surgery ◼Current hypertension ◼Current anticoagulant therapy ◼Diabetes ◼Smoking ◼ Less favorable wound healing for both  Need for Pre-medication ◼Hx of Infective Endocarditis ◼Current presence of artificial heart valve ◼Current malfunctioning heart transplant ◼ Variety of congenital cardiac problems > MD-consult ◼ Hx of orthopedic surgery? Rx? ◼ Pending Orthopedic consult? >>  Post-op Instructions ◼ Plaque control ◼ CHX 0.12% rinses, bid ◼ Patient comfort ◼ NSAIDS / Acetaminophen / Opiates ◼ Wound stability ◼ Soft diet 24-48 hrs ◼ Antibiotics ◼ Pending systemic conditions / Procedure-dependent ◼ Suture removal 7-10 days  Final Patient Review ◼ Adequate preparation of patient ◼ “Initial therapy” completed ◼ Good home care established ◼ Procedure explained to patient ◼ Reasons for surgery.. expected results.. possible complications ◼ Understanding anatomy of the surgical site ◼ Nerve proximity ◼ Effect on adjacent teeth? ◼ Plan ahead ◼ Be ready for unexpected surprises ◼ Outline incisions on a study model ◼ “Visualize” procedure  Blade? / Incision? ??? External bevel Internal bevel Intra-sulcular  Other Considerations ◼ How deep the incision? ◼ Full or partial depth ◼ How far to extend the incision? ◼ Mesially ….Distally….Apically ◼ Is re-contouring of bone required? ◼ Is a graft required? ◼ What type? ◼ Materials / proper instruments available ◼ How to close the surgical site? ◼ What suture ◼ Type of needle...size of thread…material? ◼ What suture configuration for best results? ◼ Simple interrupted...continuous etc Periodontal Surgery Surgical Procedures Examples  Types of Periodontal Surgeries ◼ Access surgery / Open Debridement……… Improves SRP ◼ Soft Tissue Resection (Gingivectomy) ◼ Removal / Re-contouring of Gingiva ◼ Osseous Resection ◼ Removal / Re-contouring of Bone Pocket reduction ◼ Osseous Regeneration / Reconstruction ◼ Procedures to regenerate bone / attachment Mucogingival surgery……………………… Correct Mucogingival deformities Placement of soft tissue grafts Frenectomies  Access Surgery Open Debridement Inaccessible residual calculus  Access Surgery “Open Debridement” ◼ Expose root surfaces for better access & visibility ◼ Improve Root planing MGJ MGJ  Access Surgery Example of Procedure Sequence Conservative Incisions With minimal flap reflection Access Surgery Root Plane & Suture Soft Tissue Resection Gingivectomy & Gingivoplasty Gingivectomy / Gingivoplasty Removal of Hyperplastic Gingiva Rateitschak,et al  Gingivectomy / Gingivoplasty Example ◼ ◼ Gingivectomy ◼ Excision of gingiva ◼ Gingival hyperplasia ◼ Gingivoplasty ◼ Re-contouring of gingiva Both improve the physiologic form of the gingiva Osseous Surgery Two Main Categories 1. Resective Osseous Surgery 2. Regenerative/Reconstructive Osseous Surgery  Resective Osseous Surgery ◼ Attempts to restore bone to its ORIGINAL FORM or Shape ◼ Decreases level of bone More apically  Osseous Resection ◼ Removal of bone ◼ Reduction of bony ledges ◼ Removal of exostosis ◼ Reduction interdental bony craters>>  Osseous Resection Reduction of Interdental Bony Craters ◼ Crater reduced Pocket reduced Regenerative/Re-constructive Osseous Surgery ◼ Attempts to restore bone to its ORIGINAL LEVEL ◼ Increases level of bone ◼ Example: Bone grafts etc More coronally  Regeneration / Reconstruction Goal of all periodontal procedures ◼Methods & materials to encourage New Attachment ◼Formation of … ◼ New Cementum ◼ New PDL ◼ New Bone  Regeneration - A continuous physiologic process. - Constant Renewal of form & function - Ongoing Replacement of mature & dying cells - Present during destructive periodontal disease Defeated by ongoing bacterial challenge  Pre-requisites for Regeneration/Reconstruction ◼ Biocompatible root surface ◼ Excellent OH ◼ Good SRP ◼ Multi-walled bone defects ◼ Bio-modification of the root surface ◼ Acid etching ◼ Citric ◼ EDTA ◼ TTCN ◼ Application of Growth Factors ◼ Application of Bone Morphogenic Proteins (BMP) ◼ Emdogain ◼ Appropriate bone grafting material  Function of Bone Grafts ◼ Transfer vital precursor cells & osteoblasts to the recipient site ◼ Induce undifferentiated mesenchymal cells ◼ Osteoblasts ◼ Support regeneration of bone (Scaffolding) ◼ Serve as medium for osteoblast migration ◼ Clot stabilizer ◼ Improve vascularization ◼ Sources of bone grafts ◼ Host ◼ Cadaver material ◼ Human or animal ◼ Synthetic  Mechanisms of Bone Formation ◼ Osteogenic bone formation ◼ Presence of viable, living cells within the graft to produce new bone. ◼ Osteoinduction ◼ Process by which molecules within the graft induce… ◼ Undifferentiated mesenchymal cells > Osteoblasts > Bone ◼ Osteoconduction ◼ Passive process where graft material acts as scaffolding for osteoblast to migrate & attach to….for new bone formation  Graft Types ◼ Autograft ◼ Allograft ◼ Xenograft ◼ Alloplastic  Bone Grafting Materials Autografts ◼ Within the same person …autogenous Best grafting material ◼ Osteogenic ◼ Osteoinductive ◼ Sites or Sources for both: ◼ Intraoral ◼ Extraction sites (8-12 wks) ◼ Edentulous areas ◼ Tuberosity ◼ Chin ◼ Osseous Coagulum: Bone chips harvested during bone-contouring ◼ Extraoral Sites ◼ Iliac Crest (Orthopedic Surgeon)  Bone Grafting Materials Allografts ◼ One person to another person (same species) ◼ Osteoconductive (Primarily) ◼ Human cadaver material ◼ Freeze-Dried Bone Allograft (FDBA) ◼ Space filler ◼ Provides scaffolding ◼ Aids in migration of osteoblasts ◼ Clot stabilization ◼ Aids in revascularization of surgical site ◼ Demineralized Freeze-Dried Bone Allograft (DFDBA) ◼ Mainly osteoconductive ◼ Some osteoinductive potential ????  Bone Grafting Materials Xenografts ◼ Another Species (Animal…Non-human) ◼ Purely osteoconductive ◼ Provides scaffolding ◼ Clot stabilization ◼ Aids in revascularization of surgical site ◼ Aids in migration of osteoblasts ◼ Space filler ◼ Mineral matrix from bovine bone ◼ Example: Bio-Oss  Grafting Materials Alloplastic Grafts ◼ Synthetic ◼ Purely osteoconductive ◼ Provides scaffolding ◼ Clot stabilization ◼ Aids in revascularization of surgical site ◼ Aids in migration of osteoblasts ◼ Space filler ◼ Materials available ◼ Tri-calcium Phosphate ◼ Calcium Carbonate ◼ Calcium Sulfate ◼ Hydroxyapatite ◼ Ceramics  Pre-requisites for Successful Bone Grafts Multi-walled Bone Defects…Receptor site One-Wall Bony Defect Two-Wall Bony Defect Three-Wall Bony Defect >> Four-wall Bony Defect Best for bone grafts Socket Cup / Moat (circumferential) Multi-walled Bone Defects 2-walled Defect  Autogenous Osseous Graft Angular Defect Donor Sites ◼ Trephine drill Receptor Site Original defect Result Successful Bone Graft  “Guided Bone Regeneration” Healing by “Long Junctional Epithelium” Prevail Suppressed >> Rateitschak,et al Guided Bone Regeneration Blocking Oral Epith.cells >> Rateitschak,et al  Guided Bone Regeneration Barrier Membrane (Millipore filter) Enables proliferation of PDL-fibroblasts & Osteoblasts (3 & 4) Promotes Periodontal stem cells Intercepts LJE-formation w New attachment & Bone formation Rateitschak,et al “Gore-Tex” Procedure - 5 weeks re-opened - Membrane removed - Flap re-sutured  Barrier Membrane Materials Millipore filters ◼ Non-resorbable requires re-entry for membrane removal ◼ Gore-Tex Membrane ◼ Resorbable ◼ Vicryl ◼ Polyglycolide Synthetic ◼ Atrisorb ◼ Polylactic Acid ◼ Bio-Gide ◼ Porcine collagen ◼ Biomend ◼ Bovine collagen Animal/Human sources ◼ Alloderm ◼ Human skin Correction of Mucogingival Deformities Mucogingival Surgery  General Objectives: Repair of Mucogingival Deformities ◼ Procedures ◼ Guided Tissue Regeneration GTR ◼ Soft Tissue Grafts ◼ Deep facial recession ◼ Lack of keratinized tissue ◼ Deepen vestibule ◼ Frenectomy ◼ Reduce frenum pull ◼ Diastema Correction of Mucogingival Defects Frenectomy Frenum Pull (Aberrant frenum) Frenectomy  Frenectomy Reduces “Pull” on Ging. Margin  Frenectomy Denture Retention Problems Corrections of Mucogingival Deformities Gingival Recession - Replace KT Soft Tissue Grafts Free Gingival Grafts FGG Connective Tissue Grafts CTG Pedicle Grafts/Flaps  Classification of Gingival Recession Miller Classification Class I – IV ◼ Classification Criteria ◼ Gingival recession to… or… beyond MGJ & ◼ Loss of height of interdental papillae Now replaced by “Cairo” classification  Miller Classification Class I & Class II MGJ Class I…Defect within attached Class II… Defect into alveolar gingiva mucosa Interdental Papillae Loss: None / Minimal Complete root coverage expected  Miller Classification Class III & IV Class III No papillae regeneration Open embrasure spaces Some facial root coverage Blunted Papillae -Primarily impedes further recession - Deepens vestibule Class IV Flat or Cratered papillae No papillae regeneration Root coverage??  “Cairo” Recession Classification Relates Interprox CAL to Buccal CAL World Workshop on Periodontal & Peri-implant Diseases. Cairo et al (2018) ◼ Recession Type 1 (RT 1) ◼ Gingival recession NO interproximal CAL Some Buccal CAL ◼ Recession Type 2 (RT 2) ◼ Gingival recession With interproximal CAL smaller than Buccal CAL) ◼ Recession Type 3 (RT 3) ◼ Gingival recession With interproximal CAL greater than Buccal CAL)  Mucogingival Deformities Indications ◼ Deep facial recession ◼ Esthetic concerns ◼ Oral hygiene problem ◼ Root sensitivity ◼ Ongoing recession (progressive) ◼ Shallow vestibule ◼ Insufficient keratinized tissue ◼ Abutment tooth  Soft Tissue Grafts Types ◼ Free Gingival Graft (FGG) ◼ Free Soft Tissue Autograft ◼ Connective Tissue Graft (CTG) ◼ Subepithelial Connective Tissue Autograft ◼ Pedicle Flap/Graft Correction of Mucogingival Deformities Free Gingival Graft FGG  Free Gingival Graft Esthetic Considerations & Dentinal Sensitivity Free Gingival Graft To cover exposed root  Free Gingival Graft Lack Keratinized Tissue ◼ Free Gingival Graft ◼ To stop ongoing recession  Free Gingival Graft First: Prepare Receptor Site Free Gingival Graft Donor Site: Palate FGG. > Rateitschak,et al  Free Gingival Graft Donor Site One side is epithelium Donor site outlined Graft removal  Free Gingival Graft Six weeks of healing Deepens vestibule Stops further recession Graft sutured Rateitschak,t a  FGG Healing by “Secondary Intention” (Donor Site) Donor Site Palatal discomfort (Stent) Two weeks po Correction of Mucogingival Deformities Connective Tissue Graft CTG  Clinical Example: CTG Preparation of Receptor Site -High frenum (Frenum pull, aberrant frenum) -Recession -Lack of KT -Shallow vestibule Connective Tissue Graft Donor Site FGG CTG Rateitschak,et al Connective Tissue Graft Donor Site Two parallel Incisions Both sides CT  CTG Healing by “Primary Intention” (Donor Site) Good donor-site closure  Clinical Example Graft Placement Graft “sandwiched” between bone & flap Post-op Pre-op Pre-op Post-op Correction of Mucogingival Deformities Pedicle Grafts Lateral Displaced Flap Double Papillae Flap Coronally Displaced Flap To be discussed in “Flap” lecture ? 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