BDS11003 Periodontal Surgery 1 PDF

BDS11003 Periodontal surgery 1 Periodontal surgeries • Resective procedures • Periodontal regenerative procedures • Periodontal plastic surgery • Preprosthetic surgical procedures. • Surgical procedures for placement of implants and treatment of peri- implant disease. Indications for Periodo...

BDS11003 Periodontal surgery 1 Periodontal surgeries • Resective procedures • Periodontal regenerative procedures • Periodontal plastic surgery • Preprosthetic surgical procedures. • Surgical procedures for placement of implants and treatment of peri- implant disease. Indications for Periodontal Surgery • Access for root debridement. • Reduction of the depth of periodontal pocket. • Correction of mucogingival deficiencies or defects. • Establishment of soft tissue contours that facilitate oral hygiene. • Creation of a favorable restorative environment. • Regenerative procedures. Why is periodontal surgery a challenge? Critical zones for periodontal surgery • Zone 1: The Soft Tissue Wall • Zone 2: The Tooth Surface • Zone 3: The Bone • Zone 4: The Attached Gingiva Critical zones In periodontal surgery • Zone 1: The Soft Tissue Wall This includes morphologic features, thickness, and topography of the soft tissue pocket wall and persistence of inflammatory changes • Zone 2: The Tooth Surface The presence of deposits and alterations on the surface of the cementum and the accessibility of the root surface to instrumentation should be identified. • Zone 3: The Bone The shape and height of the alveolar bone next to the pocket wall should be established by careful probing and radiographic examination • Zone 4: The Attached Gingiva The presence or absence of an adequate band of attached gingiva is a factor to be considered when selecting the pocket treatment method. Soft tissue component Cementum Periodontal ligaments Osteogenic component Surgical therapy Resective Regenerative • Gingivectomy and Gingivoplasty. • Apically positioned flap with or without bone recontouring. • Modified Widman flap • Distal wedge • Guided tissue regeneration Contraindications for periodontal surgery • Inadequate plaque control • Uncontrolled medical conditions • Anatomic limitations • Concern for cosmetic consequences Gingivectomy vs gingivoplasty • Gingivectomy: excision of the gingiva for pocket reduction and elimination • Gingivoplasty: is reshaping of the gingiva to attain a more physiologic contour. Gingivectomy • It is the oldest surgical approach in periodontal therapy • It was defined as “the excision of the soft tissue wall of a pathologic periodontal pocket”. • The technique has evolved from starting point to the way it is applied today to being a commonly used technique to achieve esthetic outcome. Gingivectomy • External bevel gingivectomy • Internal bevel gingivectomy Steps of Gingivectomy • Pocket marking After anesthesia, the apical limit of the pocket is marked using a periodontal probe or Krane Kaplin pocket marking forceps • Primary incision Is created just apical to the bleeding points, beveled at 45 °to the tooth surface to • Secondary interdental incision To separate interdental wedge of tissues. Steps of Gingivectomy • Root debridement Is done of the exposed tooth surfaces with removal of remains of granulation tissues using curettes. • Placement of the periodontal pack Is done to protect the wound from irritation, control bleeding and control excess granulation tissue production during initial healing Contraindications of gingivectomy • Inadequate zone of keratinized tissue. • In presence of bone defects whether intra-bony defects or grade II furcation involvement. • Inflamed soft tissue. Access flap procedures Apically repositioned flap Is a surgical procedure with a displaced flap, where the final flap placement is in an apical position relative to its original position Apically Positioned flap Objective • Was used for pocket depth elimination • Preserve or widen the zone of attached gingiva • Osseous recontouring with apically positioned flap to reshape the marginal bone Apically repositioned flap • 2 vertical releasing incisions beyond the mucogingival junction. • Internal bevel incision • Reflection mucoperiosteal tissues • Removal of granulation tissue and debridement of root surfaces. • Suturing of the flap using sling suture around the tooth to prevent apical sliding Apically repositioned flap Indications • Crown lengthening procedures for esthetic enhancement • Exposure of impacted teeth APF is applied only on the maxillary buccal and mandibular lingual and buccal surfaces As the palatal gingiva cannot be displaced Apically repositioned flap Disadvantage • Possible loss of attachment • Increased potential for root hypersensitivity • Root caries Modified Widman flap • Is a surgical procedure aimed at exposing the root surfaces for meticulous instrumentation and for removal of the pocket lining. • Aimed at maximum healing in areas of previous periodontal pockets with minimum loss of periodontal tissues during and after surgery. It is not aimed at surgical elimination of the pocket walls Modified Widman flap Advantages • Debridement done with direct vision • Healing by primary intention • Minimal crestal bone resorption • Lack of post operative discomfort Disadvantages • Requires high degree of technical skill • Interproximal flap require exact placement. Modified Widman flap Modified Widman flap Distal wedge • Distal wedge procedures are performed to eliminate periodontal pockets distal to last molars • The maxillary tuberosity and retromolar area covered with hyperplastic tissues that cover a part of the crown increasing probing depths • Treatment of pockets distal to last molars. Distal wedge • Different flap designs such as square, triangular, linear and pedicle ( trap door) are used in the distal wedge procedures. • The flap design depends the thickness of the soft tissues, the depth of periodontal pockets, ease of access, the width of keratinized gingiva and the length of the clinical crown needed for the abutment teeth Distal wedge Pocket therapy today? Open flap debridement GINGIVECTOMY APICALLY REPOSITIONED) MODIFIED WIDMAN Periodontitis Disease Infection Inflammation Dysbiosis Open flap debridement Soft tissue component Cementum Periodontal ligaments Osteogenic component Osseous surgery Osseous surgery • It’s a plastic procedure where non-supporting bone is reshaped to achieved improved and more physiologic architecture VS It is plastic removal of radicular and interradicular supporting bone to eliminate osseous deformities Osseous defects • Horizontal defect • Vertical/angular defect • Reversed architecture • Furcation involvements • Osseous craters • Boney ledges • Exostosis • Bulbous bone contour Vertical bone defect Vertical osseous defects • Vertical osseous defects maybe classified according to the number of remaining osseous walls • One wall defect • Two wall defect • Three wall defect • Combined osseous defect Grafting material • Osteoproliferative (osteogenetic): bone is formed by bone forming cells contained in the grafted material • Osteoconductive: the grafted material does not contribute to new bone formation but serves as a scaffold for bone formation originating from host bone • Osteoinductive: bone formation is induced in the surrounding soft tissue immediately adjacent to the grafted material. Grafting material • Autograft (Intra / extraoral for the same individual) • Allograft (Individuals of the same species (corpse bones)) • Xenograft (Other species (Beef, pork, horse)) • Alloplast (Materials of synthetic / or inorganic origin) • Growth Factors Grafting procedures Can you regenerate bone? Assessment of periodontal regeneration • Periodontal probing • Radiographic analysis and re‐entry surgery • Histologic assessment • Reading material • Carranza`s clinical periodontology, Newman, Takei, Klokkevold, Carranza (Part 2 section V) • Clinical periodontology and implant dentistry, Jan Lindhe and Niklaus P. Lang, volume 2 (chapter 39) Thank you