Perio Flashcards
Factors influencing gingival recession
Periodontal phenotype Presence of periodontal disease and its treatment Muscle attachments Trauma Tooth position Iatrogenic factors
Gingival phenotype
Bone morphology
Gingival phenotype = gingival thickness + keratinised tissue width < can be measured by inserting probe
Bone morphology = thickness of bone plate
Types of trauma:
Mechanical - TB (evidence inconc.), choice of TB
Physical - piercings, poor dentures, habitual behaviors, foods
Chemical - drugs, irritants, tobacco
Tooth positions:
Bucco-lingual position and orientation of tooth can influence thickness of overlying gingival tissues
Mandibular incisors most susceptible to post-ortho recession
Correlation between labial bone dehiscences and recession defects
Deep overbite - trauma to palatal tissues and recession - Akerley classification
Iatrogenic factors
Overheated/USS tips Encroachment on supra-crestal width Poorly contoured restorations - plaque retentive Surgical procedures Irritants Rubber dam clamps
Sequalae of gingival recession
Dentine hypersensitivity
Non carious cervical lesions/root caries - pulp necrosis
Impaired aesthetics - open embrasures, exposed crown margins
Classification of gingival recession
Millers classification - class I - IV - old New classification - WWP (2017) based on Cairo et al., 2011 RT1 (full c), RT2 (partial c), RT3 (no c)
Conservative management gingival recession:
Reassurance
Baseline records for objective monitoring - clinical photos, dated study models, clinical measurements
Recognition and management of contributing factors - plaque retentive, tooth position, ortho, remove traumatic features, mx of habits
Sensitivity - F- varnish, dentine bonding agents, cervical lesions restored with GIC/composite
Non-surgical management gingival recession:
Pink composite
Pink ceramic
Gingival veneers
Surgical management gingival recession:
- Pedicle flap procedures - coronally advanced flap, rotational flaps
- Free soft tissue grafts - free gingival graft, connective tissue graft, processed tissue graft
- Regeneration procedures - guided tissue regeneration, enamel matrix derivative, leukocyte and platelet rich fibrin
Indications for gingival recession surgery
Progressive breakdown Hypersensitivity Aesthetics Unfavourable contour of gingival margin - limiting effective plaque control ? prior to ortho if dehiscence likely
Contraindications for gingival recession surgery:
Smoking Poor OH Periodontal pocketing Uncontrolled aetiological factors e.g. self-inflicted trauma Severe defects e.g. RT3, wide defects Poor donor sites Poor access for surgery MH considerations
Pedicle flap procedures (2):
Coronally advanced flap (CAF) - coronal shift of pedicle flap onto exposed root surface. Ensure at least 3mm keratinised tissue apical to defect. + Reported as most predictable for generalised&localised defects if sufficient and good donor tissue.
+ Can be used in combo with grafts to increase expected RC.
Rotational flap - double papilla flap - 2 papillae slide from adjacent tooth and sutured over to cover exposed root surface. Requires tissue of adequate length thickness and width of KT adjacent to defect.
+ Good for localised defects, esp if narrow defect
- potential bone loss or gingival recession at donor site
Free soft tissue gingival graft procedures:
Free gingival graft (FGG): not 1^ aim of root coverage but can be by-product. Done when wanting to ^ width of band of keratinised tissue. Can be to improve local OH, deepen vestibule, prevent fraenal reattachment, pre-ortho/implants if risk of recession high/show through
Donor site - premolar region of palate, avoid palatine vessels. Prepare recipient site - split thickness flap to expose underlying CT, extend 3mm beyond defect, donor graft placed in situ on recipient bed, interrupted sutures to close. Donor ideally 2mm thick and larger than recipient site.
Subepithelial CT graft (CTG): - similar to FGG, but aim of this procedure is full root coverage. Split thickness flap w/2 lateral relieving incisions. Donor tissue harvested from palate using trap door technique - avoiding rugae. Graft placed over recipient site and split thickness flap sutured over top of graft
++ dual blood supply from sub-epithelial tissue base and overlying flap
Processed soft tissue grafts - xenogenic collagen matrices (XCM) or cellular dermal matrix allographs (ADMAs). Porcine bioresorbable product which encourages regeneration of keratinised tissue around teeth/implants w/recession defects.
- Limited evidence but
+ good for pt’s with lack of donor tissue e.g. thin gingival & periodontal phenotypes
Split thickness flap raised, XCM cut to size of defect, moistened, placed in recipient site
Can be combined wirh coronally advanced flaps
Regeneration precedures:
Guided tissue regeneration - used for mgt of alveolar bone loss or localised bony defects. Can be used for reconstruction of recession defects.
+ possibility periodontal regeneration
- studies show CTG better
Enamel matrix derivative - porcine product used in combo with CAF for periodontal regeneration of recession defects.
+ similar root coverage achieved compared to CTG, no need for donor site
- systematic review shows CTG + CAF achieves better keratinised tissue thickness than EMD + CAF
- not suitable for all recession defects
Leukocyte and platelet rich fibrin - 2nd gen platelet concentrate used in conjunction with CAF. LRPF source of autogenous growth factors - pt’s blood taken and centrifuged. PRF layer used
- limited evidence as new technique
Systematic review gingival recession procedures:
All root coverage procedures can provide significant reduction in recession depth and CAL gain for Miller Class I and II recession-type defects. Subepithelial CT graft-based procedures provided the best outcomes for clinical practice because of their superior percentages of mean and complete root coverage, as well as significant increase of keratinised tissue.
(Chambrone et al, 2015)
Limitations of ‘closed’ RSD
May not stop progressive and aggressive disease completely
Difficult to visualise morphology of roots
Persistent acute episodes e.g. perio abscess
Deep complex bone defects
Severe hyperplasia or tissue deformity
Pathology e.g. epulides
Aims of periodontal therapy
Gain access to root surface for effective debridement Visualisation of bone defects Improvement in tissue contour Reduction/elimination of pockets Removal of chronically inflamed tissue Encourage regeneration Removal of hyperplastic gingival tissue Crown lengthening
Indications for gingivectomy
Hyperplasia
False pockets
Need to have adequate attached gingiva
Indications for open flap debridement
Deep persistent bleeding (suppurating) pockets
Indications for apically repositioned flap
+ disadvantages
Crown lengthening
Pocket elimination
Unsuccessful gingivally encroaching restorations
Roots exposed - sensitivity, caries
Poor aesthetics - gummy smile
Gingivectomy
LA Pocket depth markings - probe depths then pierce from outside depth of pocket (Goldmans technique). External bevel incision Incisions Removal of excised tissue Scaling Hameostasis Dressing
Flap procedures - stages:
LA Incisions Raise flap with periosteal elevator Currettage RSD Irrigation Sutures
Incisions - sulcular - maintains ST, hoping for regeneration
resect - resecting epithelium to eliminate pocket. Will cause recession
Modified Widman flap
Ramjford and Nissle 1974
Incision 1mm from gingival margin preserving interdental papillae
Flap raised only exposing few mm of bone
Intracrevicular/horizontal incisions to release pocket lining
Currettage of bone
Debrdiement root surfaces - USS, hand, irrigation w/saline
Replacement flaps to cover interdental bone and suture
Modified Widman flap
Ramjford and Nissle 1974
Incision 1mm from gingival margin preserving interdental papillae
Flap raised only exposing few mm of bone
Intracrevicular/horizontal incisions to release pocket lining
Currettage of bone
Debrdiement root surfaces - USS, hand, irrigation w/saline
Replacement flaps to cover interdental bone and suture
Post-op perio txt advice
Analgesia
Suture removal 7-10 days
CHX 0.2% mouthrinse 2x day for first 2-3 weeks
Not to perform mechanical cleaning in area and chew in this period over txt area
Soft TB
2 weekly dental visit to monitor plaque control
Signs of success of flap surgery
Decrease in inflammation Less bleeding on probing Decrease in pocket depths Increase in attachment Elimination of pus No increase in mobility Improvement of tissue contour Stabilisation of bone levels Regeneration
Evidence - perio:
Ramjford et al 1987 and Gothenburg group evaluated outcome of surgical vs non-surgical
All surgical resulted in decrease in PD, greater reduction in deeper sites
Surgical showerd greater short term reduction in PDs but long term variation in results between S vs NS
Sites with shallow probing depths - surgical created greater attachment loss than NS, but in deeper sites >7, greater attachment seen w S
In molar sites, surgical outcomes better than NS
Surgery w/o osseous = or greater attachment gain than w/osseous contouring
Deliberate excision of pocket by surrettage did not improve healing result
Pts with good post op plaque control mainted clinical attachment levels and PD more consistently than pt’s with poor OH
Guided tissue regeneration - perio:
Is used for the prevention of epithelium migration along the cemental wall of the pocket and maintains space for clot stabilisation
GTR - placing membrane barrier over bone, seperating the gingival epithelium from the bone and PDL
This prevents epithelial migration and favours repopulation of area by PL and bone cells
CT has chance to develop further into defect as epithelial tissues develop faster than CT
Most membranes bioresorbable e.g. BioGuide
Non resorbable not really used any more
EmgoGain
Enamel matrix derivative
Made from enamel matrix proteins from tooth germs of swine and uses propylene glycoralginate as matrix
Differentiates cells at dental follicle into cementoblasts to produce cementum which anchors collagen fibres
Applied as gel to exposed surface during surgery for intra-bony defects
Biological action after apply Emdogain:
1. Attraction
2. Attchment and proliferation
3. Differentiation
4. Alveolar bone
Predictability Emdogain: Hedbed et al 87% sites >2mm attachment gain Majority of sites >4mm attachment gain Ave. bone infill = 69% Preditable way to enhance periodontal regeneration outcome
Review protocol post regeneration therapy
1 week - suture removal from donor sites, removal from other site at 10-12 days, OH support, gentle cleaning
4-6 weeks - suture removal for CTG/FGG and OH support
3/12 - initial probing
6/12 some techniques may require longer before probing
9/12 post op PA to assess bone levels
12/12 - some root coverage may continue to occur by creeping attachment
Wound healing
- Haemostasis - blood clot, matrix for cell migration
- Inflammation - growth factors in clot recruit inflammatory cells - hours. Day 3 - macrophages releasing cytokines and growth factors to transition into granulation tissue
- Granulation - day 4 - migration and prolif of fibroblasts, endothelial cells and SM cells. 7 days - initial collagen
Maturation - fibroblasts replace provision fibrin matrix with collagen rich matrix, endothelial cells - angiogenesis
Perio healing differs slightly as one vascular side and one avascular side. Pocket reduction following nonsurgical therapy occurs through production of long junctional epithelium at 1 week, resolution of inflammation at 2 weeks, CT remodelling and collagen fibre maturation at 2-3 months so no reprobing prior to 3 months
Factors affecting healing
Local and systemic
Local: Infection Poor blood supply Foreign bodies Movement - graft destabilisation and tooth mobility Ionising radiation UV light
Systemic:
Age
Poor nutrition - vit C and D
Hormones - corticosteroids can suppress migration and macrophages. Androgenous corticosteroids from stress can suppress granulation tissue formation
Smoking
Uncontrolled diabetes - more prone to infection
Haematological abnormalities - may impair clot formation
Histological patterns of wound healing
No repair
Long junctional epithelium attaches to root surface
CT attachment to the root surface
New bone seperated from root surface
New bone with resorption or ankylosis to root surface
New attachment apparatus
