Periodontal surgery symposium P1 Flashcards
what are the 4 goals of periodontal treatment
- Reduction/resolution of gingivitis to no more than 20-30% BOP
- Reduction in PPD to <5mm
- Absence of pain
- Satisfactory aesthetics and function
what are the 3 stages of periodontal surgery
- Initial therapy
- Corrective therapy (additional therapeutic measures)
- Supportive periodontal therapy (maintenance phase)
what is the aim of initial therapy
what is the objective of initial therapy
what things does initial therapy include
- motivating pt to perform optimal plaque control
- achieve clean and infection-free conditions
- NSPT, restorations, endodontic treatment, extractions
what things does corrective therapy include
- Additional therapeutic measures
- Address sequelae of infections
- Replacement of lost tissue(s)
- Includes perio/endo/restorative Tx
- Patient’s cooperation and OH may affect the type of treatment offered
what is supportive periodontal therapy (SPT) aka
maintenance phase
what is the aim of spt
what is the objective of spt
Aim: to prevent reinfection and disease recurrence
Objectives: continued preservation of
gingival/periodontal health obtained via active
perio Tx. Regular clinical re-evaluation with
appropriate interceptive Tx
What does the recall system of SPT include
- Assessment of deeper sites with BOP
- Reinstrumentation
- Fluoride application
- Ongoing maintenance of restorations,
assessment of vitality, bitewings
Aims of non-surgical treatment
- Eliminate living microorganisms in the biofilm and calcified microorganisms from the
tooth surface and adjacent soft tissues - Reduction in inflammation, pocketing, BOP
- Improve plaque control
- Rationale for calculus removal relates to eliminating surface irregularities harbouring
bacteria. - Complete calculus removal likely over-ambitious
- Plaque and calculus remain in >90% of sites >5mm deep (Waerhaug 1978)
- Increased clinician experience -> better removal
- Periodontal healing will still occur even in the presence of calculus (Jepsen 2011)
what do you do after spt
decide
- Further NSPT
- +/- adjunctive systemic antimicrobials
- +/- extraction of teeth
- Surgical options
- Supportive therapy
what patient factors can cause further breakdown
- Increased number of sites >6mm
- Pts treated without LA (Grbic 1991)
- % BOP
- > 20-30% at risk of disease progression (Badersten 1985, 1990; Joss 1994)
- Extent of baseline attachment loss and pocket depths
what tooth level factors can cause further breakdown
- Furcation involvement
- Mobility
- Limited residual support
- Overhanging restorations etc
what site level factors can cause further breakdown
BOP
- BOP -> 30% likelihood of disease progression (Lang 1986)
- No BOP -> 98% likelihood of stability (Lang 1990)
- Short term persistence of deep pockets less useful; but long term observation especially in conjunction with BOP -> risk of further
attachment loss
- PD 5mm and above
what is the optimal time for SPT
2-4 years, should be tailored to patients risk level
what do you need to explain to patients in terms of how the chances of disease progression and tooth loss can increase
- Poorer OH
- Irregular SPT
- Interleukin polymorphism
- Smoking
- Age
- Initial diagnosis of aggressive/severe disease
surgery will not overcome the above
what are the objectives of periodontal surgery
- Improve the prognosis of the tooth
- Eliminate pockets >5mm and BOP
- Facilitate plaque control
- Elimination of deeper pockets to a more maintainable range
- Correction of abnormal gingival and bony morphology which interferes with plaque
control - Root sectioning or improvement of tooth morphology to improve oral hygiene
maintenance - Creation of cleansable embrasure spaces
- ? Regenerate lost periodontium
- ? Resolution of mucogingival problems e.g.overgrowth/recession
-> Aesthetic improvement
what are the stages of surgical strategies
- Controlling disease-
persistent sites following
NSPT
- Pocket reduction
- Regeneration - Gingivectomy
- Surgery for recession
what are 2 effect of periodntal disease
infrabony defects
furcation defects
what patient factors should you consider for case selection
Highly motivated patient
- compliance with OHI and appointments
- Plaque free scores of > 70% on more than 1 occasion
- No medical contraindications
- Non-smoker
- Thorough non-surgical periodontal therapy completed
- Localised residual pocketing
- Surgery is part of comprehensive treatment plan
-> Including ongoing SP
what patient factors should you consider for case slection
- No plaque in areas to be treated
- Surgery in the presence of poor OH leads to further
destruction - Non-mobile teeth
- Strategic teeth
- Pocketing >5mm
what are strategic teeth
Occlusal contacts
-> Consider occlusal relationship e.g. class II div 1 cases
Anterior teeth
-> If molars inappropriate for Tx consider SPT and focus on trying to
keep 5-5
Why pockets 6mm+?
Matuliene 2008: increased risk of progression (Odds Ratio 2.4)
u Surgery à better access for debridement >6mm (Caffesse 1986)
u Surgery à worse outcomes <6mm (Heitz-Mayfield 2002)
u In shallow pockets, NSPT à less attachment loss (0.5mm)
u 4-6mm: NSPT à 0.4mm more attachment gain
u >6mm: surgery à more PD reduction and 0.2mm more attachment gai
surgery for infrabony defect
raise soft tissue
make incision
retract the flap carefully to reveal the bone crest and granulation tissue within the pocket
scoop out an unhealthy tissue using standard hand scaler from inside the pocket
use ultrasonic scaler
use cow and mixx with whatever to promotes reattachment, stem cells?
stitch back toegther
moinotr up to 9 months
avpid subgingival probing to allow healing
what is the classifictaion for furcation defetcs
Class I: Horizontal loss of periodontal support
<3mm
Class II: Horizontal loss of periodontal support
>3mm
Class III: Horizontal ‘through and through’ destruction of the periodontal tissues in
the furcation
Problems with furcations
- Harder to debride- residual calculus more likely
-> Experienced operators: open debridement 32%, closed 56%
-> Inexperienced: open debridement 57%, closed 92% - McGuire 1996: molars with no furcation defect or class I had 90% survival
over 5 yrs; with no difference between these two groups.
-> Class II- 75% 5yr survival, Class III- 60% - Reduced response- teeth with furcation defects respond less favourably to
therapy than those without. - Furcation-involved teeth 2-5x more likely to be lost
- Presence of deep proximal furcation defects adversely affects the prognosis
of the adjacent teeth (Ehnevid 2001).
Favourable conditions for regenerative surgery to furcations
- Class II lesions
- Shallower lesion
- Narrower lesion
- Mandible more predictable than maxilla
- Buccal/lingual sites (?as better access) (Jepsen 2002)
- Thicker biotype -> less post-op recession
Anatomical considerations for furcation defects
- Depth of root trunk
- Root divergence
- Length and shape of root cones
- Amount of remaining support around individual roots
- Stability of individual roots
- Access for oral hygiene
what is root resection/hemisection
- Sectioning of multirooted teeth to remove the root +/-
coronal portion - Studies vary from around 5% failure to 30% at 10yrs.
- Shorter root trunk, divergent roots, larger root cones are more favourable
what are periodontal indications for root resection/hemisection
Severe bone loss around 1+
roots
Class II/III defects
Severe recession/ dehiscence
what are endodontic indications for root resection/hemisection
- Inability to treat a canal
- Root # or perforation
- Root caries
what are prosthetic indications for root resection/hemisection
Root trunk # or unrestorable caries
contraindictaions for resection/hemisection
- systemic factors
- poor OH
- root fusion
- insufficient remaining tooth tissue
- post-retained restoration required
when isnt surgery feasible
Terminal dentition
u Generalised pocketing
u Tooth mobility
u Non-motivated patient
u ?advanced age
u Poor OH
u Poor compliance with Tx
u Large furcation defects, especially in maxilla
u Extensive/hopeless bone loss
u Horizontal bone loss: regeneration not possible
What to do when surgery isn’t feasible?
Extraction
u If detrimental to remaining dentition
u ‘Palliative’ ongoing supportive therapy
u Accept gradual deterioration
u Extractions as driven by signs/symptoms
why would you do a gingivectomy
Gingival overgrowth
Crown lengthening procedures e.g. late failure of eruption, short clinical
crown height, facilitate restoration of teeth
non surgical amangement for gingival overgrowth
- Rigorous OH reduces overgrowth (Seibel 1989)
- Professional and home care
- Mechanical OH, CHX
- Discuss with medical team re: medication
how to carry out gingivectomy
Gingivectomy techniques
Scalpel/ laser/ electrosurgical
u External bevel
u Internal bevel with flap
u Similar patterns of regrowth
u Laser may lead to less post-operative discomfort
u Coe-pak dressing 1/52
u Biopsy
u Case reports have described Kaposi’s sarcoma and SCC, also pemphigus (Vasanthan
2007
Only consider surgery for gingival overgworth when…
- Good OH
- NSPT completed
- Motivated patient
- Consider modification of medical risk factors e.g. liaise with GP
regarding medications
when is surgery for management of recession not feasible
- RT3
- Generalised defects
- Consider gingival venee
role of the gdp
Assessment
u Oral hygiene instruction and patient education
u Initial NSPT
u Awareness of surgical options and when these may/may
not be appropriate
u Continued supportive therapy
