Periodontal surgery symposium P2 Flashcards
Types of surgery in disease sites
1, Resection i.e. gingivectomy
2. Open flap debridement: access flap
3. Regenerative
Indications for gingivectomy
What can it be done with
Gingival overgrowth
Can be done with scalpel/laser/electrosurgery
Send the resected tissue for biopsy
Access/repair
POCKET REDUCTION WITH RECESSION, ALLOWS CLEANING IN DIFFICULT
AREAS, WITHOUT REPLICATION OF NORMAL ATTACHMENT
* OPEN FLAP DEBRIDEMENT
REPAIR VS REGENERATION?
REPAIR
* LONG JUNCTIONAL EPITHELIUM
* CRESTAL REMODELLING
* MORE RECESSION
* TYPICALLY ACHIEVED WITH NSPT AND TRADITIONAL
PERIODONTAL SURGERY
REGENERATION
* NEW CEMENTUM
* NEW PDL
* NEW ALVEOLAR BONE
* LESS RECESSION
* CAN ONLY BE TRULY DEMONSTRATED WITH
HISTOLOGY
WHY REGENERATE?
HEALING BY REPAIR LEADS TO
* LONG JUNCTIONAL EPITHELIUM
* RECESSION (ASSOCIATED PROBLEMS – SENSITIVITY, AESTHETICS, ROOT CARIES)
* LOWER CONNECTIVE TISSUE ATTACHMENT LEVEL
AIMS OF REGENERATION
GAIN TRUE PERIODONTAL LIGAMENT CLINICAL ATTACHMENT
* MINIMISE SOFT TISSUE RECESSION
* ELIMINATE FACTORS ASSOCIATED WITH DISEASE PROGRESSION:
* RESIDUAL DEEP POCKETS (MATULIENE 2008)
* INFRABONY DEFECTS (PAPAPANOU AND WENNSTROM 1991)
* ALONGSIDE TRADITIONAL SURGERY AIMS
* REMOVAL DISEASED TISSUE
* ACCESS FOR ROOT SURFACE DEBRIDEMENT
WHAT TYPES OF CELLS ARE INVOLVED IN HEALING
1 + 2. Gingival epithelial and connective tissue cells
Lacks the potential to induce the formation of new connective
tissue attachment to a root surface deprived of its original
periodontal ligament
- Bone
* DOES NOT HAVE THE POTENTIAL TO FORM A NEW CONNECTIVE TISSUE
ATTACHMENT
* COMPLICATIONS OF HEALING:
* ANKYLOSIS
* ROOT RESORPTION - Periodontal ligament cells
* GRANULATION TISSUE ORIGINATING IN THE PERIODONTAL LIGAMENT CONTAINS
PLURIPOTENT MESODERMAL STEM CELLS WHICH HAVE THE POTENTIAL TO FORM A
NEW CONNECTIVE TISSUE ATTACHMENT.
KARRING ET AL JCP 1985 12 P51
* REPOPULATION OF A DETACHED ROOT SURFACE BY CELLS OF THE PERIODONTAL
LIGAMENT IS A PRE-REQUISITE FOR NEW ATTACHMENT FORMATION
ISIDOR ET AL 1986 JCP 13
NORMAL HEALING POST NSPT
REGENERATION OF THE TISSUES PROCEEDS AT DIFFERENT SPEEDS
* MOST RAPIDLY FROM THE EPITHELIUM - LJE
* SLOWER FOR GINGIVAL CONNECTIVE TISSUE
* VERY SLOW FOR BONE
* EVEN SLOWER FOR PDL CELLS
* REGENERATION WILL NOT OCCUR UNLESS PERIODONTAL PROGENITOR CELLS CONTACT THE ROOT
SURFACE
CLASSIFICATION
OF OSSEOUS
DEFECTS
- Suprabony
- Infrabony
* Infrabony (1-3 walls, combinations)
* Craters - inter-radicular (furcation)
* Horizontal (1, 2, 3) Glickman 1953
* Vertical (A, B, C) Tarnow 1984
what are suprabony defects
BASE OF THE POCKET
IS CORONAL TO THE
MARGINAL BONE
LEVEL
what are infrabony defects
BASE OF THE POCKET
APICAL TO THE
MARGINAL BONE
DESIRED CLINICAL OUTCOMES OF REGENERATION
PROBING DEPTHS ≤5MM
* BOP –VE
* REGENERATION OF THE DEFECT
* CLINICAL ATTACHMENT GAIN
* REDUCED PROBING DEPTH
* MINIMAL GINGIVAL RECESSION
* RADIOGRAPHIC BONY INFIL
* ENHANCE ACCESS FOR PLAQUE CONTROL AND MAINTENANCE
4 regenerative techniques
Bone grafting
guided tissue regenration (GTR)
biologics (enamel matric proteins - EMD)
growth factors (FGF-2, rh-PDGF-BB)
4 combinations of regenratrive techniqesu
HTR and grant
GTR and EMD
EMD and graft
GUIDED TISSUE REGENERATION technique aims to
– STOP RAPID DOWN GROWTH OF EPITHELIAL CELLS
ADJACENT TO ROOT SURFACE AND HENCE HEALING
BY LONG JUNCTIONAL EPITHELIUM
– CREATE SPACE FOR PERIODONTAL PLURIPOTENT STEM
CELLS TO POPULATE ROOT SURFACE
aims of gtr
PROMOTES PERIODONTAL REGENERATION (SCULEAN ET AL 1999)
* TECHNIQUE SENSITIVE (TROMBELLI 1997)
* NON CONTAINED DEFECTS, MEMBRANE MAY COLLAPSE INTO THE
SPACE LIMITING REGENERATION POTENTIAL (TONETTI 1996, CORTELLINI AND
TONETTI 2005)
what are the 2 membrane types used
NON-RESORBABLE
* GORTEX RESOLUT/ CYTOPLAST DPTFE - SYNTHETIC
RESORBABLE
* BIO-GIDE – PORCINE SOURCE
Biomaterials used for bone grafts
- AUTOGRAFT
- XENOGRAFT
- ALLOGENIC
- ALLOPLASTIC
- BIOACTIVE GLASS (PERIOGLAS) (NEVINS 2000, SCLUEAN 2005)
- HYDOXYAPATITE (HORVATH 2012)
- BETA TRICALCIUM PHOSPHATE (STAVROPOULOUS 2010)
- SOME EVIDENCE THAT AUTOGENOUS GRAFTS/ XENOGRAFTS/ ALLOGRAFTS
SUPPORT PERIODONTAL REGENERATION - USED FOR SPACE MAINTENANCE AND CARRIERS OF BIOLOGIC MATERIALS
BIOMATERIALS: ENAMEL
MATRIX PROTEINS
SYNTHESISED AND SECRETED DURING TOOTH
DEVELOPMENT BY HERS CELLS
* DEPOSITION ON TO DEVELOPING ROOT SURFACE IS
A KEY STEP IN CEMENTUM FORMATION
* DENTAL FOLLICLE CELLS DIFFERENTIATE TO
CEMENTOBLASTS WHICH FORM ACELLULAR
EXTRINSIC FIBER CEMENTUM
* PDL AND ALVEOLAR BONE FORMATION ARE
DEPENDENT ON CEMENTUM FORMATION
what does EMD do
restricts
1. Epithelial growth
2. Connective tissue
promotes
3. Bone growth
4. PDL growth
5. Cementum growth
* Wound healing and defense
restricts
bacterial growth
emdogain
- PRESENT ON TREATED ROOTS FOR UP TO 4 WEEKS POST APPLICATION (SCULEAN 2002)
- TECHNICALLY SENSITIVE BUT LOWER COMPLICATIONS THAN GTR
- IN NON-CONTAINED DEFECTS, FLAP MAY COLLAPSE LIMITING THE AVAILABLE SPACE
BIOMATERIALS AND EMD
EMD +NBM (BOVINE)
* LEKOVIC 2000
* VELASQUEZ-PLATA 2002
* ZUCCHELLI 2003
* SCULEAN 2003, 2008
EMD + DFDBA (BOVINE)
* GURINSKY 2004
EMD + AUTOGENOUS BONE
* GUIDA 2007
* YILMAZ 2011
diff between endogain and Gtr
Emdogain and GTR have similar results, however, GTR is more
challenging to perform, requires more invasive flap, greater
complications
SURGICAL CONSIDERATIONS: SOFT TISSUES
SURGICAL FLAP DESIGN
* MINIMALLY INVASIVE
* BETTER POST-OP EXPERIENCE
* MAINTAIN PAPILLAE (GRAZIANI 2012) AND INTERDENTAL TISSUE
* REDUCE RECESSION
* IMPROVED VASCULARIZATION
* IMPROVED WOUND STABILITY
MINIMALLY INVASIVE SURGICAL TECHNIQUE
- Preserve the papillae
- Minimal extension of flap
- Reveal only 1-2mm of bone crest
- No periosteal release
- Avoid relieving incision
- Careful/stable suturing technique
- (modified internal mattress)
- Magnification
- Microsurgical instruments
patient factors for case selection
- PATIENT FACTORS
➢ COMPLIANCE - <15-30% PLAQUE SCORES
➢ PATIENT COPING SKILLS/ACCESS
➢ SMOKING STATUS - MEDICAL HISTORY:
➢ BLOOD DISORDERS – I.E. HAEMOPHILLIA
➢ ANTICOAGULANTS – I.E. WARFARIN
➢ BISPHOSPHONATES – I.E. ALONDRONATE
➢ POORLY CONTROLLED DIABETES
➢ UNCONTROLLED HYPERTENSION
➢ IMMUNOCOMPROMISED PATIENTS
LOCAL FACTORS THAT INFLUENCE TECHNIQUE/ OUTCOME
- BONY DEFECT ANATOMY (KAO 2015)
- HAS TO HAVE AN INFRABONY DEFECT
- NUMBER OF ROOT SURFACES
- NUMBER OF WALLS (1-,2-,3-WALLED DEFECTS)
- ANGLE
- TOOTH MOBILITY – SPLINT DURING WOUND HEALING (CORTELLINI 2001)
- TOOTH VITALITY (CORTELLINI & TONETTI 2001)
- ANATOMY OF THE TOOTH (SINGLE/MULTI-ROOTED - FURCATIONS)
- POSITION OF TOOTH IN THE ARCH (ACCESS/AESTHETICS)
case solution factors for infrabony defects
DEFECT FEATURES
* DEPTH >3MM
* ANGULATION <25°
* HIGHER NUMBER OF BONY
WALLS
TRUE ANATOMY ONLY CLEAR AFTER FLAP
RAISED
which tehcnique would you use for wide and non-contained infrabony component
EMD + graft
Graft + GTR
which technique would you use for wide contained infrabony component
EMD + grafts
which technique would you use for narrow contained infrabony component
EMD
furcation decision making
class 1
- nspt
class 2
- extraction
- Gtr/regenerative
- resective surgery (root resection or tunnel prep)
class 3
- extraction
- resective surgery (tunnel prep or root resection/hemisection)
LDI GUIDELINES FOR
PERIODONTAL SURGERY
- NSPT CARRIED OUT TO MAXIMUM POTENTIAL
- MINIMAL SUPRA/SUBGINGIVAL CALCULUS
DEPOSITS - COMPLIANCE WITH SMOKING CESSATION
- GOOD PLAQUE CONTROL (PFS ≥ 70%)
- PRESENCE OF PPD ≥ 6MM & BOP
- RADIOGRAPHIC DEMONSTRATING BONY
ANATOMY
CONSENTING FOR PERIODONTAL SURGERY
- PAIN
- SWELLING
- BRUISING
- BLEEDING
- RECESSION
- PARAESTHESIA
- SENSITIVITY
- STITCHES
- DAMAGE TO ROOT SURFACES
- BIOMATERIALS!
Post-op care
- SUTURE REMOVAL AT 14 DAYS
- 0.2% CHLORHEXIDINE MOUTHWASH BDS UNTIL SUTURE REMOVAL
- NO MECHANICAL CLEANING AROUND SURGICAL SITE UNTIL SUTURES ARE REMOVED
- AVOID INTERDENTAL CLEANING FOR 6 WEEKS, RESUMING NORMAL REGIME FROM THEN ON
- NO PROBING OR SUBGINGIVAL INSTRUMENTATION FOR 9 MONTHS
- IF GRADE 2/3 MOBILITY, SPLINT DURING POST-OP PERIOD
