Transcript Surgical Periodontal Therapy

Surgical Periodontal
Therapy
Bilozetskyi Ivan
is directed at disease
prevention,
slowing
or
arresting
disease
progression, regenerating lost of periodontium, and
maintaining achieved therapeutic objectives. A
variety of different treatment techniques have been
used
including
subgingival
curettage,
gingivectomy, modified Widman flap, and
full- or split-thickness flap procedures with
or without osseous recontouring. The best
surgical approach remains controversial, although
the results of longitudinal clinical trials has
highlighted the advantages and disadvantages of
each technique.
Periodontal
therapy
Curettage, scaling and root planing and modified
Widman flap produced slightly better attachment level
results, while pocket elimination procedures gave the
greatest probing depth reduction.
Surgical techniques included: gingivectomy, modified
Widman flap with and without osseous recontouring,
and apically positioned flap with and without osseous
recontouring. All techniques halted loss of attachment,
but the greatest gain of attachment was achieved when
osseous resection was avoided and soft tissue was
sutured to completely cover alveolar bone. No study to
date has shown that plaque is the cause of
periodontitis, but these studies certainly demonstrated
that with no plaque there is no disease progression.
Indications for periodontal
surgery
Nonsurgical therapy is performed prior to surgical treatment for
periodontitis. Surgery is indicated where nonsurgical methods fail.
In general, the success of nonsurgical treatment should be
assessed following scaling and root planing but prior to the
administration of antimicrobial agents or antibiotics.
These medications tend to reduce inflammation and obscure sites
where scaling and root planing has failed to resolve disease.
Pocket reduction or elimination is not required in sites that
respond to nonsurgical therapy and remain stable during
maintenance. When surgery is required, however, shallower
probing depths may be an appropriate goal to facilitate
maintenance therapy and reduce the incidence of recurrence.
The advantages of surgical therapy
• Improved visualization of the root surface;
• More accurate determination of prognosis;
• Improved pocket reduction or elimination;
• Improved regeneration of lost periodontal
structures;
• An improved environment for restorative
dentistry;
• Improved access for oral hygiene and supportive
periodontal treatment.
Gingivectomy
This procedure is used to excise suprabony pockets if there is sufficient
attached gingiva, to reduce gingival overgrowth/hyperplasia, and for aesthetic
crown lengthening in certain situations. Generally, this procedure should not
be used when:
1)
Infrabony pockets/defects are present;
2)
osseous surgery is required;
3)
there is inadequate attached gingiva;
4)
frena/muscle attachments interfere;
5)
and long clinical crowns will compromise aesthetics.
A gingivectomy and gingivoplasty was used to correct
gingival aberrations
A. Preoperative. B. Gingivectomy based upon aesthetic profile ratio.
C. Gingivoplasty.
D. 8 weeks postsurgically.
Gingival Curettage
• The word curettage is used in periodontics to mean
scraping of the gingival wall of a periodontal pocket to
remove inflamed soft tissues.
• Curettage removes the soft tissue lining of the
periodontal pockets in order to completely eliminate
bacteria and diseased tissue. It may be used along with
scaling and root planing, but achieves a deeper and
more complete cleaning. Evidence indicates, however,
that it does not contribute any additional benefits
beyond simple scaling and planing.
• Inadvertant curettage:Some degree of curettage done
unintentionally when scaling and root planing is
performed.
Presurgical curettage: used in patients whose treatment plans
include strong evidence that a surgical phase will be used.
Definitive curettage: No other therapy will be required or
used.
Gracey Curettes: Used for eliminating
the Soft Tissue Wall of the
Periodontal Pocket
RATIONALE
Accomplishes removal of chronically inflamed granulation
tissue in the lateral wall of periodontal pocket.
Apart from the usual components of angioblastic and
fibroblastic proliferation in granulation tissue, may also
contain pieces of dislodged calculus and bacterial colonies.
INDICATIONS
• Curettage can be performed in moderately deep infrabony
pockets located in accessible areas where a type of ‘closed
surgery’ is deemed advisable.
• Done to reduce inflammation prior to pocket elimination
using other methods or in patients in whom surgical
techniques are contraindicated
• Shrinkage of localized areas of gingiva, particularly
interdental papillae which are bulbous and lead to plaque
retention and accumulation
• Curettage is frequently performed on recall visits as a
method of maintenance treatment for areas of recurrent
infection.
CONTRAINDICATIONS
• Presence of acute infection
• Fibrous epithelial enlargement of gingiva as in phenytoin
hyperplasia
• Frenal pull on gingival margin
• Extension of base of pocket apical to mucogingival
junction.
PROCEDURE
• Basic technique-curette is selected so that the
cutting edge will be against the tissue.
• Instrument is inserted so as to engage the inner
lining of pocket wall and is carried along the
soft tissue
• Pocket wall maybe supported by gentle finger
pressure on the external surface.
OTHER TECHNIQUES
Excisional new attachment
procedure(ENAP): Definitive
subgingival curettage
procedure.
ENAP was an attempt to overcome
some of the limitations of closed
gingival curettage.
Ultrasonic curettage
Ultrasonic vibrations disrupt tissue
continuity, lift off epithelium and
dismember collagen bundles.
Effective for debriding the epithelial
lining of periodontal pockets.
It results in a narrow band of necrotic
tissue(microcauterisation) which
strips off the inner lining of the
Also it is recommended while conducting closed
curettage, to rinse the periodontal pocket with antiseptic
solutions. Such procedure is called “one-time curettage”.
Antiseptics that can be used:Chlorhecsidine 0,2%,
peroxide hydrogeny 0,3%, Chloramini 0,5%.
• Caustic Drugs: To induce a chemical curettage of
the lateral wall of the pocket
• Drugs such as sodium sulfide, alkaline sodium
hypochlorite solution(antiformin) and phenol were
used.
• The extent of tissue destruction with these drugs
cannot be controlled and they may be increase rather
than reduce the amount of tissue to be removed by
enzymes and phagocytes.
• LASERS – Laser curettage in suprabony pockets
where osseous surgery is not required.
• When performed with mechanical root
instrumentation, it is considerably less invasive than
traditional flap surgery.
• Due to small size of fiber(ie)tip diameter,Nd:YAG
laser has been suggested as a good candidate for
gingival curettage.
TISSUE RESPONSE TO CURETTAGE
• Reversal of all signs of gingival inflammation.
• Shrinkage, resolution of oedema and exudation.
• Morphologic features in gingiva and mucosa
are delineated more clearly after inflammation
has been resolved.
• Exuberant granulation tissue rarely present
postoperatively.
• Gingiva is firm to the scalpel and is of good
texture to be beveled or split as required.
HEALING AFTER CURETTAGE
• Blood clot fills the gingival sulcus which is
totally or partially devoid of epithelal lining.
• Hemorrhage present in tissues, abundant
PMNL’s apper shortly on wound surface.
• Restoration and epithelialisation of sulcus
generally requires from 2-7days.
• Immature collagen fibres appear in 21days.
• Zander and Waerhaug et al reported that
resulted in formation of long junctional
epithileum.
CLINICAL APPEARANCE
• Gingiva appears haemorrhage and bright red.
• After 1 week, gingiva appears reduced in height owing to an
apical shift in positon of gingival margin
• After 2 weeks,with proper oral hygiene by patient, normal
consistency and color of gingiva are attained and gingival margin
well adapted to the tooth.
• GINGIVAL CURETTAGE – RELEVANCE
• Gingival curettage and debridement of soft tissue wall of the
pocket as an adjunct to SRP seems to offer no advantage in the
initial healing response over SRP alone.
• Removal vs non removal of granulation tissue during flap surgery
and non surgical therapy (SRP) was studied by Lindhe & Nyman
(1985). There results failed to show an advantage of granulation
tissue removal.
• Studies provide convincing evidence that SRP alone produce
results clinically equivalent to curettage plus SRP.
• The various methods used for epithelial removal
show that they have no advantage over mechanical
instrumentation with curette.
• Therefore gingival curettage by whatever method
performed should be considered as a procedure that
has no additional benefit to SRP alone in treatment
of chronic periodontitis.
Comparison between the results obtained in the initial
preparation of the periodontal treatment such as oral
hygiene and scaling and root planing and that of same
procedure supplement by curettage, are made to assess
the justification of using curettage to eliminate gingival
inflammation and accomplish retraction of the gingiva.
One-time curettage: X-ray study
Due to the histological and clinical healing response
investigated by current studies, the advantages of curettage
in the shallow pocket are debatable. Curettage are now to
be done in deep pocket, especially in the aggressive lesion
such as that of the localized junvenile periodontitis.
Nevertheless, there is insignificant difference between the
result of the scaling and root planing alone and scaling and
root planing with the tissue curettage.
One-time curettage: X-ray study
Modified Widman flap
This procedure, introduced by Ramfjord & Nissle, was
designed to remove the inflamed pocket wall, provide
access for root debridement, and preserve the
maximum amount of periodontal tissue. It is indicated
where aesthetics is a primary concern, especially in the
maxillary anterior sextant. The drawbacks include the
inability to achieve pocket elimination and healing
with a long junctional epithelium. (Open curettage)
After completing scalloped section, parallel to the
gingival margin, and additional sections, partly
movable muco-periosteal flap is shifted to the level of
the alveolar ridge.
Treatment of the teeth roots is carried out under
visual control by curettes or ultrasonic instruments.
Then the flap is adapted to the underlying tissues and
stitched in the interdental spaces.
A modified Widman flap was used to reduce periodontal pockets around
teeth # 12–15 (buccal and palatal view)
A, B. Preoperative.
C, D. Incision
E, F. Flap reflection.
G, H. Suture.
I, J. 1 week of healing.
K, L. 8 weeks’ follow-up.
Histological studies have shown the flap procedures
described above tend to heal with a long junctional
epithelium and not a new connective tissue
attachment. Long junctional epithelium, however,
has been shown to provide a stable therapeutic
outcome.
Principles of periodontal surgery
Historically the aims of periodontal surgery were to
remove the soft tissue pocket wall and infected bone
and to eliminate the periodontal pocket.
Currently, the goals of surgery are to: 1) gain access for
root preparation when nonsurgical methods are
ineffective; 2) establish favorable gingival contours; 3)
facilitate oral hygiene; 4) lengthen the clinical crown to
facilitating adequate restorative procedures; and 5)
regain lost periodontium using regenerative
approaches.
To ensure proper healing atraumatic surgical principles
should be followed including: 1) adequate anesthesia;
2) surface disinfection; 3) sharp instrumentation; 4)
minimal, atraumatic tissue handling; 5) short operating
time; 6) preventing unnecessary contamination; and 7)
proper suturing and dressing, if indicated.
Flap operations
The formation of the flap and the types of
sections
Throwing soft tissue flap starts with the precise cuts.
The location and direction of the cuts depends on the
type of periodontal defect, purpose of surgical
intervention and the desired result.
The horizontal incision is made in all cases. it
can be intrasulcular (within the gingival sulcus) or
paramarginal (parallel to the gingival margin, at some
distance from it). In paramarginal section, connecting
epithelium is excised, and gingival margin shifted in
the apical direction. In this type of incision is the socalled latent gingivectomy. When viewed from the
vestibular or lingual side, the paramarginal section has
scalloped shape, close to the ideal form of the gingival
margin.
If it is a wide interdental spaces, it is recommended a
special flap that preserves gingival papillae (Takei et
al, 1985). There is also a modification of this flap for
narrow interdental spaces (Cortellini et al., 1995).
Vertical sections are not always necessary or
desirable, because they lead to the appearance of
scars on the mucous membrane. If a vertical incision
is required, it should be done in order to prevent
gingival recession or loss of interdental papilla.
Horizontal sections
A. traditional horizontal sections are performed from
vestibular (red line) and the oral side (blue line). In
interdental spaces, the surface of the tissue sections
are arranged parallel or diagonally.
B. Intrasulcular section at which epithelium of the
pocket is not excised, but the maximum amount of
soft tissue is saved.
C. Paramarginal sections is performed at different
distance from the gingival edge. Part of the tissue is
excised by means of gingivectomy.
The flap that preserves the
gingival papillae.
When suturing the wound after the operation, the
soft tissue cover interdental spaces. However, this
flap can be formed only at relatively wide interdental
gaps.
D. Papilla are displaced in the vestibular direction
during the flap formation.
E. Papilla are displaced in the oral direction.
Vertical sections and
relaxing sections
Unfavorable location:
A. If the cut goes
through the papilla,
there is risk of
recession and loss of
interdental papilla.
B. The middle section is
undesirable
in the presence of
vestibular pocket, as
it increases the
probability of gum
recession.
The favorable location:
C. The section at the side
of midline does not
leads to significant
shrinkage
and is better for healing.
D. For the treatment of
local defects it is
recommended a
triangular flap, to
unfold it ,
two paramedial sections
is conducted.
• Guided Tissue Regeneration. A more
advanced technique, called guided tissue
regeneration, is used to stimulate bone and gum
tissue growth:
• First, the root surfaces and diseased bone are
meticulously cleaned out. Preventing bacterial
contamination is very important. The more
residual bacteria, the greater the chance that the
treatment will fail.
• A specialized piece of fabric is sewn around the
tooth to cover the crater in the bone left after the
cleaning. It is either absorbable or nonabsorbable.
(Some studies report highly beneficial results
with new absorbable materials, including those
coated with the antibiotic doxycycline.)
• Bone Grafting. In some cases of severe bone loss, the
surgeon may attempt to encourage regrowth and restoration
of bone tissue that has been lost through the disease process.
This involves bone grafting:
• The surgeon places bone graft material into the defect.
• The material may be either bone from the same patient or a
substance called decalcified freeze-dried bone allografts
(DFDBA) which is obtained from a donor.
• This material then stimulates new bone growth in the area.
• Enamel Matrix Protein Derivative. Amelogenin is a
derivative of a major protein in the structure (the matrix) of
enamel that helps stimulate gum tissue growth. A gel
containing amelogenin (Emdogain) is applied during
surgery and forms a coat over the roots of the teeth. The gel
itself dissolves after 2 days, leaving the active substance
behind. Studies report that it is safe and may significantly
reduce the effects of periodontal disease. A 2001 study
suggested that the benefits, as indicated by bone attachment,
can persist for at least 4 years. (Results were similar to
guided tissue regeneration.)
Postsurgical complications
The risks of surgery include pain, swelling, blood loss,
reaction to medications, and infection. Other potential
risks include root sensitivity, flap sloughing, root
resorption or ankylosis, some loss of alveolar crest,
flap perforation, abscess formation, and irregular
gingival contours. If post-operative complications
occur, they should be managed by prompt and
appropriate treatment, which may include control of
bleeding, adequate analgesics or antibiotics.
Post-surgery discomfort is usually managed easily
with over-the-counter medications such as ibuprofen.
If discomfort is severe, stronger analgesics may be
prescribed. Some patients experience sensitivity to hot
or cold temperatures from exposed roots. These
problems can be managed with topical fluoride
treatments or, in severe cases, with dental restoration.
Thank you for your attention