Contemporary Periodontal Surgery
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1 Contemporary Periodontal Surgery Chris van Kesteren, D.D.S. CPCC Dental Hygiene Program October 18, 2011
2 Surgical Management of Periodontitis Periodontal Plastic Surgery Soft tissue and esthetics Dental Implants Bone Grafting
3 Pocket Depth 1-3mm 89% clean, 3-5mm 39% clean, >5mm 11% clean (Waerhaug 1978) 3.7 mm- Average PD that can be efficiently cleaned with Sc/RP (6.2mm- average limit) Root Anatomy CEPs, CEJ, Furcation, root flutes, line angles Access Long-term maintenance Sc/RP teeth require retreatment twice as often compared to surgical treatment (Ramfjord 1987)
4 What is The Extent of Subgingival Scaling and Root Planing?
5 Goals of Therapy Resolve inflammation Arrest disease progression Regenerate lost periodontium Maintain/establish comfort, function, esthetics Deter recurrent disease
6 Surgical Techniques Gingivectomy Flap Curettage Osseous Resection Regeneration Guided Tissue Regeneration Bone grafting Osteopromotive factors (Emdogain, GEM 21S )
7 Indications 3-5 mm suprabony pockets Adequate attached gingiva Remove gingival overgrowth (hereditary, drug induced) Contraindications Intrabony pockets Anatomical limitations (palate, ext oblique ridge) Esthetics Access to bone indicated
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11 Indications Provide access for debridement Eliminate pockets Induce new attachment
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19 Indications Provide access for debridement Eliminate pockets Induce new attachment Limited regenerative capacity Treatment of osseous defects and correction of reverse architecture
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27 GTR (Guided Tissue Regeneration) Bone Grafting Osteopromotive factors (Emdogain, GEM 21S )
28 Autograft (extraction site, tuberosity, ramus, chin) Allograft (FDBA, DFDBA, Puros ) Xenograft (BioOss, PepGen P-15 ) Alloplast (Perioglas, HTR Synthetic Graft) Composite Grafts
29 Nonresorbable eptfe-gore tex Titanium reinforced Resorbable Collagen (Ossix, BioMend, Biogide ) Calcium Sulfate (Capset ) Synthetic Polymers (Resolut, Guidor )
30 Emdogain GEM 21S rh-pdgf
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41 Around Teeth Gingival / soft tissue recession Lack of keratinized/attached gingiva Decreased vestibular depth Aberrant frenum / muscle position Gingival excess Annals of Periodontology 1999
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46 Indications Esthetics Sensitivity Root Coverage Advantages Better color match Less painful donor site Predictable root coverage Disadvantages Two surgical sites Adequate donor tissues Technically more challenging
47 Indications Minimal Keratinized Tissue Frenum Pull Shallow vestibule Advantages Less technically demanding Combined procedure Creeping attachment Disadvantages Color match Two surgical sites Less predictable root coverage Patient discomfort
48 Indications Multiple areas of recession Inadequate donor tissue Advantages Easier suturing No donor site needed Disadvantages Long-term stability Technique sensitive Slower healing (2-3 weeks) Complete coverage essential Lack of keratinized tissue Wound healing like scar tissue
49 Connective Tissue Graft
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58 Pre-op Post-op
59 Free Gingival Graft
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62 Goals: Increase band of attached / keratinized tissue Minimal root coverage due to tooth prominence Improve vestibular depth / eliminate frenum pull
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66 Connective Tissue Graft Tunnel Preparation
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68 Post-op Pre-op
69 Allograft
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77 Frenectomy / Double Pedicle Flap
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93 Ridge Preservation Lateral Ridge Augmentation Vertical Ridge Augmentation Maxillary Sinus Bone Augmentation
94 Particulate Block Combination
95 Autograft (extraction site, tuberosity, ramus, chin) Allograft (FDBA, DFDBA, Puros ) Xenograft (BioOss, PepGen P-15 ) Alloplast (Perioglas, HTR Synthetic Graft) Composite Grafts
96 Nonresorbable eptfe-gore tex Titanium reinforced Resorbable Collagen (Ossix, BioMend, Biogide ) Calcium Sulfate (Capset ) Synthetic Polymers (Resolut, Guidor )
97 Dr. Mark Lucas
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107 No treatment Conventional RPD Implant retained RPD Implant retained FPD
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143 Lateral Window Technique Osteotome Sinus Elevation (Summer s technique)
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159 Images from Periodontics Rose, Mealey, Genco, Cohen
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165 Regular clinical and radiographic evaluation Tissue health Probing depths (?) Color Tissue quality (keratinized vs mucosal) Assessment of occlusal forces and stability Proper plaque control Avoid damage to implant, abutment, and restoration Home care Professional care
166 Bottom line: Bugs that grow around teeth can grow around implants
167 Assessment of peri-implant tissues Visual assessment Color of tissues Bleeding or suppuration Probing Depths
168 That is the question!
169 Sulcus/JE CT Bone
170 Slide courtesy of Francis G. Serio, DMD, MS, MBA
171 Slide courtesy of Francis G. Serio, DMD, MS, MBA
172 Radiographic evaluation What are we looking for? Frequency Type of radiograph
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176 Mobility Abutment or implant Occlusal forces Traumatic occlusion Lateral forces
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178 Avoid damage to implant, abutment, and restoration! Home care Tools and techniques Professional care Instrumentation
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181 Slide courtesy of Francis G. Serio, DMD, MS, MBA
182 Slide courtesy of Francis G. Serio, DMD, MS, MBA
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184 Graphite lers.asp
185 Longer lasting e.do?action=refresh_browse&ctg_id=42412
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193 Chris van Kesteren, DDS 2315 W. Arbors Dr. (University Area) Charlotte, NC Website:
Maintenance in the Periodontally Compromised Patient. Dr. Van Vagianos January 22, 2009 Charlotte Dental Hygiene Study Club
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