Contemporary Periodontal Surgery Chris van Kesteren, D.D.S. CPCC Dental Hygiene Program October 18, 2011
Surgical Management of Periodontitis Periodontal Plastic Surgery Soft tissue and esthetics Dental Implants Bone Grafting
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)
What is The Extent of Subgingival Scaling and Root Planing?
Goals of Therapy Resolve inflammation Arrest disease progression Regenerate lost periodontium Maintain/establish comfort, function, esthetics Deter recurrent disease
Surgical Techniques Gingivectomy Flap Curettage Osseous Resection Regeneration Guided Tissue Regeneration Bone grafting Osteopromotive factors (Emdogain, GEM 21S )
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
Indications Provide access for debridement Eliminate pockets Induce new attachment
Indications Provide access for debridement Eliminate pockets Induce new attachment Limited regenerative capacity Treatment of osseous defects and correction of reverse architecture
GTR (Guided Tissue Regeneration) Bone Grafting Osteopromotive factors (Emdogain, GEM 21S )
Autograft (extraction site, tuberosity, ramus, chin) Allograft (FDBA, DFDBA, Puros ) Xenograft (BioOss, PepGen P-15 ) Alloplast (Perioglas, HTR Synthetic Graft) Composite Grafts
Nonresorbable eptfe-gore tex Titanium reinforced Resorbable Collagen (Ossix, BioMend, Biogide ) Calcium Sulfate (Capset ) Synthetic Polymers (Resolut, Guidor )
Emdogain GEM 21S rh-pdgf
Around Teeth Gingival / soft tissue recession Lack of keratinized/attached gingiva Decreased vestibular depth Aberrant frenum / muscle position Gingival excess Annals of Periodontology 1999
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
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
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
Connective Tissue Graft
Pre-op Post-op
Free Gingival Graft
Goals: Increase band of attached / keratinized tissue Minimal root coverage due to tooth prominence Improve vestibular depth / eliminate frenum pull
Connective Tissue Graft Tunnel Preparation
Post-op Pre-op
Allograft
Post-op Pre-op
Frenectomy / Double Pedicle Flap
Pre-op Post-op
Pre-op Post-op
Pre-op Post-op
Pre-op Post-op
Pre-op Post-op
Ridge Preservation Lateral Ridge Augmentation Vertical Ridge Augmentation Maxillary Sinus Bone Augmentation
Particulate Block Combination
Autograft (extraction site, tuberosity, ramus, chin) Allograft (FDBA, DFDBA, Puros ) Xenograft (BioOss, PepGen P-15 ) Alloplast (Perioglas, HTR Synthetic Graft) Composite Grafts
Nonresorbable eptfe-gore tex Titanium reinforced Resorbable Collagen (Ossix, BioMend, Biogide ) Calcium Sulfate (Capset ) Synthetic Polymers (Resolut, Guidor )
Dr. Mark Lucas
No treatment Conventional RPD Implant retained RPD Implant retained FPD
Lateral Window Technique Osteotome Sinus Elevation (Summer s technique)
Images from Periodontics Rose, Mealey, Genco, Cohen
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
Bottom line: Bugs that grow around teeth can grow around implants
Assessment of peri-implant tissues Visual assessment Color of tissues Bleeding or suppuration Probing Depths
That is the question!
Sulcus/JE CT Bone
Slide courtesy of Francis G. Serio, DMD, MS, MBA
Slide courtesy of Francis G. Serio, DMD, MS, MBA
Radiographic evaluation What are we looking for? Frequency Type of radiograph
Mobility Abutment or implant Occlusal forces Traumatic occlusion Lateral forces
Avoid damage to implant, abutment, and restoration! Home care Tools and techniques Professional care Instrumentation
Slide courtesy of Francis G. Serio, DMD, MS, MBA
Slide courtesy of Francis G. Serio, DMD, MS, MBA
http://www.premusa.com/enews/2010_05_2pro.asp
Graphite http://www.premusa.com/enews/2007_06_implantsca lers.asp
Longer lasting http://shop.brasselerusa.com/storefrontb2cweb/brows e.do?action=refresh_browse&ctg_id=42412
http://www.thorntonfloss.com/products.html
Chris van Kesteren, DDS drvank@trvperio.com 2315 W. Arbors Dr. (University Area) Charlotte, NC 28262 Website: www.trvperio.com