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Non-Surgical and Surgical
Management of Periodontal Disease
Dr. Sangeetha Chandrasekaran
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Course objectives
• Prevalence of periodontal disease
• Update on periodontal diagnosis
• To save or extract teeth
• Non surgical management
• Surgical management
• Functional crown lengthening
• Gingival augmentation
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PREVALENCE OF PERIODONTITIS
UPDATE ON CLASSIFICATION
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Prevalence of periodontitis
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Complex etiology in periodontitis
MICROBES
GENETICS
HOST FACTORS
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Update on diagnosis
American Academy of Periodontology Task Force Report, 2015
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Chronic vs Aggressive
Periodontitis
American Academy of Periodontology Task Force Report, 2015
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TO SAVE OR EXTRACT TEETH
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The decision to save…
Avila et al, A novel decision –making process for tooth retention or extraction,
Journal of Periodontics, 2009
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Endodontic outcomes
Treatment options for the compromised tooth:
A decision guide American Academy of endodontics
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Preop Postop 12 mo recall
Courtesy of Dr. Manpreet Sarao
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NO HERODONTICS!
Just because a tooth can be saved it doesn’t
necessarily need to be saved
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Treatment options for the compromised tooth:
A decision guide American Academy of endodontics
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Treatment options for the compromised tooth:
A decision guide American Academy of endodontics
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My Decision Tree
SAVE TEETH PROCEED WITH
CAUTION
CONSIDER
IMPLANT
Treatable Perio Endo , Perio , post core Class 3 furcations
Treatable endo Strategic value Grade 3 mobility
Minimal restorative needs Medical status of the
patient
No strategic value
Patient Compliance Finances High Caries risk
Stand alone teeth High progression of
periodontal disease
Esthetic compromise
If tx will jeopardize
the future predictable
options
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Cost of treatment
Dollars and sense: Saving teeth vs placing implants, Scott Froum
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Periodontal surgery Implant surgery
Dollars and sense: Saving teeth vs placing implants, Scott Froum
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NON SURGICAL MANAGEMENT
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Scaling and root planing:
still the treatment of choiceNew technologies Comparison to SRP
Modified ultrasonic
systems
Equivalent in results
More time
Difficulty in removing
large masses of calculus
SRP
Air abrasive systems Equivalent in results with
glycine
Less time
More patient centered
But not enough evidence
SRP
Endoscopic technology No difference with or
without endoscope
SRP
Lasers No difference with or
without lasers
SRP
Photodynamic therapy Needs to be an adjunct
No evidence
SRP
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What about adjuncts to SRP
Local drug delivery ?
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• Systematic reviews report a modest PD
reduction (0.25-0.5mm) as an adjunct to
SRP in PD >5mm
• Effects on AL gains are smaller
• Long term benefits are unknown
American academy of periodontology statement on local drug delivery of sustained or controlled release antimicrobials
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Indications for local drug
delivery
• When localized recurrent and or residual
PD> 5mm with inflammation is present
following conventional therapies
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What about adjuncts to SRP
• Systemic antibiotics
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• CAL gains can be expected if systemic
antimicrobials are used
• Effects are short term
• More useful for Aggressive Periodontitis
patients
• Most useful systemic antibiotic is the
combination of amoxicillin and
metronidazole
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Summary
PD
1-3mm
PROPHYLAXIS
6mrc
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PD
4-6mm
OHI
SRP
RE-EVAL
Amox/metro
Aggressive
Local drug
delivery
LOCALIZED PD
BOP
MAINTENANCE
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SURGICAL MANAGEMENT
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Surgical approaches
SURGERY
RESECTIVE REGENERATION
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What is regeneration?
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Components for regeneration
PDLSCBONE GRAFTS
MEMBRANE
DFDBA
EMD
PDGF
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• Diabetes mellitus
• Smoking
• Plaque control
Patient –related considerations
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Tooth-related considerations
• Type of defect3 walled > 2 walled >1 walled
Class 2 furcations
• Depth of defectNarrow > wide
Deep > shallow
• Radiographic angle of the defect25 degrees or less >
• MobilityNon mobile >mobile teeth
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Surgical decision tree
Kao et al, Periodontal regeneration- Intrabony defects: A systematic review from the AAP
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Periodontal outcomes
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Pre-op Post-op
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Biologics
• Enamel matrix derivative
• Platelet derived growth factor
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What is Enamel matrix derivative
• Dominant protein is Amelogenin
• Porcine origin
• Concept of bio-mimicry
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Biologic properties of EMD
Lyngstadaas et al, Autocrine growth factors in human periodontal ligament cells cultured on enamel matrix derivative
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What is platelet derived growth
factor ?
• Recombinant human platelet derived
growth factor
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Biologic properties of rhPDGF
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Clinical application of biologics
• Intrabony defects and furcation defects
• Results shown to be equivalent to GTR and
bone grafts
• Good on soft tissue parameters
• Good on Hard tissue parameters
• Also used in combination with bone grafts
and membrane
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Regeneration of the Periodontium
Enamel Matrix Proteins - Emdogain
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Regeneration of the Periodontium
Enamel Matrix Proteins
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Regeneration of the Periodontium
Enamel Matrix Proteins
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Regeneration of the Periodontium
Enamel Matrix Proteins
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Regeneration of the Periodontium
Enamel Matrix Proteins
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Regeneration of the Periodontium
Enamel Matrix Proteins
Baseline 6 month POT
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PD>6mm
OHI
SRP
RE-EVAL
SURGICAL MANAGEMENT
LOCALIZED PD
MAINTENANCE
Local drug
delivery
RESECTIVE
REGENERATIVE
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RESECTIVE SURGERY/
CROWN LENGTHENING
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Biologic Width (BW)
• The dimension of space occupied
by healthy gingival tissues above
the alveolar bone
• Average dimension established
by Gargiulo, Wentz, and Orban
(1961)
– Junctional Epithelium (0.97mm)
– Connective Tissue (1.07mm)
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The concept of “Supracrestal
gingival tissue (SGT)”
• BW and sulcus depth
• Approximately 3mm
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But Wait!
“Attempting to attribute a fixed measurement
to biologic width may indeed disregard
surface-surface, tooth –tooth, patient-patient
variability”:- Deas, 2004
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Tooth-tooth variation
Arora et al, Int J Dent 2012
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Surface-Surface variation
Arora et al, Int J Dent 2012
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Patient- Patient variation
Arora et al, Int J Dent 2012
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Main points
• BW plus sulcus is SGT
• SGT like BW is highly variable, and
must be established for each
individual
• SGT has a range from 2.83-4.50mm
Flores-de-Jacoby et al., 1989
Gunay et al., 2000
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Biologic width violation
• Gum recession
• Bone loss
• Tissue
inflammation
• Recurrent pocket
depth
• Mechanical failure
• Open margins
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Clinical assessment
• Amount of tooth
structure available
• Discomfort on being
assessed with a probe
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Transgingival probing
• Sounding to bone under anesthesia
• Identical to surgical measurements
60% of the time and within 1 mm
of surgical measurements 90% of
the time (Isidor et al, 1984)
• Bone sounding provided the best
estimate of open bone level
measurements when compared to
radiographs (Akesson et al, 1992)
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Contralateral SGT measurements
in the same individual are similar
Majzoub et al, Seminars in Orthodontics , 2014
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Radiographs
• An assessment of available
distance from the restorative
margin to the bone
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Main points
• Violation of biologic width can cause
inflammatory changes in the gingiva
• When it will happen depends on the quality
and fit of the restoration
• As you are planning the restoration – make
sure you check the amount of tooth
structure plus the BW of the patient . The
number quoted on an average is 3
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Indications for CL surgery
• Violation of BW
subgingival caries,
fractures, perforations,
cervical resorptions
• Surgical exposure of
tooth structure for
ferrule
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Contraindications for CL surgery
• If it significantly compromises
crown-root ratio of treated and
adjacent teeth
• If adequate supporting bone will not
remain
• Esthetic areas
• Furcation involvement is imminent
• Anatomical limitations
• Poor plaque control
• High caries risk
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Pre-op assesment- Main points
• How much tooth structure needs to be
accomplished
• Can it be a stand alone tooth
• Anatomical limitations ( 4mm rule to the
furcation entrance)
• Will it compromise the adjacent teeth
• Will esthetics be compromised
• Can alternate treatments be considered -
“10mm rule”
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“4mm rule”
• A critical distance from the furcation of
4mm was established as a landmark under
which, if surgery was performed on
mandibular molars, chances of furcation
involvement in the future was very high
Dibart et al, Crown lengthening in mandibular molars: a 5 yr restrospective radiographic analysis
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“10mm rule”
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Checklist to improve outcomes
Caries excavation – restorability
Sucessful endo treatment
Prep and margins prepared
Temporization
Communication with the Periodontist
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Technical steps for crown lengthening
• Incisions
• Flap management
• Debridement
• Osteoplasty and ostectomy
• Apically repositioned flap
• suturing
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• Very limited indication for gingivectomy
alone (soft tissue resection in crown
lengthening)
• There must be adequate attached tissue left
after the surgery
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Gingivectomy alone
• There will be significant tissue rebound if
only soft tissue is removed without osseous
contouring!
“The tissue is the issue
but the bone sets the
tone”
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Design of flap for access
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Palatal flap
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How much of tooth structure
above osseous crest is necessary
• Ferrule
The presence of 1.5-2mm ferrule has a positive effect
on fracture resistance of endodontically treated teeth.- Juloksi, 2012
• Biologic width of approximately 3mm
A minimum of 5mm above the osseous crest
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Osteoplasty and ostectomy
Osteoplasty refers to creating a physiologic
form of alveolar bone without removing
supporting bone
Ostectomy is the removal of supporting bone
(bone directly involved in the attachment of
the tooth)
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Establishing positive architecture
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Flap position
• Flap position vs. osseous reduction
– The closer the flap is sutured to the alveolar
crest, the greater the amount of rebound over
time.
• 1.33mm when flap sutured ≤ 1mm from crest
• 0.90mm when flap sutured 2mm from crest
• 0.47mm when flap sutured 3mm from crest
• -0.16mm when sutured ≥ 4mm from crestDeas et al., 2004
Deas et al, 2004
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Crown Lengthening + Distal Wedge
• Provisional Restoration
removed
• Bone Sounding complete
• Tissue marked with
bleeding points
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Crown Lengthening #15
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Crown Lengthening #15
- Blade (12b) for linear distal cuts.
- Kirkland Knife for horizontal cuts.
- Back Action Chisel used to
remove the distal wedge
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Crown Lengthening #15
Soft tissue removal
and adequate flap
mobility
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Crown Lengthening #15
Hard tissue removal
interproximally with
Sugarman file and
End cutting burs
Positive
architecture
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Crown Lengthening #15
Provisional Replaced, cement
removed, flap apically positioned.
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Crown Lengthening- main points
Soft tissue resection alone without osseous
resection can result in rebound (Specific indications)
– Access to bone is important
– Achieve positive architecture
– Overreliance on flap position, instead of
osseous reduction, can lead to excessive
rebound and inadequate clinical crown height!
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Reprovisionalization
• At 3 weeks
• Flat emergence
• 1mm supragingival
• Prevents the fibers from attaching
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Final restoration
• A stable sulcus must be formed
• Several factors influence tissue rebound
after surgery:
Flap position
Tissue biotype
Esthetic conditions
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Recommendations
• Non-esthetic areas
- Minimum- 6 weeks , Optimal- 3months, Ideal-6 months
• Esthetic areas
- Minimum 3 months and ideal is 6 months.
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GINGIVAL RECESSION /
TREATMENT
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FREE GINGIVA
ATTACHED GINGIVA
MGJ
KERATINIZED GINGIVA
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Is attached or keratinized tissue
essential for gingival health ?
• BL :
Inadequate width of attached gingiva is as resistant to
plaque induced gingival inflammation as an adequate
one and not more susceptible to recession (as long as
the patient maintains good oral hygiene)
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So why and when to augment?
• Patient discomfort
• Orthodontic movement
• Subgingival restorations
• Progressive recession
• Augmentation around implants
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What determines the success of soft
tissue augmentation procedures?
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Surgical options
Free Gingival graft
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Surgical options
Connective tissue graft
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Surgical options
Acellular Dermal Matrix
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Procedure-related
Outcomes FGG CAF CTG ADM XCM PDGF EMD
Root coverage
KT gain
Attachment to
the root
Thickness
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Patient- related
Outcomes FGG CAF CTG ADM XCM PDGF EMD
Comfort
Esthetics
Cost
Stability