l22_phase ii therapy
TRANSCRIPT
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Periodontal Therapy:
Phase II
Rikko Hudyono
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The Concept of PeriodontalTherapy
to eliminate infammation
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The Concept of PeriodontalTherapy
‘no one can clean calculus completely’
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Interdisciplinary cooperation
The Concept of PeriodontalTherapy
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The Concept of PeriodontalTherapy
ing an oral environment that is conducive to maintaining the padentition in a healthy com!orta"le and !unctional esthetic state and
#hen !easi"le to regenerate and preserve the periodontal attachmen
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Periodontal Therapy$e%uences
Phase I:&on $urgical Peridontal Therapy
Phase I:
(aintenance
Phase II:$urgical Peridontal
Therapy
Phase III:Restorative Phase
)mergency Phase
* h y +
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*hy is phase II come
a!ter the phase I+
(ost o! periodontal diseases are pla%ue,associated disorders
&on,$urgicalPeriodontal
Therapy
Pla%ue
Periodontal-reakdo#n
(otivational
Intervie#ing $upra.ingivalPla%ue/ontrol
&on,surgicalroot
de"ridement
$urgical 0Reconstructive
Therapy
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3"5ectives
The surgical phase o! periodontaltherapy has the !ollo#ing maino"5ectives:
12 Improvement o! the prognosiso! teeth and theirreplacements2a2the pocket #hich esta"lished an environment
conducive to progression o! periodontal disease #aseliminated and
"2the root sur!ace #as made accessi"le !or scaling and!or sel!,per!ormed tooth cleaning a!ter healing2
42 Improvement o! esthetics2
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*hat do #e do in surgicalphase+
• /ontrolling or eliminatingperiodontal disease2
• /orrecting anatomic conditions
that may !avor periodontal diseaseimpair esthetics or impedeplacement o! the correct prostheticappliances2
• Placing implants to replace lostteeth and improving theenvironment !or their placement
and !unction2
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Indications !or Periodontal$urgery12 =reas #ith irregular "ony contours deep craters and
other de!ects
42 Pockets on teeth in #hich a complete removal o! root
irritants is not considered clinically possi"le2
;2 In cases o! !urcation involvement o! grade II or III
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• )sthetic cro#nlengthening
• $o!t tissue gra!ting• Papilla reconstruction
• -iopsy o! enlargement• Treatment o! a"scess
• /ro#n lengthening• .ingival
augmentation• Ridge augmentation• Tori reduction• Tu"er reduction• esti"ulopasty• Implant $urgery
• =ccess to osseous de!ect• Regeneration• Resective
PocketReducti
on
Prosthetic
$urgery
Plastic
$urgery
3ther
$urgery
Periodontal $urgery
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/ontra,Indications
12 Poor Pla%ue control
42 High caries rate
;2 ?nrealistic patient e@pectation or desire
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/ontra,Indications
Uncontrolled medical conditions:
1. Patient cooperation
. Cardiovascular disease
!. Organ transplantation
". #lood disorders
$. %ormonal disorders
&. 'eurologic disorders
(. Smo)ing
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Access to osseous defect
• Visibility
• Effective SRP
• Less trauma
•
Maintenance
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Osseous defect modification
• Resection
• Augmentationes ta " l is
h
p h ys io log ic
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No biologic architecture of hard tissue
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Last molar problem
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$ome cases in #hich periodontalsurgery may "e indicated
a2/reating accessi"ility !or properpro!essional scaling and root planing
"2)sta"lishing a gingival morphology #hich!acilitates the patient’s sel!,per!ormed
in!ection control2
/onclusion o! purpose o! periodontal surgery:
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*hen #e do +
! " months interval
#hat are $e $aiting for%
& 'true( soft tissue and poc)et*& +irm and resilient tissue,& Evaluate the self maintenance
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$urgical Phase
The surgical phase consists o!
12 Pocket reduction surgery
42 /orrection o!anatomicBmorphologic de!ects7mucogingival de!ects8
In many cases procedures are com"ined so thatone surgical intervention !ullls "oth o"5ectives2
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Poc)et
*eductionSurgery
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*hy Pocket Therapy+
.ingivalinfammati
on
Pocket
deepening
Pla%ue=ccumulati
on
The e9ectiveness o! periodontal therapy is predicated on success incompletely eliminating calculus pla%ue and diseased cementum !rom the
tooth sur!ace2 6eeper pocket makes everything more diCcult2
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Periodontal Pockets
Dalse Pocket
True Pocket
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Periodontal Pockets
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$urgical Pocket Therapy
• )liminating the pathologic changes in the
pocket #allsE• /reating a sta"le easily maintaina"le
stateE
•
Promoting periodontal regeneration7i! possi"le8
Purpose:
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$urgical Pocket Therapy
Targets mainly on:
access surgery to ensure the removal o!irritants !rom the tooth sur!ace or elimination
reduction o! the depth o! the periodontalpocket
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$urgical Pocket Therapy
-y surgical therapies #e can:
• increase accessi"ility to the root sur!acemaking it possi"le to remove all irritantsE
• reduce or eliminate pocket depthmaking it possi"le !or the patient tomaintain the root sur!aces !ree o!
pla%ueE and• reshape so!t and hard tissues to attain a
harmonious topography2
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$urgical Pocket Therapy
Pocket reduction surgery seeks toreduce pocket depth "y either
• Resective surgery – gingivectomy
– apically displaced fap
– undisplaced fap #ith or #ithout osseous reduction
• Regenerative surgery – faps #ith gra!ts mem"ranes etc
• /om"ination o! "oth methods
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$urgical Pocket Therapy
T#o !actors are taken intoconsideration:
718the character o! the pocket #allE
and
748the accessi"ility o! the pocket2
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(ethods o! Pocket Therapy
• &e# =ttachment Techni%ue
ideal therapy
• Removal o! the Pocket *allRetraction or shrinkage: $caling and rootplaning
$urgical removal: gingivectomyundisplaced fap
=pical displacement: =pically repositionedfap
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Result o! Pocket Therapy
= periodontal pocket can "e
• =ctive state2 In an active pocketunderlying "one is "eing lost
• Inactive state or %uiescence2
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The possi"ility o! the treatmen
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$pecial /onsideration
The pocket #all can "e either edematous or "rotic2
• Edematous tissue shrinks a!ter the elimination o!local !actors there"y reducing or totallyeliminating pocket depth2 There!ore scaling androot planing are the techni%ue o! choice in thesecases2
• Pockets #ith a fbrotic #all are not apprecia"lyreduced in depth a!ter scaling and root planingEthere!ore they are eliminated surgically2
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6o #e need to Remove all Periodontal
Pocket+
Pocket )liminationsPocket (aintenance
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+ucogingivalSurgery
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(ucogingival $urgery
Purpose
• /orrecting the anatomic morphologicde!ects that may !avor pla%ue accumulation
and pocket recurrence or impair esthetics2
It is important to understand that theseprocedures are not directed to treat disease "utaim to alter the gingival and mucosal tissues tocorrect de!ects that may predispose to disease2
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+ucogingival Surgery
• Plastic surgery techni%ues to #idenattached gingiva 7!ree gingival gra!tsother techni%ues etc8
• )sthetic surgery 7root coverage re,creationo! gingival papillae8
• Preprosthetic techni%ues 7cro#n
lengthening ridge augmentation andvesti"ular deepening8
P i d t l !
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Periodontal surgery !orImplant
Placement o! dental implantsincluding techni%ues !or sitedevelopment !or implants
• guided "one regeneration
• sinus gra!ts
• FateraliGation o! mandi"ular nerve
• Ridge augmentation
• *idening the attached gingiva
R l ti ! Ph I
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Re,evaluation o! Phase I Therapy• 1 ; months and sometimes as
much as months a!ter thecompletion o! Phase I therapy2
• Dull,mouth repro"ing2
• The presence o! calculus root cariesde!ective restorations and signs o!
persistent infammation should also"e evaluated2
/ iti l J i P k t
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/ritical Jones in Pocket$urgery=reas that shall "e evaluated inchoosing the proper therapy:
• The so!t tissue pocket #all
• Tooth sur!ace
• ?nderlying "one and
•
=ttached gingiva2
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• Zone 1: Soft Tissue Pocket Wall
• the morphologic !eatures
• thickness
• topography o! the so!t tissue pocket
#all• persistence o! infammatory changes
in the #all2
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• Zone 2: Tooth Surface
• the presence o! deposits
• alterations on the cementum sur!ace
• determine the accessi"ility o! the
root sur!ace to instrumentation2Phase I therapy should have solved many i! notall o! the pro"lems on the tooth sur!ace2)valuation o! the results o! Phase I therapy
should determine the need !or !urther therapy
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• Zone 3: Underlying Bone
• the shape and height o! the alveolar "one
ne@t to the pocket #all through care!ulpro"ing and clinical and radiographice@aminations2
• -ony craters horiGontal or angular "one
losses and other "one de!ormities areimportant criteria in selection o! thetreatment techni%ue2
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/riteria !or (ethod
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/riteria !or (ethod$election12 /haracteristics o! the pocket: depth relation to "one and
conguration2
42 =ccessi"ility to instrumentation including presence o!!urcation involvements2
;2 )@istence o! mucogingival pro"lems2
2 Patient cooperation including a"ility to per!orm e9ectiveoral hygiene2 $mokers must "e #illing to stop their ha"it2
A2 =ge and general health o! the patient2
L2 3verall diagnosis o! the case: various types o! gingivalenlargement and types o! periodontitis 7e2g2 chronicmarginal periodontitis localiGed aggressive periodontitisgeneraliGed aggressive periodontitis82
M2 )sthetic considerations2
2 Previous periodontal treatments2
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Therapy !or $light
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Therapy !or $lightPeriodontitis• In slight or incipient periodontitis a small
amount o! "one loss has occurred and pocketsare shallo# to moderate2
• In these patients the conservative approach#ith good oral hygiene #ill generally suCce tocontrol the disease2
• Incipient periodontitis that recurs in previouslytreated sites may re%uire a thorough analysis o!the causes !or the recurrence2 3ccasionally asurgical approach may "e re%uired to correctthe pro"lem2
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Th ! ( d t t $
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Therapy !or (oderate to $everePeriodontitis in Posterior =rea
• Treatment !or premolars and molarsusually poses no esthetic pro"lem "ut!re%uently involves diCcult
accessi"ility2• The purpose o! surgery in the posterior
area is either enhanced accessi"ility or
the need !or denitive pocket reductionre%uiring osseous surgery2 It can "eregeneration or resective surgery2
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Remem"er that 2222
• Phase II therapy is used to surgically treatresidual periodontal pockets and "one
de!ects remaining a!ter Phase I therapy2• =ll patients treated surgically need to have
a preoperative history o! ade%uatepla%ue control #ith 4NO or more o!
the tooth sur!aces !ree o! pla%ue a!ter oralhygiene procedures2
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Remem"er that 2222
• (ost types o! surgical therapy #illresult in some postsurgical gingivalrecession and so they are not use!ul
in the anterior segments o! the mouthin those patients in #hom theesthetic shape o! the gingiva is
visi"le2• This patient may "est treated #ith
non,surgical procedure
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Remem"er that 2222
• Ho#ever ne# innovativeregeneration surgical techni%uesusing modied papilla preservation
approaches together #ith minimallyinvasive procedures o!ten coupled#ith a "asis o! microsurgery are
sho#ing promising results inmaintaining and even improvingpapillary and la"ial tissue levels2
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Thank you