overview of periodontics for the general practitioner ...overview of periodontics for the general...

Overview of Periodontics for Overview of Periodontics for the General Practitioner the General Practitioner

-- Surgical TherapySurgical Therapy

Nashville Area Dental Continuing EducationNashville Area Dental Continuing EducationOctober 22, 2008October 22, 2008

Phillip D. Woods, DDS, MPHPhillip D. Woods, DDS, MPHCommander, USPHSCommander, USPHS

BOP National Periodontal ConsultantBOP National Periodontal ConsultantDiplomate, American Academy of PeriodontologyDiplomate, American Academy of Periodontology

Chief Dentist, MCC San DiegoChief Dentist, MCC San Diego

References for this PresentationReferences for this Presentation

Manual of Clinical Periodontics , 2Manual of Clinical Periodontics , 2ndnd Edition Edition by Francis Serio and Charles Hawleyby Francis Serio and Charles Hawley

Copyright (c) LexiCopyright (c) Lexi--Comp, Inc. 1978Comp, Inc. 1978--2008 All Rights Reserved.2008 All Rights Reserved.

E. Barrie Kenney, D.D.S., M.S., F.R.A.C.D.S.,E. Barrie Kenney, D.D.S., M.S., F.R.A.C.D.S.,Professor and Chairma Division of Associated Professor and Chairma Division of Associated Clinical Specialties UCLA School of DentistryClinical Specialties UCLA School of DentistrySeveral of his clinical slides are presentedSeveral of his clinical slides are presented

Carranza's Clinical Periodontology, 9Carranza's Clinical Periodontology, 9thth Ed. Ed. Michael Newman, Henry Takei, Michael Newman, Henry Takei,

Fermin Carranza and Perry KokkevoldFermin Carranza and Perry Kokkevold

Preferred Sequence of Preferred Sequence of Periodontal Therapy Periodontal Therapy

1.1. Emergency PhaseEmergency Phase

2.2. Etiotrophic PhaseEtiotrophic Phase

3.3. Maintenance PhaseMaintenance Phase

4.4. Surgical Phase Surgical Phase -- -- -- -- -- Restorative PhaseRestorative Phase

Overview of Presentation #3Overview of Presentation #3Indications for Periodontal SurgeryIndications for Periodontal SurgeryReview of Basic Periodontal Surgical ConceptsReview of Basic Periodontal Surgical Concepts2 Suturing Techniques2 Suturing TechniquesCrown Lengthening (several cases)Crown Lengthening (several cases)Briefly CoverBriefly Cover

GingivectomyGingivectomyFlap Surgery Flap Surgery

Principles of SurgeryPrinciples of Surgery

Above all, periodontal surgery Above all, periodontal surgery should do no harmshould do no harm to the patient.to the patient.Be discussed, in all aspects, in advance with the patient.Be discussed, in all aspects, in advance with the patient.Be understood, in all aspects, by the patient and that understanBe understood, in all aspects, by the patient and that understanding ding should be acknowledged as written consent.should be acknowledged as written consent.Be as atraumatic as possible.Be as atraumatic as possible.Be conducted in an aseptic environment.Be conducted in an aseptic environment.Not exceed the limits of physical tolerance of the patient in teNot exceed the limits of physical tolerance of the patient in terms of rms of discomfort, blood loss, and stress.discomfort, blood loss, and stress.Produce a benefit for the patient.Produce a benefit for the patient.Be actively monitored postoperatively to assure uneventful healiBe actively monitored postoperatively to assure uneventful healing ng

Indications for Perio SurgeryIndications for Perio Surgery

Provide access to root surfaces exposed to Provide access to root surfaces exposed to periodontitis for root debridement. This is the periodontitis for root debridement. This is the primary indication for periodontal flap surgery.primary indication for periodontal flap surgery.Provide access to periodontal bony defects for Provide access to periodontal bony defects for correction by osseous or regenerative correction by osseous or regenerative procedures.procedures.Provide an opportunity to remove periodontal Provide an opportunity to remove periodontal tissue infected by periodontal pathogens.tissue infected by periodontal pathogens.

Review of Basic Surgical ConceptsReview of Basic Surgical ConceptsWe learned all these in dental school, right?We learned all these in dental school, right?

Types of Periodontal FlapsTypes of Periodontal FlapsFullFull--thicknessthicknessPartial Partial --thicknessthicknessRepositioned flapRepositioned flap

Suturing TechniquesSuturing TechniquesCrown LengtheningCrown LengtheningClinical Cases Clinical Cases Postoperative InstructionsPostoperative Instructions

Mucoperiosteal FlapsMucoperiosteal Flaps

Full Thickness FlapFull Thickness Flap

Partial Thickness FlapPartial Thickness Flap


FullFull--thicknessthicknessflaps, elevatedflaps, elevatedpast the MGJ, past the MGJ,

revealingrevealingAlveolar boneAlveolar bone


PartialPartial--thickness flap thickness flap revealing revealing bleeding bleeding periosteum periosteum covering covering bone.bone.


PartialPartial--thickness thickness lateral lateral pedicle flap pedicle flap placed over placed over root root recessionrecession

Initial Surgical IncisionsInitial Surgical Incisions

A. SulcularA. Sulcular

B. MarginalB. Marginal

C. SubC. Sub--marginalmarginal


SubSub--marginal marginal incisions incisions being being placed placed palatallypalatally

Perio Wound ClosurePerio Wound Closure

Methods of Wound Closure (Methods of Wound Closure (continuedcontinued))

CementsCementsIsoIso--butyl cyanoacrylatebutyl cyanoacrylate

Good hemostatic capabilities, must be careful to restrict Good hemostatic capabilities, must be careful to restrict flow. Can flow under flaps or, in extreme circumstances, flow. Can flow under flaps or, in extreme circumstances, compromise the patient's airway.compromise the patient's airway.

Wound ClosureWound Closure

Healing via Healing via Primary Primary ClosureClosure

Suturing Techniques for Suturing Techniques for Periodontal Flap SurgeryPeriodontal Flap Surgery

Perio Wound ClosurePerio Wound Closure

Methods of Wound ClosureMethods of Wound Closure

SuturesSuturesMaterialsMaterials

Resorbable Resorbable gut, chromic gut, Vicrylgut, chromic gut, VicrylNonresorbable Nonresorbable silk (braided, may cause wicking and silk (braided, may cause wicking and inflammation), nylon (monofilament), Goreinflammation), nylon (monofilament), Gore--TexTex(monofilament, very (monofilament, very tissuetissue tolerant)tolerant)

Wound ClosureWound Closure

Healing via Healing via secondary secondary closure closure following a following a gingivectomy gingivectomy procedureprocedure

Interrupted SuturesInterrupted Sutures

Two VersionsTwo VersionsCircumferential SuturesCircumferential Sutures

Figure 8 SuturesFigure 8 Sutures

InterruptedInterrupted CircumferentialCircumferential

Interrupted Figure 8 SuturesInterrupted Figure 8 Sutures

InterruptedInterrupted CircumferentialCircumferential

Continuous Sling SuturesContinuous Sling Sutures

Continuous Sling SuturesContinuous Sling Sutures

ApicallyApically--Positioned Positioned Flap Flap Positioned at Positioned at Crest With a Crest With a Continuous Continuous Sling Suture. Sling Suture.

Clinical Crown Clinical Crown LengtheningLengthening

Clinical Crown LengtheningClinical Crown Lengthening

Indications (2) Indications (2) Development of Adequate Crown PreparationDevelopment of Adequate Crown Preparation

Gingival Margins must not invade Biological Width Gingival Margins must not invade Biological Width Requirements for Periodontal HealthRequirements for Periodontal Health

EstheticsEsthetics

Biologic WidthBiologic Width

Crown Margins Crown Margins which extend which extend apically beyond the apically beyond the Junctional Junctional Epithelium can Epithelium can violate the violate the requirements for requirements for periodontal health.periodontal health.


Biological WidthBiological WidthGargiulo A., Wentz F., Orban F. Gargiulo A., Wentz F., Orban F.

Dimensions and Relations of the Dentogingival Dimensions and Relations of the Dentogingival Junction in Humans Circumferential Sutures J. Junction in Humans Circumferential Sutures J. Periodontol 1961 32:261 Periodontol 1961 32:261 Used histologic sections to measure average Used histologic sections to measure average

dimensions of biologic width.dimensions of biologic width.Width of junctional epithelium plus connective tissue Width of junctional epithelium plus connective tissue

width was width was Biologic widthBiologic width, approximately 2 , approximately 2 mm.mm.

Biological WidthBiological Width

There must be a There must be a minimum of 1mm minimum of 1mm between the apical between the apical level of the level of the Junctional Junctional Epithelium and the Epithelium and the bone crestbone crest

Biological WidthBiological Width

If a subgingival If a subgingival crown margin is crown margin is placed in the middle placed in the middle of the gingival of the gingival sulcus, the crest of sulcus, the crest of bone should be a bone should be a minimum of 2 mm minimum of 2 mm apically positioned.apically positioned.


Flap Surgery with Osseous ResectionFlap Surgery with Osseous Resection

This is the method of choice when crown margins This is the method of choice when crown margins will impinge on the Biologic Widthwill impinge on the Biologic Width


Periapical Periapical Radiographs are Radiographs are needed to ensure needed to ensure sufficient root length sufficient root length is available. This case is available. This case cannot have surgical cannot have surgical crown lengthening crown lengthening and both premolars and both premolars need to be extracted.need to be extracted.

Clinical CaseClinical CaseThis patient had This patient had extensive tooth extensive tooth wear and loss of wear and loss of Vertical DimensionVertical DimensionThere was There was insufficient clinical insufficient clinical crown volume of crown volume of the incisors for the incisors for adequate retention adequate retention so flap surgery was so flap surgery was indicatedindicated

Prior to Flap Prior to Flap SurgerySurgery

Full thickness labial and lingual flaps

Bone is Bone is recontoured so recontoured so that there is a 2 that there is a 2 mm distance mm distance between level of between level of proposed crown proposed crown margin and crest margin and crest of bone.of bone.

The lingual side The lingual side requires minimal requires minimal bone surgery.bone surgery.

Flaps are Flaps are positioned apically positioned apically to increase length to increase length of clinical crowns.of clinical crowns.

Note similar Note similar apical apical positioning of positioning of flap on lingual.flap on lingual.

Crown Crown preparations 12 preparations 12 weeks after weeks after crown crown lengthening lengthening surgery.surgery.

Final upper Final upper and lower and lower restorations.restorations.

Results of Crown LengtheningResults of Crown Lengthening

Inadequate clinical Inadequate clinical crowns for crowns for retention of new retention of new restorationsrestorations

Flap design on Flap design on buccal. buccal. Intrasulcular Intrasulcular incisions, mesial incisions, mesial vertical incision, vertical incision, distal wedge.distal wedge.

Flap design on Flap design on palatal. Reverse palatal. Reverse bevel incision bevel incision removing gingival removing gingival margin ,mesial margin ,mesial vertical incision, vertical incision, distal wedge.distal wedge.

Buccal full Buccal full thickness flap thickness flap elevation to elevation to expose at least 3 expose at least 3 mm of crestal mm of crestal bone.bone.

Crown LengtheningCrown Lengthening

BuccalBuccal PalatalPalatal

Palatal flap Palatal flap elevation to elevation to expose at least 3 expose at least 3 mm of crestal mm of crestal bone.bone.

The gingival level The gingival level of new crown of new crown margin is margin is estimated and estimated and bone removed so bone removed so bone crestal level bone crestal level is 2 mm apical to is 2 mm apical to this.this.

Buccal crown Buccal crown margins will be margins will be subgingival for subgingival for esthetics, so margins esthetics, so margins will be in middle of will be in middle of gingival sulcus i.e. 1 gingival sulcus i.e. 1 mm coronal to mm coronal to probing depth; add probing depth; add another 1 mm for another 1 mm for connective tissue to connective tissue to determine bone level determine bone level from crown margin.from crown margin.

Palatal crown Palatal crown margin will be margin will be supragingival. So supragingival. So allow 1mm for allow 1mm for connective tissue connective tissue plus 2 to 3 mm for plus 2 to 3 mm for sulcus, so bone sulcus, so bone level = 3 to 4 mm level = 3 to 4 mm apical to level of apical to level of crown margin.crown margin.

Buccal flap is Buccal flap is sutured apically sutured apically with increased with increased tooth structure for tooth structure for crown preparation.crown preparation.

Palatal flap Palatal flap repositioned with repositioned with continuous sling continuous sling mattress sutures mattress sutures and simple U and simple U shaped sutures of shaped sutures of distal wedge and distal wedge and vertical incisions.vertical incisions.

Buccal Healing Buccal Healing at 3 weeks.at 3 weeks.

Palatal Healing Palatal Healing at 3 weeks.at 3 weeks.

Crowns placed Crowns placed at 6 weeks.at 6 weeks.


BeforeBefore AfterAfter

After Before


Case Selected Case Selected for Crown for Crown Lengthening. Lengthening. Additional Additional clinical crown clinical crown is needed for is needed for restoration of restoration of the lateral the lateral incisorsincisors

Crown LengtheningCrown LengtheningApicallyApically--Positioned Positioned Flaps After Flaps After Crown Crown Lengthening. Lengthening. Additional Additional increased increased length of the length of the clinical crowns clinical crowns is apparent.is apparent.


Healed and Healed and Restored Restored CaseCase

In esthetic areas a In esthetic areas a minimum of 12 minimum of 12 weeks afterweeks after--surgery surgery is recommended to is recommended to be ensure minimal be ensure minimal additional gingival additional gingival recession will occur.recession will occur.

Final crown restorations should not be completed until a minimum of 6 weeks after surgery .

Most cases need flap Most cases need flap and osseous surgery. and osseous surgery. Gingivectomy used Gingivectomy used when have when have adequate adequate band of Keratinized band of Keratinized tissue and bone crest tissue and bone crest is positioned apically is positioned apically with an initial wide with an initial wide Biological WidthBiological Width..

Gingivectomy for Crown Lengthening

GingivectomyGingivectomyThe The excisionexcision of a portion of the gingiva; usually of a portion of the gingiva; usually performed to reduce the soft tissue wall of a performed to reduce the soft tissue wall of a periodontal pocket. periodontal pocket. It is performed using an external bevel initial It is performed using an external bevel initial incision (in contrast to the internal bevel initial incision (in contrast to the internal bevel initial incision of the APF), which is kept, where incision of the APF), which is kept, where possible, entirely within the band of keratinized possible, entirely within the band of keratinized gingiva. gingiva. The gingivectomy may be performed with a The gingivectomy may be performed with a knife, electrosurgery, or a laser knife, electrosurgery, or a laser

GingivectomyGingivectomyNearly all of the Nearly all of the Indications for a Indications for a Gingivectomy Exist Gingivectomy Exist (suprabony pockets, (suprabony pockets, no intraosseous no intraosseous defects, gingival defects, gingival enlargement due to enlargement due to medications, medications, adequate zone of adequate zone of attached gingiva, and attached gingiva, and ample vestibular ample vestibular depth) depth)

GingivectomyGingivectomy

It is made using It is made using a Kirkland knife a Kirkland knife held at a 45held at a 45angle with the angle with the tooth beginning tooth beginning just apical to the just apical to the clinical clinical attachment level attachment level and ending at the and ending at the attachment level.attachment level.


A completedA completedGingivectomy Gingivectomy

showing showing blended blended margins and margins and interproximal interproximal grooves.grooves.

GingivoplastyGingivoplastyThis is the reshaping This is the reshaping of the gingival of the gingival surface using a surface using a blade, rotary blade, rotary instrument, instrument, electrosurgery, or electrosurgery, or laser. This procedure laser. This procedure does not remove any does not remove any of the wall of the of the wall of the pocket but pocket but recontours the recontours the gingiva gingiva

Poor crowns with Poor crowns with recurrent caries.recurrent caries.

Soft tissue Soft tissue removal will be removal will be adequate for adequate for exposure of exposure of sound tooth for sound tooth for margins.margins.

Electrosurgery Electrosurgery used for used for gingivectomy. gingivectomy. This can also be This can also be done with done with scalpels or laserscalpels or laser(note dating of (note dating of photo).photo).

Tissue is Tissue is recontoured recontoured to expose to expose root surfaces root surfaces for adequate for adequate preparation preparation of margins.of margins.

Provisional Provisional restorations at restorations at 12 weeks. 12 weeks. Marginal Marginal gingiva is now gingiva is now stable so final stable so final subgingival subgingival crowns can be crowns can be completed.completed.

Periodontal Flap SurgeryPeriodontal Flap Surgery

DefinitionDefinition

IndicationIndication

Periodontal Flap SurgeryPeriodontal Flap Surgery

References References E. Barrie Kenney, D.D.S., M.S., F.R.A.C.D.S.,E. Barrie Kenney, D.D.S., M.S., F.R.A.C.D.S.,Professor and Chairma Division of Associated Professor and Chairma Division of Associated Clinical Specialties UCLA School of DentistryClinical Specialties UCLA School of Dentistry

Several of his clinical slides were presentedSeveral of his clinical slides were presented

Carranza's Clinical Periodontology, 9Carranza's Clinical Periodontology, 9thth Ed. Ed. Michael Newman, Henry Takei, Michael Newman, Henry Takei,

Fermin Carranza and Perry KokkevoldFermin Carranza and Perry Kokkevold

Manual of Clinical Periodontics , 2Manual of Clinical Periodontics , 2ndnd Edition Edition by Francis Serio and Charles Hawleyby Francis Serio and Charles HawleyCopyright (c) LexiCopyright (c) Lexi--Comp, Inc. 1978Comp, Inc. 1978--2008 All Rights Reserved.2008 All Rights Reserved.

Great narratives, clinical photographs, and online accessGreat narratives, clinical photographs, and online access

SpecialSpecial ThanksThanksCAPT Tim Ricks, IHS Nashville Area DirectorCAPT Tim Ricks, IHS Nashville Area Director

E. Barrie Kenney, D.D.S., M.S., F.R.A.C.D.S., E. Barrie Kenney, D.D.S., M.S., F.R.A.C.D.S., Professor and Chairman Division of Associated Professor and Chairman Division of Associated Clinical Specialties UCLA School of Dentistry; Clinical Specialties UCLA School of Dentistry; Professor and Chairman, Division of Associated Professor and Chairman, Division of Associated Clinical SpecialtiesClinical SpecialtiesDr. Debra Lacy, Clinical Director, MCC San DiegoDr. Debra Lacy, Clinical Director, MCC San Diego

Overview of Periodontics for the General Practitioner - Surgical TherapyReferences for this PresentationPreferred Sequence of Periodontal Therapy Overview of Presentation #3Principles of SurgeryIndications for Perio SurgeryReview of Basic Surgical ConceptsMucoperiosteal Flaps Mucoperiosteal Flaps Mucoperiosteal Flaps Mucoperiosteal Flaps Mucoperiosteal FlapsInitial Surgical Incisions Mucoperiosteal FlapsPerio Wound Closure Wound ClosureSuturing Techniques for Periodontal Flap SurgeryPerio Wound Closure Wound ClosureInterrupted Sutures Interrupted CircumferentialInterrupted Figure 8 SuturesInterrupted CircumferentialContinuous Sling SuturesContinuous Sling SuturesContinuous Sling Sutures Continuous Sling SuturesClinical Crown LengtheningClinical Crown LengtheningBiologic WidthBiologic WidthClinical Crown LengtheningBiological WidthBiological WidthClinical Crown LengtheningClinical Crown LengtheningClinical CasePrior to Flap SurgeryResults of Crown LengtheningCrown LengtheningCrown Lengthening Crown Lengthening Crown Lengthening Crown LengtheningGingivectomy GingivectomyGingivectomy GingivectomyGingivectomy GingivoplastyPeriodontal Flap SurgeryPeriodontal Flap SurgeryPeriodontal Flap SurgeryPeriodontal Flap SurgeryPeriodontal Flap SurgeryReferences Special Thanks

overview of periodontics for the general practitioner ...overview of periodontics for the general...

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