Antibiotic of choice of ANUG and ANUP
- Metronidazole and Hydrogen peroxide rinses
- Antibiotic for aggressive periodontitis is Doxycycline 100mg x day for 14 days
Best predictability in walled defects
- 3 walled defect, is the best even without a graft.
- Most are combined defects with the most apical have 3 walls and the coronal have less, potential to regenerate bone is high in apical part, but almost impossible to bring to tooth level
A piece of living tissue that is transplanted surgically; a viable tissue that, after removal from a donor site, is implanted within a host tissue which is then restored, repaired, or regenerated.
- A graft
- *** BUT If the material is not coming from a living source (ie synthetic material) it cannot be called a graft, it should be called a substitute
Where should the source of the autogenic bone graft be for an intrabony defect?
- It is best to not need a secondary surgical site, but..
- - Osteoplasty and ostectomy sites
- Extraction socket – the best site to harvest the graft because it has the most osteogenic material
- Tuberosity, edentulous sites, Chin, Ramus, Tori
- Extraoral donor sites: iliac crest, tibia, fibula, ribs
What are the forms of autografts?
- 1. Cortical bone chips: scraping from the external surface of the bone
- 2. Osseous coagulum: mix of blood and bone produced when the bone is reduced with the drill (bone-blood slurry)– the best graft material
- 3. Combination of cortical and cancellous bone (bone blend)
A graft which is transferred between genetically dissimilar members of the same species.
- Allograft (indicated when there is not source for autograft)
- Xenograft: A graft which is transferred from one species to another
- Allograft or xenograft serves as a biologic scaffolds (osteoconductive)
- Mammalian ECM composed of laminin, fibronectin, elastin, and collagen
- Difference between allograft and xenograft: Tissue source, Species of
- origin, Methods of processing
What type of allograft is at the higest risk for transmission of disease?
- Fresh frozen bone (FFB), because it contains viable cancellous bone and marrow (which can have the disease)
- Freeze dried mineral and demineralized bone have no risk of disease transmission
- All are osteoinductive and osteoconductive
_______ is derived property of bone morphogenetic protein (BMP)
- BMP is rich in cortical bone
- During bone remodeling, resorption of cortical bone releases BMP, Bone cannot be regenerated to the CEJ
What does emdogain do?
- Induce cellular cementum formation
- Applicable in 2 walled or 3 walled intrabony defect
- Most often used in conjunction with bone graft
Biological materials completely synthetic or chemical processing of xenograft material
- Advantage: Unlimited availability, durability, No transfer of pathogens, No immune reaction
- Disadvantage: No osteogenesis, no osteoinduction, Questionable osteoconduction, No definable absorption and transformation rates, Different mechanical capacity
What 3 major factors important for new attachment ?
- Remember C.E.O.
- o CEMENTOGENESIS
- o EPITHELIAL EXCLUSION/RETARDATION***
- o OSTEOGENESIS
Degeneration has occurred over a long period of time (>10 yrs), so the cementum is completely necrotic and requires complete removal.
Degeneration of bone occurs acutely (few years at most) and the defect does not have plaque and calculus. Therefore, treatment involves very light scaling. Since the cementum was not exposed to bacteria for a long period of time, it can regenerate.
Major determinants of predictability of graft success...
- Epithelial retardation
- Patient selection
- Morphology of the defect
- Nature of root preparation
- Type of graft used
- Plaque control effectiveness
- Patient repair potential
- Periodontal maintenance
Positive factors influencing periodontal regeneration...
- o Cells and tissues with regenerative potential (alveolar bone, PDL , cementum)***
- o Matrix factors (adhesion proteins, growth factors)
- o Bonegrafts
- o ? Barrier material
FUNCTION OF THE SURGICALLY PLACED BARRIER?
- 1) PREVENTS APICAL PROLIFERATION OF GINGIVAL EP INTO THE WOUND
- 2) PREVENTS GINGIVAL CT FROM CONTACTING A DEBRIDED ROOT SURFACE
- 3) ALLOWS PDL PROGENITOR CELLS*** TO PROLIFERATE CORONALLY AND LATERALLY IN THE WOUND
Main difference between first and second generation membranes
- First generation: are non-resorbable and need a second surgery
- Second generation: resorbable
The Natural healing process of the socket results incomplete bony healing up to the level of the alveolar crest, at which point can an implant be placed?
- 30-60 days (6-8 weeks): lamellar bone formation, acceptable for implant placement
- Week 1 : blood clot
- Week 2: Woven bone formation
- ** Placement of graft delays healing process
If you have a patient with > 5mm pocket, what are the chances of you removing plaque and calculus beyond 5 mm?
Composition of the periodontum?
Cementum, PDL, Alveolar bone, Gingiva*
5 current diagnostic indicators:
- Gingival inflammation (clinically relevant)
- CT loss (clinically relevant)
- GCF change and composition
- Host response
- Microbial index
Gingival enlargement due to medications
Nifedipines, CCB, cyclosporines
Best radiograph to determine crestal bone height
Objectives of periodontal therapy
- Lower Pathogenic bacteria
- Lower pockets
- Lower inflammation
- Establish healthy root surface (basis of SRP)
- * Most important factors in the treatment of gingivitis is calculus removal and home care***
What is the normal thickness of cementum? and what does Root Planing do (3 things)?
- 1. Remove most but not all calculus
- 2. Removes most but not all bacterial plaque
- 3. Releases bacteria and bacterial antigens into the blood or local tissues stimulating an antibody response.
- Gingival curettage (removal of ulcerated lining of pocket) has no clinical benefit
Initial therapy is necessary before surgery because ...
- SRP prepares area for surgery (remove inflmmation)
- - because a clean incision cannot be made
- - Inflamed tissues will be hemorrhagic and will fall apart during suturing
- Ultrasonic instrument is only for scaling
- Hand instruments must be used for root planning
Indications for gingivectomy...
- - Pocket retention after SRP
- - Sufficient keratinized gingiva must remain
- after gingivectomy
- - No significant bone loss (<4-6 mm)
- - Areas of hyperpigmentation.
- o But gingivoplasty (removal of outer layer
- of gingiva only) is more conservative in
- removing pigmented tissues.
- - Areas with excessive fibrotic tissues
- - Medication induced gingival enlargement
- - Gingival overgrowth over the implant
Contraindications for gingivectomy...
- - Inadequate attached gingiva
- o If too much of the gingiva must be
- removed to have access to the subgingival
- calculus, it would be better to raise a flap
- - Intrabony pocket: necessitates osseous surgery
- or open-pocket debridement with flaps
- - Large wound area: if the patient has a flat
- broad plate, the incisional bevel will be very
- wide. The bevel will take a long time to heal
- with secondary intention.
Indications for gingivoplasty.
- Trimming the gingiva around a new restoration
- Creating ovate pontic receptor site for natural emergence profile
Benefits of gingivectomy compared to open-flap surgery
- o Bone exposure to oral fluid induces bone loss.
- o Gingivectomy needs no flap
- no bone exposure
- no bone loss
Principles of not doing harm to the
Halstead’s principle (Tenets of halstead)
3 incision for better access to dental pocket
- Internal bevel
- External bevel
What suture allows the flap to be placed at the exact desired position?
- Continuous sling suture
- **Replaced or repositioned flap puts it back to original level, but is not possible in periodontal therapy because CT can never attach without GTR)
- Apically positioned flap always loses long junctional epithelium
Removal of supporting bone, which is in contact with the root, to reshape deformities in the marginal and interdental bone caused by periodontitis.
- - Inconsistent margins
- - Interproximal craters
- - Furcation involvement
- - Crown lengthening
- - Hemisepta
- - Combination of deformities and anatomic abberations
Reshaping cortical bones to create a smooth bony contour for soft tissue healing without removing any supporting bone.
- - Inconsistent bony margins
- - Reverse osseous structure
- - Interproximal crater (The most common intrabony defect)
- - Exostosis, thick marginal ridges
Contraindications for osseous surgery
- Contraindications of osseous resection
- Poor C/R ratio - Need either bone graft or extraction
- 3-walled intrabony defects- Need either bone graft or extraction
- Osseous resection: Correction of osseous defects from periodontal
- disease or anatomic architectural abnormalities or both.
This procedure s indicated in maxillary tuberosity and retromolar pad areas,
which is associated with thick fibrotic tissues that create pseudo-pockets.
- Distal wedge
- Gingivectomy is contraindicated in these areas because it will create a large
- wound, which will take weeks to heal with secondary intention.
- Distal wedge procedure: Full-thickness Incision made around distal of the molar and extended distally. Mucoperiosteal flap is raised. Internal reduction of the tissue (the shaded area in the third picture) is done. Suture with primary intention.
What is the difference between Crown lengthening vs periodontal flap surgery?
- SRP & gingivectomy & Flap surgery: can increase the length of the clinical crown by reducing inflammations or by removing gingival tissues, respectively. However, the purpose of SRP and gingivectomy are to remove pathology from the affected teeth. Increase in clinical crown is only coincidental.
- Crown lengthening: Deliberate opening of the flap and removal of bone around healthy teeth with the purpose of elongating the clinical height.
2 techniques of Crown lengthening
- CORONAL EXTENSION
- Forced Orthodontic extrusion: brings osseous housing and soft tissues
- Site preparation for implant surgery: Extruded the non-restorable
- tooth, bring up the bone level, then implant
- Reduction of osseous defect from periodontal disease
- APICAL EXTENSION
- Gingivectomy or crown lengthening
- Apically positioned flap with or without osseous resection
Biologic width ?
- Junctional Epithelium + supracrestal fibers = Distance from bone to coronal limit of JE = 2.04mm
- Junctional epithelium: 0.97 mm
- Connective tissue attachment: 1.07 mm
Delayed apical migration of the gingiva causing more crown being covered by the gingiva – cause of the gummy smile
- Altered Passive Eruption
- Gingivectomy: may or may not indicated in gummy smile depending on the ANATOMIC CAUSE OF THE PROBLEM I.E. CRESTAL HEIGHT
- o If bone and FGM is far -> Gingivectomy
- o If bone and FGM is close ->CL
- o If gingivectomy is done where bone and FGM are close -> recurrence
What is the process of plaque accumulation?
- 4-5 days of no brushing: Sudden increase in plaque, Gram+toGram–, Cocci to rods, Filaments to spirochetes
- 10-12 Days: onset of gingivitis
- more than 21 days: formation of calculus from plaque
- * Gingival inflammation is reversible with oral hygiene 5-7 days.
Initiating factor of gingivitis and periodontitis?
- Plaque initiates gingivitis (1 g of wet weight of supragingival plaque: 250 billion organisms)
- Host response initiates and progresses tissue destruction
Chronic immune response is established when..
Macrophages communicate with Lymphocytes to orchestrate chronic response.
Best rinses for effect for controlling supragingival plaque
- Clorhexidine (30% stays in the mouth for 24 hours), side effect staining on teeth.
- Listerine (ethanol 21.6)
- Diabetes: 2-3x increased risk of gum disease
- Smoking: 3-4x increased risk of gum disease
Gram + effect Antibiotic
- Tetracycline, this is why Periostat (doxycycline is used in the sulcus)
- Use of low doses of doxycycline mod-sev periodontitis is not acceptable
- * It is better to use doxycycline for maintenance
- Glickman Classification of Furcation
- Grade 1: Horizontal probing<3mmo (SRP, good-fair prognosis with apical position flap)
- Grade 2: Horizontal probing >3mm, but not a through and through (gaurded prognosis, root hemisection is for complicated cases)
- Grade 3: Through and through, complete loss of interradicular bone (root hemisection is recommended)
- Grade 4: Clinically visible furcation (hopeless prognosis)
- * Teeth with furcation involvement have approximately 5x greater probability of being extracted than single rooted teeth, bacteria retention in furcation difficult to clean
What does occlusal trauma do to periodontal disease?
- No contribution to the onset of perio disease
- Occlusal trauma doesn't contribute to periodontitis, but exacerbates attachment loss.
- TFO can be primary or secondary
- Primary: excessive force on normal periodontum
- Secondary: is normal force, on diseased periodontum.
Classifications of recessions
- Class I: (does not extend to MGJ, complete coverage with perio surgery possible)
- Class II: extends to MGJ but doesnt involve bone
- Class III: extends to MGJ but involves proximal bone
- Class IV: extends to MGJ and papilla is lost, no treatment available, recession is circumferential
Treatment for this?
- Partial thickness flap (apically positioned): indicated to address both mucogingival problem (lack of KG) and deep probing depth.
- If partial thickness flap is done, the site heals with keratinized scar tissue resembling the gingiva
- Although gingival graft has similar effect, partial thickness flap is less painful, more predictable, and does not require secondary surgical sites
Difference between free gingival graft and connective tissue graft?
- CT brings subepithelial graft from host site and has a variation called "tunneling technique"
- Free gingival graft: is an epithelial graft 1.5-2mm of thickness, will give 2 final shades and is unesthetic.
- ** CT graft needs enough keratinized gingiva, if not then FGG must be used.
Ultimate contraindication for grafts
- Smoking = guaranteed failure
- First 36 hours of grafts are most important for success of gingival grafts (thats when the graft gets its blood supply)
Indications for tunneling technique
- For multiple recession areas
- CT used but Allograft can also be used
What treatment is indicated?
- GTR: induces CT rather than long junctional epithelium
- -Complete root coverage can be achieved but minimum increase in gingiva amount- Not enough KT tissue for CT graft and area is too wide for FGG
- 1. Reflect flap and flatten root surface
- 2. Please membrane over root surface to allow blood clot between membrane and root surface
- 3. Suture flap coronally covering the roots and allow granulation tissue to form. Wait 6 weeks
- 4. Remove membrane. Suture. Fibrous CT has formed (not JE)
What is the procedure of choice in class I gingival recession?
- Connective tissue graft, with correct technique 100% success
- 2nd place is GTR 54%
- 3rd place Lateral positioned Pedicle graft 40%
- FGG is only 11%
- ** Treat class Vs like a periodontal patient with graft
COMMON DENOMINATORS OF NUG:TRIAD
- SEPSIS (DIRTY MOUTH)
Which microorganism is in 90% of patients with Aggressive periodontitis?
Aggregatbiacter actinomycetemcomitans (AA)***