[ppt]powerpoint presentation · web viewgingivectomy,gingivoplasty gingivectomy:excision of soft...
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Rational and objectivesNikhil Dubey BDS Intern,GDC Raipur
Non surgical periodontal therapy.
Surgical periodontal therapy.
*Why do we do periodontal surgery?
*To provide access and direct vision of the root surfaces for thorough debridement. Because in some situation non –surgical therapy is not enough to clean the environment.
Surgical periodontal therapy seeks to
Improve the prognosis of teeth.
Improve aesthetics.
Purpose of surgical pocket therapy
To eliminate the pathological changes in the pocket walls.
To create a stable, easy maintainable state.
May promote periodontal regeneration .
To gain surgical access to deep pockets for adequate cleaning and smoothening of the root surfaces.
To facilitate plaque control by reduction or elimination of potential plaque retention areas(correction of morphologic defects).
Objectives, cont. To provide an environment for an
adequate prosthesis.
For periodontal regenerative therapy.
To correct cosmetic abnormalities.
Indications for periodontal surgery
Areas with irregular bony contours or deep craters.
Pockets on teeth in which a complete removal of root irritants is not considered clinically possible. (molars).
In cases of grade II or III furcation involvement.
Infrabony pockets in distal areas of last molars.
Persistent inflammation in areas with moderate to deep pockets may require a surgical approach.
Contraindications Patients who do not exhibit good plaque
control. Uncontrolled or progressive systemic
disease (uncontrolled diabetics,leukemia ect.).
Patients taking large doses of corticosteriods may have reduced resistance to stress associated with surgery ..
Patients with imminent terminal disease who are debilitated are not candidates for surgery.
Results of pocket therapyConversion of an active pocket to
inactive pockets and heal by long junctional epithelium with or without gain of attachment.
Pocket elimination or reduction.Improved gingival attachment
promotes restoration of bone height, with reformation of periodontal ligament fibers and layers of cementum.
Surgical instruments
Classification of periodontal surgery
Introductory points:
Pocket is a pathological deepening of the sulcus.
Initially ------Pocket (8mm)Re-evaluation------Pocket(6mm)We need to gain access for thorough
cleaning.However, some time we add bone
and some time we resects bone.
Classification of periodontal surgery
Resective Procedures.
New attachment procedures.
Regeneration procedures.
Resective procedures
It is the procedure that means to eliminate or reduce the pocket, by excising or amputating the tissue constricting the pocket wall.
(in this case we remove bone).
New attachment procedures
It is the reunion of connective tissue by formation of new cementum with inserting collagen fibers on root surface that has been deprived of its periodontal ligament.
Regeneration proceduresAre surgical procedures aimed at
Reproduction or reconstruction of lost or injured periodontium.
Aim is to restore the periodontium to the normal physiologic levels. We have new bone and periodontal ligament formation
Resective procedures includes:
Gingivectomy, Gingivoplasty.Apically positioned flap without
osseous surgery.Apically positioned flap with osseous
surgery (Osteoplasty, Osteoctomy).Root resection.
Gingivectomy,GingivoplastyGingivectomy:Excision of soft tissue
wall of periodontal pocket.Basic rational is pocket elimination to
allow access for root instrumentation.
Gingivoplasty:To restore gingival contours.(not commonly used now days).
External bevel incision is done to remove excess gingiva and healing is by secondary intention.
Apically positioned flap without osseous surgery
The idea is to move the gingival margin Apically and not to excise the gingiva.
Indications:Deep supra and infra bony pockets.Crown lengthening procedures with
minimal attached gingiva.Increase the zone of attached
gingiva.
Contra-Indications (Apically positioned flap without osseous surgery)
Anatomical reasons:due to location of the pocket.(e.g.. Anterior oblique ridge in the mandible in the 3rd molar area.
Esthetic and cosmetic reasons: Anterior area with high lip line.
Severely compromised Alveolar bone support.
Apically positioned flap with osseous surgery
We remove bone to have normal architecture by doing Osteoplasty or Osteoctomy.
Indications:Pre-restorative periodontal
procedures(exposure of crown).Active pockets with mild or moderate
infrabony defects where the base of the pocket is apical to crest of the bone.
Contraindications(Apically positioned flap with osseous surgery)
Anatomical limitations,poor crown\root ratio.
Presence of excessive tooth mobility.
DefinitionsOsteoctomy:Removal of
some alveolar bone, thus changing the position of crestal bone on tooth surface.
OsteoplastyReshape the
bone by thinning it and not to reduce from its height therefore gingiva can adapt nicely.
Root Resection Therapy
In cases of multirooted teeth with infrabony deep pockets and root proximity.
In case of furcation grade III. The bone around the area will
be thin, therefore affected root can be removed.
Objectives of Resective procedures
Pocket elimination or reduction.A physiological gingival
contour,tightly adapted to alveolar bone and apical to pre surgical site.
A clinically maintainable condition.
Requirements for Resective procedures
Access proper root instrumentation. Access for underlying alveolar crest. Maintain adequate band of attached
gingiva. Heal in rapid fashion. Minimize the alveolar crest height. Maintain levels of clinical attachment on a
long term basis. Reduce probing on a long term basis.
New Attachment Procedures
Closed curettage.Excisional new attachment
procedure (ENAP).Open flap curettage.Modified widman flap
procedure.
Closed curettageNot commonThe idea is to to remove the
epithelium that lines the pocket wall.This will promote natural healing
process (reattachment).Scientific evidence to prove this is
week.
Excisional new attachment procedure (ENAP).
Done extensively in 1960-----1970---. Not common now days. Indicated in localized, mild to moderate
Periodontitis, especially interdentally in the anterior region.To eliminate suprabony pockets.
Advantage is minimum tissue loss. Disadvantage, is limited vision and it is
not applicable in case of deep or irregular pockets
Modified widman flap procedure
&Open flap curettageMost common done periodontal
surgery.Internal bevel incision.Reflect flap,clean the area.Position the flap back to its original
site, therefore have attachment between tissue and root surface.
Pocket is reduced.
Grafts, bone grafts, soft tissue grafts.
Guided tissue regeneration.Coronal positioned flap.Root surface demineralization
(citric acid chemicals).Interdental denudation.
GraftsNot predictable nor overwhelming.Auto grafts (from same person, two
step procedures,freeze and dry the bone.
Allografts (from same species).Alloplasts (from synthesized
materials),an implant from inert material.
Guided tissue regenerationTo guide the right type of cells
(periodontal ligament)to attach to root surface, and trying to exclude undesirable cells(epithelium) from attaching to root surface.
Root surface demineralization
Modify the root surface that the right type of cells will attach to it.
Factors influencing the success or failure of all regeneration techniques Plaque control. Systemic status that affect the
periodontium. Traumatic injury to teeth and tissue. Root preparation. Wound closure. Soft tissue approximation. Post operative and long term
maintenance.
Criteria for method selection
Characteristics of the pocket: depth,relation to bone,and configuration.
Accessibility to instrumentation, including presence of furcation involvements.
Existence of mucogingival problems. Response to initial therapy. Plaque control. General health. Diagnosis of the case and previous
periodontal treatment. Aesthetic consideration.
Post operative instruction Pain killer Keep pack in place. Avoid hot food. Use ice pack on the face. Do not brush the area. Use mouth rinse after one day. Do not smoke, follow normal activity,
however avoid excessive exertion. Come back to your next appointment.
Surgical versus non surgical treatment of periodontal disease is controversy.
Only moderate and sever pockets should be treated surgically.
Doing surgery in shallow pocket will result in attachment loss.
Gain in attachment will be more after surgery than non-surgery in deep pocket.
Thank you