Professional Documents
Culture Documents
Bartolucci
first volume
RIOD O
Text - .das
by
'co Bart
CONTENTS Volume I
Chapter 1
THE MECHANISM OF PERIODONTAL DESTRUCTION page 1
Bacterial colonization of the crevic e
Host defenc e
Gingivitis and Periodontiti s
Pocket formatio n
Gingival Recession formatio n
Bone resorptio n
Progression of periodontal diseas e
Chapter 2
DIAGNOSIS page 3 9
Classification of Periodontal diseas e
Clinical examinatio n
Periodontal probing
Tooth mobilit y
Clinical chartin g
Radiographic analysi s
Diagnosis
Chapter 3
TREATMENT PLANNING page 9 3
Initial treatment planning
Reexaminatio n
Definitive treatment plannin g
Non surgical treatment
Surgical treatment
Maintenance therap y
Chapter 4
ORAL HYGIENE REHABILITATION page 11 1
Plaque contro l
Interrelation between plaque, inflammation and tissue distructio n
Instruments and instrumentatio n
Supragingival scalin g
Subgingival scaling and root planing
Antiseptics in periodontal therap y
Antibiotics in periodontal therapy
Sharpening of the instrument s
Reevaluation
VI
Chapter 5
PRINCIPLES OF PERIODONTAL SURGERY page 17 1
Classification of surgical procedur e
Local anesthesi a
Incision s
Flaps elevatio n
Full and partial thickness flap s
Flaps positionin g
Suturing tchniques
Periodontal dressing s
Post-surgical care
Instruments sterilizatio n
Chapter 6
PERIODONTAL FLAP PROCEDURES page 24 3
Indications and controindication s
Access flap
Modified Widman flap
Apically positioned flap
Palatal flap
Distal wedg e
Smoking and surgical therapy
Chapter 7
RESECTIVE OSSEOUS SURGERY page 29 5
Osseous defects
Osteoplasty
Ostectomy
Surgical instruments
Surgical technique s
Clinical case
Chapter 8
RESECTIVE GINGIVAL SURGERY page 32 1
Gingival hyperplasi a
Gingivectomy
Surgical instruments
Surgical technique s
Clinical cases
VII
CONTENTS Volume I I
Chapter 9
SURGERY OF FURCATION-INVOLVED TEETH page 345
Anatomy
Diagnosis
Radiographs
Classificatio n
Treatment of degree I
Treatment of degree II
Treatment of degree II I
Chapter 1 0
MUCO -GINGIVAL SURGERY page 38 5
The function of keratinized and attached gingiv a
Gingival recessio n
Sullivan and Atkins Classificatio n
Miller Classificatio n
Surgical instrument s
Frenulectomy
Pedicle soft tissue grafts Coronally positioned Laterally positioned Bipapillar
Free soft tissue graft s
Connective tissue graft s
Chapter 1 1
GUIDED TISSUE REGENERATION page 46 9
Biology of GT R
Barrier material s
Indications
Patient selectio n
Surgical procedure
Treatment of Intrabony defect s
GTR in mucogingival surger y
Bone grafts and biomaterial s
Prognosis of GT R
Chapter 1 2
PREPROTESIC SURGERY page 535
Biologic width
Crown lenthenin g
Intraoperatory preparation of the abutment s
Preprotesic mucogingival surger y
Surgical removal of exostosi s
Tuber reductio n
Localized ridge augmentatio n
VIII
Chapter 1 3
JUVENILE PERIODONTITIS page 61 1
Localized Juvenile Periodontitis
Generalized Juvenile Periodontiti s
Batteriology
Immune responce
Treatment
Clinical case s
Chapter 1 4
PERIODONTITIS AND JUVENILE DIABETES page 63 1
Early onset diabetes (type I) and periodontiti s
Matur onset diabetes (type II) and periodontiti s
Initial treatment
Farmacological treatmen t
Surgical rational e
Surgical treatmen t
Clinical case
Chapter 1 5
DESQUAMATIVE CHRONIC GINGIVITIS page 653
Clinical symptom s
Diagnosis
Immunofluorescenc e
Pemphigoi d
Pemphigus vulgaris
Lichen Planu s
Hormonal Gingiviti s
Osler-Weber-Rendu Syndrom e
Therapy of desquamative chronic gingiviti s
IX
Chapter 1
The mechanis m
of periodonta l
destruction
THE MECHANISM OF PERIODONTAL DESTRUCTION
---------------------------
Epithelial
attachment
0 .97 mm
Biologic
width
2 .04 m i
Ideal gingival morphology and diagrammatic representation : pink colour, scalloped margin ,
"orange peel" appearance, papillae in the interdental spaces, adequate band of keratinized gingiva .
The gingival sulcus is shallow (0 .69 mm), the epithelial attachment is located on the enamel (0 .97 mm) ,
the connective attachment is inserted in the root cementum (1 .07 mm) .
The distance from the bottom of the sulcus to the osseous crest is known as the biological width (2 .04 mm).
3
CHAPTER 1
A small quantity of
pericrevicular bacteria l
plaque highlighted with
a colorant can be seen .
This consists of Gram +
cocci-type flora .
If removed daily, th e
plaque does not have
time to proliferate an d
reach the sulcus, modi-
fying its qualitative
characteristics .
4
!
Plaque
Aerobic Supragingiva l
Anaerobic Subgingival - adherent
Anaerobic ! Subgingival - not adheren t
Supragingival plaqu e
PERIODONTAL DISEASE
IMMUNE RESPONS E
BACTERI A Positive Response
!Intact tissue s
! Quantity of plaqu e !Exudation
! Quality of plaqu e !Phagocytosis
! Plaque retainin g ! Immune respons e
factor
! Bacterial product s Deficient Respons e
!PMN defect s
! Hypersensitivity reactions
! Systemic disease s
The presence of specific bacteria in the sulcus is a vital element in determining inflammatory peri -
odontal diseases (Loe - Theilade - Socransky - Listgarten - Newman) . On the other hand, the presence o f
microorganisms is not in itself sufficient to cause the destruction of tooth support tissue. The bacterial
flora, in fact, triggers off a complex immune response in the host organism and it is this response which
leads to the destruction of periodontal tissues (Taichman - Page - Schroeder - Toto - Levine -Genco) .
Healthy condition .
6
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Subgingival plaqu e
Disease condition .
CHAPTER 1
IMMUNE RESPONSE
Crevicular leukocyte s
~--- Crevicular fluid
8
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Epithelial cells .
Ground substance.
Plaque Enzyme s
9
CHAPTER 1
Polymorphonuclear leukocytes in th e
non-migratory phase .
10
!
11
CHAPTER 1
GINGIVITIS
Supragingival plaque
Gram+ filamentous rod-shaped microbe s
X PMN s
J . Y.CIIO
Marginal gingivitis
Note the plaque in the pericrevicular zone and the red and edematous gingival margin .
definition according to
PAGE and SCHROEDER 1976 HISTOPATHOLOG Y
Increase in infiltrat e
Early gingiviti s Early lesion (appearance of a number
of plasma cells)
Stable lesio n Considerable increas e
Stable gingivitis (without bone loss or apica l in infiltrat e
migration of the epithelium ) (10-30% plasma cells)
Stable lesio n Considerable increas e
Periodontitis (with bone loss and apica l in infiltrat e
migration of the epithelium) (> 50% plasma cells)
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Marginal gingivitis in two recessions caused by traumatic toothbrushing after the patien t
had stopped brushing in that zone .
CHAPTER 1
PERIODONTITIS
. Viscosu s
H 30-40'% AA . Naeslundi
Grain- rod-shaped microbes
II Spirochete s
X PMN s
Plasma cells
J . Y.CIIO
14
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Chronic periodontitis
15
CHAPTER 1
7F
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
l7
!
CHAPTER 1
CELLULAR INFILTRATE
Lymphocyte s
These are white series cells deriving from lymph nodes (B lympho-
cytes) and the thymus (T lymphocytes) and play an extremely important rol e
in the defence mechanism .
One particular form of lymphocyte is the helper lymphocyte whose role is t o
assist lymphocyte reproduction .
Other types of lymphocyte include : killer lymphocytes responsible for elimi -
nating extraneous cells (cancer cells, for example) and suppressor lympho-
cytes which suppress the immune reaction when no longer required .
Lymphocytes produce a wide variety of substances such as interferon, a
growth factor, interleukines and lymphokines .
MACROPHAGE
n
Thymus
Bone a marro w
Lymph nodes —..B lymphocytes
Memory *Killer cell s Spleen
cell s -0-B and T lymphocyte s
Thymus --!T lymphocytes
T-suppressors
T-helpers ONk
n /
IgA -v Secretor y
Ig D
- ~ Ig G
Ig M
Bursa equivalents I IgE.-Mast cells
PLASMA CELL
18
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
B Lymphocyte
Homologous receptor s
T lymphocyte
19
CHAPTER 1
Macrophages
These monocyte-derived cells have varied and extremely important func-
tions, acting as phagocytes, B lymphocyte activators and T lymphocyte mitogen s
(lymphokine production) .
The phagocytic function is important in the initial stages of the disease (gingivi-
tis) as the macrophages phagocyte the hydrolytic enzymes produced by th e
PMNs, reducing cell damage . They also phagocyte the altered cells of the con-
nective tissue .
Macrophages are also important in the advanced phase of the disease (peri -
odontitis) when they interact with the B lymphocytes, thus maintaining the lat-
ter in a strategic position to identify and neutralise large quantities of antigens .
However, they are above all important for the interaction with the lymphocyte T-
helper that stimulates secretion of interleukin-1 (IL1) : this helps production o f
interleukin-2 (IL2) which stimulates the T-helpers and T-killers to reproduce, trig -
gering the lymphokine cascade .
Macrophages
20
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Connective fibre
during digestion .
CHAPTER 1
Lymphocyte activatio n
Lymphocytes may be activated by an antigen-antibody reaction wit h
the presence or otherwise of the complement. Alternatively, with the coopera -
tion of a T-helper, they may enter the transformation and blastogenesis phase .
During this phase, the lymphocytes produce lymphokines, non-immunoglobu -
linic substances with numerous extremely important activation and inhibitio n
functions .
Antigens
r!
Blast cell
T lymphocyte
activatio n
Lymphokin e
B lymphocyt e
activatio n
Lymphokine
22
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Macrophage-Lymphocyte interactio n
In the most advanced phases of the disease (stable gingivitis - peri -
odontitis), the macrophages and lymphocytes interact, strengthening thei r
respective defensive functions and giving rise to the lymphokine cascad e
which greatly amplifies the immune response .
Periodontitis
The macrophages
maintain the antigens
in an accessible posi -
tio n
B lymphocytes
A number of lympho -
cytes can be observed
approaching a non -
migratory
macvophage.
23
CHAPTER 1
Lymphokine cascad e
1) A macrophage phagocytes a microorganism
2-3) The M-T-helper complex secretes IL-1 (interleukin-1) . This activates T-
helpers to produce IL-2 (interleukin-2) which stimulates the reproduc -
tion of T-helpers and T-killers .
4-5) T-helpers produce B-cell growth factor which stimulates the cells t o
reproduce and produce antibodies .
6) T-helpers produce gamma-interferon
* activates killer T-cell s
* stimulates B-cell s
* stimulates the M-T complex
Microorganism
acrophage phagocyte s
microorganism
25
CHAPTER 1
BONE REABSORPTION
A) Osteoclastic activatio n
The T-lymphocytes produce OAF lymphokine (Osteoclastic Activating Factor) ,
responsible for activating the osteoclasts which reabsorb the minerals from the bone an d
return them to the blood circulation .
9ti
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Alternative
pathway
• Bacterial plaque
• Bacterial endotoxi n
• Proteolytic enzyme s
Liberation of C3A-05 A
Bone reabsorption has led to exposure of the coronal third of the roo t
surface.
• Edema
• Chemotaxis
• Cell damage
PGE2
27
CHAPTER 1
Plasma cells
Plasma cells are large white series cells deriving from the bone mar -
row and numerous in chronic periodontal lesions (accounting for more tha n
50% of the inflammatory infiltrate) .
The plasma cells produce immunoglobulin specific antibodies (IgA) whic h
enter the sulcus together with the crevicular fluid through fenestrations in th e
sulcular epithelium .
Chronic adul t
periodontitis .
Presence of
periodontal pocket .
28
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Plasma cell
Antibodies
CHAPTER 1
Mast cells
In the most severe forms of periodontitis where inflammation is pre -
dominant, together with spontaneous bleeding, local pain and rapid progres-
sion of lesions, cells with particular functions appear : mast cells .
These cells are numerically proportional to the severity of the periodontal dis -
ease.
Mast cells are activated via a sensitization mechanism, reacting with a n
immunoglobulin (IgE) . Subsequently they fix an antigen and degranulatio n
thus commences with production of histamine, heparin and serotonin . These
substances are responsible for local capillary vasodilatation causing hyper-
emia and localized pain .
Severe form of
periodontitis.
Mast cell.
Qn
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Vasodilatatio n
T Permeability
Degranulation of th e
mast cells .
A) Sensitization B) Antigen C) Degranulatio n
fixation
Histamin e
Heparin
Serotonin
Mast cell .
z
0
0
x
W
cn
FORMATION OF
PLAQUE IN THE
SULCUS
Production
of enzymes
Destruction
of ground
substance
Passage of
plaqu e
products int o
the gingiv a
Onset o f
inflammation
'
I
Spreading of
inflammation to
deep tissue s
through the Destructio n
vascular system of gingival
collagen
Proliferation
of junctional
epithelium Formatio n
of granulation
tissue
THE MECHANISM OF PERIODONTAL DESTRUCTION
Immune response
Possible immune mechanism activated by the presence of bacteria l
plaque in the sulcus .
BACTERIAL PLAQUE
COMPLEMENT
PMN CHEMIOTAXI S
MACROPHAGE ACTIVATIO N
PROSTAGLANDINS
B-T LYMPHOCYTE S
DESTRUCTION OF FIBROBLAST S
Macrophage
CELLS INVOLVED IN TH E
IMMUNE RESPONS E
PMNs
LYMPHOCYTE S
MACROPHAGE S
33
!
CHAPTER 1
Progression of
the periodonta l
lesion
Motility
In this site, the attachment system has been lost and Subgingival bacterial plaque triggers destruc-
bone tissue has been reabsorbed . tion of the attachment system and bone tissue .
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
Periodontal diseases
Gingiviti s
Periodontiti s
35
CHAPTER 1
P. Gingivalis • • •• • • • • •
P. Intermedi a
B. Forsythus • • •• • • • • •
Fusobacterium spp
Peptostreptococcus spp
Campylobacter rectus • • • • •
Spirochetes •• •• • • • • • • ••
CONCLUSION S
To eradicate periodontal infection, the microorganisms causin g
it must be controlled.
An alternative would be to amplify the immune response aime d
at combating them . However, at present this latter possibilit y
does not seem feasible .
Treatment thus has two main objectives :
1) Control of the periodontopatic microbial flora .
2) Surgical reconstruction of an anatomy which facilitate s
maintenance of periodontal health .
37
Chapter 2
Disease diagnosis
DISEASE DIAGNOSI S
Chronic gingiviti s
Allergic gingivitis
Gingival Eruptive gingiviti s
Herpetic gingivitis
Ulcerous-necrotic gingiviti s
INFLAMMATORY
CONDITIONS
Prepuberal periodontitis
Juvenile periodontitis
Early onset periodontitis
Periodontal
Chronic adult periodontiti s
Refractory periodontitis
Gingival recession due to plaqu e
Puberal gingiviti s
Pregnancy gingiviti s
Vitamin C deficit gingiviti s
Gingival Desquamative gingiviti s
Leukemia-associated gingivitis
NON-INFLAMMATORY Drug-related hyperplasia
CONDITIONS Hereditary hyperplasi a
41
CHAPTER 2
Medical history
Have you ever had : YES N O Are you taking or have you YES N O What kind of toothbrus h YE S N O
iene treatment ?
dd any other° information you think might be importan t
Example of questionnaire to be submitted to the patient for correct compilation of medical history .
!
DISEASE DIAGNOSI S
Clinical examinatio n
The aim of the clinical examination is to identify signs of possible disease .
The signs to look for include : colour, shape, consistency and height of the gin-
giva and other oral structures such as the lips, mucosa, tongue, oropharynx ,
floor of the mouth, hard palate and soft palate .
It is important to examine both the general aspect of these structures and als o
any possible localized alteration .
The gingiva are assessed on the basis of the following parameters :
PARAMETER S
Colour
Contours
Marginal Festoonea Altered festonatio n
Edematous - Fibrous
Fibroedematous
43
CHAPTER 2
-Wit!
DISEASE DIAGNOSIS
45
CHAPTER 2
DISEASE DIAGNOSIS
it+
Fibrom a
This fibroma affecting the mucosa of the cheek i s :
:1\2
of irritatative-masticatory origin . nI~ORi~0~6ipiiV i tZ N' •~j,4
.1
ry,ryAgll»•
uJes,
,f v
41 ' i
. 1. ~ Se' ' •rA "
tey
.
i *ear
.•j. . . ; f .j•~\ ti
47
CHAPTER 2
Drug-induced hyperplasi a
In these two cases, gingival hyperplasia has been
induced by the assumption of drugs to treat a
systemic disease.
The top image shows an accumulation of bacteri-
al plaque, aggravating the hyperplasia .
In the absence of periodontitis, the pocke t
explored by probing is a pseudopocket (caused by
coronal growth of the gingiva and not attachmen t
loss).
Vitamin C deficiency
Ascorbic acid (vitamin C) deficiency cause s
scurvy, a systemic disease characterized b y
accentuated weakness, anaemia, capillary dis -
ease and a tendency for both the skin an d
mucosa (gingiva) to bleed, with the appearanc e
of petechiae on the limbs .
49
CHAPTER 2
Instrumental examinatio n
A ) Periodontal probing
The periodontal probe enables the presence and severity of a peri-
odontal lesion to be verified simply and immediately .
A periodontal probe can be used to reveal :
Periodontal prob e
University of Michigan .
The periodontal probe is inserted into the gingival sulcus (the virtua l
space existing between the gingiva and the tooth enamel) .
The penetration depth depends on various factors : the shape and diameter o f
the probe, the insertion force, tissue resistance, the convexity of the crow n
and the insertion direction .
Histologic research by Schroeder and Listgarten (1971) demonstrated that
periodontal probing may not correspond to the actual depth of the sulcus o r
periodontal pocket .
Later, Listgarten (1976) demonstrated that, after crossing the epithelial attach -
ment, the point of a probe consistently penetrates at least 0 .3 mm further int o
the more coronal part of a healthy connective attachment . On the basis o f
these studies, it has been established that the sulcus or histologic pocket doe s
not coincide with the clinical pocket .
The histologic depth of a pocket is determined by the distance between th e
gingival margin and the bottom of the pocket (corresponding to the corona l
margin of the junctional epithelium) .
The clinical depth (or probing depth) of a pocket corresponds to the penetra-
tion depth of the probe into the pocket .
POCKET
> 3 mm.
51
CHAPTER 2
Long junctiona l
epitheliu m
Note the proliferation of
the junctional epitheli-
um as far as the roo t
cementum .
Bleeding on probing
In 1979, Van der Velden introduced the concept of "bleeding on probing "
in diagnosing between a healthy and a
diseased condition .
53
CHAPTER 2
Probing technique
The dental probe should be held as though it were a pen . Keeping it
parallel to the long axis of the tooth, it should be delicately inserted betwee n
the free gingival margin and the tooth .
Three readings are taken for each tooth : distal, intermediate and mesial .
Particularly in the case of molars with a convex clinical corona, for the mesia l
and distal readings, the instrument should be held at an angle of about 25 °
(Ziegler - Allen 1980) .
Probe angle
In the mesial and distal interproximal spaces, the probe should be held at an angle of 25° .
DISEASE DIAGNOSIS
Incorrec t
The presence of subgingival calculus may stop the probe and lead to a faulty reading of pocket depth .
55
CHAPTER 2
Probing sites
For each tooth, three vestibular and three palatal or lingual readings
should be taken : distal (1), intermediate (2) and mesial (3) .
Deep periodontal pocket (>7 mm .) in the vestibular surface of the central incisor . Note the accompa-
nying gingival recession and presence of subgingival calculus .
!
!"!!
!
DISEASE DIAGNOSI S
The probings (in millimetres) for each tooth should include vestibular
and lingual readings, starting from the maxillary arch and proceeding in suc-
cession from no . 18 to no . 28 . The examination then continues with th e
mandibular arch, starting with vestibular probing in succession from no . 38 to
no . 48, followed by lingual probing first of the mandibular arch from no . 48 to
no . 38 and then the maxillary arch from no . 28 to no . 18 .
Maxillary arc h
: ,
2
1 air r r r r ~r s aj g
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MI MI MU
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WI/ W = =
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t8 V 28
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-
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MIll
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ow
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57
CHAPTER 2
B) Measurements
Measuring the keratinized gingiv a
The periodontal probe is indispensable for measuring the quantity o f
keratinized and attached gingiva .
To assess the keratinized gingiva, the mucogingival junction must first be iden -
tified. The periodontal probe is then used vertically to measure the distanc e
between the free gingival margin and the mucogingival junction .
A periodontal prob e
(CP11) is used to iden-
tify the mucogingival
junction. The height of
the keratinized gingiv a
from the free gingival
margin to the mucogin-
gival junction is then
measured .
DISEASE DIAGNOSI S
A periodontal prob e
(CP11) is used to mea-
sure the height of th e
keratinized gingiva
and depth of the sulcus .
The latter is subtracted
from the former to cal-
culate the quantity of
attached gingiva .
59
CHAPTER 2
Bacterial plaqu e
derived recession .
61
CHAPTER 2
Classification
A: Horizontal loss of bone tissue for less than half the furcation .
B: Horizontal loss of bone tissue for more than half the furcation .
Nabers 2N probe .
C)
DISEASE DIAGNOSI S
Degree I
63
CHAPTER 2
Degree II
Type A
Type B
Type C
Degree III
65
CHAPTER 2
C) Tooth mobility
Tooth mobility is caused by absorption of alveolar bone as a result o f
bacterial plaque or occlusion damage .
Tooth mobility is an early symptom of occlusion damage and a late sympto m
of periodontitis.
It is assessed using the ends of two instruments .
Classificatio n
Degree 0 Absent
DISEASE DIAGNOSIS
Tooth mobility
Occlusion traum a
Ingravescent:
Presence of disease in progress Bone reabsorption caused by excessive occlusal
(Occlusion trauma) •
(Inflammatory) • accompanied by attachment loss .
(Glossary of Periodontic terms . American
Stabilized : Academy of Periodontology, 1986 )
Poor bone support .
Orthodontic trauma
Mono-directional forces exerted on individual teeth produce pres-
sure and tension fields within the periodontal space . As a result, the tooth
becomes progressively more mobile and starts migrating in the direction of th e
force .
When the tooth leaves the influence of the trauma, the periodontium is reor-
ganized and the tooth becomes stable in its new position.
67
CHAPTER 2
Jiggling trauma
The combined effect of pressure and tension forces in the periodon-
tal tissues causes thrombosis, hemorrhage, collagen destruction and reab-
sorption of bone and cementum . This leads to progressive enlargement of the
periodontal space and subsequent hypermobility of the tooth .
Subsequently, the larger periodontal space neutralizes the trauma and there -
fore blocks bone reabsorption .
Various experiments carried out first on animals then on humans have demon-
strated that neither mono-directional orthodontic forces nor jiggling force s
cause pockets or periodontal attachment loss in a healthy periodontium .
However, if the trauma is accompanied by bacterial plaque-derived periodon-
tal disease, the disease progresses more rapidly . From a clinical point of view ,
the fundamental moment in treating inflammatory periodontal diseas e
involves elimination of the bacterial plaque as this will halt periodontal tissu e
destruction, even in the presence of trauma from occlusion .
Occlusio n
trauma-derived
bone lesio n
0
DISEASE DIAGNOSI S
CLINICAL CAS E
69
!"!
CHAPTER 2
Maxillary arc h
3
2
1
Vestibular
• f t t • • • • I 1 / I I
13 12 11 21
1g 14
R f8 17 1'6• ® 23 24 25 26_ , 37- 2S
Lingual
1
2
3
Mandibular arch
3
2
1
Vestibular
Lingua l
1
2
3
##"!!!!
""
DISEASE DIAGNOSI S
Maxillary arc h
T
3
2
1 9B~ ~F6;L55?4S Sy'555'S"6l y 6545i~{4C1 i44 ~b ;Si
. - A i A
1101510twoo-ifraloia::.i .vOlOIE
yrwateavx
Vestibular
~ . ~r ~ live-war ~
wiry -
11 22 .
900 ® 23
R ®.m 9s
A A
.
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.- . s a*
.tqt!g
Mandibular arc h
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71
CHAPTER 2
X-ray analysis
If well performed, a set of intraoral and periapical X-ray images pro -
vide valuable information on the condition of the patient's bone tissue .
1. Height of alveolar bone .
2. Characteristics of the bone trabeculae .
3. Localized areas of bone destruction.
4. Bone loss from the furcations .
5. Extent of the periodontal space .
6. Crown - root relationship .
Note the difference between the photographic details in the X-ray and in the orthopantomography .
DISEASE DIAGNOSIS
Note the difference between the photographic details in the X-ray and in the orthopantomography .
73
CHAPTER 2
75
CHAPTER 2
X-ray techniqu e
D Ml M 10 1I Y I
••tVw H
1 1 1
ad o
77
CHAPTER 2
Maxillary arc h
Four films vertically Position between :
DF-56 no .1 1 - 2 right and left
(from the front) 3 - 4 right and left
Mandibular arch
Four X-ray films vertically Position between :
DF-56 no .1 1 - 2 right and left
(from the front) 3 - 4 right and left
An intraoral status may consist of 21 X-ray films if four bite-wing films and 1 film for the interin-
cisor sector between the upper sectors are included (11-21) .
~o
DISEASE DIAGNOSIS
uaituttlitti'mai
Film Dentaire
Zahnfil m
Pelicula Denta l
Correct Incorrec t
The X-rays must hit the films at right angles to avoid superimposition of
the points of contact with the teeth and obtain correct images of the bon e
tissue.
79
CHAPTER 2
Front secto r
For the incisor sector, if five X-ray images are to be taken, the bite must be positioned between th e
central incisors . Alternatively, if four X-ray images are required, the bite must be placed between th e
central and lateral incisor, first on the right, then on the left . The series of X-rays is completed b y
positioning the bite between the canine and lateral incisor ; once again, first on the right, then on the le,
,zn
!
DISEASE DIAGNOSI S
Lateral secto r
Normal Diseased
The crestal and radicular laminae dura are The crestal laminae dura of the premolars are
intact. The trabeculae are in the norm . decalcified . Calculus can be observed on the roo t
surfaces.
81
CHAPTER 2
Rear sector
A cotton roll is
inserted under th e
bite to guarante e
patient comfort and
the stability of the
positioner :
Normal Diseased
The crestal and radicular laminae dura ar e Note the deep distal bone reabsorption corre-
intact. The trabeculae are in the norm . sponding to the first molar and the intraosseou s
pocket identified by probing .
#
DISEASE DIAGNOSIS
Front sector
G
I ,iI ..-_J
rrrt . _rte
In the incisor sector ; the positioner bite should be inserted between the central incisors, then betwee n
the canine and lateral incisor, first on the right, then on the left .
Norma l
No bone lesions are
identified.
Diseased
Bone reabsorption ca n
be noted for more than
50% of the length of the
roots . The crestal lami-
na dura has disap -
peared . An accumula-
tion of calculus can b e
observed on the roo t
surfaces.
8
CHAPTER 2
Lateral sector
In the premolar sector, the positioner bite should be inserte d O
between the two premolars, first on the right, then on the left .
84
!
DISEASE DIAGNOSI S
Normal Disease d
Calcification of the crestal laminae dura is Bone reabso'iption prevents identification of the
normal. crestal laminae dura. A large quantity of
calculus can be observed on the root su ifaces.
Normal Diseased
Calcification of the crestal laminae dura is Considerable bone reabsorption can be observe d
normal. corresponding to the molars with possibl e
damage to the furcations (degree 2) .
85
CHAPTER 2
Lamina dur a
This X-ray image was produced by directing Roentgen rays to the sec -
tor where they were partly blocked by calcification of the cortical plate .
In the presence of inflammation, the calcification disappears and the greate r
quantity of X-rays crossing the cortical plate prevents the lamina dura fro m
being detected.
RA
DISEASE DIAGNOSI S
Bone defect
By lifting a mucope -
riosteal flap and remov -
ing the granulation tis -
sue, the bone defec t
shown in the top X-ray
image can be observed
to have three walls .
87
CHAPTER 2
DISEASE DIAGNOSIS
Periodontal diseases
Bleeding on probin g
Angular bone reabsorptio n
Pocket
Complicated and 2nd or 3rd degree
Possible tooth mobility
furcation involuement
Furcation involvement
Gingivitis
Shis term is used to describe localized or generalized inflammation o f
the gingiva . The clinical system of this disease is "bleeding on probing" .
Gingivitis is diagnosed in the absence of a periodontal pocket and when X-ra y
examination does not indicate bone reabsorption. Pseudopockets may b e
present .
Margina l
gingivitis .
QQ
DISEASE DIAGNOSI S
Slight periodontitis
Probing depth, attachment level and X-ray analysis indicate a unifor m
loss (horizontal reabsorption) of bone tissue not exceeding a third of th e
length of the root (coronal third) .
Inflammation is present .
Probing to the bottom of the pocket causes bleeding.
Chronic adul t
periodontitis (slight) .
Severe periodontitis
(Advanced periodontitis)
Probing depth, attachment level and X-ray analysis indicate a unifor m
loss (horizontal reabsorption) of bone tissue exceeding a third of the lengt h
of the root.
Probing to the bottom of the pocket causes bleeding .
Chronic adult
periodontitis (severe) .
89
CHAPTER 2
Complicated periodontitis
This diagnosis is reached when angular (vertical) bone reabsorption is
present, accompanied by 2nd to 3rd degree furcation involvement .
Complicated periodonti-
tis in an adult suffering
from diabetes mellitus
with tooth mobility, dam-
age to all bifurcations and
trifurcations and angular
bone defects .
DISEASE DIAGNOSI S
Severe gingival inflammation and the accumulation of bacterial plaque can be observed .
CONCLUSION S
Periodontal disease is diagnosed by means of a thorough assessment of th e
patient based on clinical, instrumental and radiographic data . Only a correc t
diagnosis can enable a suitable treatment plan to be drawn up .
91
TREATMENT PLANNIN G
95
CHAPTER 3
TREATMENT PLANNING
Patient cooperatio n
4
DEFINITIVE
o Peri-implant surgery
TREATMENT
0 Construction of definitive
prosthese s
PERIODI C
FOLLOW-UP
APPOINTMENTS
Supportive therapy
TREATMENT PLANNIN G
Initial treatmen t
The aim of initial treatment is to eliminate, or at least control, bacteri-
al plaque. It involves implementation of the following phases :
1) Oral hygiene instruction .
The patient is instructed in
correct home use of oral
hygiene instruments an d
attempts are made to motivate
him or her towards positive
compliance .
Before scaling .
2) Scaling and root planing .
These manual or mechanical
operations enable bacterial
plaque to be completel y
removed from the crown and
root surfaces of the tooth.
97
CHAPTER 3
Reevaluatio n
A reasonable period of time (possibly several months) after the end of
initial treatment, the patient undergoes a thorough examination to check th e
state of gingival inflammation (which should have disappeared), periodonta l
pocket depth and residual tooth mobility. The level of patient cooperatio n
must also be verified . The examination covers every tooth and the result s
determine the choice of definitive treatment .
Before initia l
treatment .
At reevaluation .
nQ
TREATMENT PLANNIN G
Raising a mucoperiosteal flap, bone reabsorption of the interdental septum can be observed .
99
CHAPTER 3
Definitive treatmen t
If the patient cooperates, surgical treatment can commence .
1 nn
TREATMENT PLANNING
101
CHAPTER 3
PRE-PROSTHETIC SURGERY
to modify the length of the clinical crown, the shape and length of tooth abutments and the shape o f
bone and soft tissues, enabling a functional and aesthetically satisfactory prosthesis to be constructed .
1r)
TREATMENT PLANNIN G
MUCOGINGIVAL SURGERY
to reconstruct the gingiva, improve appearance and reduce root sensitivity .
103
CHAPTER 3
Surgical treatmen t
of periodontitis
Mucogingival surgery
Improves aesthetic s
Free grafts Clinical variability
Reconstructs gingival defects
Pedicle graft s Results linked to surgical techniqu e
Reduces root, sensitivity
Pedicle grafts + GT R
Significant increase i n
GT R attachment level s
Non-reabsorbable membran e The best results are obtained with Results linked to surgical techniqu e
Reabsorbable membrane Class II mandibular furcations an d
intraosseous defects
Autologous bone
Increase in bone level
If the patient is not cooperative or does not wish to or cannot undergo surgery,
non-surgical treatment can be administered, followed by the maintenance phas e
with a cycle of periodic follow-up appointments .
!!
TREATMENT PLANNIN G
Chemical treatment
of bacterial plaqu e
No long term benefits
Mouth washes Gingivitis
in periodontitis
Gel
Irrigation
Allergy
Topical antibiotics
Periodontitis Recessions
Tetracycline impregnated fibres
Candid a
Systemic antibiotic s
Tetracyclin e
Metronidazol e Aggressive destructive Gingiviti s
Amoxicilli n
Clavulanic aci d periodontitis Adult periodontitis
Clindamycin
Spiramycin
105
!
CHAPTER 3
CLINICAL CASE
Male patient aged 48 fitted with two cardiac by-passes. The periodon-
tal examination led to a diagnosis of chronic periodontitis . The clinical file
reproduced below indicates tooth mobility, pocket depth and furcatio n
involvement.
Maxillary arc h
. IIMII'IHI V INV
R
Lingual
1! i! i! I I! ! 2
3
Mandibular arc h
TREATMENT PLANNIN G
TREATMENT PLAN
1 gross-scaling sessio n
HYGIENIC PHASE 4 scaling and root planing session s
8 78
ex
8 8
6 6
end o
76 7
temp . prosth .
76 . 4 5 . 7
REEVALUATION
1
SURGERY
APF+B .S.
APF APF+B.S .+GTR
+hemisections
4 6
def . prosth .
76 . 4 5 . 7
MAINTENANCE
10 7
CHAPTER 3
Maintenance
At the end of treatment, the patient is included in a programme of peri -
odic follow-up appointments formulated to prevent possible relapse . The
appointment schedule is established in relation to the patient's ability to main-
tain a high standard of oral hygiene . Longitudinal studies have shown that a
maintenance programme with appointments every three months is optimu m
for preventing relapse in the majority of cases .
During each session, oral hygiene is assessed and scaling is performed for the
entire mouth, usually associated with polishing. If necessary, the patient is re-
motivated to maintain positive compliance .
At least once a year, bone level should be assessed via X-ray analysis .
Compliance
The patient's behavioural
response in relation to his/he r
health and the means at his/he r
disposal to maintain it .
ono
TREATMENT PLANNING
Follow-up programm e
CONCLUSION S
A treatment plan is a sequence of therapeutic measures aimed at healing o r
halting periodontal disease.
It is vital that the phases are applied according to this algorithm . Each play s
a vital role in determining the success of the treatment.
It is important to emphasise that it is impossible to prevent bacterial colo -
nization and thus avoid relapse of the disease without effective maintenance .
109
#
Chapter 4
Oral Hygien e
Rehabilitation
'ow
• ':
111
ORAL HYGIENE REHABILITATIO N
Toothpaste
Antiseptics (chlorhexidroe)
Rotary instruments
113
CHAPTER 4
Toothbrush
None of the toothbrushes currently available on the market is better than th e
others. The best brush is probably the one used with the most effective tech-
nique .
The advantages of electric toothbrushes over normal toothbrushes are con -
fined to patients with reduced manual ability. Sonic toothbrushes (Sonicare 0)
supplement the electrical movement with cavitating vibration and a water je t
to facilitate removal of plaque and stains from the supragingival surface of the
teeth.
Conventional toothbrush.
ORAL HYGIENE REHABILITATIO N
Electric toothbrush .
Does not remove bacterial plaque more efficiently tha n
conventional toothbrushes.
Brushing methods
Numerous brushing methods have been described, but none ha s
proved more efficient than the others .
The Bass Method effectively removes bacterial plaque from the supragingival
and subgingival pericrevicular zone . The head of the toothbrush is placed on th e
gingival margin at an angle of 45° with respect to the axis of the tooth and move d
from the front towards the back, in association with short pulses of vibration .
In the Charter Method, the bristles of the toothbrush are placed at an angle o f
45° in the interdental spaces and moved backwards and forwards with a rotat -
ing movement . This method is particularly effective in removing bacteria l
plaque in the presence of open interdental spaces caused by papillary recession .
Other techniques include:
• Roller
• Circular
• Vertica l
• Horizontal
115
CHAPTER 4
Toothbrushing techniqu e
Step 1
The toothbrush is positioned at 45° to the axis of the tooth and the bristle s
are pushed into the gingival sulcus .
Step 2
The toothbrush is moved in a mesial-distal or circulatory-vibratory directio n
to remove bacterial plaque from the pericrevicular or inter-proximal areas .
ORAL HYGIENE REHABILITATIO N
Step 3
The same movements are repeated for th e
other sectors of the mouth following an
established sequence (about 10 second s
for each sextant) .
Step 4
In the front palatal and lingual sectors, th e
toothbrush must be held perpendicularly
to the arch .
Step 5
To conclude, first the lower and
then the upper occlusal surface s
are brushed .
117
CHAPTER 4
Plaque can be observed in the pericrevicular zone . Invisible to the naked eye ,
it is highlighted by the dye .
I1Q
ORAL HYGIENE REHABILITATIO N
MARGINAL GINGIVITI S
.
T.TT
Note the modest quantity of bacterial plaque in the pericrevicular region, highlighted b y
single colour dye .
119
CHAPTER 4
Complianc e
The patient's behavioural response in relation to his healt h
and the means at his disposal to maintain it .
By placing a small quantity of bacterial plaque taken from the patient's mouth on a slide and using a
phase contrast microscope, the composition and amoebic movements of the mobile life-forms in th e
plaque can be displayed on a television screen . This method is effective in active patient motivation .
121
CHAPTER 4
Dental floss
Dental floss effectively removes bacterial plaque from between the
teeth and under the papillae and is an indispensable part of the daily ora l
hygiene programme .
Various types are available : single thread, multi-thread, ribbon and super floss ;
waxed or unwaxed and in various flavours .
w
ORAL HYGIENE REHABILITATIO N
Step 1
A length of dental floss approximately 30 cm lon g
is taken and rolled around one finger of eac h
hand, leaving about 20 cm free .
Step 2
For the maxilla, the index finger and thumb are used .
For the mandible, the two index fingers are used .
Step 3
The floss is passed delicately acros s
the contact point with a backwards an d
forwards movement .
123
CHAPTER 4
Step 4
The floss is curved into
a "C" around the tooth
and moved delicately in
an apical direction .
Then with a single rapid
movement, it is move d
in an occlusal direction ,
scraping the plaque .
ORAL HYGIENE REHABILITATIO N
Step 5
Using clean sections of the floss, the operation is repeated for the othe r
interproximal surfaces .
BLEEDIN G
If the floss is used correctly without damaging the epithelial attachment, any papillary bleeding ca n
be attributed to the presence of plaque or subgingival calculus .
125
CHAPTER 4
Proxa- brush
Patients with papillary recession or with a prosthesis may effectivel y
replace the dental floss with an interdental toothbrush (proxa-brush) to com-
pletely remove interdental plaque .
Two shapes of proxa-brush exist, conical and cylindrical, the latter being avail -
able in various sizes .
CONICAL PROXA-BRUSH
After periodontal surgery, the
space between the premolar an d
molar is wider as a result of pap-
illary recession . Use of a conica l
proxa-brush is therefore recom-
mended .
CYLINDRICAL PROXA-BRUS H
127
CHAPTER 4
Toothpaste
129
CHAPTER 4
Scaling: involves the use of instruments to remove plaque and calculus fro m
the supragingival and subgingival surfaces of the teeth .
Root planing : involves the use of instruments to remove softened cementu m
from the root surfaces .
Scaling and root planing are usually carried out without incision an d
therefore without a direct view of the deposits on the roots . The manual o r
mechanical instruments used for these operations must have very fine point s
and an extremely sharp cutting edge .
In the case of single root teeth, irritative stimuli can be completely remove d
and the roots planed . However, this is not possible with multi-root teeth an d
scaling and root planing must therefore be completed with the tooth and roo t
exposed during periodontal surgery .
Calculus: hard, widely distributed calcareous deposit adhering tenaciously t o
the surface of the teeth, formed by calcification of bacterial plaque by certai n
groups of Gram+ bacteria .
From a topographical point of view, it is divided into supragingival calculu s
and subgingival calculus .
Instruments
The instruments used for scaling and root planing include :
Manual instruments (scalers - curettes )
Mechanical instruments (sonic, hyposonic )
Rotary instruments (burrs )
Alternating movement instrument s
MANUAL INSTRUMENT S
Manual instruments are made up of three parts : blade, shaft and handle .
SCALER
Triangular section instrument with two cutting edges, a back and a point . Its
particular shape makes it strong and rigid enough to remove thick calculu s
deposits. Scalers may be straight or curved .
Use: supragingival scaling, shallow pockets .
1Q
ORAL HYGIENE REHABILITATIO N
CURETT E
The ideal curette should have a very small blade enabling it to be inserted easil y
into the pocket . It should also be shaped in such a way that it can be used in al l
sectors of the mouth.
133
CHAPTER 4
Pen grip
1Qh
ORAL HYGIENE REHABILITATION
135
CHAPTER 4
Titan-S
Rotary instrument s
The use of diamond burrs mounted on rotary instruments to remov e
residues of calculus and softened root cementum is confined to devitalize d
teeth transformed into prosthetic abutments . This operation is carried ou t
exclusively with the tooth exposed during pre-prosthetic surgery .
137
CHAPTER 4
Iatrogenic filling .
The interproximal exces s
contour must be remove d
(EVA TIPS no. 20-21) fo r
optimum hygiene i n
these areas .
139
CHAPTER 4
Supragingival scaling
Definition : removal of all accretions (plaque, calculus, stains) fro m
the supragingival surface of the teeth .
Supragingival scaling can be carried out using manual instruments (curettes ,
scalers) and/or mechanical instruments (sonic, hyposonic) .
TECHNIQUE
Manual instruments : the blade is rested on the tooth and adequate pressur e
is applied . The instrument is then moved in a coronal direction with a move-
ment repeated across the entire supragingival surface of the tooth until all vis-
ible accretions have been removed .
Magnifying glasses (x 2-3) can be used to facilitate this operation .
Supragingival scaler
DEPPELER M23.
Note the blade of the instrument resting on the surface of the tooth t o
perform supragingival scaling .
14Q
ORAL HYGIENE REHABILITATIO N
Supragingival scaling .
Mechanical instruments : the point of the instrument (sonic, hyposonic) is held flat on the surface of th e
tooth with a very light pressure and moved backwards and forwards . To break very thick calculus con-
cretions, the point of the instrument may be positioned perpendicularly to the surface of the tooth . If this
is not successful, rather than persist, manual scalers should be used .
The Titan- S 12 sonic instrument is also highly effective in tooth surface planing, using its rhomboid-sectio n
point flat and performing brush-type movements .
141
CHAPTER 4
Pre-hygienic phas e
Post-hygienic phas e
Pre-hygienic phas e
143
CHAPTER 4
Subgingival scaling and root planing are presented together as they are both performe d
at the same time .
Subgingival work must be carefully targeted and performed under local anaesthetic
following identification of pocket depths and the presence of subgingival deposits .
Subgingival scaling
Definition: removal of all accretions (plaque, calculus) from the sub -
gingival surface of the teeth .
Subgingival scaling may be performed using manual instruments (curettes )
and/or mechanical instruments (sonic/hyposonic) .
Subgingival curette
Deppeler M23 A Tl.
ORAL HYGIENE REHABILITATIO N
Root planing
Definition : involves the use of instruments to remove the final
residues of calculus, the softened and infiltrated cementum and smooth th e
root surface .
Root planing is normally carried out using manual instruments (curettes) . Th e
same result can also be obtained using certain hyposonic mechanical instru-
ments (Titan-S®) with a particular shaped point .
Titan-S ® .
145
CHAPTER 4
Subgingival scaling
and root planing
technique
Step 1
The pocket is probe d
and the solid concretio n
is identified .
Step 2
The curette is reste d
on the tooth with th e
rounded back toward s
the gingiva.
Step 3
The curette is
pushed under the
gingiva, delicatel y
moving the gingiva l
tissue .
If calculus i s
encountered on the
root, the curette is
moved away fro m
the tooth, shiftin g
the soft tissues until
the obstacle i s
passed .
1hf
ORAL HYGIENE REHABILITATIO N
Step 6
When the sensation is of scrapin g
a hard, smooth surface, roo t
planing is complete .
Step 5
The apical-coronal movement o f
the curette is repeated a numbe r
of times to remove the softene d
surface of the root cementum.
Step 4
When the depth of th e
pocket has bee n
reached, the blade of th e
curette is engaged in th e
root cementum an d
moved with an apical-
coronal movement .
This operation remove s
the calculus and part o f
the root cementum .
147
CHAPTER 4
Polishing
Polishing completes scaling, leaving the supragingival surfaces of th e
teeth smooth and clean . It also removes any pigmentation left by smoke, food
and drugs (chlorhexidine) .
Polishing is carried out using a rubber cup mounted on a rotary instrument o r
alternatively using air and water jet instruments with abrasive paste .
RUBBER CUPS
The rubber cups, used in association with variable grain size abrasive
pastes (fine, medium, coarse), can be pushed under the gingiva using a ligh t
pressure and moved in a coronal-apical direction . The friction of the cup pro-
duces heat and it is therefore advisable to polish two teeth at the same time .
Both the vestibular and lingual and/or palatal aspects are polished .
To polish under the gingival margin, the cup is positioned on the tooth, a light pressure is applied and th e
micro-motor is activated . By sloping the cup apically and then moving it in a coronal-apical direction, i t
can be inserted under the gingival margin . The cup should be held in that position for no longer than tw o
or three seconds .
149
CHAPTER 4
WATER-JET INSTRUMENT S
Air and water jet instruments (air flow) are highly effective in remov-
ing pigmentation from the tooth surface . They are normally used with highl y
abrasive powders containing pumice grains . In the presence of gingival reces -
sion, use of less abrasive powders containing sodium bicarbonate is prefer-
able.
The jet of the instrument must never be directed into the sulcus and should no t
hit the gingival margin.
1 g-n
Abrasive powder crystals .
151
CHAPTER 4
11Q
ORAL HYGIENE REHABILITATIO N
The following substances are also used during OHR in support of mechanica l
treatment .
153
CHAPTER 4
Systemic Local
Mechanical Chemical
antibiotic antibioti c
treatment treatment
treatment treatmen t
Adul t
periodontiti s
- Advanced
- Progressive
Amoxycil .+Clay. Ac .
Yes Yes Clindamycin Ye s
Ciprofloxaci n
Metronidazole
Yes Metronidazole+Amoxycil . Ye s
Amoxycil.+Clay. Ac .
C
ORAL HYGIENE REHABILITATIO N
Tetracycline concentration in
the crevicular fluid (CF) afte r
application of the fibres .
Note that the concentration is
still high 240 hours after th e
start of treatment.
155
CHAPTER 4
Insertion technique
Step 1
After scaling and root planing ,
the pocket is thoroughly probed .
Step 2
Using tweezers, a fibre (23 cm long, 0 .5 m m
diameter) is inserted in the pocket .
Step 3
A small spatula or curette is used to push th e
fibre in such a way that they fold over each other ,
completely filling the periodontal pocket . An y
excess fibres must be trimmed .
ORAL HYGIENE REHABILITATIO N
Step 4
After inserting the last segment of fibre under th e
gingiva, several drops of cyanoacrylate based sealan t
are applied to keep it in place .
Step 5
After about 10 days, the fibre is removed and th e
patient may resume normal oral hygiene mea -
sures at this site .
157
CHAPTER 4
X-ray examination: note the presence of crestal and radicular laminae dura .
The bone tissue is normal .
ORAL HYGIENE REHABILITATION
As the patient complained of pain when toothbrushing, she was treated with a mouth was h
containing 0.2% chlorhexidine for a week . The image shows the case immediately before scaling
and after application of a bacterial plaque detector .
159
CHAPTER 4
AFTER A MONTH : the clinical signs of inflammation and papillary edema have disappeared .
The patient demonstrates a high degree of positive compliance and scrupulously follows the
home hygiene programme .
AFTER TWO MONTHS : the patient will now be included in a maintenance programm e
with regular follow-up appointments every three months .
ORAL HYGIENE REHABILITATIO N
The case after a yea' : As a result of existing heart problems, the patient
did not undergo periodontal surgery . At the end of OHR, only a fe w
periodontal pockets remained . A maintenance programme followed,
adhered to by the patient with scrupulous cooperation .
161
CHAPTER 4
The image shows the case a year after completion of OHR. The patien t
refused surgical treatment and was included in a maintenance phase
with follow-up appointments every three months .
ORAL HYGIENE REHABILITATIO N
The case at the end of OHR. The patient is cooperative and has agreed t o
surgical treatment .
163
CHAPTER 4
Sharpening
Instruments must be sharp in order to perform scaling and root plan-
ing efficiently. Blunt instruments increase operation time, tire the operator ,
smooth the calculus rather than remove it completely from the root surfac e
and cannot be used to plane the root .
The instruments on the previous pages (Deppeler M23-M23A TI) are extreme -
ly easy to sharpen as they have two lateral faces which can be sharpened b y
resting them flat on an Arkansas stone . A bottle of sharpening oil (Sharpe n
EZ® -Hu Friedy) and a ceramic rod are also necessary to finish the curved cut -
ting sections.
Sharpening techniqu e
Sharpening oi l
(Sharpen EZ 1z -Hu Friedy)
ORAL HYGIENE REHABILITATIO N
Step 1
The stone is lubricated with a drop of oil and the excess is remove d
with gauze.
Step 2/A
Supragingival curette (M23-TI) : one of the two sides of the instrumen t
to be sharpened is rested flat on the lubricated stone . Exerting slight pressure ,
it is moved backwards and forwards until the edge is sharp . Repeat for the
other side .
': 165
CHAPTER 4
Step 2/B
Subgingival curette (M23A-TI) : sharpen using the same technique a s
described for the supragingival curette . This curette has a rounded point
which must be respected during sharpening .
Step 3
The internal part of these instruments is curved and must therefore b e
finished with a cylindrical ceramic rod or Arkansas stone .
Protected back
ORAL HYGIENE REHABILITATIO N
Sharpening
Instruments must be sharpened each time they are used and before
sterilization. If necessary, they may also be sharpened during scaling and root
planing sessions.
(Bartolucci-Parkes)
167
CHAPTER 4
Reevaluatio n
At the end of OHR, the patient must be reevaluated according to th e
following parameters :
Resolution of gingival inflammation .
Reduction of probing depth .
Reduction of tooth mobility.
Evaluation of the patient's ability to maintain oral hygiene .
On reevaluation, th e
clinical signs of
inflammation are
absent .
On reevaluation,
probing does no t
cause bleeding .
ORAL HYGIENE REHABILITATIO N
Patient cooperation
L
NO YES
CONCLUSION S
Inflammatory gingivitis and periodontitis are extremely widespread disease s
which can be prevented by mechanically controlling supragingival bacteria l
plaque.
Treatment of these diseases is largely mechanical. Use of antiseptics an d
antibiotics is necessary only in a small number of cases .
Surgical treatment may follow initial treatment to improve it or to correc t
alterations induced by the disease .
169
Chapter 5
Principles of Periodonta l
Surgery
171
!
Periodontal Surger y
Gingivectomy
Free Graft s
Resective Surgery
173
CHAPTER 5
SURGICAL TREATMENT
PATIENT SELECTIO N
FACTOR S
I CONTROLLABL I
E I
YES NO
SURGICA L MAINTENANCE
TREATMEN T
The patient has concluded the hygienic phase of periodontal treatment and is ready for the surgical phc
PRINCIPLES OF PERIODONTAL SURGER Y
The undersigne d
confirms that the following have been clearly explained :
Date
175
CHAPTER 5
Operating room fo r
periodontal procedures.
Cardiac monitoring
system for at-risk
patients.
------------ -
c
Standard set of
instruments
for periodonta l
flap surgery.
The specifi c
instruments
for individual
operations will
be described in
the relativ e
chapter.
PRINCIPLES OF PERIODONTAL SURGER Y
177
CHAPTER 5
LOCAL ANAESTHESIA
Instruments
Cook-Waite syringe
Aspirating syringe fo l
intraoral anaesthesia .
PRINCIPLES OF PERIODONTAL SURGER Y
Disposable needles of
various lengths an d
diameters .
Carpule of anaesthetic .
To reduce local bleedin g
to a minimum, th e on ADRENALIN A
anaesthetic is combine d FORTE 1 :100 .00 0
with epinephrin e
(1 :100,000 or 1 :50,000) .
179
CHAPTER 5
Anterior superior
alveolar nerve
Posterior superio r
alveolar nerve
To administer anaesthesi a
in the maxillary
Palatine nerve arch, the patient must
be in a prone positio n
with the head in
hyperextension .
PRINCIPLES OF PERIODONTAL SURGER Y
Mandibular arch
Lingual nerv e
To administer anaesthesi a
in the mandibula r
arch, the patien t
must be in a semi-prone
position with the hea d
upright.
181
CHAPTER 5
Anaesthesia blocking
the inferior alveola r
nerve.
Buccal nerve
Inferior alveolar nerve
Lingual nerv e
1 R2
PRINCIPLES OF PERIODONTAL SURGERY
Anaesthesia blocking
the lingual nerve .
Anaesthesia blocking
the buccal nerve.
183
CHAPTER 5
Infiltration anaesthesi a
of the incisive nerve .
1Q1
!
Variations in anastomosis
between the incisor and mylohyoid nerve s
End-to-end anastomosis of the right and left inci- The right and left incisive nerves do not anasto-
sive nerves. mose.
CHAPTER 5
Anaesthesia blockin g
the posterior superio r
alveolar nerve .
Anaesthesia o f
the suborbital forame n
Permeation of the anaes-
thesia through the bone
makes blocking of th e
suborbital forame n
superfluous. It is there-
fore sufficient to inject
1/2 ml of anaestheti c
solution into the zon e
below the foramen at a
distance of a few cen-
timetres. The regional
anaesthesia is complete d
by injecting anaestheti c
solution into the zone of
the central incisors t o
the right and left of th e
median line. For opera-
tions in the sector
between the right an d
left canines, the regional
block must be complete d
by also injecting anaes-
thetic solution on the
palatine side near the
exit point of the
nasopalatine nerve .
Infiltration
anaesthesia of
the incisor sector.
187
CHAPTER 5
Anaesthesia blocking
the palatine nerve.
PRINCIPLES OF PERIODONTAL SURGER Y
189
CHAPTER 5
SURGICAL INCISIONS
/on
PRINCIPLES OF PERIODONTAL SURGER Y
Indication s
This incision is used in the presence of periodontal pockets to eliln inate th e
epithelium inside the pocket and to provide access to the deep planes .
A = intrasulcular incision
B = crestal incisio n
C = marginal incision
191
CHAPTER 5
Marginal incisio n
This is the most commonly employed incision in periodontal surgery.
It is performed at a distance of 1-2 mm apical to the free gingival margin an d
follows the contour of the gingival festoon, cutting around the interdenta l
papillae which are preserved.
Inc)
PRINCIPLES OF PERIODONTAL SURGER Y
Intrasulcular incisio n
This incision is performed within the crevicular sulcus, usually in th e
anterior-superior sector, when there is little keratinized gingiva or for aesthet-
ic reasons.
The intrasulcular
incision is performe d
by inserting the blade
into the sulcus .
In the presence of
periodontal pockets
limited to the
interdental spaces ,
incision of th e
papillae eliminate s
the epithelium
inside the pocket .
1,93
CHAPTER 5
Scalloped incisio n
The scalloped incision, performed in either the vestibular or palata l
and lingual sectors, is employed in order to preserve the interdental papillae ,
following the contour of the gingival festoon and also obtaining healing by firs t
intention in the interproximal area . This incision is performed in associatio n
with the internal bevel incision .
Interrupted palatal
scalloped incision.
Continuous palatal
scalloped incision .
Near a furcation an d
in the presence of a
retracted flap, th e
scalloped incision
follows the anatom y
of the mesial an d
distal root of th e
tooth.
195
CHAPTER 5
Linear incision
The linear incision is performed in particular situations and location s
only. In the anterior-inferior lingual sector, the linear incision is preferable to
the festooned incision . It would, in fact, be difficult to trace around the papil -
lae given the limited diameter of the interdental space in this zone . The inci-
sion may also be performed in edentulous and retromolar spaces.
The incision is
performed with a
scalpel (B.P no . 1 5
blade) positione d
parallel to the axi s
of the tooth at a
distance of about 2
mm from the free
gingival margin.
PRINCIPLES OF PERIODONTAL SURGER Y
Linear incision of a n
edentulous area .
197
CHAPTER 5
Releasing incisio n
A releasing incision facilitates access to the deep planes and enable s
the size of the periodontal flap to be limited . This incision may be performe d
mesially or distally to the primary incision . In the case of limited sectors (one
or two teeth), both may be performed .
1QQ
PRINCIPLES OF PERIODONTAL SURGER Y
IF 4
the presence of grade 2 (type A )
compromised furcation,
a full thickness flap is lifte d
after performing an intrasulcula r
incision and a realising
incision .
199
CHAPTER 5
Interproximal incisio n
This incision is performed with an interproximal scalpel (Orban' s
scalpel no . 1-2 ; Buck's scalpel no. 5-6) and continues into the interproxima l
spaces to separate the col from the bone tissue . The triangular Buck's scalpe l
is used in the narrowest interdental spaces (front sector) . The oval Orban' s
scalpel is used in the widest interdental spaces (rear sector) .
FLAPS
Pedicle flap
Deli n i tion: section of gingival tissue separated from the surroundin g
tissues except for at the base .
Free graft
Definition: section of gingival tissue completely separated from the
surrounding tissues .
201
CHAPTER 5
Dissected flap
Definition : section of gingival tissue raised after incision using a
scalpel. The dissected flap raised is partial thickness, leaving the periosteu m
and a certain quantity of connective tissue on the bone surface .
Elevated flap
Definition: section of gingival tissue raised after incision using a
periosteal elevator. The elevated flap is full thickness, leaving the bone surfac e
exposed .
203
CHAPTER 5
Pritchard's periosteal In the case illustrated, osteoplasty and ostectomy were performed t o
elevator remodel the bone . The extremity of the Pritchard's periosteal elevator i s
used to keep the flap raised and protected during bone surgery .
205
CAPITOLO 5
The thin end of the instrument is used as a periosteal elevator to elevate full thickness flaps .
9n~
PRINCIPLES OF PERIODONTAL SURGER Y
Non-slip function.
207
CHAPTER 5
Secondary flap
Definition: residual tissue around dental elements after the primary
flap has been elevated .
Perpendicular (1 )
and intrasulcular (2)
incisions.
Titan°: hyposonic The granulation tissue of intraosseous defects is easily and rapidl y
instrument. removed with mechanical vibration instruments .
209
CHAPTER 5
Bone reshaping
If the bone tissue is deformed due to increased volume (exostosis) o r
local reabsorption (intraosseous defects), before closing the periodontal flap
the bone must be reshaped to allow optimum positioning of the flap and thu s
functional recovery . For a description of these surgical techniques, see the
respective chapters .
APICALLY
POSITIONE D
FLAP
LATERALLY LATERALLY
POSITIONE D POSITIONE D
FLAP FLAP
CORONALLY
POSITIONE D
FLAP
211
CHAPTER 5
APICAL
REPOSITION ]
BIPAPILLARY
FLAPS
CORONAL
PRINCIPLES OF PERIODONTAL SURGERY
OSITIONED FLAP
'LAP
LATERALLY
POSITIONED FLAP S
'OSITIONED FLAP
!
CHAPTER 5
SUTURES
Materials
Various types of material and suture needles are used in general
surgery, only some of which are used in periodontal surgery .
TEAR LEFT
4-0 (2 .0 metric) / 7771
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Types of suture
Various types of suture are used in periodontal surgery .
Circular
Figure-of-eigh t
Interrupted Mattress (ver°tical - horizontal)
Sling
Continuous Spiral
Blocked
Compression
21 5
CHAPTER 5
Instruments
In periodontal flap surgery, 15 cm long Crile-Wood forceps are com-
monly used . Accessibility with this needle holder is excellent, even in the pos-
terior-lateral and retromolar sectors of the mouth, and large FS2 type needle s
can be handled easily. For pedicle or free flaps, a needle holder with a differ-
ent grip is preferable, the Castrovejo forceps . This more delicate instrument
enables small V5, P2, DA1 needles to be handled more easily. Two version s
exist, straight point or curved point . The latter is preferable for mucogingival
surgery.
15 cm Crile-Woo d
needle forceps .
t Reg. 199@9
ago P- 2
I
P2 needle with
non-chromic catgut.
217
CHAPTER 5
SUTURE TECHNIQUE S
Surgeon's kno t
This knot can be performed using either Castrovejo or Crile-Wood needle forceps .
Step 1
The needle forceps (Crile-Wood) ar e
held with the thumb and middle figure
of the operating hand .
Step 2
The needle is passed through the tissues .
The needle end of the suture thread is held
with the non-operating hand . The suture is
pulled through the gingiva leaving about 2
cm of thread free at the end . The suture i s
rolled twice clockwise around the needl e
forceps .
Step 3
The free end of the suture i s
gripped with the needle forceps .
PRINCIPLES OF PERIODONTAL SURGER Y
Step 4
The free end of the suture is pulled
with the needle forceps .
Step 5
The thread is rolled around the needl e
forceps again in an anticlockwis e
direction (opposite direction to step 2) .
The end of the thread is gripped with
the needle forceps .
Step 6
The free end of the thread is pulled ,
keeping the needle forceps stationary ,
until the second part of the surgeon' s
knot is tight.
219
CHAPTER 5
Sep 3
221
CHAPTER 5
Step 1
222
PRINCIPLES OF PERIODONTAL SURGERY
223
CHAPTER 5
Mattress suture
This type of suture is indicated when optimum adaptation of the flap s
to the deep planes is required . The stitches are anchored to the periosteum and
leave a minimal amount of thread within the flap .
There are two variations :
Vertical mattress suture
Horizontal mattress suture
Vertical mattress
suture is often used t o
adapt the papilla i n
the interdental space .
9 911
PRINCIPLES OF PERIODONTAL SURGER Y
Horizontal mattress
suture is used in th e
vestibular and palata l
sectors to obtain a
high degree of fla p
adaptation to the deep
planes .
225
titi<
CHAPTER 5
Step 1
The first papilla is caught with the sutur e
needle. In this phase, Corn's forceps are
extremely useful, enabling the flap to b e
supported while it is perforated in the
precise position identified . The thread
entry hole may be in the epithelial part
(see drawing) or the connective part
(see photograph) .
Step 2
The thread is passed lingually (or palatally )
around the tooth and catches the second papilla.
PRINCIPLES OF PERIODONTAL SURGER Y
Step 3
The thread is passed around the tooth agai n
and into the interproximal space, to retur n
vestibularly.
Step 4
Once the flap is positioned, the suture thread s
are held and the two ends are knotted with a
surgeon's knot .
Note the two ends of the suture The sling (simple suspended) suture has bee n
(Dacron - Ethibond®) held under tensio n knotted . Note the knot positioned on the mesia l
to position the flap at the cemento-enamel papilla of the flap. Three sutures in 5-0 simpl e
junction. catgut have been performed in the mesial an d
distal edges of the flap .
227
CHAPTER 5
Step 1
The first papilla of the flap is caught
with the suture needle and a surgeon's
knot is performed.
Step 2
The thread is passed around the tooth as fa r
as the following interdental space, exitin g
with the thread vestibularly. The secon d
papilla is caught with the needle, followe d
by the third, the fourth, etc .
Step 3
Once the surgical quadrant has bee n
completed, a surgeon's knot is performe d
as shown in the drawing.
c)6) o
PRINCIPLES OF PERIODONTAL SURGER Y
Step 4
The flap is fixed in the required positio n
with the continuous suture . If the lingual
(or palatal) flap is also to be sutured ,
the procedure is repeated as for the
vestibular flap .
Continuous suspend -
ed suture in 4- 0
black silk.
Continuous suspended
suture in 4-0 simple
catgut .
229
CHAPTER 5
Step 1
The suture begins at one end of th e
incision with a circular stitch ,
performing a surgeon's knot.
Step 2
It continues by passing the needl e
and thread about 3 mm away fro m
the first stitch . The needle re-emerge s
in a direction perpendicular to th e
surgical wound.
9 9n
PRINCIPLES OF PERIODONTAL SURGERY
Step 3
The thread is now passed at 45° to th e
surgical wound obtaining a continuou s
spiral suture .
Step 4
The process is continued, keeping a
constant distance between the stitche s
and the thread under tension .
Step 5
At the end of the incision, a surgica l
knot is performed to block the end with
one end of the suture thread and a sli p
knot with the last loop which is no t
tightened .
231
CHAPTER 5
Step 1-2-3
The first two steps are identical to the
continuous spiral suture . The needle i s
then passed under the thread to block i t
before performing another stitch about 3
mm away from the first .
Step 4- 5
The suture is continued, keeping th e
end under tension . When the end of th e
incision is reached, a surgeon's knot is
performed with the end of the thread
and a slip knot with the last loop whic h
is not tightened .
PRINCIPLES OF PERIODONTAL SURGER Y
Compression suture
This type of suture is used in association with free flaps for optimu m
adaptation to the underlying bed . The objectives are to reduce the layer of fib-
rin between the free grafts and the receiving bed, prevent the formation o f
hematoma and facilitate take of the graft . Compression sutures also anchor th e
edge of the graft without perforating it, thus avoiding possible necrosis in th e
perforation site .
There are two variations :
Vertical compression suture
Horizontal compression sutur e
Vertical compressio n
suture .
Horizontal compression
suture .
233
CHAPTER 5
Materials
The most commonly used periodontal pack and the easiest to prepar e
is the soft type (Coe-Pack ®) . This consists of a basic paste containing zin c
oxide, a fungicide and an accelerant containing carboxylic acids and a bacte-
riostatic agent .
Pack technique
Two parts of material of an equal length are placed on a mixing shee t
and are mixed rapidly and thoroughly with a spatula for at least a minute t o
obtain a rubbery paste. The pack is then immersed in a glass of warm water fo r
2-3 minutes . If cold, the water accelerates hardening of the pack .
PRINCIPLES OF PERIODONTAL SURGERY
Application techniqu e
With moist gloved hands, a small cylinder of pack is prepared an d
applied directly to the surgical wound, after having dried the region concerne d
with air and a surgical aspirator . Exerting a certain pressure, the pack i s
spread apically and coronally on the surface of the teeth and, using a mois t
instrument, is inserted in the interdental spaces . The pack is applied both
vestibularly and palatally or lingually .
23 5
CHAPTER 5
POST-OPERATIVE MEASURE S
Clinical case on the tenth day with the suture stitches stil l
in place. Once removed, the patient must spread the oper-
ated area with a chlorhexidine based gel (0.2%) twice a
day for a week .
PRINCIPLES OF PERIODONTAL SURGER Y
Clinical case with repositioned flap one month after the operation .
237
CHAPTER 5
STERILIZATION
SURVIVAL INCUBATIO N
Monitoring
It is absolutely vital to monitor correct sterilization . This is achieved by
verifying destruction of bacterial spores, the most resistant of the viruses o r
the bacteria themselves, exposed to the same conditions . Their destruction is
proof of successful sterilization .
0 0
1 Z 3 4 s 10 15 s 10 7s 20
Minute s Minute s
- - • — B. Stearothermophilus — • - - - B. Stearothermophilus
B. Sottilis B. Sottilis
Bacterial spores.
239
CHAPTER 5
Sterilization
cycle
Sterile instruments
before surgery
"
L
1 L.' -
es
Monitoring with spor
241
Chapter 6
Periodontal Flap
Surgery
PERIODONTAL FLAP SURGER Y
Indication s
To completely eliminate bacterial plaque and subgingival calculus .
To eliminate periodontal pocket .
Contraindications
Psychological reasons.
General medical reasons .
TYPE OF GINGIVA
EDEMATOUS FIBROU S
NECESSITY
FOR ACCESS
TO THE BONE Not necessary Necessary
245
!
CHAPTER 6
L. SURGICAL RATIONALE
Pocke t
Loss of connective attachment with bone reabsorption .
MATERIALS FO R
PERIODONTAL SURGER Y
J
PERIODONTAL FLAP SURGER Y
Surgical instruments
Instruments employed in periodontal flap surgery include :
247
CHAPTER 6
A) Access flap
Described for the first time by Kirkland in 1931, this flap is easy to per -
form . The aim is to obtain full access to root surfaces in order to complet e
mechanical treatment and perform any chemical treatment necessary.
Indications:
Indicated in chronic adult periodontitis to complete root planing and reduc e
pocket depth .
mwmmfwtmmwwmr-
Surgical techniqu e
A saturated solution is
prepared by dissolving
citric acid in hot water
until precipitation
forms on the bottom of
the bottle. The pH is
measured (it must b e
highly acid, pH 1) .
The citric acid is use d
to sterilize the surfac e
layer of root cementu m
penetrated by bacteria l
plaque.
249
CHAPTER 6
The tetracycline paste is applied for about three minutes to the root surfac e
of the teeth.
PERIODONTAL FLAP SURGER Y
f
To remove the tetracycline paste, the site of the operation is irrigated wit h
sterile physiological solution.
Post-operative imag e
(after six months) .
251
!!
CHAPTER 6
Definition :
Scalloped, internal bevel, mucoperiosteal flap reflected just enough to allo w
access to the root and bone surfaces .
Objectives:
Performance of a minimally invasive operatio n
Reduction of post-operative symptoms.
Improvement of post-operative aesthetics .
Indications :
Moderate periodontitis (4-6 mm pockets)
Front sectors of the mouth.
Contraindications :
None.
Surgical techniqu e
Step 1 : Incisions
After administering local anaesthesia with an anaesthetic containin g
epinephrine (1:100,000), the incisions are performed using a Bard-Parker blad e
(no . 15).
FIRST INCISIO N
The first incision is made about 1 mm from the margin of the fre e
gingiva, holding the blade parallel to the longitudinal axis of the tooth .
253
CHAPTER 6
SECOND INCISIO N
The flap is elevated minimally and an incision is made in the botto m
of the gingival sulcus as far as the osseous alveolar crest, holding the blad e
parallel to the longitudinal axis of the tooth .
PERIODONTAL FLAP SURGERY
THIRD INCISIO N
This incision is performed holding the blade perpendicularly to th e
longitudinal axis of the tooth .
Once the secondary flap has been eliminated, the col is removed using a 1/2
Orban interproximal scalpel .
CHAPTER 6
Step 4: Suture
Circular suture . At the end of the surgical operation, the palatal and vestibular flaps ar e
repositioned and sutured in the pre-operative site . The suture is performe d
with silk thread or simple catgut .
257
CHAPTER 6
INTRACREVICULAR INCISION
Where aesthetics are a priority, the first incision is performed directl y
in the crevicular sulcus as far as the osseous crest .
Post-operative image
(after one month) .
The final aesthetic result
is clearly better after an
intracrevicular incisio n
than after a margina l
incision.
PERIODONTAL FLAP SURGERY
BONE RESHAPING
Ramfjord did not describe resective bone surgery in the Widman mod-
ified flap .
However, in some cases, ostectomy and osteoplasty may be used to improv e
adaptation of the flaps and obtain better interproximal closure .
259
CHAPTER 6
CLINICAL CASE 1
Male patient aged 42 with moderately severe periodontitis . At the end
of the hygienic phase, 4-5 mm pockets are still present, largely in the inter -
proximal sectors .
It was decided to use the modified Widman flap technique with intracrevicula r
incision to reduce crown lengthening to a minimum .
Pre-hygienic phase :
presence of periodonta l
pockets with an averag e
depth of 4-5 mm.
Post-hygienic phase :
the case at the end of the hygienic phase and immediately before the surgical phase .
Incision :
note the first incision pel for med i n the crevicular sulcus .
A, n
PERIODONTAL FLAP SURGERY
Suture :
the vestibular and palatal flaps are repositioned in their pre-operative site and sutured with 4-0 blac k
silk and an FS2 needle using interrupted circular stitches .
261
CHAPTER 6
CLINICAL CASE 2
Male patient aged 50 with moderately severe periodontitis (4-5 mm) .
However, in the upper canine zone, there are pockets compatible wit h
advanced periodontitis (6-7 mm) . It was therefore decided to use the modifie d
Widman flap technique to preserve aesthetics as far as possible following th e
specific request of the patient .
Incision :
the first incision is performed a millimetre from the gingival margin ,
holding the scalpel almost parallel to the longitudinal axis of the tooth .
A continuous internal bevel scalloped incision is performed .
263
CHAPTER 6
When the flap has been elevated, it can be seen that the vestibular sectors of the incisors are free fro m
bone reabsorption . However, in the vestibular sectors of the canines, there are small bone defects .
Thorough curettage of these defects is performed, but without bone reshaping .
Post-operative phase :
the case six months after the operation .
F /,
PERIODONTAL FLAP SURGERY
Suture :
the vestibular and palatal flaps are repositioned in thei r
pre-operative site and sutured with 4-0 black silk and a n
FS2 needle using interrupted circular stitches .
265
CHAPTER 6
Definition :
Mucoperiosteal flap, elevated beyond the mucogingival line an d
apically positioned.
Objectives :
To obtain full access to the deep planes .
To eradicate periodontal pockets .
Indications :
Periodontitis with deep pockets (>6 mm).
Clinical crown lengthening.
Resective bone surgery .
Pre-prosthetic bone surgery.
Contraindications :
Aesthetic - after the operation, there is always clinical crow n
lengthening .
PERIODONTAL FLAP SURGERY
Pre-operative phase
Before the operation, the gingival margin is positioned at the cemento-enamel junction .
Post-operative phase
After the operation, the gingival margin of the flap is positioned apically to cover th e
osseous crest .
267
CHAPTER 6
Surgical technique
Pre-hygienic phas e
Post-hygienic phas e
Step 1
Incision
An internal bevel scalloped incision
is performed at the gingival margin .
It is then deepened as far as th e
osseous crest .
PERIODONTAL FLAP SURGERY
Step 2
Elevating the flap
Once the secondary flap and col
have been removed, a mucope-
riosteal flap is elevated beyond th e
mucogingival junction to expose
the osseous crest and any bon e
defects present . If necessary, resec-
tive bone surgery is performed .
Step 3
Suture
The vestibular and lingual flap s
are positioned apically and
sutured to cover the osseous crest
with 4-0 black silk sutures and a n
FS2 needle .
Step 4
Stabilization
In the event of massive bone
reabsorption with reversal of th e
crown/root ratio causing perma -
nent tooth mobility, stabilizatio n
may be indicated .
269
CHAPTER 6
CLINICAL CASE 1
Female patient aged 46 with advanced chronic periodontitis . Periodontal pockets, an average of 6-7 m m
deep, are present . At the end of the hygienic phase, a surgical operation is performed to eradicate th e
pockets.
Pre-osseou s
Suture :
the flaps are sutured a t
the osseous crest using a
simple catgut suture .
Post-surgical phase:
PERIODONTAL FLAP SURGERY
Bone reabsorption is predominantly horizontal and evenly distributed . Conservative resective bon e
surgery is therefore performed to avoid impairing the stability of the teeth which already have a reverse d
crown/root ratio .
Post-osseous
Suture :
the flaps are sutured at the
osseous crest using simpl e
catgut suture.
CLINICAL CASE 2
Incisio n
Flap elevatio n
Bone surgery
Suture:
the flaps are positioned apicall y
and sutured at the crest with
Dacron sutures using interrupte d
circular stitches . Post-operativ e
image on removal of the suture s
(12 days) .
Post-operative phase :
the case a month after th e
operation .
273
CHAPTER 6
CLINICAL CASE 3
Male patient aged 32 with root caries near the cemento-enamel junction of the right mandibular canin e
and premolars.
Reconstruction of these lesions would be difficult and would be either too near the gingival margin o r
below it.
The surgical treatment plan includes an apically positioned flap elevated vestibularly only.
On healing, the therapeutic programme provides for aesthetic reconstruction of the caries .
PRE-OPERATIVE IMAGE
An intracrevicular incision i s
made as far as the osseous
crest . Using a Pritchard
periosteal elevator, a full
thickness flap is raised
beyond the mucogingiva l
junction.
9'7h
PERIODONTAL FLAP SURGERY
BONE SURGERY
POST-OPERATIVE IMAG E
The case three months after the operation. Note the perfectly
healed gingival tissue positioned apically to the caries .
The case is ready for cosmetic reconstruction .
275
CHAPTER 6
D) Palatal Flap
When an apically positioned flap is performed in the vestibular sec -
tion, once elevated beyond the mucogingival junction, the tissue can usually b e
moved without difficulty. However, in the palatal sector where the flap con-
sists exclusively of connective tissue, the lack of elasticity prevents it bein g
apically positioned.
Definition :
The term palatal flap describes a particular surgical technique enabling th e
palatal connective tissue to be incised, elevated, thinned and positione d
apically.
Objectives :
To provide access to the root and bone surfaces .
To obtain apical mobility of the palatal flap .
Indications :
Periodontitis .
Clinical crown lengthening .
Resective bone surgery.
Pre-prosthetic surgery.
Contraindications :
Too narrow and/or low a palate would make thinning of the flap difficult .
Care must be taken to avoid damaging the palatine artery.
PERIODONTAL FLAP SURGERY
CLINICAL CASE 1
277
CHAPTER 6
Surgical techniqu e
9 '7Q
PERIODONTAL FLAP SURGERY
279
CHAPTER 6
CLINICAL CASE 2
Male patient aged 48 with chronic periodontitis. Pocket an average o f
6-7 mm deep and horizontal bone reabsorption are present. Probing performe d
after anaesthesia (bone sounding) revealed the need to shorten the palatal flap
by about 3 mm .
The first internal bevel incision (no . 15 B.P.) is performed about 3 mm from th e
gingival margin to thin and shorten the flap . The incision is extended to th e
retromolar area .
After elevating the primary flap, the secondary flap can be clearly seen .
PERIODONTAL FLAP SURGER Y
The secondary flap is removed after making a second incision in the sulcus (no . 1 5
B.P.) and a third interproximal incision (no . 1/2 Orban) at the base of the col .
Thorough root and bone curettage is performed together with bone reshaping .
Note the thinned palatal flap .
The palatal flap is adapted to the bone planes and held under compression) with a
gauze moistened with physiological solution for 2-3 minutes . This minimizes the fil m
of fibrin and encourages coagulation . Immediately afterwards, the flap is closed wit h
continuous suspended suture using 4-0 black silk .
281
CHAPTER 6
CLINICAL CASE 3
Female patient aged 35 with amelogensis imperfecta . The crown enam-
el is completely destroyed and the clinical crowns must therefore be length-
ened to allow for prosthetic reconstruction of the teeth .
The palatal flap is positioned apically in the osseous crest and sutured with interrupted mattres s
stitches . Now seeming considerably longer, the teeth are then prepared for optimum reception of firs t
the temporary prosthesis, then the definitive prosthesis .
The case six months after the operation with a temporary prosthesis in situ .
283
CHAPTER 6
Definition :
The term distal wedge is applied to a particular surgical technique employe d
to eradicate retromolar pockets and reduce the extent of retromolar tissue .
Objectives :
To eradicate retromolar pockets .
To reduce the volume of the retromolar area .
To create access to the deep planes .
Indications:
Periodontal pockets .
Clinical crown lengthening .
Retromolar bone surgery.
Pre-prosthetic surgery.
Contraindications :
None.
PERIODONTAL FLAP SURGERY
Surgical techniqu e
The retromolar zone may be surgically reduced by means of :
A) Gingivectomy
B) Distal wedge procedure .
GINGIVECTOMY
This operation is indicated exclusively in the case of moderately sever e
gingival hyperplasia . In these cases, a section perpendicular to the axis o f
the tooth is sufficient to completely eradicate a pocket or the gingiva l
hyperplasia.
285
CHAPTER 6
DISTAL WEDG E
The flap incisions to reduce the retromolar zone can be performed in thre e
different ways :
I) Triangular incisio n
II) Parallel incision s
III) Page incision
I) TRIANGULAR INCISION
A triangular incision is
made angled from th e
median part towards
the exterior so as t o
obtain a thinned flap .
The incision is then
continued along the
intracrevicular line a s
far as the interproxi-
mal space between th e
last two molars.
Curettage is performe d
and the area is irrigat -
ed with physiologica l
solution . If there is a n
intraosseous pocket ,
this is treated by means
of bone surgery (resec -
tive or regenerative).
287
CHAPTER 6
Pre-operative image.
Two parallel incisions are made in the keratinized retromolar gingiva ter-
minating in the mucosa . The incisions are undercut by sloping the scalpel .
The result is two thinned flaps . The incisions are then extended around th e
last two molars and may either be intracrevicular or 1-2 mm from the gin-
gival margin . This depends on whether epithelium needs to be remove d
from within the periodontal pocket .
PERIODONTAL FLAP SURGERY
After elevating the two mucoperiosteal flaps, the block of intermediate tissu e
is removed with the help of an Ochsenbein chisel .
The bone tissue and root surfaces of the two molars are exposed and curet -
tage is performed . The area is then irrigated with physiological solutio n
and, if necessary, bone surgery (resective or regenerative) is performed.
The flaps are adapted accurately to the deep planes and sutured with inter-
rupted circular stitches, using 4-0 black silk in order to obtain healing b y
first intention .
289
CHAPTER 6
The flap is carefully adapted to the deep planes and sutured with inter-
rupted circular stitches .
291
CHAPTER 6
Smoker patien t
Eighteen months previously ,
the patient underwen t
periodontal flap surgery.
The photographs were take n
during a routine professiona l
scaling session (every thre e
months) . Note the enormous
quantity of black pigmentatio n
(nicotine and tar)
and gingival inflammation .
292
PERIODONTAL FLAP SURGERY
CONCLUSION S
Longitudinal studies have shown (1st European Workshop on
Periodontology, 1993) that the various surgical methods are equally effectiv e
in reducing periodontal pocket depth and controlling the progression o f
chronic adult periodontitis .
Post-operative control of bacterial plaque is, however, the most important fac -
tor in determining the long term success of periodontal surgery, regardless of
the technique used .
These observations reduce the significance of the traditional differentiatio n
between surgical techniques indicated to reduce pocket depth (access flap an d
modified Widman flap) and surgical techniques indicated to eliminate th e
pocket (apically positioned flap and gingivectomy) .
293
Chapter 7
Resectiv e
Bone Surgery
RESECTIVE BONE SURGERY
297
CHAPTER 7
Bone defects
Bone defects consist of localized reabsorption of the osseous alveola r
crest around the tooth . They are also known as intraosseous defects as the y
are formed within the bone mass and are classified according to the number o f
constituent walls .
Bone defects may occur in various sites around the same tooth and are usual-
ly located in the interproximal space . However, they may also occur in th e
vestibular and/or palatal and lingual bone tissue .
If they occur in the bone tissue of a root furcation, there may also be som e
degree of reabsorption between the roots, in the severest cases, establishing
communication between the vestibular and palatal or lingual sectors .
Two walls
299
CHAPTER 7
Crater
A bone defect is defined as a crater whe n
the two surviving bone walls are th e
vestibular and lingual or palatal walls .
Three walls
RESECTIVE BONE SURGERY
Circumferential
Resective bone surgery is not indicated for very large bone defect s
which are more effectively treated by regenerative or additive bone surgery (or
a combination of both) .
Bone grafts
ADDITIVE
Bone implants
Guided tissu e
REGENERATIVE
regeneration (GTR)
301
CHAPTER 7
Bone
Osteoplasty Non e
reshaping
OSTEOPLASTY
Surgical techniqu e
After elevating a full thickness flap, osteoplasty is performed using mediu m
grain diamonds mounted on a turbine or micromotor .
The operation site must be abundantly irrigated with cold (4-5°C sterile salin e
solution).
Initially, the diamond is moved in a coronal-apical direction to reduce th e
thickness of the bone . The surface is then finished with the same diamon d
used with a brush-type movement in a mesial-distal direction .
During the operation, great care must be taken to avoid touching the root sur-
faces with the rotating diamond.
Diamonds fo r
osteoplasty .
RESECTIVE BONE SURGERY
Bone reabsorptio n
caused by periodonta l
disease has modifie d
the bone architecture .
After elevating a full
thickness flap, it wa s
therefore decided to
reshape the bon e
architecture b y
osteoplasty .
A fter Osteoplasty
After osteoplasty, th e
bone margin is thinner
and the ledge has bee n
eliminated withou t
removing the
supporting bone .
303
CHAPTER 7
OSTECTOM Y
Before Ostectom y
The physiologica l
architecture of the bon e
has been completel y
altered by bone
reabsorption caused b y
periodontal disease .
A fter Ostectomy
Ostectomy (removal of
the supporting bone)
has been performed .
This operation has
recreated the physiolog-
ical architecture of the
alveolar bone.
The interproximal bone
is now more tapere d
and located more coro-
nally to the radicular
bone . This type of con -
tour is defined as `par-
abolic".
Qni,
RESECTIVE BONE SURGER Y
Surgical instruments
Ostectomy requires a number of specific instruments in addition t o
the standard set for flap surgery :
a\ No. 1 Ochsenbein chise l
c' No. 2 Ochsenbein chisel:
designed for ostectomy in, respectively, the mandibular and maxillar y
arches and to finish the parabolic bone profile . The curved side of th e
chisel can also be used to shape the bone .
c 'N No. 36/37 Rhodes chisel :
with backwards hoe-like action .
a\ No. 1S/2S Sugarman file :
for finishing the osseous crest in the interdental spaces .
No . 1 Ochsenbein chise l
No . 2 Ochsenbein chise l No. IS/2S Sugarman file
No . 36/37 Rhodes chisel
305
CHAPTER 7
Using Chisels
Bone chisels are used to remove vestibular and palatal support bone
and to give the bone profile a parabolic (festooned) shape capable of support-
ing a similar gingival architecture .
Following periodonta l
disease, bone reabsoi p -
tion has taken place .
The bone profile has
been completely altered .
!
Using files
Interdental files are used to remove small pieces of connective tissu e
from the interradicular bone while at the same time filing the surface . The
sides of the files are not sharp so as to avoid damaging the surface of the tooth
during the operation .
Pre-operative Post-operative
Pre-operative Post-operative
309
CHAPTER 7
Step 4 : Parabolization
o The scalloping of the flap should anticipate the anatomy of the underlyin g
bone after surgery.
311
CHAPTER 7
?1)
RESECTIVE BONE SURGERY
Step 4 : Parabolizatio n
Bone chisels are used to obtain the definitive contour.
313
CHAPTER 7
The definitive architecture is festooned, thin and with interdental crests situate d
more coronally to the vestibular bone profile .
RESECTIVE BONE SURGERY
Human maxilla :
palatal view
Note the perfect bone
architecture .
315
CHAPTER 7
The definitive
architecture i s
festooned and th e
osseous crest i s
positioned more
coronally to the
palatal profile .
.q 16
RESECTIVE BONE SURGERY
CLINICAL CAS E
Patient suffering from chronic adult periodontiti s
Premolar and molar periodontal pockets are present in the rear maxillary sec -
tion with an average depth of 6-7 mm .
The hygienic phase reduces the depth of the pockets (average 5-6 mm) .
The surgical treatment involves elevation of a mucoperiosteal flap and reshap -
ing of the bone to eradicate the pockets and obtain an anatomy suitable fo r
patient maintenance of a healthy periodontium .
An internal beve l
incision has been
performed, a full
thickness flap has
been elevated and th e
secondary flap ha s
been removed .
The physiologica l
bone contour has
been altered by bon e
reabsorption caused
by the periodontitis .
The alterations can
be corrected b y
resective bon e
surgery .
317
CHAPTER 7
The vestibular an d
palatal flaps will b e
positioned so as t o
cover the osseous cres t
and sutured indepen-
dently with continuous
suspended suture.
RESECTIVE BONE SURGERY
Maintenance
This new architecture facilitates bacterial plaque control and thu s
maintenance of a healthy periodontium . The patient will be included in a cycl e
of regular follow-up appointments for professional prophylaxis .
CONCLUSION S
Resective bone surgery is by definition destructive and does not in itself cur e
periodontitis as this is an infectious disease .
This type of surgery is performed exclusively in the case of minor alteration s
in the bone architecture which, in association with periodontal pockets ,
facilitate the progression of periodontal disease .
319
Chapter 8
Resectiv e
Gingival Surgery
321
RESECTIVE GINGIVAL SURGER Y
Gingival Enlargements
GENERALIZED LOCALIZED
*Fibroepithelial Epuli s
Acute Myeloid Leukemi a *Giant Cell Tumour
Preleukemia *Hormonal Epulis
Aplastic Anemi a Sarcoidosis
*Drug s Multiple Myeloma
(Diphenylhydantoin, Cyclospori n
Ca Channel Blockers)
Langerhans' Cell Tumour
*Chronic Inflammatory Hyperplasia
323
CHAPTER 8
HORMONAL HYPERPLASIA
PREGNANCY EPULIS
325
CHAPTER 8
327
CHAPTER 8
PATHOGENIC HYPOTHESIS
Salivary
Gland s
329
CHAPTER 8
SURGICAL JUSTIFICATIO N
Pocke t
Connective attachment loss with bon e
reabsorption.
Pseudopocke t
Pocket caused by gingival hyperplasia withou t
connective attachment loss or bone reabsorption.
RESECTIVE GINGIVAL SURGER Y
Surgical instruments
The instruments used in Resective Gingival Surgery include:
Double-sided mirror :
for improved visibility.
CP12 graduated periodontal probe :
for measurements and probing .
G'N Goldman-Fox right and left pocket marker:
forceps to establish pseudopocket depth .
Straight round scalpel :
for excising the hyperplastic tissue .
No. 15/16 Kirkland scalpel:
for incising the hyperplastic tissue.
Universal curette :
for removing pieces of tissue and root planing.
H3 curved Cocker Mosquito :
for removing pieces of tissue .
Surgical Forceps
Columbia retractor:
to retract cheeks and lips .
Cook-Waite syringe for anaesthesi a
LaGrange scissors :
to finish gingival tissue .
331
CHAPTER 8
SURGICAL TREATMENT
333
CHAPTER 8
Step 2: Incisio n
The initial incision is made slightly on the apical side of the bleedin g
points with a no . 15 Bard-Parker blade or a no. 15/16 Kirkland scalpel . The
instrument should slope in an apical-coronal direction and the incision shoul d
reach the bottom of the pseudopocket .
Step 3: Excisio n
After the hyperplastic tissues have been incised, they are remove d
using a no . 1/2 Orban interproximal scalpel. The operation is completed with
the help of a curette .
No . 5/6 Buck
interproximal scalpel.
Qh,
RESECTIVE GINGIVAL SURGER Y
Step 4: Gingivoplasty
The definitive gingival profile and shape are obtained using LaGrang e
scissors. In some cases, a coarse grain turbine-mounted diamond may also b e
used for gingivoplasty.
Step 5: Hemostasis
The raw gingival surface is covered with a strip of Surgicel' to control
post-operative hemorrhage and then with a soft periodontal pack . The pack is
left in situ for about a week .
Surgicel"
335
CHAPTER 8
Post-operative treatmen t
Once the periodontal pack has been removed, topical 0 .2% chlorhexi-
dine treatment (gel) is continued for a week . At the same time, normal ora l
hygiene procedures are gradually resumed . Drug-induced gingival hyperplasia
tends to reoccur. Post-operative treatment therefore involves a rigid pro -
gramme of follow-up appointments (every three months) . During the profes-
sional prophylactic sessions, the following operations are performed :
1) Reinforcement of patient compliance .
2) Scaling and polishing .
3) Minor and localized gingivectomy (if necessary) .
4) Topical chemotherapy.
Post-operative image
(after two months) .
Note the excellen t
aesthetic an d
functional results .
Post-operative imag e
(after two years) .
The patient continues
the diphenylhydantoin
therapy. Note the mod-
erate hyperplasia start-
ing to re-form in corre-
spondence with the
interdental papillae,
perhaps caused b y
reduced plaque contro l
by the patient.
,`.
RESECTIVE GINGIVAL SURGERY
Pre-operative imag e
337
CHAPTER 8
Localized gingival hyperplasia in a female The first incision is performed with a Kirkland
patient aged 13 . scalpel sloping in an apical-coronal direction (4 ,
After excising th e
hyperplastic tissue ,
a gingivoplasty i s
performed .
A small quantity of
Avitene® is applied as a
hemostatic .
000
RESECTIVE GINGIVAL SURGERY
Post-operative image
(after one month) .
Histologic examinatio n
reveals an epithelial
hyperyplasia in the fibrou s
mass removed. The basal
layer is normal.
339
CHAPTER 8
eh,n
RESECTIVE GINGIVAL SURGER Y
341
CHAPTER 8
Pre-operative image.
Post-operative imag e
(after six months) .
CONCLUSION S
Resective gingival surgery is the preferred treatment for gingival hyperplasia .
However, these conditions have a specific etiology and therefore tend to relapse if
the etiological agent is not eliminated.
In order to maintain the result obtained, it is therefore necessary for thes e
patients to adhere meticulously to a rigid programme of follow-up appointments .
343