FAILURES IN PERIODONTAL THERAPY

Dr shabeel pn

Contents
Introduction Classification of failure Pre Therapeutic Therapeutic Surgical
Non surgical

Post Therapeutic Summary & Conclusion

INTRODUCTION

Dentist related failures

Patient related failures

Dentist related failures

Gathering data Improper diagnosis Improper investigations Inadequate motivation Improper treatment sequencing Incomplete treatment Irregular follow ups.

Patient Related Factors

Maintenance Smoking Systemic Diseases. Poor healing potential. Psychological component probably the least studied and the most critical aspect in periodontics.

Classification
Pretherapeutic Therapuetic Post Therapuetic

Pretherapeutic
Incorrect Patient Selection Age Socio economic status and nutritional deficiencies

s
Systemic disease:
Diabetes Mellitus Blood Dyscrasias : leukemia, Cyclic neutropenia Immune deficiences : Neutrophil monocytic chemotactic defects, AIDS Genetic disorders : Downs syndrome, Papillion Lefevre syndrome, hypophosphatasia , Chediak Higashi Syndrome) ; Vitamin deficiences

Pretherapeutic

Incomplete diagnostic procedure or misdiagnosis

Improper Clinical diagnosis Radiological interpretations Microbiological interpretation Biochemical interpretation Immunological interpretation

Inappropriate or improper dental restorations or prosthesis

Overhanging Class II , overextended crowns & bridges.

Failure to carry out assoc. Prosthetic-restorative procedure

Pretherapeutic

Morphology of tooth surfaces :

Lateral accessory canals, dev. Grooves, resorption lacunae act as Guide planfor bacterial penetration..

Habits Occlusal corrections or teeth preparation: TFOprevent

proper adaptive remodelling of periodontium

Therapeutic
Non-Surgical
Scaling Root Planing Splinting Occlusal therapy Local Drug Delivery

Surgical
Curettage Gingivectomy Abscess Drainage Flap Surgery Bone Grafts GTR procedures Root coverage procedures Implant Aesthetic surgeries

Scaling
Obviously recognized by remnants of calculus Causes: 1. Incorrect instrumentation & Poor condition of instruments. 2. Burnishing Calculus. 3. Induced Bleeding. 4. Prescription of Gum paints. 5.Assessment of calculus ratio.

Root Planing
Rough root surface and persistence of inflammation. Inadequate RPdetection of caries. Over instrumentation..hypersensitivity Presence of developmental grooves.Use of rotary instruments to smoothen as far as possible

Splinting
Failures could be: Inflammation in the area Breaking of splint Increased plaque accumulation.

How to Prevent?
Diagnose whether a temporary or permanent splint is required. Contouring the splint Proximal cleaning aids to be prescribed. Should be clear of occlusal interferences. Margins of splint should be flush with tooth surface

Occlusal therapy
Diagnosis of occlusal abnormalities. occlusal scheme of pt., plunger cusps, or other occlusal Interference. Assessment of tooth wear and judgement whether it can be corrected by selective grinding or a full fledged occlusal rehabilitation procedure is needed. Fremitus Test.

Occlusal therapy
Correction of worn out teeth must be done prior to invasive periodontal surgery. Patients with other oral habits like tongue thrust, occupational habits must be either advised to quit or forced to quit before attempting any periodontal therapy. Gross malocclusion must be corrected following basic therapy.

Surgical
Improper treatment sequencing :
Role of interdisciplinary dentistry is today unquestionable and this helps in sequencing Not only the removal of primary etiological factors is important need to eliminate the secondary complicating and confounding factors. Malocclusion, occlusal interferences, mild mobility, faulty restorations, open contacts, etc and so on and so forth.

Improper selection of technique: Design of surgery or procedure, right from types of incisions to the required modification Improper selection of technique could be a primary trigger that leads to a cascade of events precipitating in failure. Incomplete treatment: Incomplete debridment Improper asepsis: Improper primary closure:delays healing

Curettage
Persistence of inflammation after procedure Causes: 1. Diagnosis per se 2. Procedural errors; instrumentation when to stop 3. failure to irrigatetags of tissue 4. Suture a curetted area. granulation

Gingivectomy
Defined by recurrence of lesion either immediately within a few weeks or by destruction of the periodontal apparatus.

Wade (1954) outlined 15 reasons why gingivectomy fail: 1. Unsuitable case selection. Cases underlying
osseous or intrabony defects. 2. Incorrect pocket markings 3. Incomplete pocket elimination 4. Insufficient beveling of the incision 5. Failure to remove tissue tags, resulting in excessive tissue 6. Failure to remove etiologic factors calculus and plaque 7. Beginning or terminating the incision in a papilla

8. Failure to eliminate or control the predisposing factors 9. Inaccessible interdental spaces 10. Loose dressings 11. Lost dressings 12. Insufficient use of dressings 13. Failure to prescribe stimulators or rubber tip for interproximal use 14. Failure to use stimulators or rubber tip 15. Failure to complete treatment

Abscess Drainage
Defined by the recurrence of abscess/ resultant increase in periodontal destruction. 1. Identification of source/ origin.tortousity of pocket & complexity of the tooth . 2. Removal of entire abscess wall.remenant tags act as a nidus. 3. Chronic abscesses tend to show more recurrence. 4. Systemic/ Local drug delivery is mandatory; if its a periodontal abscess.

Flap Surgical Techniques

Failures could be recurrence of pockets, flabby tissue, abscess formation, gingival recession, cleft formation, loss of interdental papilla. In most situations, some amount of gingival tissue recession and loss of papilla occurs, accepted to such an extent that we do not consider it a failure anymore.

Elimination of inflammationRemoval of depositsimproves tissue tone & texture Failure to remove the entire pocket lining Recurrence of the pocket epithelium. Failure to correct bony ledges.improper maintenance, periodontal infections & attachment loss Incomplete debridement of granulation tissue and deposits. Excessive reflection can cause increased postoperative surface resorption.

Regenerative Techniques
Bone grafting Procedures

GTR Procedures

Growth Factor usage

Bone grafting Procedures

i. Pre surgical considerations.decision to place a bone graft. ii. Assessment of defect morphology: interproximal well supported 3 or 2 walled defects & Furcation Involment. iii. Technique of placement increments, compacted not

iv. Maintenance of vascular continuity.. Alloplasts & xenograftsosteoconductive.only act as a scaffold. Establishment of vascular continuity Clot.should preferably arise from bone.penetrations of cortical plate is reqd to enhance blood flow from marrow..trephinationaid in neovascularization.

iv. Overfilling the defect lead to fibrous encapsulation of the graft

Bone grafting Procedures

v. Flap margin bleed ..persistent bleeding on flap surface results in clot forming from the flap involving graft.fibrous encapsulation. vi. Postoperative infection control.antibiotics & antibacterial mouthrinse.. vii. Graft sterilizationmost commonly overlooked aspects viii.Primary closure with no intervening graft

GTR Procedures
Adaptation of membrane.to provide adequate space to the periodontal ligament cells to migrate Prevention of collapse..use in conjunction with bone graft. Trimmed membrane..should cover at least 2mm of adjacent alveolar bone, no sharp edges Membrane exposuretension free flap,

Barrier-Independent Factors
Poor plaque control Smoking Occlusal trauma Sub optimal tissue health (i.e. Inflammation persists) Mechanical habits (e.g.. Aggressive tooth

Barrier-Independent Factors

Overlying gingival tissue

Inadequate zone of keratinized tissues. Inadequate tissue thickness

Surgical technique
improper incision Traumatic flap elevation and management Excessive surgical time Inadequate closure or suturing

Barrier-Independent Factors Post surgical factors premature tissue challenge #Plaque recolonization #Mechanical insult Loss of wound stability (loose sutures, loss of fibrin clot).

Barrier Dependent Factors

Inadequate root adaptation (absence of barrier effect) Non sterile technique Instability (movement) of barrier against root. Premature exposure of barrier to oral environment and microbes.

Growth factor usage

Method of draw various techniques blood bank draw technique..superior viable platelet conc. Shelf life.24 hours, chair side equipment. Use of thrombin; and its ratioreleased during surgery is enough, ratio 1:7 Aspiration techniqueplatelets fragile When used alone will invariably fail to show desired results.

Root Coverage Procedures

Rotated flaps

Soft tissue grafts

Root Coverage Procedures

Presurgical considerations. depends on the position of the tooth, the extent of malocclusion if present, the thickness of the gingiva present in the adjacent area The etiology of the recession must be corrected. Depth of the vestibule , width of attached

Graft handling could be one of the reasons for failure. Squeezing of the graft leads to leakage of the plasmatic fluid ..dessication Size of the graft should be adequate. ideal size should be 1.25 1.5 mm The presence of clot between the graft and root surface. Compression of graft against root surface Root conditioning is a must; esp in soft tissue graft procedures

Rotated flaps
Intra surgical considerations:
Horizontal incision; mandatory to maintain viability of papilla.

Cut back incision; prevents tissue ledges.

Partial thickness is desired as this may prevent

Rotated flaps

Coronally displaced flaps fail most often because they are either secured in tension and are not stable; thus vertical incisions play a critical role in success of this procedure. These procedures show limited success if

Laterally positioned flap

Common reasons for failure Tension. Distal incision Pedicle too narrow Exposure of bone at radicular surface Poor stabilization

Double papilla flap

Common reasons for failure
Non union of component flaps Full tickness flap..Dehiscence or fenestrations Inadequate attached gingiva in the papillary area Proper placement of the flap on periosteal bed Adequate fixation of the flap to prevent

Free Soft tissue grafts

Epithelialized grafts

Sub epithelial Connective Tissue Grafts

Epithelialized grafts

The sutured graft should always be either at the

level or higher than the level of adjacent

recipient bed but never below; this leads to

graft rejection (Chiranjeevi 1989).

Recipient bed preparation should be beveled and

broader at the base.

Sub epithelial Connective Tissue

2 techniques of procurement; separation of full thickness yields more C.T. and easier. Grafts have to be trimmed and the lipid layer has to be removed. Tunnel technique gives only marginal recession coverage as opposed to pouch technique

 Reasons for failure. Langer & Langer 1992 Recipient bed too small Flap perforation Inadequate graft size Inadequate coronal positioning of flap Too thick a CT graft Poor root preparation Poor papillary bed preparation

Implants
Inadequate union of bone and implant at the time of surgical insertion. Improper biomaterials a) Use of dissimilar materials b) Bio incompatible materials Contamination of the implant surface & infection Surgical overheating of bone Structural design that does not transmit forces evenly to the bone Premature loading with occlusal forces prior to healing phase Increased periodontal pocket activity

Post Therapeutic
Instruction & Motivation Preservation of the periodontal health requires as positive programme If periodontist follows a very good therapeutic procedures..pt does not maintain or not under PD,tooth loss etc. proper recall visits.signs of failure bone loss Motivation + reinforcement of OHI. Failure to continue with treatmentconscious or unconscious decision

Unsupervised healing: Absence of supervision Professional cleaning of supragingival area periodically Failure to assess OH status Inbility to monitor nutritional status Persistent or reintroduction of certain microorganisms Failure to eliminate certain microorganisms..A.a.persistence or recurrence. Some remain in the DEJresistant to antibioticsrecurrence.

New Disease:

Refractory Periodontitis: a disease in multiple

sites in patients which continue to demonstrate attachment loss after appropriate therapy

Ability or skill of the operator:

CONCLUSION

References
Dr.Ramaswamy. Causes of failure of periodontal treatment. JISP 1995; 19:23 24. Gerald Kramer. Dental failures associated with periodontal surgery. DCNA 1972;16:13 31. Leon Lefer. Failures in motivation of dental home care. DCNA 1972;16:1:pg3. Bradley RE. Periodontal Failures related to improper prognosis & treatment planning.DCNA 19726:1:pg33 43. Wang HL, MacNeil RL. GTR. DCNA1998; 42:509.

Recent advances

 AlloDerm is an acellular dermal matrix derived from donated human skin that undergoes a multi step proprietary process that removes both the epidermis and the cells that can lead to tissue rejection. AlloDerm has been used in a wide variety of soft tissue grafting procedures such as root coverage, soft tissue augmentation and guided bone regeneration with a consistent record of excellent results.1 7

What is AlloDerm Regenerative Tissue Matrix?

Advantages compared to the connective tissue autograft from the patients palatal surgery palate: Eliminates the need for
Removes palatal harvesting limitations from treatment planning considerations Reduces patient reluctance to follow through with surgical treatment Consistent quality Provided in multiple convenient sizes Available in two thickness ranges for use in different procedures: 0.9 to 1.6 mm AlloDerm for root coverage, soft tissue ridge augmentation, etc. 0.5 to 0.8 mm AlloDerm GBR for guided bone regeneration and barrier membrane function

How does AlloDerm work?

AlloDerm provides a matrix consisting of collagens, elastin, vascular channels, and proteins that support revascularization, cell repopulation and tissue remodeling. After placement, the patients blood infiltrates the AlloDerm graft through retained vascular channels, bringing host cells that adhere to proteins in the matrix. Significant revascularization can begin as early as one week after implantation. The host cells respond to the local environment and the matrix is remodeled into the patients own tissue, in a fashion similar to the bodys natural tissue attrition and replacement process.

Documented equivalence to autogenous connective tissue

Multiple, randomized clinical trials (RCT) have shown root coverage results with AlloDerm to be equivalent to autogenous connective tissue, and concluded that the procedure was predictable and practical. A meta analysis of eight RCTs showed no statistically significant differences between the two groups for measured outcomes: recession coverage, keratinized tissue formation, probing depth and clinical attachment levels.

Acellular Dermal Matrix for Mucogingival Surgery: A Meta-Analysis. Gapski R, Parks CA and Wang HL. J Periodontol 2005;76(11):1814-1822.

Application of Regenerative Tissue Matrix

Root Coverage

Soft Tissue Ridge Augmentation

Soft Tissue Augmentation Around Dental Implants

Guided Bone Regeneration

References
Management of Gingival Recession by the Use of a Acellular Dermal Graft Material: A 12-Case Series. Santos A, Goumenos G and Pascual A. J Periodontal 2005;76(11):1982-1990. Subpedicle Acellular Dermal Matrix Graft and Autogenous Connective Tissue Graft in the Treatment of Gingival Recessions: A Comparative 1-Year Clinical Study. Paolantonio M, Dolci M, Esposito P, DArchivio D, Lisanti L, Di Luccio A and Perinetti G. J Periodontol 2002;73(11):1299-1307. Clinical Evaluation of Acellular Allograft Dermis for the Treatment of Human Gingival Recession. AichelmannReidy ME, Yukna RA, Evans GH, Nasr HF and Mayer

 Predictable Multiple Site Root Coverage Using an Acellular Dermal Matrix Allograft. Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer MJ, Goldsmith LJ and Rebitski G. J Periodontol 2001;72(5):571-582. Surgical therapies for the treatment of gingival recession. A systematic review. Oates TW, Robinson M and Gunsolley JC. Ann Periodontol 2003;8:303-320. Root coverage of advanced gingival recession: A comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. Tal H, Moses O, Zohar R, et al. J Periodontol 2002;73:14051411. The clinical effect of acellular dermal matrix on gingival

Platelet rich Fibrin