Non-Surgical and Surgical

Management of Periodontal Disease

Dr. Sangeetha Chandrasekaran

Course objectives

• Prevalence of periodontal disease

• Update on periodontal diagnosis

• To save or extract teeth

• Non surgical management

• Surgical management

• Functional crown lengthening

• Gingival augmentation

PREVALENCE OF PERIODONTITIS

UPDATE ON CLASSIFICATION

Prevalence of periodontitis

Complex etiology in periodontitis

MICROBES

GENETICS

HOST FACTORS

Update on diagnosis

American Academy of Periodontology Task Force Report, 2015

Chronic vs Aggressive

Periodontitis

American Academy of Periodontology Task Force Report, 2015

TO SAVE OR EXTRACT TEETH

The decision to save…

Avila et al, A novel decision –making process for tooth retention or extraction,

Journal of Periodontics, 2009

Endodontic outcomes

Treatment options for the compromised tooth:

A decision guide American Academy of endodontics

Preop Postop 12 mo recall

Courtesy of Dr. Manpreet Sarao

NO HERODONTICS!

Just because a tooth can be saved it doesn’t

necessarily need to be saved

Treatment options for the compromised tooth:

A decision guide American Academy of endodontics

Treatment options for the compromised tooth:

A decision guide American Academy of endodontics

My Decision Tree

SAVE TEETH PROCEED WITH

CAUTION

CONSIDER

IMPLANT

Treatable Perio Endo , Perio , post core Class 3 furcations

Treatable endo Strategic value Grade 3 mobility

Minimal restorative needs Medical status of the

patient

No strategic value

Patient Compliance Finances High Caries risk

Stand alone teeth High progression of

periodontal disease

Esthetic compromise

If tx will jeopardize

the future predictable

options

Cost of treatment

Dollars and sense: Saving teeth vs placing implants, Scott Froum

Periodontal surgery Implant surgery

Dollars and sense: Saving teeth vs placing implants, Scott Froum

NON SURGICAL MANAGEMENT

Scaling and root planing:

still the treatment of choiceNew technologies Comparison to SRP

Modified ultrasonic

systems

Equivalent in results

More time

Difficulty in removing

large masses of calculus

SRP

Air abrasive systems Equivalent in results with

glycine

Less time

More patient centered

But not enough evidence

SRP

Endoscopic technology No difference with or

without endoscope

SRP

Lasers No difference with or

without lasers

SRP

Photodynamic therapy Needs to be an adjunct

No evidence

SRP

What about adjuncts to SRP

Local drug delivery ?

• Systematic reviews report a modest PD

reduction (0.25-0.5mm) as an adjunct to

SRP in PD >5mm

• Effects on AL gains are smaller

• Long term benefits are unknown

American academy of periodontology statement on local drug delivery of sustained or controlled release antimicrobials

Indications for local drug

delivery

• When localized recurrent and or residual

PD> 5mm with inflammation is present

following conventional therapies

What about adjuncts to SRP

• Systemic antibiotics

• CAL gains can be expected if systemic

antimicrobials are used

• Effects are short term

• More useful for Aggressive Periodontitis

patients

• Most useful systemic antibiotic is the

combination of amoxicillin and

metronidazole

Summary

PD

1-3mm

PROPHYLAXIS

6mrc

PD

4-6mm

OHI

SRP

RE-EVAL

Amox/metro

Aggressive

Local drug

delivery

LOCALIZED PD

BOP

MAINTENANCE

SURGICAL MANAGEMENT

Surgical approaches

SURGERY

RESECTIVE REGENERATION

What is regeneration?

Components for regeneration

PDLSCBONE GRAFTS

MEMBRANE

DFDBA

EMD

PDGF

• Diabetes mellitus

• Smoking

• Plaque control

Patient –related considerations

Tooth-related considerations

• Type of defect3 walled > 2 walled >1 walled

Class 2 furcations

• Depth of defectNarrow > wide

Deep > shallow

• Radiographic angle of the defect25 degrees or less >

• MobilityNon mobile >mobile teeth

Surgical decision tree

Kao et al, Periodontal regeneration- Intrabony defects: A systematic review from the AAP

Periodontal outcomes

Pre-op Post-op

Biologics

• Enamel matrix derivative

• Platelet derived growth factor

What is Enamel matrix derivative

• Dominant protein is Amelogenin

• Porcine origin

• Concept of bio-mimicry

Biologic properties of EMD

Lyngstadaas et al, Autocrine growth factors in human periodontal ligament cells cultured on enamel matrix derivative

What is platelet derived growth

factor ?

• Recombinant human platelet derived

growth factor

Biologic properties of rhPDGF

Clinical application of biologics

• Intrabony defects and furcation defects

• Results shown to be equivalent to GTR and

bone grafts

• Good on soft tissue parameters

• Good on Hard tissue parameters

• Also used in combination with bone grafts

and membrane

Regeneration of the Periodontium

Enamel Matrix Proteins - Emdogain

Regeneration of the Periodontium

Enamel Matrix Proteins

Regeneration of the Periodontium

Enamel Matrix Proteins

Regeneration of the Periodontium

Enamel Matrix Proteins

Regeneration of the Periodontium

Enamel Matrix Proteins

Regeneration of the Periodontium

Enamel Matrix Proteins

Baseline 6 month POT

PD>6mm

OHI

SRP

RE-EVAL

SURGICAL MANAGEMENT

LOCALIZED PD

MAINTENANCE

Local drug

delivery

RESECTIVE

REGENERATIVE

RESECTIVE SURGERY/

CROWN LENGTHENING

Biologic Width (BW)

• The dimension of space occupied

by healthy gingival tissues above

the alveolar bone

• Average dimension established

by Gargiulo, Wentz, and Orban

(1961)

– Junctional Epithelium (0.97mm)

– Connective Tissue (1.07mm)

The concept of “Supracrestal

gingival tissue (SGT)”

• BW and sulcus depth

• Approximately 3mm

But Wait!

“Attempting to attribute a fixed measurement

to biologic width may indeed disregard

surface-surface, tooth –tooth, patient-patient

variability”:- Deas, 2004

Tooth-tooth variation

Arora et al, Int J Dent 2012

Surface-Surface variation

Arora et al, Int J Dent 2012

Patient- Patient variation

Arora et al, Int J Dent 2012

Main points

• BW plus sulcus is SGT

• SGT like BW is highly variable, and

must be established for each

individual

• SGT has a range from 2.83-4.50mm

Flores-de-Jacoby et al., 1989

Gunay et al., 2000

Biologic width violation

• Gum recession

• Bone loss

• Tissue

inflammation

• Recurrent pocket

depth

• Mechanical failure

• Open margins

Clinical assessment

• Amount of tooth

structure available

• Discomfort on being

assessed with a probe

Transgingival probing

• Sounding to bone under anesthesia

• Identical to surgical measurements

60% of the time and within 1 mm

of surgical measurements 90% of

the time (Isidor et al, 1984)

• Bone sounding provided the best

estimate of open bone level

measurements when compared to

radiographs (Akesson et al, 1992)

Contralateral SGT measurements

in the same individual are similar

Majzoub et al, Seminars in Orthodontics , 2014

Radiographs

• An assessment of available

distance from the restorative

margin to the bone

Main points

• Violation of biologic width can cause

inflammatory changes in the gingiva

• When it will happen depends on the quality

and fit of the restoration

• As you are planning the restoration – make

sure you check the amount of tooth

structure plus the BW of the patient . The

number quoted on an average is 3

Indications for CL surgery

• Violation of BW

subgingival caries,

fractures, perforations,

cervical resorptions

• Surgical exposure of

tooth structure for

ferrule

Contraindications for CL surgery

• If it significantly compromises

crown-root ratio of treated and

adjacent teeth

• If adequate supporting bone will not

remain

• Esthetic areas

• Furcation involvement is imminent

• Anatomical limitations

• Poor plaque control

• High caries risk

Pre-op assesment- Main points

• How much tooth structure needs to be

accomplished

• Can it be a stand alone tooth

• Anatomical limitations ( 4mm rule to the

furcation entrance)

• Will it compromise the adjacent teeth

• Will esthetics be compromised

• Can alternate treatments be considered -

“10mm rule”

“4mm rule”

• A critical distance from the furcation of

4mm was established as a landmark under

which, if surgery was performed on

mandibular molars, chances of furcation

involvement in the future was very high

Dibart et al, Crown lengthening in mandibular molars: a 5 yr restrospective radiographic analysis

“10mm rule”

Checklist to improve outcomes

Caries excavation – restorability

Sucessful endo treatment

Prep and margins prepared

Temporization

Communication with the Periodontist

Technical steps for crown lengthening

• Incisions

• Flap management

• Debridement

• Osteoplasty and ostectomy

• Apically repositioned flap

• suturing

• Very limited indication for gingivectomy

alone (soft tissue resection in crown

lengthening)

• There must be adequate attached tissue left

after the surgery

Gingivectomy alone

• There will be significant tissue rebound if

only soft tissue is removed without osseous

contouring!

“The tissue is the issue

but the bone sets the

tone”

Design of flap for access

Palatal flap

How much of tooth structure

above osseous crest is necessary

• Ferrule

The presence of 1.5-2mm ferrule has a positive effect

on fracture resistance of endodontically treated teeth.- Juloksi, 2012

• Biologic width of approximately 3mm

A minimum of 5mm above the osseous crest

Osteoplasty and ostectomy

Osteoplasty refers to creating a physiologic

form of alveolar bone without removing

supporting bone

Ostectomy is the removal of supporting bone

(bone directly involved in the attachment of

the tooth)

Establishing positive architecture

Flap position

• Flap position vs. osseous reduction

– The closer the flap is sutured to the alveolar

crest, the greater the amount of rebound over

time.

• 1.33mm when flap sutured ≤ 1mm from crest

• 0.90mm when flap sutured 2mm from crest

• 0.47mm when flap sutured 3mm from crest

• -0.16mm when sutured ≥ 4mm from crestDeas et al., 2004

Deas et al, 2004

Crown Lengthening + Distal Wedge

• Provisional Restoration

removed

• Bone Sounding complete

• Tissue marked with

bleeding points

Crown Lengthening #15

Crown Lengthening #15

- Blade (12b) for linear distal cuts.

- Kirkland Knife for horizontal cuts.

- Back Action Chisel used to

remove the distal wedge

Crown Lengthening #15

Soft tissue removal

and adequate flap

mobility

Crown Lengthening #15

Hard tissue removal

interproximally with

Sugarman file and

End cutting burs

Positive

architecture

Crown Lengthening #15

Provisional Replaced, cement

removed, flap apically positioned.

Crown Lengthening- main points

Soft tissue resection alone without osseous

resection can result in rebound (Specific indications)

– Access to bone is important

– Achieve positive architecture

– Overreliance on flap position, instead of

osseous reduction, can lead to excessive

rebound and inadequate clinical crown height!

Reprovisionalization

• At 3 weeks

• Flat emergence

• 1mm supragingival

• Prevents the fibers from attaching

Final restoration

• A stable sulcus must be formed

• Several factors influence tissue rebound

after surgery:

Flap position

Tissue biotype

Esthetic conditions

Recommendations

• Non-esthetic areas

- Minimum- 6 weeks , Optimal- 3months, Ideal-6 months

• Esthetic areas

- Minimum 3 months and ideal is 6 months.

GINGIVAL RECESSION /

TREATMENT

FREE GINGIVA

ATTACHED GINGIVA

MGJ

KERATINIZED GINGIVA

Is attached or keratinized tissue

essential for gingival health ?

• BL :

Inadequate width of attached gingiva is as resistant to

plaque induced gingival inflammation as an adequate

one and not more susceptible to recession (as long as

the patient maintains good oral hygiene)

So why and when to augment?

• Patient discomfort

• Orthodontic movement

• Subgingival restorations

• Progressive recession

• Augmentation around implants

What determines the success of soft

tissue augmentation procedures?

Surgical options

Free Gingival graft

Surgical options

Connective tissue graft

Surgical options

Acellular Dermal Matrix

Procedure-related

Outcomes FGG CAF CTG ADM XCM PDGF EMD

Root coverage

KT gain

Attachment to

the root

Thickness

Patient- related

Outcomes FGG CAF CTG ADM XCM PDGF EMD

Comfort

Esthetics

Cost

Stability