1

Periodontology
Dr. Rawand Samy Mohamed Abu Nahla
Oral Medicine, Periodontology&oral Radiology Department.
Dr. Haydar.A.Shafy Faculty Of Dentistry.
El Azhar University.
 2

Lecture 6
Procedures for the Treatment 3

of Osseous Defects
 Periodontitis, by definition, involves the loss of the
connective tissue attachment to the root surface of the
tooth and loss of alveolar bone.

 This bone loss creates osseous defects around the teeth.

 During osseous surgical procedures, the periodontist treat

the alveolar bone with chisels or specially designed dental
burs to remove these osseous defects or allow for apical
positioning of the flaps.
 4
 If alveolar bone is removed that contains
periodontal fibers that support the tooth,
then the procedure is termed ostectomy.

 If only bony ledges or nonsupporting bone

is removed, then the procedure is termed
osteoplasty.
Procedures for the Treatment 5

of Osseous Defects (Cont.)

 Osseous
recontouring is
illustrated in the
following figure.
Osseous Defects 6

Indications for Surgically Treating Osseous

Defects
 Periodontal pockets extend below the level of the osseous crest
or infrabony pockets.
 Thick bony ledges prevent the gingival flap from being
adapted at a more apical level.
 Reverse alveolar bony architecture is present.
 Bone loss, in which the interproximal bone is apical to the
facial and lingual bone, is the reverse of the configuration
of alveolar bony architecture in periodontal health.
 The reverse bony architecture and the procedure
7
to correct it are presented in the following figure.
 8
Procedure for Surgically Treating Osseous
Defects
 The mucoperiosteal flaps are elevated.
 Bony ledges and craters are modified with burs and
chisels.
 Thismodification allows the overlying gingiva to follow
a more physiologic contour.
 If possible, the walls of bony craters are removed.
 Ledges are thinned, and interproximal bony regions
are fluted to a form more generally found in
periodontal health.
 Bone loss associated with a lingual groove, access flap 9
surgery, and bone recontouring are presented in the following
figure.
10
Root resection and Hemisection:11

Root Resection
 Root resection may be indicated in multirooted
teeth with grades II to IV furcation involvements.
Root resection may be performed on vital teeth or
endodontically treated teeth.
 It is preferable, however, to have endodontic
therapy completed before resection of a root(s).
Teeth planned for root resection include the following:
12
1. Teeth that are critically important to the overall dental treatment
plan. Examples are teeth serving as abutments for fixed or
removable restorations for which loss of the tooth would result in
loss of the prosthesis and entail major prosthetic retreatment.

2. Teeth that have sufficient attachment remaining for function.

Molars with advanced bone loss in the interproximal and
interradicular zones, unless the lesions have three bony walls, are
not candidates for root amputation.
3. Teeth for which a more predictable or cost-effective method of
13
therapy is not available. Examples are teeth with furcation defects
that have been treated successfully with endodontics but now
present with a vertical root fracture, advanced bone loss, or caries
on the root.

4. Teeth in patients with good oral hygiene and low activity for
caries are suitable for root resection. Patients unable or unwilling
to perform good oral hygiene and preventive measures are not
suitable candidates for root resection or hemisection.

Root resected teeth require endodontic treatment and usually cast

restorations.
The following is a guide to determining which root
should be removed in these cases: 14
1. Remove the root(s) that will eliminate the furcation and
allow the production of a maintainable architecture on the
remaining roots.

2. Remove the root with the greatest amount of bone and

attachment loss. Sufficient periodontal attachment must
remain after surgery for the tooth to withstand the functional
demands placed on it such as bridge abutments. Teeth with
uniform advanced horizontal bone loss are not suitable for
root resection.
3. Remove the root that best contributes to the elimination of
15
periodontal problems on adjacent teeth. For example, a
maxillary first molar with a Class III buccal-to-distal furcation
is adjacent to a maxillary second molar with a two-walled
intrabony defect between the molars and an early Class II
furcation on the mesial furcation of the second molar.

The removal of the distobuccal root of the first molar allows the
elimination of the furcation and management of the two-wall
intrabony lesion and also facilitates access for instrumentation
and maintenance of the second molar.
 16
4. Remove the root with the greatest number of
anatomic problems such as severe curvature,
developmental grooves, root flutings, or accessory
and multiple root canals.

5. Remove the root that complicates future

periodontal maintenance.
Hemisection 17
 Hemisection is the splitting of a two-rooted tooth into two
separate portions.
 This process has been called bicuspidization or separation
because it changes the molar into two separate roots.
 Hemisection is most likely to be performed on mandibular
molars with buccal and lingual Class II or III furcation
involvements. As with root resection, molars with advanced bone
loss in the interproximal and interradicular zones are not good
candidates for hemisection.
 After sectioning of the teeth, one or both roots can be retained.
This decision is based on the extent and pattern of bony loss, root
trunk and root length, ability to eliminate the osseous defect, and
endodontic and restorative considerations
Root Resection/Hemisection 18

Procedure
 The most common root resection involves the distobuccal root
of the maxillary first molar,.
 After appropriate local anesthesia, a full-thickness
mucoperiosteal flap is elevated. Root resection or hemisection
of teeth with advanced attachment loss usually requires
opening both facial and lingual/ palatal flaps .
 Typically, a root cannot be resected without elevating a flap.
 The flap should provide adequate access for visualization and
instrumentation and minimize surgical trauma.
 After debridement, resection of the root begins
19be
with the exposure of the furcation on the root to
removed.
 The removal of a small amount of facial or palatal
bone may be required to provide access for
elevation and facilitate root removal .
 A cut is then directed from just apical to the
contact point of the tooth, through the tooth, and to
the facial and distal orifices of the furcation.
 This cut is made with a high-speed, surgical-length
fissure or crosscut fissure carbide bur.
 For hemisection, a vertically oriented cut20 is
made faciolingually through the buccal and
lingual developmental grooves of the tooth,
through the pulp chamber, and through the
furcation.
 If the sectioning cut passes through a metallic
restoration, the metallic portion of the cut
should be made before flap elevation.
 This prevents contamination of the surgical
field with metallic particles.
 21

B
 22

D
 23

E
 24

Fig. Resection of a root with advanced bone loss. A, Facial osseous contours.
There is an early grade II furcation on the facial aspect of the mandibular first
molar and a Class III furcation on the mandibular second molar. B, Resection of
the mesial root. The mesial portion of the crown was retained to prevent mesial
drift of the distal root during healing. The grade II furcations were treated by
osteoplasty. C, Buccal flaps adapted and sutured. D, Lingual flaps adapted and
sutured. E, Three-month postoperative view of the buccal aspect of this
resection. New restorations were subsequently placed. F, Three-month
postoperative view of the lingual aspect of this resection.
 25

Lecture 7
Procedures for Correcting 26
Mucogingival Defects
 Periodontal disease often causes deformities in the
oral tissues because of the recession of the marginal
gingiva and the development of fissures and clefts.

 Recession can lead to extension of the periodontal

pocket beyond the mucogingival junction, resulting
in no attached gingiva existing on the tooth

surface. These areas are called mucogingival defects.

 27
 The term mucogingival surgery was initially
introduced to describe surgical procedures for the
correction of relationships between the gingiva and the
oral mucous membrane with reference to three specific
problem areas: attached gingiva, shallow vestibules,
and a frenum interfering with the marginal gingiva.
 A mucogingival defect and its corrective surgery are presented
28
in the following figure.
Procedures for Correcting 29
Mucogingival Defects
 Mucogingival surgery includes a variety of
periodontal plastic surgery–type procedures. These
include:
1. Problems associated with attached gingiva
2. Problems associated with a shallow vestibule
3. Problems associated with an aberrant frenum
Indications for Mucogingival Surgery 30
 Areas of recession have significantly reduced the width
of the keratinized gingiva or have progressed beyond
the mucogingival junction.
 Is possibly indicated before orthodontic tooth
movement.
 Broad labial or lingual frenum attachments near the
gingival margin may result in diastema.
 Shallow vestibular depth must be deepened to improve
the fit and retention of removable dental prostheses.
 31
Procedure for Mucogingival Surgery
 The procedures differ, depending on the specific
mucogingival problem.
 The most common procedures in treatment of gingival
recession are:
 Lateral pedicle gingival graft
 Double papillae flap.
 Coronally repositioned flap
 Free autogenous gingival graft
 Subepithelial connective tissue graft
Lateral Pedicle Gingival Grafts 32
 This procedure slides gingival tissue from an adjacent tooth or
papilla.

 It is dependent on an adequate source of tissue adjacent to

the area that needs augmentation.

 A risk of causing gingival recession to the donor site exists.

 The donor pedicle is dissected from the underlying periosteal

bed, rotated to the recipient site, and sutured in place.
A step-by-step surgical description: 33
 Step 1: Prepare the recipient site. Epithelium is
removed around the denuded root surface. The
exposed connective tissue will be the recipient site for
the laterally displaced flap. The root surface will be
thoroughly scaled and root planed (Figure, B).
 Step 2: Prepare the flap. The periodontium of the
donor site should have a satisfactory width of
attached gingiva and minimal loss of bone, without
dehiscence or fenestration.
 A full-thickness or partial-thickness flap may be used, but 34
the

latter is preferable because it offers the advantage of rapid healing

at the donor site and reduces the risk of loss of facial bone height.
This is especially important if the bone is thin or a dehiscence
or fenestration is suspected. However, if the gingiva is thin,
even a partial-thickness flap may not be sufficient for flap
survival.
 With a #15 blade, make a vertical incision from the gingival
35
margin to outline a flap adjacent to the recipient site.
 Incise to the periosteum, and extend the incision into the oral
mucosa to the level of the base of the recipient site.
 The flap should be sufficiently wider than the recipient site to
cover the root and provide a broad margin for attachment to the
connective tissue border around the root.
 The interdental papilla at the distal end of the flap, or a major
portion of it, should be included to secure the flap in the
interproximal space between the donor and the recipient teeth.
 Make a vertical incision along the gingival margin 36and
interdental papilla, and separate a flap consisting of epithelium
and a thin layer of connective tissue, leaving the periosteum on
the bone.
 A releasing incision is sometimes needed to avoid tension on
the base of the flap, which can impair the blood supply when
the flap is moved.
 To do this, make a short oblique incision into the alveolar
mucosa at the distal corner of the flap, in the direction of the
recipient site.
 37
Step 3: Transfer the flap. Slide the flap laterally onto the adjacent

root, making sure that it lies flat and firm without excess tension on
the base. Fix the flap to the adjacent gingiva and alveolar mucosa
with interrupted sutures (Figure, D).

A suspensory suture may be made around the involved tooth to

prevent the flap from slipping apically.

Step 4: Protect the flap and donor site. Cover the operative field

with aluminum foil and a soft periodontal dressing, extending

it interdentally and onto the lingual surface to secure it. Remove

the dressing and sutures after 1 week.
A 38

B
C 39

D
 D 40

Fig. Laterally displaced flap. A, Preoperative view, maxillary bicuspid. B,

Recipient site is prepared by exposing the connective
tissue around the recession. C, Incisions are made at the donor site in preparation
of moving the tissue laterally. D, Pedicle flap is sutured
in position. E, Postoperative result at 1 year.
 41
“Double-Papillae Laterally Positioned Flaps”
This procedure was first described by Wainberg It
is designed to achieve an adequate attached gingiva
and/or coverage of a radicular surface of a tooth.
denuded root surface by joining two interdental
papillae.
 42
Indications:
 When the interproximal papillae adjacent to the
mucogingival problem are sufficiently wide.
 When the attached keratinized gingiva on
approximating tooth is insufficient to allow for
laterally positioned flap
 When periodontal pockets are not present
 43
Advantages:
 The risk of loss of alveolar bone is minimized
because the interdental bone is more resistant to
loss.
 The clinical predictability of this procedure is
fairly good.
Disadvantage: 44

 The primary disadvantage of this procedure is in that having

to join together two small flaps in such a way they act as a
single flap.

 The “double-papilla flap” attempts to cover roots denuded

by isolated gingival defects with a flap formed by joining
the contiguous halves of the adjacent interdental papillae.
Results with this technique are unpredictable because blood
supply is impaired by suturing the two flaps over the root
surface.
Coronally Displaced Flap. 45

The purpose of the coronally displaced flap

procedure is to create a split-thickness flap in
the area apical to the denuded root and
position it coronally to cover the root.
Technique 46

Step 1.

 With two vertical incisions, delineate the flap.

These incisions should go beyond the
mucogingival junction.

 Make an internal bevel incision from the gingival

margin to the bottom of the pocket to eliminate the
diseased pocket wall. Elevate a mucoperiosteal flap
using careful sharp dissection.
Step 2. 47
Scale and plane the root surface.

Step 3.

Return the flap and suture it at a level coronal to the

pretreatment position. Cover the area with a

periodontal dressing, which is removed along with
the sutures after 1 week. The periodontal dressing is
replaced for an additional week if it is necessary
 48
A

B
c 49

D
 E 50

Figure . Coronally displaced flap. A, Preoperative view. Note the

recession and the lack of attached gingiva. B, After placement of a
free gingival graft. C, Three months after placement of the graft. D,
Flap, including the graft, positioned coronally and sutured. E, Six
months later. Note the root coverage and the presence of attached
gingiva. Compare with A.
Free Autogenous Gingival Grafts 51
 Donor sites are located somewhere in the mouth.
 The most common site is the palate, but edentulous areas are
also used.
 The recipient site is prepared in a manner similar to the
pedicle graft site.
 Surgical excision removes a donor graft of keratinized
epithelium with some underlying connective tissue.
 The graft is sutured in place and held with firm pressure until
the initial blood clot forms to stabilize the graft.
Free Gingival Autograft. 52
Successful and predictable root coverage has been
reported using free gingival autografts.

The Classic Technique.

Step 1: Root planing. Root planing is performed with the

application of saturated citric acid for 5 minutes on the
root surface.
 53
Step 2: Prepare the recipient site. Make a horizontal incision in
the interdental papillae at right angles to create a margin against
which the graft may have a butt joint with the incision.
Vertical incisions are made at the proximal line angles of adjacent
teeth and the retracted tissue is excised. Maintain an intact
periosteum in the apical area.
Step 3: Transfer and immobilize the graft. Remove the sponge
from the recipient site; reapply it with pressure if necessary until
bleeding is stopped. Remove the excess clot. A thick clot
interferes with vascularization of the graft.
 54 a
Step 4: Protect the donor site. Cover the donor site with
periodontal pack for 1 week, and repeat if necessary.

This technique results in predictable coverage of the denuded

root surface but may present esthetic color discrepancies with
the adjacent gingiva because of a lighter color.
 55

B
C
56

D
 57

E F

Figure 63-3 Free gingival graft. A, Before treatment; minimal

keratinized gingiva. B, Recipient site prepared for free gingival
graft.
C, Palate will be donor site. D, Free graft. E, Graft transferred
to recipient site. F, At 6 months, showing widened zone of
attached gingiva.
(Courtesy Dr. Perry Klokkevold, Los Angeles.)
 58
Subgingival (Subepithelial) Connective Tissue
Graft
 Grafting subepithelial connective tissue has become the
procedure of choice when root coverage is the objective of
mucogingival surgery.
 Advantages of subepithelial connective tissue grafting include:
 Postoperative discomfort and bleeding are reduced.
 Tissue color and texture are more similar to the preoperative
appearance.
Free Connective Tissue Autograft. 59
The difference between this technique and the free gingival
autograft is that the donor tissue is connective tissue.

The following is a step-by-step surgical description of the free

connective tissue autograft technique:
Step 1: Divergent vertical incisions. Divergent vertical incisions
are made at the line angles of the tooth to be covered creating a
partial-thickness flap to at least 5 mm apical to the receded area.
Step 2: Suturing. Suture the apical mucosal border to the
60
periosteum using a gut suture.

Step 3: Scaling and root planing. Thoroughly scale and root plane,
which also reduces any prominence on the root surface.

Step 4: Obtain the graft. From the palate, obtain a connective tissue
graft. The donor site is sutured after the graft is removed.
Step 5: 61
Transfer the graft. Transfer the graft to the recipient site, and
suture it to the periosteum with a gut suture. Good stability of
the graft must be attained with adequate sutures.

Step 6:

Cover the graft. Cover the grafted site with dry aluminum

foil and periodontal dressing.

 62

B
 63

D
 64

F
 65

H
 66

I J

Fig. Free connective tissue graft. A, Lack of keratinized, attached gingiva

buccal to central incisor. B, Vertical incisions to prepare recipient site. C,
Recipient site prepared. D, Palate from which connective tissue will be
removed for donor tissue. E, Removal of connective tissue. F, Donor site
sutured. G, Connective tissue for graft. H, Free connective tissue placed
at donor site. I, Postoperative healing at 10 days. J, Final healing at 3
months. Note wide, keratinized, attached gingiva.
 67
Contraindications for Mucogingival
Surgery
 Lack of donor tissue
 Lack of adequate keratinized tissue at the recipient site
Techniques to Remove the Frenum68
Frenectomy and Frenotomy
 Frenectomy and frenotomy refer to surgical procedures that
differ in degree.

 Frenectomy is complete removal of the frenum, including its

attachment to underlying bone, and may be required in the
correction of an abnormal diastema between the maxillary
central incisors.

 Frenotomy is the relocation of the frenum, usually in a more

apical position.
Procedure 69
If the vestibule is deep, the procedure is confined to the frenum.
It is often necessary to deepen the vestibule to provide space for
the repositioned frenum.

This is accomplished as follows (Figure 63-19):

Step 1. After anesthetizing the area, engage the frenum with a

hemostat inserted to the depth of the vestibule.

Step 2. Incise along the upper surface of the hemostat, extending

beyond the tip.

 70
Step 3. Make a similar incision along the undersurface of the
hemostat.
Step 4. Remove the triangular resected portion of the frenum
with the hemostat. This exposes the underlying fibrous attachment
to the bone.
Step 5. Make a horizontal incision, separating the fibers, and
bluntly dissect to the bone.
Step 6. If necessary, extend the incisions laterally and suture the
labial mucosa to the apical periosteum. A gingival graft or
connective tissue graft is placed over the wound.
 71
Step 7. Clean the surgical field with gauze sponges until
bleeding stops.
Step 8. Cover the area with dry aluminum foil and apply the
periodontal dressing.
Step 9. Remove the dressing after 2 weeks and redress if
necessary.
One month is usually required for the formation of an
intact mucosa with the frenum attached in its new position.
A
72

B
C D 73

Fig. Removal of the frenum. A, Preoperative view of

frenum between the two maxillary central incisors. B,
Removal of the frenum from both the lip and gingiva. C,
Site is sutured after it is placed over the wound. D,
Postoperative view at 2 weeks.
 74

1-Before surgery. 2-Holding frenum

3-Cutting of frenum 4-Suturing

 75

5-After surgery.
Therapy to Correct Excessive 76

Gingival Display
 Excessive gingival display, commonly called a “gummy
smile,” represents an esthetic concern for many patients. This
appearance may be caused by a skeletal problem called
vertical maxillary excess, by dentoalveolar extrusion, or by
incomplete exposure of the anatomic crown, often referred
to as altered passive eruption.
 It may be associated with a short upper lip or excessive lip
translation. There may be a combination of causative factors
requiring more than one treatment option.
 The cause of the “gummy” appearance is incomplete exposure 77
of the
anatomic crown, the teeth will appear short and unattractive.

 This appearance is often noticed in adolescent patients during orthodontic

treatment.

 It has been found that if there is a need for esthetic crown lengthening before
orthodontic therapy, there will still be a need after orthodontic therapy and
likely still a need 5 years later.

 Although patients may complain of the gummy exposure, the real esthetic
issue is the altered tooth form. Surgical crown lengthening addresses both
concerns, but its focus should be the exposure of a properly proportioned
tooth.
 78
Ideally, the width/length ratio of a maxillary central incisor clinical crown
should fall between 0.78 and 0.85.

 Thus a central incisor with a width of 8.5 mm should have a length

between 10 and 11 mm. The length of the maxillary canine is equal to or
slightly less than the central incisor, and its gingival margin should be
aligned with the central incisor gingival margin. The gingival margin of the
lateral incisor is usually about 1.0 mm coronal to the margins of the
adjacent teeth, although in patients with a high lip line, it is generally more
pleasing to have the lateral incisor gingival margin equal to the central
incisors and canines
Surgical Techniques
79
 Exposure of the full anatomic crown is necessary to achieve
a smile with minimal gingival exposure.

 Measurements before surgery should include clinical crown

width and length, anatomic crown length, and height of
keratinized tissue.
Surgical crown lengthening may be accomplished by soft tissue excision
80
alone or by flap surgery with or without osseous surgery.

The determinates for choice of surgical procedure are

(1) the need to leave a minimum of 3.0 mm of keratinized marginal tissue

and

(2) the possible need for osseous surgery. If excision of soft tissue for full
anatomic crown exposure would leave at least 3.0 mm of keratinized
marginal tissue and there is no need for osseous surgery, soft tissue
excision alone is the treatment of choice. If less than 3.0 mm of
keratinized marginal tissue would remain after the necessary excision, an
apically positioned flap would be required.
Osseous Surgery.
81
 Soft tissue level is determined by thickness and level of the
underlying alveolar bone. A thick bone margin or an alveolar
crest at or near the CEJ causes the overlying gingiva to cover
more of the anatomic crown than that seen where the alveolar
crest is of normal thickness and positioned 2 mm apical to the
CEJ.
 82 3
The facial soft tissue margin is located approximately
mm coronal to the osseous crest, allowing 2 mm for
biologic attachment and 1 mm for sulcus depth. Failure to
adjust bone form and level to account for these dimensions
leads to rebound of surgically reduced soft tissue to reform
this biologic width
Precise osseous surgery is best accomplished after elevation83of a
full-thickness mucoperiosteal flap that provides good visibility
and access for three-dimensional ostectomy and osteoplasty. In
esthetic crown lengthening, only a facial flap is raised to prevent
loss of papillary fill. Initial gross osteoplasty is accomplished
withA round bur to reduce excessive bone thickness, followed by
alteration of the crestal level with hand chisels and curettes. It is
important to reduce the osseous crest so that the new position
parallels the CEJ at each tooth both facially and proximally.
However, the height of the interdental crest is not reduced in
esthetic crown lengthening.
 If full exposure of the anatomic crown is desired, the
84
alveolar crest should be reduced to a position 3 mm
apical to the CEJ. Excessive bone thickness interdentally
is reduced with a round bur to produce a slight
prominence of the roots relative to the alveolar ridge.

 Flap closure is accomplished with interrupted 7-0

sutures. Postoperative instructions are focused on plaque
control to prevent soft tissue rebound.
A
85

B
C
86

D
E 87

F
 88

G
 H 89

Fig. A, Excessive gingival display and short clinical crowns. B, Short clinical
crowns and thick periodontium. C, Excision of marginal gingiva to expose full
anatomic crown. D, Full-thickness flap elevation revealing thick alveolar bone
with irregular crest. E, Ostectomy and osteoplasty completed. F, Flap
repositioned and sutured with interrupted sling sutures. G, Three weeks
postoperative view. H, Two months postoperative view.
 90

Lecture 8
Procedures for Regeneration 91

of the Periodontium
 Regeneration surgery procedures include a variety of
surgical techniques that attempt to restore the periodontal
tissues lost through disease.
 Periodontal regeneration is the formation of new alveolar bone,
new cementum, and new periodontal ligament on a tooth root
surface that was previously diseased.
 Current techniques include bone grafting and guided-tissue
regeneration.
Periodontal Bone Grafting 92

 Transplanting bone to restore bone lost from periodontal

disease has been attempted for many years.

 The anatomy of the periodontal defect is the most critical

factor in determining the success of bone grafting.

 The classification of periodontal bone grafts is based on the

source of graft material.
Autografts 93

 Autografts are created from donor bone from the patient’s

own body.
 Bone may also be taken from extraoral sites, such as the iliac
crest of the hip or the sternum.
 Problems may occur with obtaining the graft, and the
possibility of root resorption makes the graft less useful.
 Bone may be taken from intraoral sites, such as mandibular tori,
the maxillary tuberosity, or bone removed during osteoplasty.
 It function as osteoinductive or osteoconductive.
Allografts 94

 Allografts are created from bone that comes from another person.
 Cadaver bone, obtained from bone banks accredited by the
American Association of Tissue Banks, is the most common
source of bone allografts used in periodontics.
 Also cortical bone as ribs or iliac and vertebral bone stored by
freezing.
 The best clinical results have been obtained with bone that has
been freeze-dried and demineralized (DFDB) because it has
osteogenic and osteoinductive potential.
Xenografts 95
 Xenografts are created from bone taken from another
species, such as bovine (cow) or porcine (pig) bone and
coralline calcium carbonate (natural coral).

 Tissues from nonhuman species have strong antigenic reactions

with human graft recipients.

 The most successful use of these materials has been as fillers

for large osseous defects, using graft material with all organic
tissue chemically removed.
Alloplasts(synthetic grafts): 96

 Alloplastic grafts use a variety of synthetic bone minerals:

 Hydroxyapatite mineral or ceramics, such as plaster of
Paris and tricalcium phosphate
 Porous hydroxyapatite appears to be osteophilic,
osteoconductive.
 Bioactive glasses as periglass that composed of calcium
oxide, sodium oxide and silica oxide seem to promote
osteogenesis.
Indications for Periodontal Bone Grafting 97
 Bone grafting in infrabony defects shows a potential for
regeneration.

 Infrabony defects, ideally three-wall defects, usually have

sufficient osseous walls to promote healing.

 Furcation defects, particularly mandibular molar buccal

furcations of grade II (not through-and-through), are often
good candidates for bone regeneration with osseous grafts.
Procedure for Periodontal Bone Grafting 98
 Full-thickness mucoperiosteal flaps are elevated.

 All granulation tissues are removed with curettes.

 The bone graft material is prepared according to the

distributor’s instructions or harvested from the donor site and
inserted into the defects.

 The best results appear to be obtained with primary closure of

the flaps over the wound site.
 99

B
 10
Fig.A, Osseous 0
defect mesial to a
second premolar. B,
Graft material
placed in dappen
dish before transfer
to the graft site. C
C, Material in
place. D, Reentry 6
months later

D
 10
1
Contraindications for Periodontal Bone
Grafting
 No specific contraindications exist to bone fill

procedures.

 The most predictable bone fills occur in patients who

have a maximum number of bony walls, improving
the chances of success.
 10
Guided-Tissue Regeneration 2

 Guided-tissue regeneration, or healing by selected cell repopulation,

is a technique that permits the primary healing cells to proliferate
from the alveolar bone and periodontal ligament rather than from the
growth of epithelium from the gingiva.

 A barrier membrane, which excludes epithelial cells, is placed

between the periodontal flap and the alveolar bone; only cells from
the periodontal ligament space and the medullary bone are allowed to
repopulate the site of lost tissue.
 10
Guided Tissue Regeneration. 3
 First, the root surfaces and diseased bone are meticulously
cleaned out. Preventing bacterial contamination is very
important. The more residual bacteria, the greater the chance
that the treatment will fail.
 A specialized piece of fabric is sewn around the tooth to cover
the crater in the bone left after the cleaning. It is either
absorbable or nonabsorbable. (Some studies report highly
beneficial results with new absorbable materials, including
those coated with the antibiotic doxycycline.)
 10
 Guided-tissue regeneration selectively causes a new 4
attachment apparatus to grow.
 A number of materials have been suggested for these
barriers including:
 Non absorbable as Milipore filter, Teflon, rubber dam
and expanded polytetrafluoroethylene (ePTFE)
membranes,
 Absorbable synthetic as Polylactic acid with citric acid
ester membranes or polyurethane membranes.
 Absorbable natural as collagen type I: intrinsic collagen,
exogenous collagen, dura matter, connective tissue grafts
and oxidized cellulose mesh.
 10
Indications for Guided-Tissue Regeneration
5
 Infrabony defects and furcations appear to be the best
candidates for guided-tissue regeneration.

 In general, osseous lesions that are likely to respond

well to other forms of bone fill or grafting are also the
most promising sites for guided-tissue regeneration.
 10
Procedure for Guided-Tissue Regeneration 6
 Flaps are reflected, and débridement of the intraosseous lesion
occurs.
 A membrane is placed over the opening in the bone or furcation
and fastened to the tooth by suture or other stabilizing methods.
 The epithelium is closed over the membrane and allowed to
heal for of 30 to 60 days.
 When nonresorbable ePTFE material is used, the membrane
must be surgically removed.
 The polylactic acid material resorbs through hydrolysis in 6 to
12 months.
 10
7

A B
 10
8

C D
 10
9

Fig. Clinical photographs and radiographs of a guided tissue regeneration case using
expanded polytetrafluoroethylene (ePTFE) with titanium-reinforced membrane.
The osseous defect was along the distal interproximal area wrapping buccally over
the furcation (A, B). To prevent the membrane from collapsing over the root
surfaces, demineralized freeze-dried bone allograft (DFDBA) and adjusting the
titanium membrane provide a larger space for regeneration (C, D). One year
afterward, the radiographic and clinical signs are consistent with achieving
regeneration in this defect (E).
 11
Procedures Immediately 0

after Periodontal Surgery

 A number of procedures are required to complete the
periodontal surgery.
 These procedures include closing the wound with the
placement of sutures, possibly covering the surgical wound
with a protective dressing called a periodontal pack, and
providing the patient with postoperative instructions.
 11
1

Lecture 9
 11
2
Sutures
 Sutures are required to close periodontal surgical wounds
and to secure grafts in position.

 If a nonresorbable suture material is placed, then the sutures

must be removed in 7 to 14 days.

 Resorbable sutures are designed to dissolve in tissue fluids,

but they do not always dissolve and may require removal.
 11
3
Many techniques are used for suturing periodontal
flaps and grafts.
 Simple stitches
These are termed interrupted sutures.
 Complex sling sutures
These sutures use the teeth for an anchor.
 Mattress sutures
These sutures allow flaps to be placed in a variety of
positions.
 11
Basic Rules for Sutures 4
 Suture knots for any type or style of suture are tied on the
buccal surface.
 At least 2 or 3 mm of suture “tail” should be left beyond the
knot.
 The location and number of sutures placed must be
documented in the patient’s chart.
 During removal of the sutures, documenting the location
and number of sutures prevents the possibility of missing
a suture.
 11
Periodontal Dressing 5

 A periodontal dressing or pack is sometimes placed

over the sutures to hold the flaps tightly to the teeth and
underlying bone when pocket-reduction surgery has
been performed.

 Periodontal dressing is also used after excisional surgery,

such as gingivectomy, to protect the surgical wound
from the oral environment and to increase patient
comfort during healing.
 11
Periodontal Dressing (cont.) 6
 The most common type of periodontal dressing consists of a
paste mixture that chemically sets to a firm, rubbery consistency.
 A light-cured product is available that allows the working and
setting times to be more precisely controlled.
 Whatever dressing is selected, it is mixed according to the
manufacturer’s instructions and placed in a thin ribbon around
the necks of the teeth.
 11
Periodontal Dressing (cont.) 7
 Periodontal dressing should be compressed into the
interproximal spaces for a mechanical lock.

 The material should not extend coronally to the height of

contour of the teeth.

 Bleeding must be controlled before a periodontal dressing is

placed; the pack will not control bleeding.
 11
 The use of the periodontal dressing is 8
demonstrated in the following figure.
 11
Postoperative Instructions 9

and Procedures
 After periodontal surgery, postoperative procedures may
include a prescription for an analgesic and possibly an antibiotic.
 Many periodontists recommend the use of a disinfectant rinse
twice a day to help with plaque biofilm control.
 A chlorhexidine or essential oil mouthwash may be used to
freshen the mouth and inhibit plaque.
 12
0
Postoperative instructions
 Limiting physical activity

 Control bleeding with light finger pressure on a

gauze sponge in the area of surgery

 Soft diet for the first few days

 Review of any prescriptions for medications

with the patient
 12
1
Postoperative instructions (cont.)
 Portions of the periodontal dressing may break off.
 Swelling may occur.
 An ice pack can be used for short intervals for the first
few hours after surgery.
 Smoking should be avoided.
 The surgical site should be cleaned with an extra
soft toothbrush, using warm water and gentle interproximal
cleaning.
 Unaffected teeth should be cleaned normally.
 12
Postoperative instructions (cont.) 2
 The patient must be given a list of postoperative instructions
that include a telephone number if problems arise.
 The patient should be urged to contact the office if any
problems develop or questions arise.
 A postoperative visit should be scheduled for approximately 7
days after the surgery.
 12
3

 A sample postoperative
instruction sheet is
demonstrated in the
following figure.
 12
Postoperative Treatment 4

 At the postoperative appointment, the patient is examined,

the periodontal dressing and sutures are removed, and the
surgical site is cleaned.
 The wound is usually well epithelialized by 7 to
10 days after surgery.
 12
 A surgical site with the periodontal dressing, 5
sutures, and accumulated plaque removed after 1
week is demonstrated in the following figure.
 12
 Homecare instructions for plaque biofilm control should6be
reviewed.
 Interproximal brushes may be indicated.
 Dental floss should be carefully used to avoid damaging
the healing junctional epithelium and connective tissue
attachment.
 Tooth sensitivity, especially to cold, is common.
 Use of home fluoride gels or rinses and desensitizing
toothpastes should be suggested.
 Topical desensitizing office treatments with
potassium oxalate or ferric oxalate may help with
hypersensitivity.
 12
Healing after Periodontal 7

Surgery
 Healing of the periodontal surgical wound begins shortly
after the procedure is completed.
 Gingivectomy wounds require slightly more time to
heal than flap procedures.
 A blood clot forms at the surgical site, protecting the
wound and allowing the tissue to begin to heal.
 The epithelial cells are the first to heal.
 12
 Connective tissue healing begins after the 8
epithelium has begun to heal.
 Osseous healing does not begin until late in the
healing process.
 Bone grafting procedures usually take more
time for healing than other osseous
procedures.
 12
 The clinical appearance of an access flap 9
procedure after 1 week is demonstrated in the
following figure.
 13
 Healing 3 months after periodontal surgery is 0
demonstrated in the following figure.
 13
1

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