CHAPTER 52: PHASE II PERIODONTAL THERAPY RATIONALE

 Removal of chronically inflamed granulation tissue that forms in the

OBJECTIVES OF THE SURGICAL PHASE lateral wall of periodontal pocket
1. Improvement of prognosis of teeth & their replacements
2. Improvement of esthetics INDICATIONS
1. Performed as part of new attachment in moderately deep infrabony
To fulfill these objectives, surgical techniques: pockets located in accessible areas where a type of “closed surgery” is
1. Increase access to root surface advised.
2. Eliminate pocket depth 2. Done as a non-definite procedure to reduce inflammation prior to
3. Reshape soft & hard tissues pocket elimination procedures like flap surgeries.
3. Performed in patients where extensive surgical procedures are
Second Objective of Surgical Phase contraindicated like aging, systemic complications where tx is
 Correction of anatomic morphologic defects compromised & prognosis impaired.
o Performed on noninflamed tissues 4. Curettage is frequently performed on recall visits as a method of
o Absence of periodontal pockets maintenance treatment for areas of recurrent inflammation & pocket
depth, particularly where pocket reduction surgery has previously been
Plaque Accumulation leads to: performed.
1. Gingival inflammation
2. Pocket deepening HEALING AFTER SCALING & CURETTAGE
 Blood clot fills pocket area
Surgical pocket therapy can be directed toward:  Hemorrhage present in tissues w/ dilated capillaries & increased PMN’s
1. Access surgery to ensure removal of irritants  Rapid proliferation of granulation tissues
2. Elimination of pocket depth  Restoration & epithelialization of sulcus take place in 2-7 days

Absence of deep pockets: excellent predictor of stable periodontium CLINICAL APPEARANCE AFTER SCALING & CURETTAGE
 Gingiva appears hemorrhagic & bright-red
CRITICAL ZONES IN POCKET SURGERY  After 1 week, gingiva appears reduced in height w/ apical shift
1. Soft tissue wall  After 2 weeks w/ proper oral hygiene, gingiva comes back to normal
2. Tooth surface
3. Underlying bone TECHNIQUES
4. Attached gingiva EXCISIONAL NEW ATTACHMENT PROCEDURE (ENAP)
 Developed by US Naval Corps
INDICATIONS FOR PERIODONTAL SURGERY  Definitive subgingival curettage procedure performed w/ a knife
1. Areas w/ irregular bony contours & deep craters
2. Removal of root irritants is not possible due to deep pockets frequently 1. After LA, an internal bevel incision is made from free gingival margin
in molars & premolars apically below base of pocket. It is carried all around tooth surface
3. In case of furcation involvement Grade II or III attempting to retain as much interdental tissues as possible.
4. Intrabony pockets on distal areas of last molars 2. The excised tissue is then removed w/ curette & root surface is planed
5. Persistent inflammation in areas w/ moderate to deep pockets to smooth consistency.

METHODS OF POCKET THERAPY GINGIVECTOMY | external bevel

1. New attachment techniques
2. Removal of pocket wall
3. Removal of tooth side of pocket: EXO, hemisection
CRITERIA FOR METHOD SELECTION
1. Characteristics of pocket
2. Accessibility to instrumentation
3. Existence of mucogingival problems
4. Response to Phase I therapy
5. Patient cooperation
6. Age & general health of px
7. Overall diagnosis of case
8. Esthetic considerations
9. Previous periodontal tx
Approaches to Specific Pocket Problems
Therapy for Gingival Pockets
EDEMATOUS
S&P
Therapy for Mild Periodontitis
 Conservative approach: S & P, adequate oral hygiene
 Excision of the gingiva by removing the pocket wall
 Performed by scalpel, electrodes, lasers, or chemicals
 Periodontal knives angled at 45 degrees
 Kirkland knives: for incisions on facial & lingual surfaces
 Orban knives: for supplemental interdental incisions
INDICATIONS
1. Eliminate suprabony pockets & abscess
2. Eliminate fibrous / gingival enlargements
3. Create more esthetic form in cases in which exposure of the anatomic
crown has not fully occurred
4. Expose additional clinical crown
CONTRAINDICATIONS
1. The need for bone surgery
2. Bottom of pocket is apical to MGJ
3. Esthetic considerations in anterior maxilla
FIBROTIC
Gingivectomy, MWF PREREQUISITES
1. Adequate zone of attached gingiva
2. Normal underlying alveolar bone
3. No any intrabony defects or pockets

Therapy for Moderate to Severe Periodontitis in Anterior Section SURGICAL PACK/ DRESSING
If esthetics is a CONCERN If esthetics is NOT a concern  Physical barrier placed in site to protect healing tissues
1. S & P 1. MWF  Consists of ZOE | Eugenol (oil of cloves) = obtundent
2. Surgery 2. Apically displaced  Leave in place for 1 week
1) Papilla preservation flap flap  Protect wound, minimize discomfort, prevent overgrowth of
2) Sulcular flap granulation tissue, & control post-op bleeding
 DOES NOT ENHANCE HEALING!
Therapy for Moderate to Severe Periodontitis in Posterior Section
1. Papilla preservation flap HEALING AFTER SURGICAL GINGIVECTOMY
2. Sulcular flap  Initial response: formation of blood clot
3. Modified Widman flap  Clot is replaced by granulation tissue
 In 24 hrs, increase in new CT cells (angioblasts)
CHAPTER 56: GINGIVAL SURGICAL TECHNIQUES  Complete epithelization takes about 1 month

GINGIVAL CURETTAGE: removal of inflamed soft tissue lateral to the pocket wall & GINGIVOPLASTY: recontour gingiva in the absence of pockets
junctional epithelium  Technique resembles festooning of denture which consists of:
1. Tapering gingival margin
SUBGINGIVAL CURETTAGE: performed apical to junctional epithelium & severing CT 2. Creating scalloped margin
attachment down to osseous crest 3. Thinning attached gingiva
4. Creating vertical interdental grooves
INADVERTENT CURETTAGE: some degree of curettage is accomplished 5. Shaping interdental papillae
unintentionally during scaling & root planning
ELECTROSURGERY/ SURGICAL DIATHERMY (1.5-7.5 million cycles/second) A. HORIZONTAL INCISION
ADVANTAGE DISADVANTAGES INTERNAL / REVERSE BEVEL CREVICULAR INCISION INTERDENTAL INCISION
Permits adequate Cannot be used in poorly shielded cardiac pacemaker Flap is reflected to expose Made from the base of Separates collar of
contouring of Causes unpleasant odor underlying bone pocket to crest of bone gingiva from tooth
tissues & controls Necrosis of bone occurs if contact w/ bone occurs #15C blade #12D blade Orban knife
hemorrhage
B. VERTICAL INCISION/ OBLIQUE RELEASING INCISION
INDICATIONS  Used for repositioning flap apically or laterally
1. Gingivectomy  Must extend beyond MGJ to displace flap
2. Gingivoplasty  Should be made at line angles of tooth either to include papilla in
3. Relocation of frenum & muscle attachments the flap or avoid it completely
4. Incision of periodontal abscess & pericoronal abscess  Lingual & palatal areas are avoided
 #15 blade
CHAPTER 57: PERIODONTAL FLAP
ENVELOPE FLAP (sulcular flap)
PERIODONTAL FLAP SURGERY  Simplest flap done in horizontal incision; no vertical incisions made
 Most widely used surgical procedure to reduce pocket depth & access
subgingival root surfaces BASIC RULES FOR FLAP DESIGN
1. Base of the flap should be wider/ broad for adequate blood supply
A. POCKET REDUCTION SURGERY 2. Flap should rest over healthy bone
1. Resective 3. Incisions that traverse a bony eminence should be avoided.
a. Gingivectomy 4. All corners should be rounded. Sharp points will delay healing.
b. Flap techniques
2. Regenerative HEALING AFTER FLAP SURGERY
a. Flaps w/ grafts & membranes  Immediately after suturing (up to 24 hrs): blood clot is established
B. CORRECTION OF ANATOMIC DEFECTS  After 1-3 days, epithelial cells migrate over border of flap
1. Plastic surgery  After 1 week, epithelial attachment to the root has been established.
a. To widen attached gingiva Blood clot is replaced by granulation tissue.
2. Esthetic surgery  In 21 days, granulation tissue is replaced by connective tissue
a. Root coverage  Epithelial attachment healing is completed in 4 weeks
b. Recreate gingival papillae  After 1 month, a fully epithelialized gingival crevice w/ well-defined
3. Preprosthetic surgery epithelial attachment is present
a. Crown lengthening
b. Ridge augmentation * Full thickness flap result in superficial bone necrosis at 1-3 days
c. Vestibular deepening * Osteoclastic resorption follows & reaches a peak at 4-6 days
C. REMOVAL OF POCKET WALL * Bone loss is GREATER if bone is THIN.
D. NEW ATTACHMENT TECHNIQUES * Split thickness flap results in LESS bone loss than full thickness flap.

CLASSIFICATION OF FLAPS CHAPTER 59: FLAP TECHNIQUE FOR POCKET THERAPY

Based on Bone Exposure After Flap Reflection
FULL THICKNESS FLAP PARTIAL THICKNESS FLAP
USES OF FLAPS FOR POCKET THERAPY
BLUNT dissection SHARP dissection
1. Increase accessibility to root deposits
Mucoperiosteal flap Mucosal flap / Split thickness flap 2. Eliminate or reduce pocket depth by resection of pocket wall
All soft tissues + periosteum to Includes only the epithelium & a layer 3. Gain access for osseous resective surgery if necessary
expose underlying bone of underlying CT 4. Expose area to perform regenerative methods
Indicated when resective Indicated when flap is to be
osseous surgery is positioned apically or when operator FLAP TECHNIQUES
contemplated does not want to expose bone MODIFIED WIDMAN FLAP (MWF)
Used where attached gingiva is Used where attached gingiva is THICK  Objectives:
THIN (2 mm or less in width) (2 mm or more) 1. Facilitate root debridement
2. Remove pocket lining
* BOTH flaps can be DISPLACED.  INCISIONAL procedure | ENOUGH attached gingiva
* Palatal flaps CANNOT be displaced due to absence of unattached gingiva.  Shallow to moderate pocket w/ base CORONAL to MGJ

Based on Flap Placement After Surgery UNDISPLACED FLAP (internal bevel gingivectomy)
NONDISPLACED FLAP DISPLACED FLAP  Objective: Eliminate pocket wall
Flap is returned & sutured to its Flap is placed apically, coronally, or  EXCISIONAL procedure | ENOUGH attached gingiva
original position laterally to their original position  Most frequently performed type of periodontal surgery

Example of Displaced Flap or Repositioned Flap APICALLY DISPLACED FLAP

LATERALLY POSITIONED FLAP  Objective: Eliminate pocket
 Also called pedicle graft or double papilla technique  INCISIONAL procedure | MINIMAL attached gingiva
 For long narrow single-tooth recession defects  Moderate to deep pocket w/ base APICAL to MGJ
 Better color matching & less damage  High degree of predictability & “workhorse” of periodontal therapy
 Indications:
CORONALLY POSITIONED FLAP 1. Moderate to deep pockets
 Split-thickness flap that is advanced coronally to gain root coverage 2. Furcation involved teeth
 For single or multiple-tooth recession defects & sensitivity 3. Crown lengthening
 Contraindication: If px is at RISK for root caries
Based on Management of Papilla (RECONSTRUCTIVE SURGERY)  For pocket elimination & increase width of attached gingiva
CONVENTIONAL FLAP PAPILLA PRESERVATION FLAP
Interdental flap is split beneath Incorporates the entire papilla in one Anatomic Landmarks to Evaluate Amount of Attached Gingiva After Surgery
contact point of two approximating of the flaps by crevicular interdental 1. Pocket depth
teeth to allow reflection of buccal & incisions to sever CT attachment & 2. Location of MGJ
lingual flaps horizontal incision at the base of
papilla, leaving it connected to one of MILLER CLASSIFICATION SYSTEM FOR RECESSION
the flaps CLASS I DOES NOT extend to MGJ, NO bone loss
Used when interdental spaces are too Gives more ESTHETIC results CLASS II Extends beyond MGJ, NO bone loss
narrow or when flap is to be replaced CLASS III Extends beyond MGJ, there IS bone loss
CLASS IV Extends beyond MGJ, SEVERE bone loss
 Parameters MWF UNDISPLAC APICALLY GOLDMAN & COHEN CLASSIFICATION OF ANGULAR DEFECTS
ED FLAP DISPLACED FLAP (based on the number of left or remaining walls)
Procedure Incisional Excisional Incisional
THREE-WALL DEFECT TWO-WALL DEFECT ONE-WALL DEFECT
Objective Facilitate root Eliminate To eliminate
debridement pocket wall pocket Distal, lingual, facial Distal, lingual Distal
Remove Interdental crater Osseous crater Hemiseptum
Best prognosis Most common Poorest prognosis
pocket lining
Regenerative Regenerative Resective
Indications Shallow to When Moderate to deep
moderate there is pockets w/
pocket depth enough base of
BONE DESTRUCTION PATTERNS IN PERIODONTAL DISEASE (CHAPTER 14)
w/ base of attached pocket apical
pocket gingiva to MGJ * Bone formation occurs in an attempt to buttress or give support to bony
coronal to trabeculae weakened by resorption.
MGJ
Vertical Not needed Not needed Needed OSSEOUS CRATERS
incision  Concavities in the crest of the interdental bone confined w/in facial &
Bleeding Not marked Marked Not marked lingual walls
points
BULBOUS BONE CRATERS
Ability to treat No No Yes
 Bony enlargements caused by exostoses, adaptation to function or
osseous
buttressing bone formation (lipping)
defects
Degree of Low Low High REVERSED ARCHITECTURE
difficulty  Defects produced by loss of interdental bone including facial & lingual
plates w/out loss of radicular bone, thereby reversing the normal
CHAPTER 60: RESECTIVE OSSEOUS SURGERY architecture

OSSEOUS SURGERY LEDGES

Defined as the procedure by which changes in the alveolar bone can be  Resorption of thick margins resulting in plateau formation
accomplished to rid it of deformities induced by periodontal disease process
Depending on the relative position of the interdental bone to the radicular bone,
ADDITIVE SUBTRACTIVE osseous surgery may result to the ff types:
Directed towards restoration of Restore the form of preexisting
bone to its original level alveolar bone to the level existing at Positive architecture If radicular bone is apical to the interdental bone
(regenerative osseous surgery such the time of surgery or slightly apical to Negative architecture If interdental bone is more apical than radicular bone
as graft & GTR) this level (resective osseous surgery) Flat architecture Radicular & interdental bone at same height
Ideal architecture When the bone is consistently more coronal on the
RATIONALE interproximal surface than on facial & lingual surfaces
 Goal of osseous surgery is based on the tenet that discrepancies in the
levels & shapes of the bone & gingiva predispose patients to the OSSEOUS RESECTION TECHNIQUES
recurrence of pocket formation & deepening post surgically 1. VERTICAL GROOVING | osteoplasty
 Hence, the need to RESHAPE alveolar bone  Usually performed w/ rotary instruments such as round, carbide or
diamond burs
Periodontal Disease –> Bone Irregularities –> Pocket Recurrence  Indicated in thick, bony margins, shallow crater formation to reduce
thickness of alveolar housing & provide continuity from the
interproximal surface into radicular surface
 Contraindicated in areas w/ close roots or thin alveolar housing

2. RADICULAR BLENDING | osteoplasty

 Attempt to gradualize bone over entire radicular surface to provide
smooth, blended surface for good flap adaptation
 Not necessary if vertical grooving is very minor or if radicular bone is
thin or fenestrated

FENESTRATION DEHISCENCE 3. FLATENNING OF INTERPROXIMAL BONE | ostectomy

Root surface is denuded of bone &
covered by periosteum & gingiva;
does not extend to marginal bone
Procedures Used to Correct Osseous Defects:
OSTEOPLASTY
Refers to shaping WITHOUT
removal of supporting bone
INDICATIONS
Osseous craters
One-walled, two-walled,
three-walled defect
Furcation involvement
Tori & exostoses
Loss of buccal/ lingual bone overlaying  Requires removal of very small amounts of supporting bone
root portion of tooth, leaving area  Indicated when interproximal bone levels vary horizontally, for one-
covered by soft tissue only walled defect
 Can be helped in obtaining good flap closure & improved healing in
three-walled defect
OSTECTOMY  Contraindicated in advanced lesions
Refers to excision INCLUDING removal
4. GRADUALIZING MARGINAL BONE | ostectomy
of supporting bone
 Bone removal should be minimal to provide a sound regular base for
gingival tissues to follow
CONTRAINDICATIONS
 May result in “widow’s peak” which allows tissue to rise to a higher
Anatomic factors High caries index
level than the base of bone loss in the interdental area
Age Extreme root sensitivity
Systemic health Advanced periodontitis EXPLORATORY SURGERY
Improper oral Unacceptable esthetic  The only sure way to determine the presence & configuration of osseous
hygiene result defects

BONE DESTRUCTION PATTERNS IN PERIODONTAL DISEASE

CHAPTER 61: RECONSTRUCTIVE OSSEOUS SURGERY
HORIZONTAL BONE DEFECT
 Most common pattern of bone loss Nonbone Graft Associated New Bone Graft Associated New
 Bone is reduced in height but margins remain perpendicular to tooth Attachment Attachment
surface (suprabony pockets)
Removal of JE & Pocket Epithelium  Autograft
VERTICAL / ANGULAR BONE DEFECT  Curettage  Allograft/ homograft
 Chemical agents  Alloplastic graft
 Occurs in oblique direction
 Surgical techniques  Xenograft/ heterograft
 Base of defect is apical to surrounding bone (infrabony pockets)
 Angular defects are classified by Goldman & Cohen
Prevention of Epithelial Migration  Osteoinduction
 GTR  Osteoconduction
 One-wall, two-wall, or three- wall vertical defect
Biomodification of root surface  Contact inhibition
PATTERNS OF BONE LOSS
1. HORIZONTAL: chronic periodontitis, adult onset
2. VERTICAL: LAP, trauma from occlusion, early onset
GUIDED TISSUE REGENERATION (GTR) Osseous Grafting Techniques & Materials
 Placement of nonresorbable barriers or resorbable membranes & AUTOGENOUS BONE GRAFTS
barriers over a bony defect
o ePTFE / expanded polytetrafluoroethylene Osseous coagulum Mixture of bone dust from cortical bone & blood
(NONRESORBABLE) Bone blend Uses autoclaved plastic capsule & pestle
o polylactic acid & acetyl tributylcitrate (RESORBABLE) Cancellous bone marrow Obtained from maxillary tuberosity, edentulous
 Utilizes bio-material membrane to act as protective barrier between transplants areas, & healing sockets
gingiva & periodontal defect for generation of periodontal tissues Bone from extraoral sites Fresh or preserved iliac cancellous marrow bone
(iliac autografts taken from medial aspect)
OBJECTIVES
 To use the bio-material membrane as a space-maker to isolate the ALLOGRAFT FDBA (Undecalcified Freeze-Dried Bone Allograft)
defect from epithelium & gingival connective tissue during healing DFDBA (Demineralized Freeze-Dried Bone Allograft)
 The isolation will enable new attachment/ regeneration to occur on the XENOGRAFT Calf bone, kiel bone, anorganic bone
previously diseased tooth/ root ALLOPLASTIC/ Bioactive glass, hydroxyapatite, tricalcium phosphate,
NONBONE GRAFT HTR polymer, coral-derived materials
AVOID formation of: long junctional epithelium
BIOLOGIC MEDIATORS
INDICATIONS CONTRAINDICATIONS
 Use of growth factors secreted by macrophages, endothelial cells,
Furcation involvement (Grade 2 & 3) Defects w/ minimal attachment loss
fibroblast & platelets
Two-walled & three-walled defect Defects w/ too little remaining PDL
1. Platelet-derived growth factor (PDGF)
Defects w/ abundant attached gingiva
2. Insulin-like growth factor (IGF)
3. Basic fibroblast growth factor (BFGF)
Order of Which Cells Arrive First During Periodontal Pocket Healing:
4. Bone morphogenetic protein (BMP)
1. EPITHELIAL CELLS
5. Transforming growth factor (TGF)
2. GINGIVAL CT CELLS
3. PDL CELLS ENAMEL MATRIX PROTEIN
4. BONE CELLS  Called amelogenin secreted by HERS during tooth development &
induce acellular cementum formation (trade name: Emdogain)
BIOMODIFICATION OF THE ROOT SURFACE
 Derived from developing porcine teeth, 90% is amelogenin – a viscous
Substances used to condition root surface for attachment of new CT fibers:
gel applied into root surface
 Citric acid: demineralize root surface which can induce cementogenesis
SOURCES OF BONE
& adhesion of collagen fibers
 Healing extraction wound
 Fibronectin: glycoprotein that fibroblast require to attach to root
 Bone from edentulous ridges
surface
 Bone trephined from w/in jaw w/out damaging roots
 Tetracycline: antibiotic that shows in vitro studies in dentin surfaces
 Newly formed bone in wounds especially created for the purpose
increases binding of fibronectin which in turn stimulates fibroblasts
 Bone removed from tuberosity & ramus
attachment & migration
 Bone removed during osteoplasty & ostectomy
STEPS
1. Raise full thickness flap CHAPTER 62: FURCATION: INVOLVEMENT & TREATMENT
2. Perform thorough root planing
3. Apply cotton pellet soaked in citric acid pH1 for 2-3 mins FURCATION
4. Remove & irrigate root surface profusely w/ NSS  Area of complex anatomic morphology that may be difficult or
5. Replace flap & suture impossible to debride by routine periodontal instrumentation

BONE GRAFT ASSOCIATED NEW ATTACHMENT

FURCATION INVOLVEMENT
GRAFT: viable tissue/ organ that after removal from donor site is implanted/
 Refers to invasion of bifurcations & trifurcations of multirooted teeth by
transplanted w/in host tissue, which is then repaired, restored, & remodeled
periodontal disease
 “Defined as pathologic resorption of bone within the furcation” (AAP,
AUTOGRAFT Tissue transfer from one position to new position in same
2001)
individual (from yourself)
ALLOGRAFT/ Tissue transfer of the same species w/ non-identical genes
ETIOLOGICAL FACTORS
HOMOGRAFT
1. Bacterial plaque: primary etiologic factor
ALLOPLASTIC Graft of inert synthetic material sometimes called implant 2. Extension of inflammation
GRAFT material 3. CEPs
XENOGRAFT/ Donor of graft is from different species (from animal) 4. Trauma from occlusion
HETEROGRAFT
CLINICAL DIAGNOSIS
PEDICLE GRAFT  Naber’s probe w/ simultaneous blast of warm air to facilitate
 Soft tissue graft that is rotated or otherwise positioned to correct an visualization
adjacent defect  Radiographs also help detect furcation defects
 Base of graft remains attached to donor site to maintain blood supply
ANATOMIC FACTORS
BONE GRAFTING MATERIALS EVALUATED BASED ON THEIR POTENTIAL:
1. ROOT TRUNK LENGTH
OSTEOGENIC Contains viable bone cells & is the ideal property of a
o Root trunk: landmark from CEJ & separation of roots
bone graft | ex: autogenous cancellous bone
o The shorter the root trunk, the less attachment needs to be
OSTEOINDUCTIVE Actively induce bone formation | ex: DFDBA
lost before furcation is involved
OSTEOCONDUCTIVE Acts as passive matrix; induce bone formation when o Short root trunks are more accessible
placed next to viable bone only | ex: hydroxyapatite 2. ROOT LENGTH
CONTACT Process by which the graft material prevents apical o Directly related to the quantity of attachment supporting
INHIBITION proliferation of epithelium the tooth
o Long root trunks & short roots may have lost their support
AUTOGRAFT/ AUTOGENOUS GINGIVAL GRAFTS 3. ROOT FORM
FREE GINGIVAL GRAFT o Curvature & fluting increases potential for root perforation
 Involves taking a section of attached gingiva from another area of during endodontic therapy & VRF
mouth & suturing it to recipient site 4. INTERRADICULAR DIMENSION
 Success depends on the graft being immobilized at the recipient site o Fused roots can preclude adequate instrumentation
 Epithelium of graft degenerates o Widely separated roots are more readily treated
 Used to widen attached gingiva & for gingival recession 5. ANATOMY OF FURCATION
 Graft is DEVOID of blood supply o Presence of bifurcation ridges, concavity of dome &
 Common donor site: PALATE w/ 1-1.5 mm thickness accessory canals
6. CEPs
FREE MUCOSAL GRAFT (recipient site) o Highest prevalence: MAN & MAX 2nd molars
 Aka subepithelial connective tissue graft o Affect plaque removal
 Used for root exposure problems o Complicate scaling & root planing
 Graft is from dense CT w/ BLOOD SUPPLY
 Transplant is connective tissue w/ epithelial covering
MASTERS & HOSKINS CLASSIFICATION OF CEPs (1964) SAS 17: IMPORTANT DRUGS USED FOR PERIODONTAL THERAPY
Grade I Enamel projection extends from CEJ toward furcation entrance
Grade II Enamel projection approaches entrance to furcation. Does not Classification of Drugs Used in Periodontal Therapy
enter furcation & no horizontal component is present 1. Antiplaque & anticalculus agents (pyrophosphates)
Grade III Enamel projection extends horizontally into furcation 2. Antibiotics for periodontal disease
3. Anti-inflammatory for pain
INDICES OF FURCATION INVOLVEMENT
GLICKMAN CLASSIFICATION (1953) CHEMOTHERAPEUTIC AGENTS
Grade I Incipient bone loss or early lesion; depression on furcal opening  Ability of an active chemical substance to provide therapeutic clinical
described as dimpled benefits
Grade II Partial bone loss; cul-de-sac lesion
Grade III Total bone loss w/ through & through opening of furcation; seen ANTIMICROBIAL AGENTS
radiographically  Chemotherapeutic agents that reduce the amount of microorganisms
Grade IV Same as grade III w/ gingival recession; seen clinically present

TARNOW & FLETCHER (1984): based on vertical component BACTERICIDAL BACTERIOSTATIC

Subgroup A Vertical destruction of bone up to 1/3 of inter-radicular Process or agent that Process or agent that INHIBITS
height (1-3 mm) DESTROYS bacteria growth of bacteria
Subgroup B Vertical destruction of bone up to 2/3 of inter-radicular Targets cell wall Targets protein synthesis
height (4-6 mm) PENICILLINS TETRACYCLINES
Subgroup C Vertical destruction beyond apical 3rd (7 mm or more)
ANTIBIOTICS
HAMP et al. (1975): based on horizontal component  Antimicrobial agents produced by or obtained from bacteria that have
Degree I Horizontal bone loss of LESS than 3 mm the capacity to kill bacteria or inhibit growth
Degree II Horizontal bone loss of MORE than 3 mm
Degree III Through & through horizontal lesion PENICILLIN G PENICILLIN VK
IV or IM route Oral route
TRADITIONAL TREATMENT PROCEDURES
CLASS PROGNOSIS TREATMEMT 1. PENICILLIN
o AMOXICILLIN
Grade I POOR Odontoplasty, curettage, S&P
 500 mg TID for 1 week
Grade II POOR Osteoplasty w/ limited ostectomy
o AUGMENTIN (amox + clavulanate potassium)
Grade III POOR Root resection/ amputation
 375 mg TID for 1 week
 DB root of max. 1st molars
 625 mg BID for 1 week
Grade IV GOOD Bicuspidization/ premolarization (man. molar)
2. CIPROFLOXACIN
Hemisection
o Quinolone; active against gram (-)
o Effective against A. actinomycetemcomitans (LAP)
PREMOLARIZATION HEMISECTION
3. CLINDAMYCIN
Splitting into two rooted into Surgical removal of root along o Prescribed if px is allergic to penicillin
two separate portions w/ crown o Acts against anaerobic bacteria
o Side effect is associated w/ P. colitis
TUNNEL PREPARATION 4. METRONIDAZOLE
 Transform grade II to III & IV for better access, not performed anymore o Effective against P. gingivalis (chronic periodontitis) &
due to increased incidence of root caries P. intermedia (ANUG)
 Allows px access for plaque control (interdental brushing)  200 mg QID for 1 week
 400 mg TID for 1 week
REGENERATIVE TREATMENT PROCEDURES Side effects
CLASS TREATMEMT o Has antabuse effect when alcohol is ingested
Grade I Traditional tx o Inhibits warfarin metabolism
Grade II Autogenous bone grafts 5. TETRACYCLINE
Allografts o Derived naturally from Streptomyces
Alloplasts (hydroxyapatite, tricalcium phosphate) o Concentration in GCF is 2-10x more than in serum
Citric acid root conditioning Adverse effects
 Removal of endotoxin & smear layer o GI disturbances: nausea, vomiting, diarrhea (NVD)
 Regeneration of bone o Overgrowth of resistant organisms: stomatitis
GTR o Photosensitivity: skin rashes
Grade III-IV Success rate is limited Contraindications
o Pregnancy: cause tooth staining
ALLOGRAFTS o Breastfeeding
 FDBA (Freeze-Dried Bone Allograft) o Renal impairment
 DFDBA (Demineralized Freeze-Dried Bone Allograft) o Liver disease
o SLE
Drugs that bind to 30s ribosomes Drugs that bind to 50s ribosomes
 Tetracycline  Macrolides
(minocycline, (erythromycin,
doxycycline) azithromycin,
 Aminoglycosides clarithromycin)
(streptomycin,  Clindamycin
gentamicin, neomycin)  Chloramphenicol
 Linezolid

NSAIDs
 Interfere w/ arachidonic acid; inhibit prostaglandin synthesis

1. IBUPROFEN: can slow the loss of alveolar bone in periodontitis

2. MEFENAMIC ACID
3. NAPROXEN
4. FLURBIPROFEN
o Decreased PMNL migration
o Decreased vascular permeability
o Decreased platelet aggregation
 IMPLANTS SURGICAL PROCEDURES: ENDOSSEOUS IMPLANT
ONE-STAGE/ NONSUBMERGED
DENTAL IMPLANT  Coronal portion stays exposed through gingiva during healing period
 Permucosal device that is compatible & biofunctional & is placed on or  Healing abutment protrudes about 2-3mm from crest of bone & flaps
w/in the bone to provide support for prosthesis are adapted around implant
TWO-STAGE/ SUBMERGED
STRUCTURE OF DENTAL IMPLANT  1st stage ends by suturing soft tissues over implant so it remains
 CROWN excluded from oral cavity
 ABUTMENT: retain crown in place  Implants are left undisturbed for 2-3 months in mandible & 4-6 months
 SCREW in maxilla
 In 2nd stage, implant is uncovered & titanium abutment is connected
IMPLANT PROCEDURE to implant body
1. Implant is inserted into bone
2. Healing process of bone (osseointegration) ONE-STAGE/ NONSUBMERGED TWO-STAGE/ SUBMERGED
3. Dental abutment is placed on implant Implant left partially & exposed Implant covered w/ flap closure
4. Ceramic crown is placed which replaces the real tooth Healing abutment attached immediately Undisturbed healing period
No need for additional surgery to Requires second surgery to uncover
BONE-IMPLANT INTERFACE uncover implant implant & place abutment
1. FIBRO-OSSEOUS INTEGRATION
 Defined as “tissue to implant contact by interposition of healthy dense STRUCTURE Minimum required distance between
collagenous tissue between implant & bone interface” implant & indicated structure
 Attributed to proliferation of connective tissue into the interface Buccal plate 0.5 mm
 Not desirable since union is WEAK Lingual plate, maxillary sinus, 1 mm
nasal cavity, inferior border
2. OSSEOINTEGRATION Adjacent natural tooth 1 – 1.5 mm
 Defined as “direct structural & functional connection between ordered Inferior alveolar canal 2 mm from superior aspect of bony canal
living bone & surface of load carrying implant” Inter implant distance 3 mm between outer edge of implants
 Growth of bone in direct contact w/ implant surface w/out intervening Mental nerve 5 mm from anterior or bony foramen
band of organized connective tissue Incisive nerve Avoid midline maxilla

3. BIOACTIVE INTEGRATION SPLINT

 Defined as integration which results by physiochemical interaction  Used for immobilization of injured or diseased parts
between collagen of bone & hydroxyapatite crystals of implants
DENTAL SPLINTING
CLASSIFICATION OF IMPLANTS BASED ON SHAPE & FORM  Joining of two or more teeth into a rigid unit by means of fixed of
1. ENDOSTEAL/ ENDOSSEOUS removable restorations/ devices
 Directly placed into bone
 Shaped like small crew, cylinder or blade PERIODONTAL SPLINT
 Most popular implant  Used for maintaining or stabilizing mobile teeth in their functional
position
2. SUBPERIOSTEAL
 Is surgically placed under periosteum & rests on bone MAIN OBJECTIVE
 Located on or above bone  Promote healing & increase patient’s comfort & function
 Most common in mandible
OBJECTIVES OF SPLINTING
3. TRANSOSTEAL/ MANDIBULAR STAPLE  Provides rest
 Consists of horizontal beam attached to metal rods & inserted all the  For reduction of forces: forces of occlusion are redirected in a more
way through the mandible from superior border to inferior border axial direction
 Seldom used due to its highly invasive nature  For redistribution of forces: to ensure forces do not exceed the
 Most commonly used to support mandibular denture w/ severe adaptive capacity of periodontium
resorption  To preserve arch integrity: splinting restores proximal contact, reduced
food impaction
BASED ON SURFACE CHARACTERISTICS  Restoration of functional stability: restores occlusion, stabilizes mobile
1. Titanium plasma-sprayed coating abutment & increase masticatory efficiency
2. Sand blasting-surface etching  Psychologic well-being gives px freedom from mobile teeth
3. Hydroxyapatite coating  To prevent eruption of teeth w/out antagonist

CLASSIFICATION OF BONE QUALITY TWO SCHOOLS OF THOUGHT REGARDING SPLINTING

TYPE I BONE Composed of homogenous dense cortical bone, less blood BENEFICIAL EFFECTS HARMFUL EFFECTS
supply, takes 5 months to integrate Since they are splinted to Creates an environment for plaque
 Consider bone tapping neighboring healthy, mobility accumulation
 Found in anterior mandible, most suitable during mastication is prevented
TYPE II BONE Composed of thick layer of compact bone surrounded by Non-mobile teeth heal faster than Since functional movement of
core of dense cancellous or trabecular bone, takes 3-4 mobile teeth tooth w/in socket is not possible, it
months to integrate may lead to ankylosis
TYPE III BONE Composed of thin layer of cortical bone surrounded by core
of dense trabecular bone, takes 6 months ANKYLOSIS other terms:
TYPE IV BONE Composed of thin layer of cortical bone surrounded by core  Replacement resorption
of low density trabecular bone of poor strength, requires  Submerged tooth
longest time to integrate 8 months Tx: NONE, especially if it’s not causing any functional or aesthetic problems
 Do not bone tap
 Found in posterior maxilla CLASSIFICATION OF SPLINTS
Highest rate of implant failure occurs in type IV According to Period of According to Type According to
Risk of implant failure is higher in: Stabilization of Material Location on Tooth
 Cigarette smokers Temporary stabilization: Bonded, Intracoronal
 Poorer quality bone worn less than 6months composite resin (composite resin
 Maxilla than in mandible button splint w/ wire, inlays,
 Individuals w/ uncontrolled diabetes nylon wires)
Provisional stabilization: Braided wire splint Extracoronal
BEST PROGNOSIS FOR IMPLANTS WORST PROGNOSIS worn for months or (tooth-bonded
ANTERIOR MANDIBLE (Type I) POSTERIOR MAXILLA (Type IV) several years plastic, night
Due to favorable bone density Has low bone density Permanent splints: used A-splints guard, welded
Healing faster due to higher vascularity indefinitely bands)
INDICATIONS OF SPLINTING
 Stabilizes moderate to advanced tooth mobility that cannot be
reduced by other means
 When it interferes w/ normal masticatory function
 Facilitates scaling & surgical procedures
 Stabilizes teeth after ortho movement & after acute dental trauma
(subluxation, avulsion)
 Prevent tipping & drifting of teeth
 Prevent extrusion of unopposed teeth

CONTRAINDICATIONS OF SPLINTING
 Moderate to severe tooth mobility in the presence of periodontal
inflammation
 Insufficient number of teeth to stabilize mobile teeth
 Prior occlusal adjustment has not been done on teeth w/ occlusal
trauma or interference
 Patient not maintaining oral hygiene

RATIONALE
 To prevent or minimize recurrence of periodontal diseases by
controlling factors known to contribute to disease process
 To provide supervised control for px in order to maintain healthy &
functional, natural dentition throughout lifetime

OBJECTIVES OF MAINTENANCE PHASE

1. Preservation of alveolar bone support
2. Maintenance of stable, clinical attachment level
3. Reinforcement & reevaluation of proper home care
4. Maintenance of healthy & functional oral environment

DETERMINATION OF MAINTENANCE RECALL INTERVALS

 After periodontal surgery, immediate recall is done after 1 week
 Recommended recall 2-4 weeks following tx
 Interval can be extended to 3 months after 3-4 sessions
 May vary according to px needs!!!

MAINTENCANCE RECALL PROCEDURES

PART I: Medical history changes, oral pathologic examination,
EXAMINATION oral hygiene status, gingival changes, pocket depth
changes, mobility changes, dental caries, restorative &
prosthetic status
PART II: Oral hygiene reinforcement, scaling, polishing, chemical
TREATMENT irrigation
PART III: Schedule next recall, schedule further periodontal
SHEDULE treatment, schedule or refer for restorative/ prosthetic
NEXT treatment
PROCEDURE

FAILING CASE
1. Recurring inflammation revealed by gingival changes & bleeding of
sulcus on probing
2. Increasing depth of sulcus leading to recurrence of pocket formation
3. Gradual increase in bone loss as determined by radiographs
4. Gradual increase in tooth mobility as ascertained by clinical
examination