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AHMED Y. GAMAL. PROF. OF PERIODONTOLOGY .
The main rational of periodontal therapy is that it interrupts a sequence of events that leads to final loss of teeth, which can disrupt and destroy complete dentition (scaling and root planing, conservative non surgical approach), in addition to the reconstruction of the periodontal tissues that has been previously destroyed by periodontal disease (advanced surgical approaches). Periodontal reconstruction or regeneration is defined as restoration of the lost supporting tissues including new alveolar bone, new cementum, and a new periodontal ligament.
To get predictable amount of regeneration we have to:
1. Control infection: through the removal of local irritants by either closed or opened debridement, chemical adjunctive therapy either systemically or locally at a site, and oral self care. 2. Control apical migration of epithelial attachment: by the use of guided tissue materials with or without bone fillers. 3. Maximum recruitment of the periodontal tissues, namely PDL and bone cells to repopulate the destroyed periodontal tissues by the use of biologic enhance modifiers. 4. And finally to render the root surface more biocompatible for PDL and bone cell colonization. Steps of periodontal Treatment: All forms of gingivitis or periodontitis almost follows a similar general periodontal coarse:
Following periodontal examination and determination of the case diagnoses and prognoses the patient will pass into the following phases:
1- Initial therapy (Phase 1) 1. Oral hygiene instruction (Patient motivation) for either mechanical or chemical plaque control. 2. Supra-gingival plaque removal, together with the removal of eitrogenic (poor restorations, fillings, ortho. wires…) or naturally occurring (ledges, craters….) plaque retentive areas.
1 - Initial therapy (Phase 2)
Sub-gingival plaque and calculus removal (scaling, root planing and sub-gingival curettage).
2- Re-evaluation: To get definitive prognoses and definitive treatment plane, whether we will consider scaling and root planing are final treatment or the case needs further periodontal procedures. 3- surgical therapy (corrective phase). In deep inaccessible areas or if reevaluation following initial, non surgical therapy indicates that inflammation and infection are not resolved, and disease progression has occurred, a clinician decision must be made regarding the reasons of non response, and the need for further therapy including surgery. 4- Maintenance therapy (recall visits)
Check for pocket activity. If there is no pocket activity, the patient needs to be re-motivated. If there is pocket activity, plaque and calculus removal and treatment of a recurrent disease should be done.
* Non-surgical approach: Is defined as “ Plaque removal, plaque control, Supra- and sub- gingival scaling, root planing, and the adjunctive use of chemical agents”. Scaling, root planing and sub-gingival curettage: Scaling: refer to the removal of calculus, bacteria and their products from the crown and root surfaces or lying free in the pocket. Root planing: refer to the removal of calculus, bacteria and their products, and contaminated cementum and dentine from the root surface, rendering the root surface more biocompatible for periodontal ligament fibroblasts adhesion, and smooth enough to prevent plaque retention and subsequent re-infection (A. Gamal definition). Curettage: refers to scraping of the inner surface of the gingival wall of the periodontal pocket to clean out, separate and remove diseased soft tissue.
Scaling and root planing are extremely difficult for deep pockets without direct vision. complete debridement for deep pockets could not be achieved for two reasons: 1. hoe) could not be used for sub-gingival curettage. 2. since the root surface exhibit a wide variety of irregularities and grooves. Early differentiation of progenitor cells delays its proliferation. 3. The thoroughness of root preparation. 2. in other words the morphology of the roots rather than the probing depth determines the limitations of closed sub-gingival scaling. But the CT of the PL is slower in his rate of growth because: 1. * The amount of pocket reduction induced by non-surgical approach depends on: The original depth of the pocket The amount of the oedematous fluid in the tissue. (Why) Pocket epithelium migrate rapidly since it requires two factors to migrate: 1. 3. Re-adaptation of the gingival connective tissue to the root surface decreasing retractability of the soft tissue from the tooth surface. The amount of the fibrous connective tissue. as it does not get to the bottom of the pocket. Limited surface area of the periodontal ligament structure. Slow angiogenesis of avascular root and periodontal ligament.Heavy instruments (scalers. 2. * Pocket reduction following scaling and root planing occur through a combination of: 1. 2. New attachment by long junctional epithelium. Substratum (fibrin strands) as contact guidance. Pocket reduction: Shallow and moderately deep pockets could be completely debrided by scaling and root planing. Vascular CT for nutrition. Tissue shrinkage: due to reduction in gingival inflammation. .Indications: 1.
it is : * Difficult to be self-cleansed. by common usage the term periodontal surgery is applied only to procedures. uncontrolled diabetes…. It is aimed at treatment of the unresolved periodontal pockets. advancing loss of attachment. 4. 3. .Render the tissue easier to handle during surgery. 3. Deep pocket reduction: root cleaning and smoothing with direct vision. Treatment of compromise situations: 1. with only longer junctional epithelium will form. Periodontal surgical approach: While nearly all-periodontal treatment techniques are surgical in nature. Some degree of pocket reduction which my render surgical outcome unnecessary. When scaling and root planning was intended as a pre-surgical preparation but after that the patient and or the therapist decide to discontinue treatment because of the dramatic improvement of the periodontal condition. 2. hemophilia. and infection. 2. 2. 3. Maintenance of the treated patients: Repeated scaling and root planing and soft tissue curettage is necessary to prevent recurrence of disease in a previously treated areas.These resulted in epithelium that proliferate apically on the root surface before the other supporting tissues reach the area.). heart failure. Systemic and medical problems may render the patient not be able to undergo more extensive surgery (Ex. or need for regenerative procedures. Leukemia. which require incisions or excisions of periodontal tissues. Pre-surgical preparation of tissue: (deep pockets) * The main objectives of pre-surgical preparations are to: 1st. Patients psychologically unwilling to accept surgical manipulation of their tissue. Decrease bleeding and increase visibility during surgery. Decrease postoperative pain . 4. Objectives of periodontal surgery: 1. Deep pockets are areas which are difficult to be cleaned by closed scaling and root planing.
* Retention areas for food and calculus.General contraindications and precautions: 1. 4. Correction of muco-gingival defects. 7. pulmonary fibrosis. Re-contouring of the gingival tissue for esthetic appearance. 4. 3. thrombocytopenic purpura.* Difficult to be cleaned by the patient and the dentist. Patient under severe emotional stress until the stress is relieved. 2. and hypertensive heart diseases require consultation with the patient cardiologist. 8. 5. 6. Many alcoholics do not heal well following periodontal surgery. 3. 2. some kidney disorders. should be under control. Preoperative sedation and use of minimal or no vasoconstrictors are routine measures when doing periodontal surgery for such patients. 5. Cardiac disorders. Other contraindications include: 1. bronchial asthma. tachycardia. prothrombin deficiency. Bleeding disorders: Such as hemophilia. Patient with short life expectancy. scleroderma. such as coronary insufficiency. Prolonged systemic corticosteroid therapy. and anticoagulant therapy. These patients do not tolerate stress well and are not capable of coping infection. such as rheumatoid arthritis. . or other cardiac arrhythmia. Re-contouring of osseous tissue. Patients with congenital or prosthetic heart valves require antibiotic premeditation. 2. Implants insertion. pemphegus. treatment of periodontal abscesses. Re-contouring of the gingival tissue to aid in effective hygiene. Favor the connective tissue attachment (re-constructive surgery and tissue conditioning materials) 3. If surgery must be done the patient’s dosage of corticosteroid must be increased to cover the period of stress and antibiotic should be prophylactic ally administered. lupus erythematosis . Hyperthyroidism. Contraindications and precautions of periodontal surgery: 1. surgery done on an uncontrolled hyperthyroid could precipitate a thyrotoxic episode characterized by angina .
Total pocket eradication. 2. Re-constructive modalities.A gingival abscess entirely contained in the soft tissue. 3. Restoration of periodontal health by closed mechanical debridement. 4. 5. Dental contraindications and precautions 1. . 2. 2.gingival curettage and root planning.3. *Surgical modalities could be classified as follows: 1. Indications: 1. Fast and simple procedure. Gingivectomy and gingivoblasty: Gingivectomy is the complete removal of the soft tissue wall of the pocket. Inadequate plaque control: Individual who will not keep etiologic factors under control will not benefit from periodontal surgery.Presence of supra-bony pockets >5mm which persist despite repeated sub. Periodontal flap procedures . and where gingivectomy would leave adequate amount of attached gingiva. 3. Advantages: 1. 4. 5. Resectional surgery ( Gingivectomy and gingivoblasty). Surgical sub-gingival curettage ( Excesional new attachment procedure ENAP)) 3. Good visibility to the root surface 3. Muco-gingival surgeries.presence of furcation evolvement (without associated osseous defects) where there is a wide zone of attached gingiva. 2.A peri-coronal flap. Root exposing surgery in anterior region.presence of dense and fibrous gingival enlargement.
with an internal bevel incesion started from the gingival margin to the apical end of epithelial attachment. 3. 5. Alveolar bone defects are not exposed and therefore it is contraindicated in the presence of intrabony lesions. * Tissue elevation is not a part of this procedure. Gingivoblasty: Is a term used when gingivectomy is done in the absence of pockets with the sole purpose of recontouring the gingiva. Exposed roots my be sensitive and liable to caries. Open curettage): * It is essentially a sub-gingival curettage performed by a knife. craters. The clinical crown my be lengthened. that is why it is restricted to suprabony pockets whose apical extent lies within the keratinized gingiva. 7.Surgical subgingival curettage: Excisional new attachment procedure (ENAP) ( Mini flap. 2. 6. Some loss of CT attachment my occur during healing. and bulbous interdental papillae. * New attachment refer to embedding of new PDL fibers into new cementum and formation of a new gingival attachment in an area previously degenerated by periodontitis ( Caranza 1996) . Tissue is wasted which could be used to close the wound and obtain healing by primary intention. -Secure good access to the root surface. It creates an open wound.Disadvantages: 1. Disadvanteges: -Limited scope -Limited attachment gain . Reattachment refers to reattachment of periodontal tissues in an area not previously exposed to the pocket. as in cases of rolled gingival margins. 4. ex. The zone of attached gingiva my be eliminated. which heal by secondary intention. Advanteges: -The procedure permits through soft tissu preparation. Such clean difinitive excesion of the junctional epithlium offer greater probability of new clinical attachment. Reattachment that follows periodontal surgery or following access to periapical lesion. 2.
to allow the cervical wedge to be removed easily.5 to 1mm from the free gingival margin ( supra-crestal internal bevel incision) to the alveolar crest. ( cervical wedge) from the flap. The aim of this incision is to separate the pocket epithelium and inflamed C.3. Initial internal bevel incision begun 0. . whereas the original procedure included removal of osseous defects. * Difference between the original Widman and modefied Widman flap: Modefied widman described by Ramfjord and Nissle in 1974 is consederd more conservative than that originally described by Widman (1916): Widman flap envolve raising of a full thickness flap without internal beviling . Access periodontal flap procedure: Flap procedure are indicated in cases of periodontitis with active pockets 5-6 mm deep or greater that do not respond to initial therapy.T. but maximum healing of periodontal pocket with minimum loss of tissue. The main reasons for doing periodontal flap are 1. The flap consisted of three basic incisions: 1. To secure access for root planing and to the underlying intraosseous defects. Less bone is exposed in modefied flap. The third one is a horizontal incision made from the crest of the bone to the tooth surface. The incision should follow the scalloping of the free gingival margin to get complete coverage of the interdental areas after suturing. The modified Widman flap (Ramfjord technique) (Partial flap reflection): The primary objective of the procedure is not pocket elimination per se. Sharp knifes rather than curettes are used to separate the cevical wedge in modified widman Modified technique maintain bony pocket walls . 3. 2. The second incision made from the base of the pocket to the bone crest. followed by reflection of a full thickness flap that exposes 1 to 2 mm of alveolar bone. 2. To facilitate removal of the lining epithelium and granulation tissue that may interfere with healing. To facilitate attempts to reestablish new CT attachment (reconstructive procedures). 3.
Need for endotoxin free root surface. Stable after sterilization. . Multiple factors must be consederd when attempting regeneration. 4 . 4. These craters developed because of the minimal reflection of the muco-periostium that did not allow for complete coverage of the interdental tissues.Advanteges: A-Optimize accesses to the root surface and intra-bony lesions. by meticulous oral hygiene the interdental tissue regenerates over few monthes. 2. 5. they include: 1.reconstructive procedures: Bone grafts: Attempts to obtain some fill-in of the bone defects and reattachment by simple curettage of the bone defect are an unpredictable procedure. Host response factors. It should have osteoginic potential. less post operative sensitivity or caries. Control of epithelial migration into the root surface. Induction of a new cementum and incorporation of connective tissue fibers. The essential requirements of the graft materials are: 1. Implant materials with varieng osteoginic potential. Allow optimal soft tissue coverage to the root surface which gives a good esthetic. 3. Inexpensive. Non toxic 4. 5. Because the alveolar bone is minimally exposed there is a decreased post operative pain and bone resorption Disadvantages: Interdental tissue architecture is poor immediately following removal of the dressing. 2. 3. 3. 2. It should be immunologically acceptable (non-antigenic). Optimize postsurgical adaptation of healthy CT and epithelium to the root surface. 4.
-Bone blind coagulum: is a term applied if the autogenous bone obtained by a trephine bur.It must be frozen before use to prevent these.Freeze. The need for second surgical insult with bone sources. In the form of: -Osseous coagulum: is a term applied when the autogenous bone obtained with a bur and mixed with blood. 2.A number of different types of graft materials have been tried : 1. tori . Advantages of autogenous grafts: 1. intra-oral: Sources: Ostectomy . . edentulus area. Extra-oral: Iliac cancellus bone. it did not represent an ideal graft because of the. Decreases coast to the patients. chisel or rongeur and triturated into particle size of about 100. This type is used because its small particle size is resorbed and replaced by host bone. A-Limited quantity of the available intraoral sources. 2. . 3. Allogenic ( allograft) : bone from an individual of the same species. 200 um -Healing socket autogenous bone: is usually obtained 8 to 12 weeks after extraction to allow newly forming bone to mature. Autogenous: which is bone from the same indivedual. It is used with some success however: * Tapping this site my not be justifiable. 1. Although the osteoginic potential of this materials was good. Eliminate the possibility of graft rejection. extration sockets.dried cortical bone allograft (FDBA). Poses no danger of diseases transfer. tuberosety. * Fresh marrow tissue often produce root resorption and ankyloses. max.
c.dried allograft.( Bio-oss. Bone matrix contains bone inductive proteins as BMP2 and 7. contagious diseases. long term medications that known to affect bone (corticosteroid).porous Hydroxylapatite (periograf. All cancellus bone and marrow elements removed and discarded. . malignances.Freeze dried deminirelized bone allograft (FDDBA). and other bone derived growth factors. The lyophilized bone was ground under sterile condition through a sterile sieve with 400 um openings. and Bio-guide. the opposite may be true in autogenous grafts. Sample frozen in liquid nitrogen. long half-life isotops. Xenograft: Bone from different species treated with EDTA to remove the organic compounds and antiginic fraction. studies showed that cortical bone is superior to cancellus bone when used as a freeze. The bone chips were lyophilized in freeze-drying chamber. This materials has been used in the fabrication of contact lenses. Bovine bone menial and collagen) 4. The donor should be free from viral. Lyophilization: is the process of freeze drying that permits storage within a vacuum for an indefinite shelf life and also markedly reduces the antigenicity of the graft. prothetic heart valves and has no inflammatory or immune responses. At the end of about 2 weeks at least 95% of the total water content had been removed. which facilitate vascular ingrowth and subsequent new bone formation b. Shaft of long bone) taken from cadaver within 24 h of death. but they are not an Osteoinductive materials a.Hard tissue replacement polymer (HTR) Is a non.Tricalcium phosphate ceramics( Synthograft). It may be combined with collagen to facilitate its retention.. Grafts of bone substitutes and synthetic materials ( Alloplastes) : Are biocompateble materials that are used to fill osseous defects. Sample (ex.resorbable microporous biocompatible composite of Polymethylmethacrylate (PMMA) and polyhydroxyethylmethacrylate(PHEMA) . bacterial.Porous and non. or durapatite): Porous hydroxylapatite has a uniform pore size . 3. The cortical plates were reduced in size to approximately 1 to 2 cm.
Biocompatible . Not improving tooth mobility.PMMA beads are 550 . D. . -reduce any tiny risk of disease transfer by infected allogenic bone. Some inflamatory reactions my occure. Theoritically Ca phosphate ceramics becomes rapidly encapsulated in collagen and act as an enhancer for new bone growth. Ions from the implant dissolve in tissue fluids and increase the local concentration of Ca and Phosphate ions which are the most common stimulus for the differentiation of pleuripotential cells to differentiate into osteoblastes. Implants my promote osseous repair by there ability to act as matrix (scaffold) around which bone is formed (osteo-conductive). 3. Autogenous materials need donor tissue and additional surgry.The most accepted theory is that the implant act only as a space filler in the defect preventing the flap from collapsing into the bony defect. . Possible mode of actions of re-constructive materials: 1. then the composite beads coated with calcium hydroxide / calcium carbonate. Thus the actual surface interface with bone is the calcium surface layer and both fibrous tissue and bone can form on and attach to this layer.880 um diameter with pores of 50-300 um form the core of the material. thus retarding reepithelialization until true regeneration occur (mechanical barrier). There is a potential of root resorbtion of fresh materials. 2. Limited new attachment. These are coated with liquid PHEMA . Advantages of alloplasts: -Unlimited amount of materials negating the need for human donor. Disadvantages: Partial or complete exfoliation. Closure of the defect occure by long junctional epithelium.
periodontal ligament and cementum. . .: act as a guidance for osteogenic cells. For that reason the membrane should be firm to the extent of not ristricting the space of bone and PL. Types: 1.Stimulatory properties of the membrane: *The surface of the membrane my be osteoconductive i. For that reason recruitment of PDL and bone cells are important steps in regenerating the periodontium.resorbable: Plytetrafloroethyline mem.( Bone morphogenitic protein. (teflon mem. * ePTFE is permeable to tissue fluids and macromolecules .T. as well as an occlusive membrane. Regeneration takes place by growth from the same type of tissue that has been destroyed or from its precursor ( Caranza 1996b). at the same time to allow time for population of the curreted root by cells arising from the periodontal ligament. Non. Sometimes the procedure called osteopromotion because it is a more general term not restricted to only placement of a membrane for guidance. . neogeneses. PDGF. thus allowed nutreins to pass while unwanted cell types are kept out. cementum derived growth factor). extending from 2-3 mm below the bone margin to just below the C.) (Gore-tex) * It consists of a narrow. penetration to produce a seal at the coronal margin of the root. -Locally concentrate growth stimulatory factors derived from bone.( It differs from repair or healing by scar.It protects the blood clot and favours its adherence to the root surface by its mechnical supportive effect (scaffold). open microstructure margin which is designed to allow C.E. as it could be of a value in regeneration. * It is adapted to fit over th intrabony defect and the root of the tooth. by which surgical procedures are designed to mechanically prevent the epithelial attachment and gingival CT which has no potential to provoke formation of new CT from reaching curreted root surface by a membrane. improving bone graft results.J on the root.e. restore the tissue but does not necessarily restore the original architecture or function) GTR is a technique used to increase the chance of obtaining a new CT attachment. Guided tissue regeneration (GTR): Regeneration is the “ growth and differentiation of new cells and intercellular substances to form new tissues “.
but in horizontal defect only the PL cells of the Pl migrate coronally. And the root surface. then the flap is sutured back to just cover the membrane. tying it to a gold bar. this include: -Polyglactin Mem. some trials with biodegradable materials showes a good results. Flaps replaced over Gore-tex mem. -Lyodura (6-8 weeks) Disadvantages: 1-Local inflammatory response of phagocitic activity. Disturbing the newly formed osteoid material. -ýpolylactic acid ( 3-4 month). may be diffecult. * The mem. (4-8 weeks). To tent it out.Horizontal defects failed to regenerate after GTR application becouse in the angular defects PL cells migrate into the defect from the lateral border as well as from the coronal border of th e PL . 2. removed after 4-6 weeks by a marginal incesion.* It is held in place by a Teflon sling suture. or using a tetanium reinforced mem. ( Disentigrate after 1-2 month). -Cargile Mem. 3. Indications of guided tissue application: .It is important to be stressed that this technique is applicable only to the treatment of single teeth with 2 or 3 walled intrabony defect. Space maintenance is a problim as ePTFE easly collapse eradecting any space between the mem. 3-Impossible removal in case when it is needed. -Calcium sulfate . To avoid this disadvantege several approaches have been proposed like placing a suture in the mem. -Collagen Mem. May shrink and coverage of any osteoid. Biodegradable membrane: It is desirable for the auxillary material to desentegrat at the end of the wound healing. Disadvanteges: 1. which might form. The need of secondery procedure to remove the mem. ( 2-6 weeks). . 2. 2-The need to maintain proper timing between completion of PL regeneration and degeneration of the membrane.
2. Laminine: promote epithelial cell proliferation. Good substantivity: react with dental hard tissue. EDTA (prefgel 24%) * It exerts its demeniralizing effect through chelating divalent cation at a neutral PH. 4. Demineralization and exposure of collagen from the superficial portion of dentine where CT attachment occur by integration of new and old collagen fibers. b. 2. Promote fibroblast adhesion and growth. Stop apical migration of epithelial attachment through early fibrin linkage. 3. * In contrast to etching at low PH it does not alter the structure of dentin associated collagen * it is as effective as low PH with respect to smear removal and superior in exposing root associated collagen. 3. Tetracycline HCL: 1. * Expose and widen the orifices of dentinal tubules which favor periodontal ligament fibroblasts adhesion to the root surface.(Extracelllular matrix) Fibronictin is an extracellular matrix protein provide attachment of fibroblasts to diseased root. Citric acid: (20% for 3 minutes) 1. Bacteriocidal property of low PH on microbes. Anticollagenolytic activity. antienzymatic effect that retard collagen breakdown 4. . Which in contrast to etching at low PH preserve tissue vitality. Collagen exposure. Root conditioning agents in promoting connective tissue attachment: (Acids) 1. 5. Exposing inducers of cementoblastes and osteoblastes by exposing collagen fibers . from which it slowly released in an antibiotically active form. It my act as a solvent for endotoxins.
Synergestic effects are observed on mitogeneses of PDL cells when IGF-1 is combined with PDGF. BMP . Platelet derived growth factor(PDGF): Have a potent effect on proleferative activety of periodontal ligament fibroblastes(PDL). formation of a blood clot Platelet gel mimics the final stages in the clotting cascade. Bone grafts with its contained growth factors and growth factor application seems to stimulate cells capable of regeneration. IGF .c. including: 1. Chemotactic for PDL cells Promote collagen and total protein syntheses. Improve adhesion of PDL cells to the root surface( Gamal et al 1998) Can reduce the inhibitory effects of lipopolysaccaride on gingival fibroblast proleferation. Have an influential effect on PDL mitogeneses and protein syntheses. They then aggregate to the site of injury and further platelet degranulization occurs. Platelets are our primary mechanism for hemostasis. Platelet rich plasma: Is exactly what its name suggests. Platelets rich plasma perform many functions. The most related and most studied growth factors in periodontal regeneration include: PDGF . The platelet rich plasma in the presence of thrombin activates platelets.(Growth factors): The most important factors determining periodontal regeneration are: Excluding epithelium: GTR seeks to produce these condition by excluding epithelial down-growth and thus proving an anatomical environment for the coronal migration of these cells. TGF . Promote fibroblastes proleferation under an expanded GTR membranes increase metalloproteinase syntheses from PDL cells. Insulin growth factor (IGF-1): Chemotactic for cells derived from PDL. Stimulation of cells of periodontal ligament and alveolar bone populated the healing tissue coronal to the residual alveolar bone. The substance is a by-product of blood (plasma) that is rich in platelets. converts fibrinogen to fibrin and stimulates further platelet aggregation . They circulate in our bodies looking for exposed endothelium.
The aim of this type of surgery was to maintain an adequate amount of attached gingiva and to prevent continuous loss of attachment. this natural and insoluble surface layer encourages the migration of cementum forming cells from the surrounding tissues . The term Mucogingival Surgery was proposed by Friedman in 1957 to indicate any surgery “designed to preserve attached gingiva. Its key component (amelogenin) naturally produced by the ameloblastes during tooth development. the patient need not incur the expense of the harvesting procedure in hospital or at the blood bank. The more growth factors released/sequestered into the wound. the more stem cells stimulated to produce new host tissue.2. emdogain is naturally absorbed by the body . clinical and experimental studies by Wennstrِm and Lindhe (1983) demonstrated that . This philosophy was supported by many horizontal observations in humans that confirmed the need for a certain band of attached gingiva to maintain periodontal tissue in a healthy state. Ease of use: PRP is easy to handle and actually improves the ease of application of bone substitute materials and bone grafting products by making them more gel-like. and insulin-like growth factor ILGF) function to assist the body in repairing itself by stimulating stem cells to regenerate new tissue. These GF (platelet derived growth factors PGDF. leaving only a residue of enamel matrix protein on the debrided root surface. Autologous platelet rich gel has several advantages: eliminated the risk of disease (viral transmission) related to donor blood products. It is an enamel matrix protein( amelogenin) that applied as a gel directly into the tooth root during periodontal flap surgery .) Emdogain A recently developed biologically based product represents a new way of thinking in periodontal regeneration. following cementum formation the PL is established creating true CT attachment to the tooth . Once applied. platelet-rich glue. Subsequently. to remove frena or muscle attachment. this protein is involved in the formation of tooth supporting tissues. transforming growth factor beta TGF . rapidly forming gelatinous. (Calcium chloride is added to counteract the anticoagulant citrate. 4. and release of growth factors (GF) into the wound. Cost effectiveness: Since PRP harvesting is done with only 55 cc of blood in the doctor’s office.Muco-gingival techniques in periodontal surgery: Many techniques have been attempted to correct abnormal topographic relations between gingiva and alveolar mucosa that interfere with the elimination of periodontal pockets or favor the recurrence of gingival inflammation. and to increase the depth of the vestibule”.
Loss of interdental papilla which presents an aesthetic and/or phonetic problem. teeth not likely to erupt ).Augmentation of the edentulous ridge. The production of a periodontal anatomy which allows effective plaque control . 2. 4. 9.Pockets extend at or below the mucogingival line. 2.Insufficient attached gingiva without pocket formation. In this respect the Mucogingival Therapy includes: 1. *and/or amount of soft tissue and underlying bone ( inadequate attached G . 8. crown lengthening) *position ( pocket at the mucogingival area. This assigns importance to non-surgical therapy and to the bone condition because of its influence on the morphology of the defects. 3.Teeth that are not likely to erupt. ridge augmentation.Crown lengthening. 6. Treatment of pocketing below the muco-gingival junction: A number of surgical procedures have been proposed to solve muco-gingival problems of this type . frenum. and therefore prevent disease recurrence. (Gingival augmentation). More recently the Consensus Report of the American Academy of Periodontology (1996) defines Mucogingival Therapy as “non surgical and surgical correction of the defects in *morphology ( Recession. 7. All have the common aim of: 1. 1.Prevention of ridge collapse associated with tooth extraction. The removal of the disease. 5. prevention of ridge collapse). papillary loss.as long as plaque buildup is kept under careful control there is no minimum width of keratinized gingiva necessary to prevent the development of periodontal disease.Isolated gingival recession. .Frenum insertion in or close to the gingival margin.
This will separate the pocket lining from the inner wall of the flap. Full thickness flap reflection and removal of the cervical wedge together with scaling and root planning. the remaining tissue namely. One should ensure that the flap is displaced apically so that its edge just covers the alveolar crest. Its width varies from one to nine mm. It was originally believed that a minimum width of attached gingiva required to maintain gingival health and to prevent recession. Suturing: It is important to make sure that the flap is not pulled coronally when suturing Sutures should be made first near to the margin of the free flap with loose interdental interrupted or suspensory sutures and apically in the affixed tissue to ensure the degree of apical repositioning.Deep pocketing of this type may be treated by partial or full thickness apically repositioned flaps Apically repositioned flap: The apically repositioned flap achieves pocket elimination by moving the flap in an apical direction converting the pocket wall into an attached gingiva.. from the gingival margin to the alveolar crest. 4. The width of attached gingiva is considered functionally adequate if it can dissipate the pull of the frena and muscle of the lip and cheeks. Incisions: Two parallel vertical releasing incisions to bone at either ends of the operative area extending to the base of the vestibule to get an adequate mobility of the flap. Procedure: 1. 5. 3. . Apical repositioning: The flap is reflected to the base of the vestibule. This tissue is left on the surface of the tooth when the flap is raised and is referred to as the cervical wedge (or secondary flap). Placing the periodontal dressing: It helps in prevention of coronal displacement so it should extend to the base of the vestibule 6. The attached gingiva starts at the base of sulcus or free gingival groove to the mucogingival junction. Treatment of insufficient attached gingiva: The term-attached gingiva refer to gingival tissue that is bound to the tooth and underlying bone. It has been observed that following removal or in the absence of the attached gingiva. An inverse bevel incision start 1mm. 2. once released the flap tend to contract and fold up so that apical positioning often takes place spontaneously.
1.Preparation of recipient site : II. 3.alveolar mucosa will * curl * will not respond to treatment * and will not withstand the rigors of mastication or oral physiotherapy However several longitudinal studies have demonstrated that the lack of or presence of minimal amount of attached gingiva does not necessarily result in progression of soft tissue recession. Indications: There are factors to help guide the clinician in determining the need for surgery when there is 1mm of attached gingiva or less.Free grafts: I. the term adequate attached gingiva should describe the amount of tissue that is conductive to gingival health in the clinician's opinion. Recession becomes an esthetic concern to the patient.Full thickness free graft: Is the procedure of relocation of keratinized palatal epithelium and connective tissue from its original site to a remote donor tissue. Sites exhibit progressive recession.Connective tissue graft.Full thickness free gingival graft. Procedure: A. Indications: 1. 1. 2. Therefore. Sub-gingival restorative margins are continuos source of irritation to the gingiva and require at least 5mm gingival width to maintain its health. I. 2. . Treatment of gingival recession. Increase width of keratinized gingiva.
1.Healing of the graft: Vascularization of gingival graft takes place from the underlying CT bed. will prevent the donor tissue from becoming vasculerized . 2. The flap raised at the recipient site can be cut off at this point as it is no longer needed. the surface layer degenerate and desquamate. Closer color blend avoiding patchy healing of the free G. C. 3. 3. B. and a periosteal sling suture. For free graft we can use simple interrupted suture for the corners. A space between the graft and underlying CT. This type of graft has a number of advantages over the free epithelial graft: 1. Closed plalatal wound healing by primary intention which involve less postoperative pain. A layer of new epithelium is present after 4-5 days.Placement of the graft : The flap should be placed and trimmed quickly to maintain its vitality. Dissection of split thickness flap to leave connective tissue bed over bone to nourish free graft. Increasing the zone of attached gingiva. Muco-gingival incision in case of increasing the width of attached gingiva or a horizontal incision at the base of the papillae. . II . 2. Capillary buds grow from the underlying connective tissue into the graft. D. which will result in necroses and sloughing of the graft. which continued around the recession area for treatment of gingival recession.Subepithelial connective tissue graft: This procedure was introduced by Langer and Langer (1985) as a method of : Gaining root coverage in Cases of sever gingival recession involving isolated or multiple teeth. Because nutrition to the graft is minimal during the first 2-3 days. and the graft can be sutured in place by papillary and apical stretching sutures. Two vertical incisions delineate the flap.G. There is a better blood supply from the periostium (partial thickness flap around the defect and underside of the covering flap).first molar area to dissect a split thickness graft from the underlying deeper connective tissue.Preparation of donor site : Three-mm deep incision is made on the palate opposite the premolar.
Care should be taken to avoid the palatine vessels but staying anterior to the first molar should avoid this problem. The trap door is replaced and a finger pressure applied for 10 minutes. is dissected from the underlying CT. With epithelial trap door reflected. Apart for use in obtaining a suitable CT. coronal to the CEJ. Additional preparation with citric acid or tetracycline may also carried out.Preparation of the recipient site: Elevating a partial thickness envelope flap (without vertical incisions) around the denuded root (It could be done by vertical incisions). Another approach is done by making two parallel horizontal beveled incisions 2mm apart from each other.Procedure : 1. No sutures usually required to the donor tissue. thick is sharply dissected from the exposed palatal tissue. can now easily visualized. The size of the CT. Donor CT. A wedge of CT. of about 1. Root preparation: Root planning of the exposed roots is carefully carried out . at the base of the trap to free the donor CT. Approximately 1mm. then placed beneath the partial thickness flap and over the exposed root at or 1mm. Without coronal displacement the replaced partial thickness flap cover 50% of the donor CT. 15 blade. This was designed by Harris 1992 . is thicker and better vascularized in this area and the rugae area of no concern because the graft is taken internally. graft ( 1. from the gingival margin using a No. the CT.5mm double scalpel knife). and 3mm. graft is determined by the size of the recipient base and its height and length are measured. (Sub-epithelial CT graft). A fourth incision is made through the CT. Are made in the palate adjacent to the 1st. The CT. It is made from the canine to the 1st. thickness along its thin border of epithelium is carefully dissected out. molar area since the CT. ( it may be sutured by resorbable sutures). and 2nd. . A special scalpel handle has been devised to accept two blades 1. The procedure leaves the outer epithelialized flap to be replaced for primary intention wound healing.5 mm. of about 2mm. ( I met Haris in Boston AAP meeting 1998) 2. A split thickness flap is raised with or without mesial and distal vertical relieving incisions. Preparation of the donor tissue: Three incisions to a depth of 3 to 4 mm.5 mm. C . of epith. Premolar area (one horizontal and two vertical).
Pedicle grafts and its modifications: Is a flap of tissue connected to its origin by a stalk. Coronal repositioned flap. Class IV: Marginal tissue recession that extends to or beyond the muco-gingival junction with sever bone loss and soft tissue loss inter-dentally and / or sever tooth mal-positioning.Apical repositioned flap. there is bone and/ or soft tissue loss inter-dentally or there is mal-positioning of the tooth. Double papillae repositioned flap. Miller expanded this classification as follows: Class I: Marginal tissue recession that does not extend to the muco-gingival junction. corresponding to Group 3 and 4 of Sullivan and Atkins classification. (See treatment of insufficient attached gingiva) 3. Laterally repositioned flap (LRF): The exposed root is covered by mobilizing a pedicle graft from a suitable adjacent area which then slide laterally to cover the defect. Sub-marginal laterally repositioned flap. CT graft with double papillae flap. .Treatment of gingival recession: Classifications: Sullivan and Atkins classified gingival recession into four morphologic categories: (1) Shallow and narrow (2) shallow wide (3) Deep narrow (4) Deep wide. There is no loss of bone or soft tissue in the inter-dental area. 1. Class III: Marginal tissue recession that extends to or beyond the muco-gingival junction . This type of recession can be sub-classified into wide and narrow. Lateral repositioned flap.2. There is no loss of bone or soft tissue in the inter-dental area. in addition . This type of recession can be narrow or wide (Group 1 or 2 in Sullivan and Atkins classification) Class II: Marginal tissue recession that extends to or beyond the muco-gingival junction. Subpidecle CT graft. Partial full rotated flap.
3-Inadequate attached gingiva. The color blend and root coverage are excellent in well chosen cases. 2. 4. 2. Partial or full thickness flaps 1 ½ wider than the recipient area. A number 15 scalpel blade is used to make a V shaped incision about the denuded root . Procedure of LRF: 1. 3. Excessive root prominence. Contraindication of LRFs: 1-Generally it is not suitable for treating isolated wide areas of recession . Vertical incision should extend to far apically to the mucosal tissue so that the tissue can be placed on the recipient bed without tension. removing the adjacent epithelium and CT . 2. A . The V shaped incision should be beveled out on the opposite side from the donor area. 5. root surface preparation. presence of deep interproximal pocket. Deep abrasion or erosion. permitting overlap and increase vascularity for the donor tissue.Indications of LRF: It is suitable to treat *single tooth * narrow areas of gingival recession *with adequate interdental bone height *and an adjacent donor area with an adequate zone of attached gingiva. or interproximal bone in the donor area. 6. to remove necrotic cementum and to reduce prominent convexity of the root. The blood supply that nourishes the flap over the avascular root surface is supplied by the wide base of the pedicle flap and from the perostium over the bone surrounding the denuded root. Advantages of LRF: 1. It is a one stage procedure whereby a pedicle flap is elevated by a split or full thickness from an adjacent area of keratinized gingiva. 2-Multiple recessions.
Indications: 1. 3. these should not encroach upon the radicular surface because these expose radicular bone Horizontal incisions across the tops of the papillae to allow better placement of the flap. When the attached gingiva on an approximating tooth is insufficient to allow for laterally positioned flap. Double papillae repositioning flap: The donor tissue is mobilized from the adjacent papillae rather than from the adjacent teeth . Mucosal flaps are reflected leaving the periostium. Lateral releasing incision at the mesio-facial and disto-facial line angles of adjacent teeth . Advantages: 1. with care to avoid separation of the flap By both sling and periosteal suture complete fixation is accomplished. The periosteum has been retained. The risk of loss of alveolar bone is minimized because the interdental bone is more resistant to loss than is radicular bone . it is designed to achieve adequate zone of attached gingiva and or coverage of a denuded root surface. 3. . when periodontal pockets are not present. 2. 2.small cut back incision to facilitate rotation was suggested. There is less exposure of donor site . Disadvantage: 1-Two small flaps have to join in such a way that they act as a single flap over avascular root surface 2-Proximal papillae must be of sufficient bulk. The V section is then removed and the root surface scaled. Suturing of the double flap. Procedure: A V shaped incision to remove a wedge of gingiva over the root. The papilla usually supply a greater width of attached gingiva than radicular surface of a tooth . However this incision rarely are necessary if the outline incision are angled toward the base of the deficiency to be corrected. When the interdental papilla adjacent to the mucogingival problem are sufficiently wide. It should extend far enough apically to prevent bunching of the tissue when the flaps are brought together.
5. Covered by a coronally repositioned buccal flap. 4 weeks later the mem was removed and the flap was sutured to cover the newly formed tissue healing was found to occur by new CT attachment while that without the mem. mesial . and from the covering double papillae pedicle flap. The CT papillae then covered by the partial thickness flap with some coronal displacement. the graft over the root surface depends on the collateral circulation in their nutrition. free rotated papillae autograft: Partial thickness envelop flap.Free gingival graft. (see above). ( See above)Hgamal1@hotmail. Subepithelial CT graft (See above). In this modification proposed by Harris(1992) the graft is covered over the root surface with tissue brought together by a double papillae type flap. Treatment of pocketing below the mucogingival junction: * apically repositioned flap. 4. Advantages: Single surgical site with no palatal discomfort. Placed at the CEJ covered by a full or partial thickness buccal flap coronally repositioned to the CEJ. 4. distal and apical to the exposed root . De-epithelialization of the adjacent papillae and removed in full thickness and placed at the recession were the bases at the CEJ and the apices at the base of the recession.the first one is full and the second partial. 3. GTR barrier mem. Partial full rotated flap: Which allow full thickness flap to cover the recession and partial thickness flap to cover the exposed bone. using 2 teeth at one side .CT graft with double papilla flap : In both free graft and CT graft . Occur by long junctional epith.com Ahmed Y Gamal [Type text] . Sub-pedicle CT graft : A pedicle flap cover a CT autograft to get more blood supply to the pedicle flap. The graft gets its blood supply both from the underling periostium . The mem. 2 .