OUTLINES OF PERIODONTAL THERAPY

AHMED Y. GAMAL. PROF. OF PERIODONTOLOGY .

2011
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)
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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.

Indications: 1. . Slow angiogenesis of avascular root and periodontal ligament. since the root surface exhibit a wide variety of irregularities and grooves. The thoroughness of root preparation. 2. * 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. Early differentiation of progenitor cells delays its proliferation. Pocket reduction: Shallow and moderately deep pockets could be completely debrided by scaling and root planing. as it does not get to the bottom of the pocket. 2. 3. (Why) Pocket epithelium migrate rapidly since it requires two factors to migrate: 1. hoe) could not be used for sub-gingival curettage. in other words the morphology of the roots rather than the probing depth determines the limitations of closed sub-gingival scaling. 3. New attachment by long junctional epithelium. Tissue shrinkage: due to reduction in gingival inflammation. 2. The amount of the fibrous connective tissue. * Pocket reduction following scaling and root planing occur through a combination of: 1. But the CT of the PL is slower in his rate of growth because: 1. Limited surface area of the periodontal ligament structure. Scaling and root planing are extremely difficult for deep pockets without direct vision.Heavy instruments (scalers. complete debridement for deep pockets could not be achieved for two reasons: 1. Vascular CT for nutrition. Substratum (fibrin strands) as contact guidance. 2. Re-adaptation of the gingival connective tissue to the root surface decreasing retractability of the soft tissue from the tooth surface.

Some degree of pocket reduction which my render surgical outcome unnecessary. 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. 2. Periodontal surgical approach: While nearly all-periodontal treatment techniques are surgical in nature. Objectives of periodontal surgery: 1. Leukemia. hemophilia. Treatment of compromise situations: 1. heart failure. 2.Render the tissue easier to handle during surgery. 3. 4.). Systemic and medical problems may render the patient not be able to undergo more extensive surgery (Ex. Pre-surgical preparation of tissue: (deep pockets) * The main objectives of pre-surgical preparations are to: 1st. 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. 3. with only longer junctional epithelium will form. Decrease bleeding and increase visibility during surgery. Decrease postoperative pain . advancing loss of attachment. Deep pockets are areas which are difficult to be cleaned by closed scaling and root planing. 4. by common usage the term periodontal surgery is applied only to procedures. . 3. which require incisions or excisions of periodontal tissues. or need for regenerative procedures. it is : * Difficult to be self-cleansed. Patients psychologically unwilling to accept surgical manipulation of their tissue. Deep pocket reduction: root cleaning and smoothing with direct vision.These resulted in epithelium that proliferate apically on the root surface before the other supporting tissues reach the area. It is aimed at treatment of the unresolved periodontal pockets. and infection. 2. uncontrolled diabetes….

bronchial asthma. 4. Implants insertion. Re-contouring of the gingival tissue to aid in effective hygiene. and hypertensive heart diseases require consultation with the patient cardiologist. 3. such as rheumatoid arthritis. 5. 4. Patient under severe emotional stress until the stress is relieved. such as coronary insufficiency. Other contraindications include: 1. thrombocytopenic purpura. pulmonary fibrosis. Preoperative sedation and use of minimal or no vasoconstrictors are routine measures when doing periodontal surgery for such patients. prothrombin deficiency. These patients do not tolerate stress well and are not capable of coping infection. 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. Prolonged systemic corticosteroid therapy. Re-contouring of osseous tissue. 2. tachycardia. 7. scleroderma. surgery done on an uncontrolled hyperthyroid could precipitate a thyrotoxic episode characterized by angina . and anticoagulant therapy. 6. or other cardiac arrhythmia. 3. 8. Patient with short life expectancy. Hyperthyroidism. Re-contouring of the gingival tissue for esthetic appearance. should be under control. pemphegus. 5. Many alcoholics do not heal well following periodontal surgery. * Retention areas for food and calculus. Contraindications and precautions of periodontal surgery: 1. treatment of periodontal abscesses. . some kidney disorders. Favor the connective tissue attachment (re-constructive surgery and tissue conditioning materials) 3. 2. Cardiac disorders.General contraindications and precautions: 1. Bleeding disorders: Such as hemophilia. lupus erythematosis . Correction of muco-gingival defects. Patients with congenital or prosthetic heart valves require antibiotic premeditation.* Difficult to be cleaned by the patient and the dentist. 2.

Restoration of periodontal health by closed mechanical debridement.presence of dense and fibrous gingival enlargement. Total pocket eradication. 5.  Gingivectomy and gingivoblasty: Gingivectomy is the complete removal of the soft tissue wall of the pocket. Dental contraindications and precautions 1. Fast and simple procedure.A gingival abscess entirely contained in the soft tissue. 2.Presence of supra-bony pockets >5mm which persist despite repeated sub. . Muco-gingival surgeries. Surgical sub-gingival curettage ( Excesional new attachment procedure ENAP)) 3. Resectional surgery ( Gingivectomy and gingivoblasty). 3.gingival curettage and root planning.presence of furcation evolvement (without associated osseous defects) where there is a wide zone of attached gingiva. 2. 2. *Surgical modalities could be classified as follows: 1.A peri-coronal flap. Re-constructive modalities. 3. Indications: 1. Root exposing surgery in anterior region. 5. Good visibility to the root surface 3. Advantages: 1. 4. and where gingivectomy would leave adequate amount of attached gingiva. Inadequate plaque control: Individual who will not keep etiologic factors under control will not benefit from periodontal surgery. Periodontal flap procedures . 2. 4.3.

The zone of attached gingiva my be eliminated. Such clean difinitive excesion of the junctional epithlium offer greater probability of new clinical attachment. 5. Advanteges: -The procedure permits through soft tissu preparation. * Tissue elevation is not a part of this procedure. with an internal bevel incesion started from the gingival margin to the apical end of epithelial attachment. that is why it is restricted to suprabony pockets whose apical extent lies within the keratinized gingiva. Open curettage): * It is essentially a sub-gingival curettage performed by a knife. Some loss of CT attachment my occur during healing. Reattachment that follows periodontal surgery or following access to periapical lesion. 2. 3. craters. * 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) . 2. 4. ex. -Secure good access to the root surface. Alveolar bone defects are not exposed and therefore it is contraindicated in the presence of intrabony lesions. Tissue is wasted which could be used to close the wound and obtain healing by primary intention. The clinical crown my be lengthened. which heal by secondary intention. Gingivoblasty: Is a term used when gingivectomy is done in the absence of pockets with the sole purpose of recontouring the gingiva.Surgical subgingival curettage:  Excisional new attachment procedure (ENAP) ( Mini flap. Disadvanteges: -Limited scope -Limited attachment gain .Disadvantages: 1. It creates an open wound. 6. as in cases of rolled gingival margins. Exposed roots my be sensitive and liable to caries. and bulbous interdental papillae. 7. Reattachment refers to reattachment of periodontal tissues in an area not previously exposed to the pocket.

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 . The second incision made from the base of the pocket to the bone crest. 3. The flap consisted of three basic incisions: 1. but maximum healing of periodontal pocket with minimum loss of tissue.T.5 to 1mm from the free gingival margin ( supra-crestal internal bevel incision) to the alveolar crest. The third one is a horizontal incision made from the crest of the bone to the tooth surface. . 2.3. To facilitate removal of the lining epithelium and granulation tissue that may interfere with healing. Initial internal bevel incision begun 0. to allow the cervical wedge to be removed easily. followed by reflection of a full thickness flap that exposes 1 to 2 mm of alveolar bone. Less bone is exposed in modefied flap. 3. 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. The incision should follow the scalloping of the free gingival margin to get complete coverage of the interdental areas after suturing. * 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 . The aim of this incision is to separate the pocket epithelium and inflamed C. To facilitate attempts to reestablish new CT attachment (reconstructive procedures). The main reasons for doing periodontal flap are 1. To secure access for root planing and to the underlying intraosseous defects. 2. whereas the original procedure included removal of osseous defects. ( cervical wedge) from the flap.

5. The essential requirements of the graft materials are: 1. 3. It should have osteoginic potential. . Control of epithelial migration into the root surface. 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. Implant materials with varieng osteoginic potential. by meticulous oral hygiene the interdental tissue regenerates over few monthes. Stable after sterilization. Need for endotoxin free root surface. Allow optimal soft tissue coverage to the root surface which gives a good esthetic. Optimize postsurgical adaptation of healthy CT and epithelium to the root surface. Induction of a new cementum and incorporation of connective tissue fibers. 2. Inexpensive. 4. Host response factors. 2. It should be immunologically acceptable (non-antigenic). Non toxic 4. 4. 3. 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. These craters developed because of the minimal reflection of the muco-periostium that did not allow for complete coverage of the interdental tissues. 3. 2.Advanteges: A-Optimize accesses to the root surface and intra-bony lesions. 5. Multiple factors must be consederd when attempting regeneration. less post operative sensitivity or caries. 4 .

It is used with some success however: * Tapping this site my not be justifiable. 2. 3. 200 um -Healing socket autogenous bone: is usually obtained 8 to 12 weeks after extraction to allow newly forming bone to mature.dried cortical bone allograft (FDBA). Eliminate the possibility of graft rejection. 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. tuberosety. tori . Autogenous: which is bone from the same indivedual. Advantages of autogenous grafts: 1. In the form of: -Osseous coagulum: is a term applied when the autogenous bone obtained with a bur and mixed with blood.Freeze. Allogenic ( allograft) : bone from an individual of the same species.A number of different types of graft materials have been tried : 1. max. Poses no danger of diseases transfer. Extra-oral: Iliac cancellus bone. Although the osteoginic potential of this materials was good. it did not represent an ideal graft because of the. . extration sockets. intra-oral: Sources: Ostectomy . 1. The need for second surgical insult with bone sources. Decreases coast to the patients. * Fresh marrow tissue often produce root resorption and ankyloses. chisel or rongeur and triturated into particle size of about 100. edentulus area. -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. .

and other bone derived growth factors. malignances. prothetic heart valves and has no inflammatory or immune responses. contagious diseases.. c. The donor should be free from viral.Hard tissue replacement polymer (HTR) Is a non. which facilitate vascular ingrowth and subsequent new bone formation b. Bovine bone menial and collagen) 4.   Sample frozen in liquid nitrogen. long term medications that known to affect bone (corticosteroid).  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. but they are not an Osteoinductive materials a.   Sample (ex.  The lyophilized bone was ground under sterile condition through a sterile sieve with 400 um openings. 3.porous Hydroxylapatite (periograf. bacterial.Tricalcium phosphate ceramics( Synthograft).Porous and non. studies showed that cortical bone is superior to cancellus bone when used as a freeze. The bone chips were lyophilized in freeze-drying chamber. and Bio-guide.resorbable microporous biocompatible composite of Polymethylmethacrylate (PMMA) and polyhydroxyethylmethacrylate(PHEMA) .( Bio-oss. Shaft of long bone) taken from cadaver within 24 h of death. Grafts of bone substitutes and synthetic materials ( Alloplastes) : Are biocompateble materials that are used to fill osseous defects. All cancellus bone and marrow elements removed and discarded. At the end of about 2 weeks at least 95% of the total water content had been removed. the opposite may be true in autogenous grafts.   The cortical plates were reduced in size to approximately 1 to 2 cm. This materials has been used in the fabrication of contact lenses. long half-life isotops. . Xenograft: Bone from different species treated with EDTA to remove the organic compounds and antiginic fraction. It may be combined with collagen to facilitate its retention. Bone matrix contains bone inductive proteins as BMP2 and 7.Freeze dried deminirelized bone allograft (FDDBA). or durapatite): Porous hydroxylapatite has a uniform pore size .dried allograft.

There is a potential of root resorbtion of fresh materials. Possible mode of actions of re-constructive materials: 1. Autogenous materials need donor tissue and additional surgry. Not improving tooth mobility.Biocompatible . These are coated with liquid PHEMA . 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. thus retarding reepithelialization until true regeneration occur (mechanical barrier). Closure of the defect occure by long junctional epithelium. then the composite beads coated with calcium hydroxide / calcium carbonate. -reduce any tiny risk of disease transfer by infected allogenic bone. 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. 3.880 um diameter with pores of 50-300 um form the core of the material. Some inflamatory reactions my occure.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. Implants my promote osseous repair by there ability to act as matrix (scaffold) around which bone is formed (osteo-conductive). 2. . Theoritically Ca phosphate ceramics becomes rapidly encapsulated in collagen and act as an enhancer for new bone growth. Disadvantages:        Partial or complete exfoliation.PMMA beads are 550 . D. Limited new attachment. Advantages of alloplasts: -Unlimited amount of materials negating the need for human donor. .

 Sometimes the procedure called osteopromotion because it is a more general term not restricted to only placement of a membrane for guidance.It protects the blood clot and favours its adherence to the root surface by its mechnical supportive effect (scaffold). extending from 2-3 mm below the bone margin to just below the C.Stimulatory properties of the membrane: *The surface of the membrane my be osteoconductive i.: act as a guidance for osteogenic cells. Types: 1. Non. * ePTFE is permeable to tissue fluids and macromolecules .J on the root. neogeneses. at the same time to allow time for population of the curreted root by cells arising from the periodontal ligament. For that reason recruitment of PDL and bone cells are important steps in regenerating the periodontium. . as it could be of a value in regeneration. -Locally concentrate growth stimulatory factors derived from bone. thus allowed nutreins to pass while unwanted cell types are kept out. . (teflon mem. * It is adapted to fit over th intrabony defect and the root of the tooth. 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. For that reason the membrane should be firm to the extent of not ristricting the space of bone and PL. PDGF. Guided tissue regeneration (GTR): Regeneration is the “ growth and differentiation of new cells and intercellular substances to form new tissues “. periodontal ligament and cementum.( It differs from repair or healing by scar.T. open microstructure margin which is designed to allow C.E. Regeneration takes place by growth from the same type of tissue that has been destroyed or from its precursor ( Caranza 1996b). as well as an occlusive membrane.resorbable: Plytetrafloroethyline mem. cementum derived growth factor). improving bone graft results. penetration to produce a seal at the coronal margin of the root.e. 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.( Bone morphogenitic protein. .) (Gore-tex) * It consists of a narrow.

To tent it out. May shrink and coverage of any osteoid. The need of secondery procedure to remove the mem. Biodegradable membrane: It is desirable for the auxillary material to desentegrat at the end of the wound healing. And the root surface. but in horizontal defect only the PL cells of the Pl migrate coronally. tying it to a gold bar. may be diffecult. -Lyodura (6-8 weeks) Disadvantages: 1-Local inflammatory response of phagocitic activity. 3. then the flap is sutured back to just cover the membrane. 2. To avoid this disadvantege several approaches have been proposed like placing a suture in the mem. Disturbing the newly formed osteoid material.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. ( 2-6 weeks). which might form. or using a tetanium reinforced mem. Space maintenance is a problim as ePTFE easly collapse eradecting any space between the mem. . 2. this include: -Polyglactin Mem. Flaps replaced over Gore-tex mem. (4-8 weeks). removed after 4-6 weeks by a marginal incesion. -ýpolylactic acid ( 3-4 month). some trials with biodegradable materials showes a good results. Disadvanteges: 1. -Cargile Mem. 2-The need to maintain proper timing between completion of PL regeneration and degeneration of the membrane.* It is held in place by a Teflon sling suture. * The mem. -Collagen Mem.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 . -Calcium sulfate . 3-Impossible removal in case when it is needed. Indications of guided tissue application: . ( Disentigrate after 1-2 month).

Anticollagenolytic activity. Root conditioning agents in promoting connective tissue attachment: (Acids) 1. Which in contrast to etching at low PH preserve tissue vitality. Laminine: promote epithelial cell proliferation. Tetracycline HCL: 1. Exposing inducers of cementoblastes and osteoblastes by exposing collagen fibers . * 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. * Expose and widen the orifices of dentinal tubules which favor periodontal ligament fibroblasts adhesion to the root surface. Promote fibroblast adhesion and growth. Good substantivity: react with dental hard tissue. 3. . Stop apical migration of epithelial attachment through early fibrin linkage. from which it slowly released in an antibiotically active form. EDTA (prefgel 24%) * It exerts its demeniralizing effect through chelating divalent cation at a neutral PH. antienzymatic effect that retard collagen breakdown 4. b. 2. 5. Collagen exposure. It my act as a solvent for endotoxins. Bacteriocidal property of low PH on microbes.(Extracelllular matrix) Fibronictin is an extracellular matrix protein provide attachment of fibroblasts to diseased root. 3. 4. Demineralization and exposure of collagen from the superficial portion of dentine where CT attachment occur by integration of new and old collagen fibers. 2. Citric acid: (20% for 3 minutes) 1.

IGF . Platelets are our primary mechanism for hemostasis. Synergestic effects are observed on mitogeneses of PDL cells when IGF-1 is combined with PDGF. formation of a blood clot Platelet gel mimics the final stages in the clotting cascade. Insulin growth factor (IGF-1): Chemotactic for cells derived from PDL. The platelet rich plasma in the presence of thrombin activates platelets. They circulate in our bodies looking for exposed endothelium. Platelets rich plasma perform many functions. The substance is a by-product of blood (plasma) that is rich in platelets.             Platelet derived growth factor(PDGF): Have a potent effect on proleferative activety of periodontal ligament fibroblastes(PDL). Bone grafts with its contained growth factors and growth factor application seems to stimulate cells capable of regeneration. including: 1. The most related and most studied growth factors in periodontal regeneration include: PDGF . TGF . Chemotactic for PDL cells Promote collagen and total protein syntheses. Promote fibroblastes proleferation under an expanded GTR membranes increase metalloproteinase syntheses from PDL cells.(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.  Stimulation of cells of periodontal ligament and alveolar bone populated the healing tissue coronal to the residual alveolar bone. BMP . Platelet rich plasma: Is exactly what its name suggests. converts fibrinogen to fibrin and stimulates further platelet aggregation . Have an influential effect on PDL mitogeneses and protein syntheses. They then aggregate to the site of injury and further platelet degranulization occurs. Improve adhesion of PDL cells to the root surface( Gamal et al 1998) Can reduce the inhibitory effects of lipopolysaccaride on gingival fibroblast proleferation.c.

the more stem cells stimulated to produce new host tissue. and insulin-like growth factor ILGF) function to assist the body in repairing itself by stimulating stem cells to regenerate new tissue. Its key component (amelogenin) naturally produced by the ameloblastes during tooth development.) Emdogain A recently developed biologically based product represents a new way of thinking in periodontal regeneration. leaving only a residue of enamel matrix protein on the debrided root surface. platelet-rich glue. following cementum formation the PL is established creating true CT attachment to the tooth .2. the patient need not incur the expense of the harvesting procedure in hospital or at the blood bank. 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. and release of growth factors (GF) into the wound. The more growth factors released/sequestered into the wound. clinical and experimental studies by Wennstrِm and Lindhe (1983) demonstrated that . emdogain is naturally absorbed by the body . It is an enamel matrix protein( amelogenin) that applied as a gel directly into the tooth root during periodontal flap surgery .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. Cost effectiveness: Since PRP harvesting is done with only 55 cc of blood in the doctor’s office. transforming growth factor beta TGF . The term Mucogingival Surgery was proposed by Friedman in 1957 to indicate any surgery “designed to preserve attached gingiva. 4. Subsequently. and to increase the depth of the vestibule”.  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. to remove frena or muscle attachment. Once applied. These GF (platelet derived growth factors PGDF. The aim of this type of surgery was to maintain an adequate amount of attached gingiva and to prevent continuous loss of attachment. this protein is involved in the formation of tooth supporting tissues. (Calcium chloride is added to counteract the anticoagulant citrate. this natural and insoluble surface layer encourages the migration of cementum forming cells from the surrounding tissues . rapidly forming gelatinous. Autologous platelet rich gel has several advantages:   eliminated the risk of disease (viral transmission) related to donor blood products.

1.Loss of interdental papilla which presents an aesthetic and/or phonetic problem.Frenum insertion in or close to the gingival margin. In this respect the Mucogingival Therapy includes: 1. All have the common aim of: 1. frenum. 6. crown lengthening) *position ( pocket at the mucogingival area. 5. papillary loss. (Gingival augmentation). 2. 2. and therefore prevent disease recurrence.Teeth that are not likely to erupt. 9. 3. Treatment of pocketing below the muco-gingival junction: A number of surgical procedures have been proposed to solve muco-gingival problems of this type .Prevention of ridge collapse associated with tooth extraction.Pockets extend at or below the mucogingival line.Insufficient attached gingiva without pocket formation. 4. prevention of ridge collapse). 7. 8. The removal of the disease.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.Augmentation of the edentulous ridge. ridge augmentation. teeth not likely to erupt ). The production of a periodontal anatomy which allows effective plaque control . 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. . This assigns importance to non-surgical therapy and to the bone condition because of its influence on the morphology of the defects.Crown lengthening. *and/or amount of soft tissue and underlying bone ( inadequate attached G .Isolated gingival recession.

The attached gingiva starts at the base of sulcus or free gingival groove to the mucogingival junction. 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. 5. the remaining tissue namely. 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. 3. 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. 2. One should ensure that the flap is displaced apically so that its edge just covers the alveolar crest. 4. once released the flap tend to contract and fold up so that apical positioning often takes place spontaneously. Its width varies from one to nine mm. 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).. Apical repositioning: The flap is reflected to the base of the vestibule. This will separate the pocket lining from the inner wall of the flap.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. . It has been observed that following removal or in the absence of the attached gingiva. Full thickness flap reflection and removal of the cervical wedge together with scaling and root planning. It was originally believed that a minimum width of attached gingiva required to maintain gingival health and to prevent recession. Procedure: 1. Treatment of insufficient attached gingiva: The term-attached gingiva refer to gingival tissue that is bound to the tooth and underlying bone. Placing the periodontal dressing: It helps in prevention of coronal displacement so it should extend to the base of the vestibule 6. An inverse bevel incision start 1mm. from the gingival margin to the alveolar crest.

1. Procedure: A.Preparation of recipient site : II. Treatment of gingival recession. 2. Indications: There are factors to help guide the clinician in determining the need for surgery when there is 1mm of attached gingiva or less. Therefore. Recession becomes an esthetic concern to the patient. Sub-gingival restorative margins are continuos source of irritation to the gingiva and require at least 5mm gingival width to maintain its health. I. Increase width of keratinized gingiva. 2. .Full thickness free gingival graft. the term adequate attached gingiva should describe the amount of tissue that is conductive to gingival health in the clinician's opinion.Free grafts: I. Indications: 1. 3. 1.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.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.

For free graft we can use simple interrupted suture for the corners. D. Muco-gingival incision in case of increasing the width of attached gingiva or a horizontal incision at the base of the papillae.Preparation of donor site : Three-mm deep incision is made on the palate opposite the premolar. This type of graft has a number of advantages over the free epithelial graft: 1. will prevent the donor tissue from becoming vasculerized . 2. C. and a periosteal sling suture. Two vertical incisions delineate the flap. II .G. and the graft can be sutured in place by papillary and apical stretching sutures. Because nutrition to the graft is minimal during the first 2-3 days. the surface layer degenerate and desquamate.Healing of the graft: Vascularization of gingival graft takes place from the underlying CT bed. . which continued around the recession area for treatment of gingival recession. The flap raised at the recipient site can be cut off at this point as it is no longer needed. Capillary buds grow from the underlying connective tissue into the graft. 3. Closed plalatal wound healing by primary intention which involve less postoperative pain. Dissection of split thickness flap to leave connective tissue bed over bone to nourish free graft. A space between the graft and underlying CT.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. 3. A layer of new epithelium is present after 4-5 days. Closer color blend avoiding patchy healing of the free G. There is a better blood supply from the periostium (partial thickness flap around the defect and underside of the covering flap).1. which will result in necroses and sloughing of the graft. B.Placement of the graft : The flap should be placed and trimmed quickly to maintain its vitality.first molar area to dissect a split thickness graft from the underlying deeper connective tissue. Increasing the zone of attached gingiva. 2.

15 blade. graft ( 1. Care should be taken to avoid the palatine vessels but staying anterior to the first molar should avoid this problem.5 mm. the CT. Apart for use in obtaining a suitable CT.5 mm. then placed beneath the partial thickness flap and over the exposed root at or 1mm. Root preparation: Root planning of the exposed roots is carefully carried out . coronal to the CEJ. ( I met Haris in Boston AAP meeting 1998) 2. from the gingival margin using a No. Preparation of the donor tissue:  Three incisions to a depth of 3 to 4 mm. Donor CT. Another approach is done by making two parallel horizontal beveled incisions 2mm apart from each other. The procedure leaves the outer epithelialized flap to be replaced for primary intention wound healing.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).  The size of the CT.5mm double scalpel knife). The trap door is replaced and a finger pressure applied for 10 minutes. ( it may be sutured by resorbable sutures). This was designed by Harris 1992 . .       Approximately 1mm. A special scalpel handle has been devised to accept two blades 1. of about 1. A split thickness flap is raised with or without mesial and distal vertical relieving incisions.  The CT. Are made in the palate adjacent to the 1st. of about 2mm. thick is sharply dissected from the exposed palatal tissue. (Sub-epithelial CT graft). thickness along its thin border of epithelium is carefully dissected out. is dissected from the underlying CT. molar area since the CT. C . can now easily visualized. With epithelial trap door reflected. A wedge of CT. is thicker and better vascularized in this area and the rugae area of no concern because the graft is taken internally. graft is determined by the size of the recipient base and its height and length are measured. Additional preparation with citric acid or tetracycline may also carried out. No sutures usually required to the donor tissue. Premolar area (one horizontal and two vertical). of epith. and 2nd. A fourth incision is made through the CT. and 3mm.   Without coronal displacement the replaced partial thickness flap cover 50% of the donor CT.Procedure : 1. at the base of the trap to free the donor CT. It is made from the canine to the 1st.

Double papillae repositioned flap. corresponding to Group 3 and 4 of Sullivan and Atkins classification. 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.2. This type of recession can be sub-classified into wide and narrow. 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. There is no loss of bone or soft tissue in the inter-dental area. There is no loss of bone or soft tissue in the inter-dental area. (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. Subpidecle CT graft.  Miller expanded this classification as follows: Class I: Marginal tissue recession that does not extend to the muco-gingival junction. CT graft with double papillae flap.        Lateral repositioned flap.Apical repositioned flap. 1. Coronal repositioned flap. Partial full rotated flap. in addition .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. Class III: Marginal tissue recession that extends to or beyond the muco-gingival junction . there is bone and/ or soft tissue loss inter-dentally or there is mal-positioning of the tooth. Sub-marginal laterally repositioned flap.Pedicle grafts and its modifications: Is a flap of tissue connected to its origin by a stalk.

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. The color blend and root coverage are excellent in well chosen cases. A number 15 scalpel blade is used to make a V shaped incision about the denuded root . 6. root surface preparation. 2-Multiple recessions. 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. 2. 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. to remove necrotic cementum and to reduce prominent convexity of the root. 2. A . Procedure of LRF: 1. Contraindication of LRFs: 1-Generally it is not suitable for treating isolated wide areas of recession . 4. presence of deep interproximal pocket. 5. 3. permitting overlap and increase vascularity for the donor tissue. Vertical incision should extend to far apically to the mucosal tissue so that the tissue can be placed on the recipient bed without tension. Excessive root prominence. Deep abrasion or erosion. or interproximal bone in the donor area. Advantages of LRF: 1. removing the adjacent epithelium and CT . 3-Inadequate attached gingiva. Partial or full thickness flaps 1 ½ wider than the recipient area. The V shaped incision should be beveled out on the opposite side from the donor area.

it is designed to achieve adequate zone of attached gingiva and or coverage of a denuded root surface.  Lateral releasing incision at the mesio-facial and disto-facial line angles of adjacent teeth . The papilla usually supply a greater width of attached gingiva than radicular surface of a tooth . Mucosal flaps are reflected leaving the periostium. with care to avoid separation of the flap By both sling and periosteal suture complete fixation is accomplished. 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. Double papillae repositioning flap: The donor tissue is mobilized from the adjacent papillae rather than from the adjacent teeth . Suturing of the double flap. . when periodontal pockets are not present. The risk of loss of alveolar bone is minimized because the interdental bone is more resistant to loss than is radicular bone . 3. 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. 3. Indications: 1. However this incision rarely are necessary if the outline incision are angled toward the base of the deficiency to be corrected. The V section is then removed and the root surface scaled. When the interdental papilla adjacent to the mucogingival problem are sufficiently wide. 2. It should extend far enough apically to prevent bunching of the tissue when the flaps are brought together. Procedure:  A V shaped incision to remove a wedge of gingiva over the root. There is less exposure of donor site . 2.small cut back incision to facilitate rotation was suggested. When the attached gingiva on an approximating tooth is insufficient to allow for laterally positioned flap. The periosteum has been retained. Advantages: 1.

 The CT papillae then covered by the partial thickness flap with some coronal displacement.CT graft with double papilla flap : In both free graft and CT graft . 3. Covered by a coronally repositioned buccal flap.Free gingival graft. free rotated papillae autograft:   Partial thickness envelop flap. 4. Sub-pedicle CT graft : A pedicle flap cover a CT autograft to get more blood supply to the pedicle flap. Occur by long junctional epith. the graft over the root surface depends on the collateral circulation in their nutrition. GTR barrier mem. 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. and from the covering double papillae pedicle flap. 4. mesial . using 2 teeth at one side . Advantages: Single surgical site with no palatal discomfort. 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. The mem. 5. Subepithelial CT graft (See above). 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. (see above). ( See above)Hgamal1@hotmail. Treatment of pocketing below the mucogingival junction: * apically repositioned flap. The graft gets its blood supply both from the underling periostium . Placed at the CEJ covered by a full or partial thickness buccal flap coronally repositioned to the CEJ. Partial full rotated flap: Which allow full thickness flap to cover the recession and partial thickness flap to cover the exposed bone. 2 . distal and apical to the exposed root .com Ahmed Y Gamal [Type text] .