Periodontology Bartolucci One

Enrico G .
Bartolucci
first volume
RIOD O
Text by
.das
'co Bart
CONTENTS
Chapter 1
THE MECHANISM OF PERIODONTAL DESTRUCTION Bacterial colonization of the crevic e Host defenc e Gingivitis and Periodontiti s Pocket formatio n Gingival Recession formatio n Bone resorptio n Progression of periodontal diseas e
Volume I
page 1
Chapter 2
DIAGNOSIS Classification of Periodontal diseas e Clinical examinatio n Periodontal probing Tooth mobilit y Clinical chartin g Radiographic analysi s Diagnosis page 3 9
Chapter 3
TREATMENT PLANNING Initial treatment planning Reexaminatio n Definitive treatment plannin g Non surgical treatment Surgical treatment Maintenance therap y page 9 3
Chapter 4
ORAL HYGIENE REHABILITATION Plaque contro l Interrelation between plaque, inflammation and tissue distructio n Instruments and instrumentatio n Supragingival scalin g Subgingival scaling and root planing Antiseptics in periodontal therap y Antibiotics in periodontal therapy Sharpening of the instrument s Reevaluation page 11 1
VI
Chapter 5 PRINCIPLES OF PERIODONTAL SURGERY Classification of surgical procedur e Local anesthesi a Incision s Flaps elevatio n Full and partial thickness flap s Flaps positionin g Suturing tchniques Periodontal dressing s Post-surgical care Instruments sterilizatio n Chapter 6 PERIODONTAL FLAP PROCEDURES Indications and controindication s Access flap Modified Widman flap Apically positioned flap Palatal flap Distal wedg e Smoking and surgical therapy
page 17 1
page 24 3
Chapter 7 RESECTIVE OSSEOUS SURGERY Osseous defects Osteoplasty Ostectomy Surgical instruments Surgical technique s Clinical case
page 29 5
Chapter 8 RESECTIVE GINGIVAL SURGERY Gingival hyperplasi a Gingivectomy Surgical instruments Surgical technique s Clinical cases
page 32 1
VII
CONTENTS
Chapter 9
SURGERY OF FURCATION-INVOLVED TEETH Anatomy Diagnosis Radiographs Classificatio n Treatment of degree I Treatment of degree II Treatment of degree II I
Volume I I
page 345
Chapter 1 0 MUCO -GINGIVAL SURGERY
page 38 5 The function of keratinized and attached gingiv a Gingival recessio n Sullivan and Atkins Classificatio n Miller Classificatio n Surgical instrument s Frenulectomy Pedicle soft tissue grafts Coronally positioned Laterally positioned Bipapillar Free soft tissue graft s Connective tissue graft s
Chapter 1 1 GUIDED TISSUE REGENERATION Biology of GT R Barrier material s Indications Patient selectio n Surgical procedure Treatment of Intrabony defect s GTR in mucogingival surger y Bone grafts and biomaterial s Prognosis of GT R
page 46 9
Chapter 1 2
PREPROTESIC SURGERY Biologic width Crown lenthenin g Intraoperatory preparation of the abutment s Preprotesic mucogingival surger y Surgical removal of exostosi s Tuber reductio n Localized ridge augmentatio n page 535
VIII
Chapter 1 3
JUVENILE PERIODONTITIS Localized Juvenile Periodontitis Generalized Juvenile Periodontiti s Batteriology Immune responce Treatment Clinical case s
page 61 1
Chapter 1 4
PERIODONTITIS AND JUVENILE DIABETES Early onset diabetes (type I) and periodontiti s Matur onset diabetes (type II) and periodontiti s Initial treatment Farmacological treatmen t Surgical rational e Surgical treatmen t Clinical case
page 63 1
Chapter 1 5
DESQUAMATIVE CHRONIC GINGIVITIS Clinical symptom s Diagnosis Immunofluorescenc e Pemphigoi d Pemphigus vulgaris Lichen Planu s Hormonal Gingiviti s Osler-Weber-Rendu Syndrom e Therapy of desquamative chronic gingiviti s
page 653
IX
Chapter 1
The mechanis m of periodonta l destruction
THE MECHANISM OF PERIODONTAL DESTRUCTION
The term "periodontal disease" describes a group of diseases initiatin g in and remaining confined to the periodontal tissue . The majority are inflammatory lesions caused by microorganisms accumulating in the pericrevicula r area. Periodontal disease can be divided into : GINGIVITIS : the inflammatory lesion is confined to the gingival tissue . PERIODONTITIS: the inflammatory lesion extends to the tooth support tis sues. Although more than 350 species of bacteria have been isolated in the mouth , human periodontal infections are apparently caused by a specific microbial infection . Less than 5% of microbial flora is, in fact, associated with disease .
--------------------------Epithelial attachment 0 .97 mm Biologic width 2 .04 m i
Ideal gingival morphology and diagrammatic representation : pink colour, scalloped margin , "orange peel" appearance, papillae in the interdental spaces, adequate band of keratinized gingiva . The gingival sulcus is shallow (0 .69 mm), the epithelial attachment is located on the enamel (0 .97 mm) , the connective attachment is inserted in the root cementum (1 .07 mm) . The distance from the bottom of the sulcus to the osseous crest is known as the biological width (2 .04 mm).
CHAPTER 1
HEALTHY GINGIVAL CONDITION (PRISTINE GINGIVA)

uation in which there is no bacterial plaque and the gingival tissue is histologi cally perfect, without inflammatory infiltration . It can be achieved only unde r experimental conditions and through meticulous oral hygiene . A healthy gingiv a is usually characterized by the presence of modest supragingival plaque which , if removed daily, consists of Gram+ cocci-type flora only .
A healthy gingival condition (known as "pristine gingiva") is an ideal sit -
A small quantity of pericrevicular bacteria l plaque highlighted with a colorant can be seen . This consists of Gram + cocci-type flora .
If removed daily, th e plaque does not have time to proliferate an d reach the sulcus, modifying its qualitative characteristics .
THE MECHANISM OF PERIODONTAL DESTRUCTIO N
BACTERIAL COLONIZATION OF THE CREVICE

If the bacterial plaque is not constantly removed, it proliferates an d spreads in the gingival sulcus . Two subgingival plaque components have bee n identified : a part adhering to the root of the tooth and a free or fluctuating par t (Listgarten, J .Perio 1976) .
Plaque
Aerobic Anaerobic Supragingiva l Subgingival - adherent
Anaerobic ! Subgingival - not adheren t
Supragingival plaqu e
Gingival crevice : interior view.
Subgingival plaque.
CHAPTER 1
PERIODONTAL DISEASE
IMMUNE RESPONS E BACTERI A ! Quantity of plaqu e ! Quality of plaqu e ! Plaque retainin g factor ! Bacterial product s
Positive Response
! Intact tissue s ! Exudation ! Phagocytosis ! Immune respons e

Deficient Respons e
! PMN defect s ! Hypersensitivity reactions ! Systemic disease s
The presence of specific bacteria in the sulcus is a vital element in determining inflammatory peri odontal diseases (Loe - Theilade - Socransky - Listgarten - Newman) . On the other hand, the presence o f microorganisms is not in itself sufficient to cause the destruction of tooth support tissue. The bacterial flora, in fact, triggers off a complex immune response in the host organism and it is this response which leads to the destruction of periodontal tissues (Taichman - Page - Schroeder - Toto - Levine -Genco) .
Healthy condition .
Subgingival plaqu e
Disease condition .
CHAPTER 1
IMMUNE RESPONSE
Impairment of the Sulcular Epitheliu m

The enzymes produced by the subgingival bacterial plaque destroy the mucopolysaccharides in the ground substance between the cells of the junctional epithelium, allowing bacterial components acting as antigens (endotox ins, fragments of bacterial capsule, etc.) to enter the organism . This further increases vessel permeability, enabling the PMNs to leak from th e blood vessels and reach the crevice through the connective tissue and junctional epithelium. During this phase, there is an increase in crevicular fluid .
Bacterial plaque enzyme s Hyaluronidase Collagenas e Proteas e Elastas e
Collecting crevicular fluid with blotting paper .
Crevicular leukocyte s ~--- Crevicular fluid
(From Attsrom & Egelberg 1971 ) During the gingiviti s development period, a gradual increase in th e number of leukocytes i n the crevice and in the flow of crevicular flui d can be observed .
28
35
Days

Epithelial cells in the desquamation phase.
Epithelial cells . Ground substance.
Plaque Enzyme s
Destroy the mucopolysaccharides o f the ground substanc e
Epithelial cell in the desquamatio n phase: note the underlying groun d substance.
CHAPTER 1
Polymorphonuclear Leukocytes (PMNs)
Gingival blood vessel : the PMNs can be observed on the inne r surface of the vessel, attracted by the adhesins (ICAM-1 , ELAM-2) . The perivascular tissue is infiltrated . Stimulated by chemoactive substances, the PMNs migrate through th e connective tissue and accumulate in the junctional epithelium and the sulcus, pe'iforming their phagocytic function .
Polymorphonuclear leukocytes in th e non-migratory phase . 10
Animal histologic preparation .
Epithelial attachment and connective attachment .
Polymorphonuclear leukocytes in diapedetic phase . 11
Phagocytosis of a bacterium by a polymorphonuclear leukocyte .
CHAPTER 1
GINGIVITIS
Inflammation localized coronally to the transseptal fibres . Probing and X-ray examination do not indicate loss of periodontal support . The PMN accumulation and activity in the pericrevicular zone lead t o the release of various enzymes with a damaging action both on the bacteri a and on the tissue of the host organism . Macrophages and lymphocytes also begin to move towards the site . The former have a phagocytic action, neutralizing the enzymes released by th e PMNs . The latter neutralize an enormous number of antigens .
Supragingival plaque Gram+ filamentous rod-shaped microbe s X PMN s
Marginal gingivitis Note the plaque in the pericrevicular zone and the red and edematous gingival margin .
J . Y.CIIO
definition according to
PAGE and SCHROEDER 1976 Histologic perfectio n Normal healthy gingiva Early gingiviti s Stable gingivitis Periodontitis Initial lesion Early lesion Stable lesio n
(without bone loss or apica l migration of the epithelium )
HISTOPATHOLOG Y A number of neutrophil s Slight infiltrat e

(Mon. Mac) : Lymph. Neutr )
Increase in infiltrat e
(appearance of a number of plasma cells)
Considerable increas e in infiltrat e

(10-30% plasma cells)
Stable lesio n
(with bone loss and apica l migration of the epithelium)
Considerable increas e in infiltrat e (> 50% plasma cells)
Transseptal fibres and diagrammatic representation : tissue infiltration is localized coronally to the transseptal fibres and consists mainly of neutrophils, lymphocytes, macrophages and plasma cells ; the latter make up 10-30% of the infiltrate . Marginal gingivitis in two recessions caused by traumatic toothbrushing after the patien t had stopped brushing in that zone .
CHAPTER 1
PERIOD ONTITIS
Presence of inflammatory infiltrate apically to the transseptal fibres , bone reabsorption, periodontal pocket . When the inflammatory infiltrate spreads apically and invades the transseptal fibres, bone begins to be reabsorbed, leaving more space for th e defensive cells which flow to the site in great numbers . Granulation tissue is formed . This is highly vascularized and full of plasm a cells which produce antibodies . In the meantime, while the epithelial layer s of the junctional epithelium are attacked and fragmented, new epithelium grows in a more apical position. All this leads to formation of a periodontal pocket .
The inflammatory infiltrate invades the transseptal fibres . Chronic periodontitis : with reabsoption of bone tissue .
A . Naeslundi H 30-40'% A
. Viscosu s
II Spirochete s
X PMN s
Grain- rod-shaped microbes
Plasma cells
J . Y.CIIO
14
Chronic periodontitis
Chronic periodontitis is clinically characterized by the presence of a periodontal pocket (>3 mm .) When the disease is in the active phase, bleeding on probing or spontaneous bleeding is observe d
Formation of a periodontal pocket: the inflammatory infiltrate spreads apically, invading th e transseptal fibres . Bone is reabsorbed, granulation tissue is formed and new epithelium grows in c more apical positio n
15
CHAPTER 1
Formation of Gingival Recession
In the gingival morphotype illustrated characterized by thin tissu e (vestibular-lingual section), gingival recession may easily be formed as a resul t of total gingival tissue destruction caused either by traumatic toothbrushing o r by bacterial plaque . Gingival recession is always accompanied by bone tissue reabsorption .
Bacterial plaque recession
7F
Traumatic toothbrushing recessio n
Brushing traumatically or with an unsuitable brush (too hard or without rounded points) may cause surface abrasion of the gingival epithelium. In a thin gingival morphotype, persistent trauma or the onset of inflammation may lead to gingival recession .
l7
!
CHAPTER 1
CELLULAR INFILTRATE
Periodontitis is accompanied by a considerable increase in cellula r infiltrate consisting mainly of lymphocytes, macrophages and plasma cells . The latter make up more than 50% of the infiltrate .
Lymphocyte s
These are white series cells deriving from lymph nodes (B lymphocytes) and the thymus (T lymphocytes) and play an extremely important rol e in the defence mechanism . One particular form of lymphocyte is the helper lymphocyte whose role is t o assist lymphocyte reproduction . Other types of lymphocyte include : killer lymphocytes responsible for elimi nating extraneous cells (cancer cells, for example) and suppressor lymphocytes which suppress the immune reaction when no longer required . Lymphocytes produce a wide variety of substances such as interferon, a growth factor, interleukines and lymphokines .
MACROPHAGE {Activates the B-cell s Memory-cells- Killer-cells Mitogenic for T-cells .
n
Thymus
Bone
marro w Memory cell s T-suppressors
*Killer cell s Spleen
Lymph nodes ..B lymphocytes -0-B and T lymphocyte s Thymus --!T lymphocytes
T-helpers
ONk
/ IgA -v Secretor y Ig D - ~ Ig G Ig M I IgE.-Mast cells
n
Bursa equivalents
PLASMA CELL
18

B Lymphocyte
Homologous receptor s T! a few hundre d B! 50 .000 - 150 .000
T lymphocyte
In periodontitis, the majority of lymphocytes present are B lymphocytes .
19
CHAPTER 1
Macrophages
These monocyte-derived cells have varied and extremely important functions, acting as phagocytes, B lymphocyte activators and T lymphocyte mitogen s (lymphokine production) . The phagocytic function is important in the initial stages of the disease (gingivitis) as the macrophages phagocyte the hydrolytic enzymes produced by th e PMNs, reducing cell damage . They also phagocyte the altered cells of the connective tissue . Macrophages are also important in the advanced phase of the disease (peri odontitis) when they interact with the B lymphocytes, thus maintaining the latter in a strategic position to identify and neutralise large quantities of antigens . However, they are above all important for the interaction with the lymphocyte Thelper that stimulates secretion of interleukin-1 (IL1) : this helps production o f interleukin-2 (IL2) which stimulates the T-helpers and T-killers to reproduce, trig gering the lymphokine cascade .
Macrophages
20
In the initial stages of the disease , the macrophages play a vital rol e in reducing the destructive poten tial of the hydrolytic PMN enzymes.
Phagocytosis of the connective tissue .
Connective fibre during digestion .
CHAPTER 1
Lymphocyte activatio n
Lymphocytes may be activated by an antigen-antibody reaction wit h the presence or otherwise of the complement. Alternatively, with the coopera tion of a T-helper, they may enter the transformation and blastogenesis phase . During this phase, the lymphocytes produce lymphokines, non-immunoglobu linic substances with numerous extremely important activation and inhibitio n functions . Antigens
r!
Blast cell
T lymphocyte
activatio n
Lymphokin e
A) Antigen activation
B) Transformatio n
C) Blastogenesis Lymphokine s MIF : Macrophage inhibition factor MAF : Macrophage activation facto r OAF : Osteoclastic activation facto r CF : Chemotactic factor LT : Lymphotoxi n
B lymphocyt e activatio n
Lymphokine
A) Antigen activation
B) Transformatio n
C) Blastogenesis
22
Macrophage-Lymphocyte interactio n
In the most advanced phases of the disease (stable gingivitis - peri odontitis), the macrophages and lymphocytes interact, strengthening thei r respective defensive functions and giving rise to the lymphokine cascad e which greatly amplifies the immune response .
Periodontitis
The macrophages maintain the antigens in an accessible posi tio n B lymphocytes A number of lympho cytes can be observed approaching a non migratory macvophage.
23
CHAPTER 1
Lymphokine cascad e
1) A macrophage phagocytes a microorganism 2-3) The M-T-helper complex secretes IL-1 (interleukin-1) . This activates Thelpers to produce IL-2 (interleukin-2) which stimulates the reproduc tion of T-helpers and T-killers . 4-5) T-helpers produce B-cell growth factor which stimulates the cells t o reproduce and produce antibodies . 6) T-helpers produce gamma-interferon * activates killer T-cell s * stimulates B-cell s * stimulates the M-T complex
Microorganism
acrophage phagocyte s microorganism 2) Activation of the T-helper an d bonding with a macrophag e
THE LYMPHOKINE CASCADE
6) Interferon

Rosette formation : macrophage surrounde d by lymphocytes (which appear) adhering t o the surface and about to be phagocytized. When the lymphocytes have concluded thei r task, they are, in fact, eliminated .
25
CHAPTER 1
BONE REABSORPTION
Bone reabsorption is a complex phenomenon occurring during periodontitis an d caused by an inflammatory process triggered by bacterial plaque . There are two main pathogenic mechanisms :
A) Osteoclastic activatio n
The T-lymphocytes produce OAF lymphokine (Osteoclastic Activating Factor) , responsible for activating the osteoclasts which reabsorb the minerals from the bone an d return them to the blood circulation .
The activated osteoclasts cause bone reabsorption .

9ti
B) Liberation of prostaglandins (PGE2)

The cell membrane damage is caused by activation of the arachidonic acid cascade with activation of PMN chemotaxis and liberation o f prostaglandins, responsible for bone reabsorption.
Alternative pathway Bacterial plaque Bacterial endotoxi n Proteolytic enzyme s
Liberation of C3A-05 A
The bacterial plaque is responsible for bone reabsorption .
Bone reabsorption has led to exposure of the coronal third of the roo t surface.
Edema Chemotaxis Cell damage
PGE2
27
CHAPTER 1
Plasma cells
Plasma cells are large white series cells deriving from the bone mar row and numerous in chronic periodontal lesions (accounting for more tha n 50% of the inflammatory infiltrate) . The plasma cells produce immunoglobulin specific antibodies (IgA) whic h enter the sulcus together with the crevicular fluid through fenestrations in th e sulcular epithelium .
Chronic adul t periodontitis .
Presence of periodontal pocket .
28
Plasma cells make up more than 50% of th e tissue infiltrate and are also present in the crevicular fluid.
Activation of a plasma cell wit h production of immunoglobuli n antibodies . Plasma cell Antibodies
CHAPTER 1
Mast cells
In the most severe forms of periodontitis where inflammation is pre dominant, together with spontaneous bleeding, local pain and rapid progression of lesions, cells with particular functions appear : mast cells . These cells are numerically proportional to the severity of the periodontal dis ease. Mast cells are activated via a sensitization mechanism, reacting with a n immunoglobulin (IgE) . Subsequently they fix an antigen and degranulatio n thus commences with production of histamine, heparin and serotonin . These substances are responsible for local capillary vasodilatation causing hyperemia and localized pain .
Severe form of periodontitis.
Mast cell.
The number of mast cells in the inflammator y tissues is proportional to the severity of th e periodontal disease .
Zacharicson, J . Perio Res ., 1986
Qn
Vasodilatatio n T Permeability
Degranulation of th e mast cells .
A) Sensitization
B) Antigen fixation
C) Degranulatio n
Histamin e Heparin Serotonin
Mast cell .
z 0
0 x
W cn
Mast cell in degranulation phase.
CHAPTER 1
Pathogenesis of periodontal disease

Diagram of the succession of events in the development of periodontitis . This condition, if not interrupted, tends to be self perpetuating with a "poussez" evolution.
FORMATION OF PLAQUE IN THE SULCUS Production of enzymes Destruction of ground substance
Passage of plaqu e products int o the gingiv a
Onset o f inflammation
' I Spreading of inflammation to deep tissue s through the vascular system
Destructio n of gingival collagen Proliferation of junctional epithelium
Formatio n of granulation tissue
Immune response
Possible immune mechanism activated by the presence of bacteria l plaque in the sulcus .
BACTERIAL PLAQUE
COMPLEMENT PMN CHEMIOTAXI S MACROPHAGE ACTIVATIO N PROSTAGLANDINS B-T LYMPHOCYTE S DESTRUCTION OF FIBROBLAST S
Macrophage
CELLS INVOLVED IN TH E IMMUNE RESPONS E PMNs LYMPHOCYTE S MACROPHAGE S
33
CHAPTER 1
Evolution of periodontal diseas e

Periodontal diseases usually proceed with periods of exacerbation an d periods of remission . During active periods, the connective attachment syste m is destroyed and bone reabsorption takes place .
Progression of the periodonta l lesion
Motility
Activity of the disease
In this site, the attachment system has been lost and Subgingival bacterial plaque triggers destruction of the attachment system and bone tissue . bone tissue has been reabsorbed .

The infection responsible for destruction of periodontal tissue occur s in one or more sites and may last a variable period of time. The phenomeno n may die down spontaneously or as a result of treatment . The host-parasite balance will remain stable until the same infection is re-acti vated or a new one commences .
Periodontal diseases
Gingiviti s
Periodontiti s
Juvenile
Pre-pubera l Localized (LIP) Generalized (JP)
Early onset (EOP )

Chronic Severe (SAP ) Refractory (REF)
35
CHAPTER 1
Periodontitis can be defined as a group of diseases associated with a subgingival microbial flora varying considerably in quantity and quality fro m disease to disease . Strong evidence now exists to suggest that Actinobacillu s Actinomicetemcomitans and Porphiromonas Gingivalis are exogenous form s and represent the infective agents of periodontal diseases .
Bacterial species associated with periodontitis

Microbial species Clinical forms of periodontitis
LJP
A. Actinomicetemcomitans P. Gingivalis P. Intermedi a B. Forsythus Fusobacterium spp Peptostreptococcus spp Campylobacter rectus Spirochetes
JP

EOP SAP REF

(Loesche et al . 1985; Slots and Rams 1990; Van Steenberger 1991)
Bone reabsorption in chronic adult periodontitis .
Gingival recession caused by bacterial plaque.
CONCLUSION S it must be controlled. An alternative would be to amplify the immune response aime d at combating them . However, at present this latter possibilit y does not seem feasible . Treatment thus has two main objectives : 1) Control of the periodontopatic microbial flora . 2) Surgical reconstruction of an anatomy which facilitate s maintenance of periodontal health .
To eradicate periodontal infection, the microorganisms causin g
37
Chapter 2
Disease diagnosis
DISEASE DIAGNOSI S
Diagnosing a specific disease is often a complex process involvin g thorough clinical, instrumental and X-ray assessment of the patient . This chapter will describe the method used to identify the presence and exten t of periodontal disease. The etiology of periodontal diseases is varied and complex and for convenience the diseases are therefore divided into inflammatory and non-inflammatory conditions .
Classification of periodontal diseas e

Chronic gingiviti s Allergic gingivitis Eruptive gingiviti s Herpetic gingivitis Ulcerous-necrotic gingiviti s
Gingival
INFLAMMATORY CONDITIONS
Periodontal
Prepuberal periodontitis Juvenile periodontitis Early onset periodontitis Chronic adult periodontiti s Refractory periodontitis Gingival recession due to plaqu e
Gingival
NON-INFLAMMATORY CONDITIONS
Periodontal
Puberal gingiviti s Pregnancy gingiviti s Vitamin C deficit gingiviti s Desquamative gingiviti s Leukemia-associated gingivitis Drug-related hyperplasia Hereditary hyperplasi a Caused by occlusal traum a Atrophy caused by lack of use Gingival recession caused b y toothbrushing
41
CHAPTER 2
EXAMINATION OF THE PATIENT
apparatus possibly involved in periodontal disease or influencing the definition of pharmaceutical or surgical treatment, a questionnaire is submitted t o the patient .
Medical and stomatologic histor y To obtain a standardized assessment of the condition of organs o r
Medical history
Have you ever had : Hepatitis or liver problems Prolonged bleeding Rh ('/1 ma tie fever Heart murmur High/low pressure Chest/shoulder pain Glaucoma Contact lenses Kidney problem s Diabetes TB Emphysema/asthm a Ulcer Cancer Epileps y Venereal disease Anaemi a Blisters in the mouth Ulcers in the mouth If yes, specify If you are female : Are you pregnant ? Are you taking contraceptives ? Are you taking other hormonal drugs? _ Are you in the menopause ? Do you suffer from allergies ? To what ? ve drug s Have you ever suffere d adverse reactions to drugs ? Which ones ? Do you grind you r teeth at night ? Do you have bad breath ? Is your mouth painfu l when you wake ? Othe r
YES N O
Are you taking or have you taken drugs such as: Antibiotics Aspirin Anticoagulant s Cortisone
YES N O
What kind of toothbrus h
YE S N O
Do you use a water pick ? Do your gums bleed ? Do you breath wit h
iene treatment ? dd any other information you think might be importan t
Example of questionnaire to be submitted to the patient for correct compilation of medical history .
DISEASE DIAGNOSI S
Clinical examinatio n
The aim of the clinical examination is to identify signs of possible disease . The signs to look for include : colour, shape, consistency and height of the gingiva and other oral structures such as the lips, mucosa, tongue, oropharynx , floor of the mouth, hard palate and soft palate . It is important to examine both the general aspect of these structures and als o any possible localized alteration . The gingiva are assessed on the basis of the following parameters :
PARAMETER S
Colour
Contours
Marginal
Festoonea
Altered festonatio n Edematous - Fibrous Fibroedematous Flat - Glossy - Stippling disappears More coronal - More apica l
junction
43
CHAPTER 2
-Wit!
Normal gingiv a The healthy gingiva is pink, the papillary con tour is flat and the marginal contour is festooned . The gingival margin is located at th e cemento-enamel junction . The interincisal papilla have a characteristi c "stippled" appearance . Probing identifies the presence of a gingival sulcus about 1 .5 mm deep .
Stippling Diagrammatic representation of the epitheliu m (E) with the collagen fibres (C) and anchorag e fibrils (A) . The latter give the epithelial surface of a health y gingiva a stippled appearance . If edema is present, the stippling disappears .
Position of the gingiv a In the case illustrated, the gingival margin is located apicall y to the cemento-enamel junction . This is probably caused by incorrect toothbrushing with a dam aging toothbrush .
Toothbrushing abrasio n A small toothbrushing abrasio n can be observed on the gingiva l margin vestibularly to the centra l incisor.
DISEASE DIAGNOSIS
Colour of the gingiv a The colour of the marginal gingiva is altered, becoming deep red, symptomatic of the presence of marginal gingivitis .
Multiple recession Bone dehiscenc e In the illustrated case, the recessions of the vestibular gingiva Recession is always accompanied are caused by two factors : thin and keratinized gingiva and by destruction of the attachmen t bacterial plaque. apparatus and bone tissue supporting the tooth.
45
CHAPTER 2
Shape of the gingiv a In the case illustrated, accumulation of bacterial plaque and chronic irritatio n have caused an inflammatory condition known as hyperplastic gingivitis . Note the bulbous appearance of the interdental papillae, the altered festonatio n of the gingival margin and the colour, now deep red becoming cyanotic .
Gingival hyperplasia caused by breathing with the mouth ope n Night-time breathing with the mouth open in adenoiditis may lead to inflammation and localized gingival hyperplasia due to chronic irritation as in the cas e illustrated. Note the change in colour and the modified shape of the gingiva i n the vestibular sector of the maxillary arch .
!
!!
DISEASE DIAGNOSIS
it+ Fibrom a This fibroma affecting the mucosa of the cheek i s of irritatative-masticatory origin . Histologic examination after removal reveale d increased keratinization of the epithelial tissue , while the other malpighian layers were normal . : :1\2
nI~ORi~0~6ipiiV
tZ
N' ~j,4
etit l
ry,ryAgll
tey .
.1 uJes, i *ear
~. a
ca
#
~ Se' f
,f 41 ' i
. 1.
v '
rA "
.j. . . ;
47
.j~\
i t
CHAPTER 2
Drug-induced hyperplasi a In these two cases, gingival hyperplasia has been induced by the assumption of drugs to treat a systemic disease. The top image shows an accumulation of bacterial plaque, aggravating the hyperplasia . In the absence of periodontitis, the pocke t explored by probing is a pseudopocket (caused by coronal growth of the gingiva and not attachmen t loss).
Vitamin C deficiency Ascorbic acid (vitamin C) deficiency cause s scurvy, a systemic disease characterized b y accentuated weakness, anaemia, capillary dis ease and a tendency for both the skin an d mucosa (gingiva) to bleed, with the appearanc e of petechiae on the limbs .
49
CHAPTER 2
Instrumental examinatio n A ) Periodontal probing

The periodontal probe enables the presence and severity of a periodontal lesion to be verified simply and immediately . A periodontal probe can be used to reveal : 1. 2. 3. 4. 5. 6. 7. The depth of a periodontal pocke t The depth of a pseudopocke t The height of the keratinized gingiv a The height of the attached gingiv a The quantity of attachment loss The depth and width of recession The presence or absence of bleeding .
Periodontal prob e University of Michigan .
Periodontal probing The sulcus is about 3 mm deep.
Periodontal prob e color probe 11mm
(CP11).
DISEASE DIAGNOSI S
The periodontal probe is inserted into the gingival sulcus (the virtua l space existing between the gingiva and the tooth enamel) . The penetration depth depends on various factors : the shape and diameter o f the probe, the insertion force, tissue resistance, the convexity of the crow n and the insertion direction . Histologic research by Schroeder and Listgarten (1971) demonstrated that periodontal probing may not correspond to the actual depth of the sulcus o r periodontal pocket . Later, Listgarten (1976) demonstrated that, after crossing the epithelial attach ment, the point of a probe consistently penetrates at least 0 .3 mm further int o the more coronal part of a healthy connective attachment . On the basis o f these studies, it has been established that the sulcus or histologic pocket doe s not coincide with the clinical pocket . The histologic depth of a pocket is determined by the distance between th e gingival margin and the bottom of the pocket (corresponding to the corona l margin of the junctional epithelium) . The clinical depth (or probing depth) of a pocket corresponds to the penetration depth of the probe into the pocket .
POCKET > 3 mm.
Periodontal pocke t Note the periodontal pocket (4 mm) and the tissu e edema, indicated by the mark (fovea) left by th e probe on the gingiva . 51
The periodontal pocke t is about 6 mm deep.
CHAPTER 2
A pathological condition is known to cause proliferation of the junctional epithelium . This grows apically, replacing the connective attachmen t destroyed by the disease, interposing between the gingival connective tissu e and the root surface, where it attaches itself . The epithelium may reach a length of 4-5 mm and in these cases is known a s long junctional epithelium (Listgarten - Rosenberg, 1979) . In the presence of inflammation, the probing depth will differ from the histo logic pocket depth . The probe penetrates the inflamed epithelial attachmen t easily, coming to a halt in the coronal part of the healthy connective attach ment . Poison (1990) demonstrated that the point of the probe is stopped by the firs t healthy connective fibres still attached to the root cementum .
Long junctiona l epitheliu m Note the proliferation of the junctional epithelium as far as the roo t cementum .
Junctional epitheliu m Diagrammatic representation of the structure of the junctional epitheliu m adhering to the surface of the enamel via hemidesmosomes . In drawing 1, the yellow line corresponds to the basal lamina and denta l cuticle . In drawing 2, note the cemento-enamel junction with a small are a of afibrillar cementum (A), the beginning of the root cementum (C), the dentine (D) and the enamel (E) .
Probing dept h In the presence of inflammation, the probe penetrates as far as the first health y fibres of the connective attachment apparatus .
DISEASE DIAGNOSIS Force applied to the prob e

In 1967, Glavind and Loe demonstrated that application of a non-standardized force resulted in variable probing depths, both in health and inflame d tissues. Using calibrated pressure periodontal probes, Van der Velden and De Vrie s (1978), found that the optimum pressure to apply to a round pointed 0 .36 mm diameter probe was 0 .75 Newtons (one pound = 0 .0098 Newtons = about 25 grams) . Using this type of probe and this constant pressure, pocket depth measurements were reproducible, even when performed by different operators .
Bleeding on probing
In 1979, Van der Velden introduced the concept of "bleeding on probing " in diagnosing between a healthy and a diseased condition . 53
CHAPTER 2 Probing technique

The dental probe should be held as though it were a pen . Keeping it parallel to the long axis of the tooth, it should be delicately inserted betwee n the free gingival margin and the tooth . Three readings are taken for each tooth : distal, intermediate and mesial . Particularly in the case of molars with a convex clinical corona, for the mesia l and distal readings, the instrument should be held at an angle of about 25 (Ziegler - Allen 1980) .
When probing the vestibular su'iface, the probe should be held parallel to the long axis of the tooth . Probe angle
TPS Probe Vivacare " Calibrated pressure probe .
In the mesial and distal interproximal spaces, the probe should be held at an angle of 25 .
DISEASE DIAGNOSIS
After delicately inserting the instrument into the sulcus or pocket, a pressure of 25 grams is exerted until the first resistance is encountered. It is important to verify that this resistance is not caused by solid concretion (cal culus) on the root surface of the tooth . Once the probing depth has been reached, the instrument should be slightl y raised and moved around the circumference of the tooth (walking the probe) .
Incorrec t
The presence of subgingival calculus may stop the probe and lead to a faulty reading of pocket depth .
Walking the probe When the probing depth is reached, the probe should be slightly raised and moved around the circum ference of the tooth.
55
CHAPTER 2
Probing sites
For each tooth, three vestibular and three palatal or lingual readings should be taken : distal (1), intermediate (2) and mesial (3) .
Deep periodontal pocket (>7 mm .) in the vestibular surface of the central incisor . Note the accompanying gingival recession and presence of subgingival calculus .
!
!"!!
!
DISEASE DIAGNOSI S
The probings (in millimetres) for each tooth should include vestibular and lingual readings, starting from the maxillary arch and proceeding in succession from no . 18 to no . 28 . The examination then continues with th e mandibular arch, starting with vestibular probing in succession from no . 38 to no . 48, followed by lingual probing first of the mandibular arch from no . 48 to no . 38 and then the maxillary arch from no . 28 to no . 18 .
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57
CHAPTER 2
B) Measurements
Measuring the keratinized gingiv a
The periodontal probe is indispensable for measuring the quantity o f keratinized and attached gingiva . To assess the keratinized gingiva, the mucogingival junction must first be iden tified. The periodontal probe is then used vertically to measure the distanc e between the free gingival margin and the mucogingival junction .
A periodontal prob e (CP11) is used to identify the mucogingival junction. The height of the keratinized gingiv a from the free gingival margin to the mucogingival junction is then measured .
DISEASE DIAGNOSI S
Measuring the attached gingiv a

The attached gingiva is the part of the keratinized gingiva attached to the tooth (epithelial attachment + connective attachment) and bone tissue . To verify the quantity of attached gingiva, the height of the keratinized gingiv a and the depth of the sulcus must be measured and the latter subtracted fro m the former.
A periodontal prob e (CP11) is used to measure the height of th e keratinized gingiva and depth of the sulcus . The latter is subtracted from the former to calculate the quantity of attached gingiva .
59
CHAPTER 2 Measuring gingival recession

The term gingival recession describes the apical migration of the gingival margin with respect to the cemento-enamel junction . This phenomenon may be caused by bacterial plaque or damaging toothbrushing .
Bacterial plaqu e derived recession .
Toothbrushing derived recession.
DISEASE DIAGNOSI S
Gingival recession is measured using a periodontal probe. The length (A-B) is the distance between the cemento-enamel junction an d the apical part of the exposed root . The width (C-D) is measured in correspondence with the cemento-ename l junction.
61
CHAPTER 2 Measuring furcation involvement

Furcation involvement is diagnosed by probing with a special periodontal probe, the Nabers 2N .
Classification Degree Furcation involvemen t

Horizontal loss of bone tissue not exceeding 2-3 rum of the depth o f the furcation .
A: Horizontal loss of bone tissue for less than half the furcation . B: Horizontal loss of bone tissue for more than half the furcation . C: Almost complete horizontal loss of bone tissue . A small diaphragm remains .
Total loss of interradicular bon e (otherwise known as a through-and-through furcation) .
Nabers 2N probe .
C)
DISEASE DIAGNOSI S
Degree I
Horizontal loss of bone tissue no t exceeding 2-3 mm of the depth of the furcation .
63
CHAPTER 2
Degree II
Type A Horizontal loss of bon e tissue for less than half the furcation.
Type B Horizontal loss of bone tissue for more than half the furcation.
Type C Almost complete hori zontal loss of bone tissue . A small diaphragm remains .
DISEASE DIAGNOSI S
Degree III
Total loss of interradicular bone . Degree III is also known as a "through-and-through" furcation .
65
CHAPTER 2
C) Tooth mobility
Tooth mobility is caused by absorption of alveolar bone as a result o f bacterial plaque or occlusion damage . Tooth mobility is an early symptom of occlusion damage and a late sympto m of periodontitis. It is assessed using the ends of two instruments .
Classificatio n
Degree 0 Degree 1 Degree 2 Degree 3
Absent
Tooth mobility in a vestibular-lingual direction by up to 1 m m
Tooth mobility in a vestibular-lingual direction by more than 1 m m Tooth mobility in a vestibular-lingual direction by more than 1 m m and/or depressibility in the alveolus .
Classification criteria of dental mobility .
DISEASE DIAGNOSIS
Tooth mobility Presence of disease in progress (Occlusion trauma) (Inflammatory) Poor bone support .
Stabilized : Ingravescent:
Occlusion traum a
Bone reabsorption caused by excessive occlusal accompanied by attachment loss . (Glossary of Periodontic terms . American Academy of Periodontology, 1986 )
Orthodontic trauma
Mono-directional forces exerted on individual teeth produce pressure and tension fields within the periodontal space . As a result, the tooth becomes progressively more mobile and starts migrating in the direction of th e force . When the tooth leaves the influence of the trauma, the periodontium is reorganized and the tooth becomes stable in its new position.
ressure zone Tightened ligament . Thrombosis, hemorrhage, collagen destruction . Bone and cementum reabsorption .
67
Tension zon e 0 Stretched ligament. 0 Bone apposition. Dilated vessels . 0 Torn periodontal fibres .
CHAPTER 2 Jiggling trauma

The combined effect of pressure and tension forces in the periodontal tissues causes thrombosis, hemorrhage, collagen destruction and reabsorption of bone and cementum . This leads to progressive enlargement of the periodontal space and subsequent hypermobility of the tooth . Subsequently, the larger periodontal space neutralizes the trauma and there fore blocks bone reabsorption .
Occlusion trauma alon e When the periodontal space i s enlarged, the trauma is neutralize d and bone reabsorption is halted .
Various experiments carried out first on animals then on humans have demonstrated that neither mono-directional orthodontic forces nor jiggling force s cause pockets or periodontal attachment loss in a healthy periodontium . However, if the trauma is accompanied by bacterial plaque-derived periodontal disease, the disease progresses more rapidly . From a clinical point of view , the fundamental moment in treating inflammatory periodontal diseas e involves elimination of the bacterial plaque as this will halt periodontal tissu e destruction, even in the presence of trauma from occlusion .
Occlusion trauma + inflammatio n When the trauma is accompanie d by an infection, the disease progresses more rapidly.
Junctional epitheliu m in the migratory phase Occlusio n trauma-derived bone lesio n
DISEASE DIAGNOSI S
CLINICAL CAS E
The clinical case illustrates a typical diagnostic and therefore therapeutic error . A young patient (male, aged 15) presented mobility of the left upper latera l incisor and a diastema between the central and lateral incisors . The initial diagnosis was : occlusion damage and night grinding of the teeth for psychological reasons . Dental treatment consisted of selective grinding and construction of a resi n "bite" to wear at night . The youth (with divorced parents) was also referred t o a psychologist. After a year of psychotherapy, "bite" and selective grinding, the patient - still a long way from being cured - was referred for a second opinion . The diagnosis was : juvenile periodontitis . The correct diagnosis was followed by suitable and successful treatment (se e chapter 13) .
The reddened and collapsed interdenta l papilla is a symptom of reabsorption of the underlying bone.
69
!"!
CHAPTER 2
The clinical record

clinical and instrumental data and the patient's medical histor y should be gathered together in a clinical record .
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DISEASE DIAGNOSI S
Continuous red line : position of the gingival margin with respect to the cemento-enamel junction. Continuous black line : probable level of the alveolar bone . Black : missing teeth and bridges . Red : teeth to be extracted. Roman numerals : damaged furcations. Arabic numbers on the crowns : tooth mobility. Arabic numbers : periodontal probing . Maxillary arc h 3 2 1
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71
CHAPTER 2
X-ray analysis
If well performed, a set of intraoral and periapical X-ray images pro vide valuable information on the condition of the patient's bone tissue . 1. Height of alveolar bone . 2. Characteristics of the bone trabeculae . 3. Localized areas of bone destruction. 4. Bone loss from the furcations . 5. Extent of the periodontal space . 6. Crown - root relationship .
Note the difference between the photographic details in the X-ray and in the orthopantomography .
DISEASE DIAGNOSIS 7. Shape and length of roots . 8. Periapical lesions. 9. Decay, quality of restoration work, presence of root calculus . 10. Identification of the maxillary sinus . 11. Missing teeth, supernumerary teeth, impacted teeth . It should be remembered that a radiographic image is a two-dimensional representation of three-dimensional structures . To reach a correct diagnosis, the radiographic status should always be correlated with a thoroug h clinical examination and correct periodontal probing .
Note the difference between the photographic details in the X-ray and in the orthopantomography .
73
CHAPTER 2
Radiographic status (14 X-r) In the incisor sectors, only three X-ray images (no . 1) per arch were used .
Radiographic status (18 X-r) In this status, the "bite-wing" X-rays were also included (2 on the right and 2 on the left) .
DISEASE DIAGNOSI S
Dig italic orthopantomograph y Note the high definition of the details and the excellent contrast obtained with this typ e of X-ray analysis .
Limitations of intraoral X-ray 1.They do not identify periodontal pockets . 2.A successfully treated case is no different from an untreated case . 3.They do not distinguish the number of walls in bone defects . 4.They do not identify the vestibular and lingual structures of the root surface . 5.Tooth mobility is not recorded . 6.It is not possible to identify dormant periodontitis until six months after the disappearance o f inflammation (calcified lamina dura) .
75
CHAPTER 2
X-ray techniqu e
The seated patient should be covered with a lead apron to protect th e gonads and thyroid. The Extension Cone Paralleling Technique is used . The most commonly used X-ray positioner is the Rinn Corporation XC P " . This is available in two types, one for the front upper and lower sectors of th e mouth and one for the rear upper and lower sectors . A plastic "bite" is positioned in the patient's mouth . This is connected via a metal arm to a plastic ring representing the target for correct positioning of the cathode tube . The most commonly used films are Kodak ultra-speed DF-58 (size 2) for th e molar and premolar sectors and Kodak ultra-speed DF-56 (size 1) for th e canine and incisor sectors . Once exposed, the radiographs should be developed, preferably using an auto matic system . After fixing and drying, the radiographs are mounted in a fram e and represent the X-ray status .
D Ml M
10 1I tVw H 1 1 1
Y I
X-ray equipment with extension cone.
ad o
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colla:
WW1
DISEASE DIAGNOSIS
Positioner for intraoral X-ray s
Rear right positioner with collimato r mrnwted on the target, .
Collimator . Metal disc to reduce dispersion of X-rays and concentrate them on the radiograph .
Rear left positioner:
Plastic bite. A spacer (cotton roll) is inserted in the mouth t o guarantee patient comfort and the stability of the positioner.
Front positioner with disposable expande d polystyrene "bite".
77
CHAPTER 2
Positioning the X-ray film s
Intraoral status with 16 film s Maxillary arc h Four films vertically DF-56 no .1 (from the front) Position between : 1 - 2 right and left 3 - 4 right and left
Four X-ray films horizontally DF-58 no . 2 (from the rear)
Position between : 5 - 6 right and left 7 - 8 right and left
Mandibular arch Four X-ray films vertically DF-56 no .1 (from the front) Position between : 1 - 2 right and left 3 - 4 right and left
Four X-ray films horizontally DF-58 no .2 (from the rear)
Position between 5 - 6 right and left 7 - 8 right and left
An intraoral status may consist of 21 X-ray films if four bite-wing films and 1 film for the interincisor sector between the upper sectors are included (11-21) .
~o
DISEASE DIAGNOSIS
uaituttlitti'mai
Film Dentaire Zahnfil m Pelicula Denta l
Correct
Incorrec t
The X-rays must hit the films at right angles to avoid superimposition of the points of contact with the teeth and obtain correct images of the bon e tissue.
79
CHAPTER 2
X-RAY ANALYSIS OF THE MAXILLARY ARCH
Front secto r
For the incisor sector, if five X-ray images are to be taken, the bite must be positioned between th e central incisors . Alternatively, if four X-ray images are required, the bite must be placed between th e central and lateral incisor, first on the right, then on the left . The series of X-rays is completed b y positioning the bite between the canine and lateral incisor ; once again, first on the right, then on the le,
Note the longitudina l bone reabsorptio n affecting the entire upper front sector:
,zn
DISEASE DIAGNOSI S
Lateral secto r
The positioner is inserted between the two premolars . A cotton rol l can be used if necessary.
Normal The crestal and radicular laminae dura are intact. The trabeculae are in the norm . 81
Diseased The crestal laminae dura of the premolars are decalcified . Calculus can be observed on the roo t surfaces.
CHAPTER 2
Rear sector
In the molar sectors, the positioner bite should be inserted i n correspondence a'ith the first molar :
A cotton roll is inserted under th e bite to guarante e patient comfort and the stability of the positioner :
Normal The crestal and radicular laminae dura ar e intact. The trabeculae are in the norm .
Diseased Note the deep distal bone reabsorption corresponding to the first molar and the intraosseou s pocket identified by probing .
#
DISEASE DIAGNOSIS
X-RAY ANALYSIS OF THE MANDIBULAR ARCH
Front sector
rrrt .
I ,iI . .-_J
_rte
In the incisor sector ; the positioner bite should be inserted between the central incisors, then betwee n the canine and lateral incisor, first on the right, then on the left .
Norma l No bone lesions are identified.
Diseased Bone reabsorption ca n be noted for more than 50% of the length of the roots . The crestal lamina dura has disap peared . An accumulation of calculus can b e observed on the roo t surfaces.
CHAPTER 2
Lateral sector
In the premolar sector, the positioner bite should be inserte d between the two premolars, first on the right, then on the left . O
In the molar sector, the positioner bite should be inserted between the two molars, first on the right, then on the left . If a third molar is present, the bite should be placed on the second molar.
84
DISEASE DIAGNOSI S
Normal Calcification of the crestal laminae dura is normal.
Disease d Bone reabso'iption prevents identification of the crestal laminae dura. A large quantity of calculus can be observed on the root su ifaces.
Normal Calcification of the crestal laminae dura is normal.
Diseased Considerable bone reabsorption can be observe d corresponding to the molars with possibl e damage to the furcations (degree 2) .
85
CHAPTER 2
Lamina dur a
This X-ray image was produced by directing Roentgen rays to the sec tor where they were partly blocked by calcification of the cortical plate . In the presence of inflammation, the calcification disappears and the greate r quantity of X-rays crossing the cortical plate prevents the lamina dura fro m being detected.
The diagram illustrates the relationship between the crestal lamina dura and the cemento-enamel junction of the two neighbouring teeth . In a normal situation, the crestal lamina dura i s always parallel to th e line between the cemento-enamel junctions of two neighbouring teeth.
RA
DISEASE DIAGNOSI S
Bone defect
X-ray image of a bon e defect of the interdenta l septum between th e first and second mola? :
By lifting a mucope riosteal flap and remov ing the granulation tis sue, the bone defec t shown in the top X-ray image can be observed to have three walls .
87
CHAPTER 2
DISEASE DIAGNOSIS
From a clinical point of view, periodontal diseases can be divided int o gingivitis and periodontitis . These are differentiated by loss of connectiv e attachment and bone reabsorption, two phenomena confined to periodontitis , classifiable as slight, severe or complicated according to the degree of damag e to anatomical structures.
Periodontal diseases
DISEASE 'TYPE LESTnN
Inflammatory infiltrate above the transseptal fibres Bone reabsorption limite d to the coronal third of the root only Bone reabsorption extended beyond the coronal third Angular bone reabsorptio n and 2nd or 3rd degree furcation involuement Bleeding on probin g Pocket Possible tooth mobilit y Bleeding on probin g Pocket Possible tooth mobility Furcation involvement
SYMPTOM S
Bleeding on probing No pocke t
Slight Periodontitis Severe Complicated
Gingivitis
Shis term is used to describe localized or generalized inflammation o f the gingiva . The clinical system of this disease is "bleeding on probing" . Gingivitis is diagnosed in the absence of a periodontal pocket and when X-ra y examination does not indicate bone reabsorption. Pseudopockets may b e present .
Margina l gingivitis .
QQ
DISEASE DIAGNOSI S
Slight periodontitis
Probing depth, attachment level and X-ray analysis indicate a unifor m loss (horizontal reabsorption) of bone tissue not exceeding a third of th e length of the root (coronal third) . Inflammation is present . Probing to the bottom of the pocket causes bleeding.
Chronic adul t periodontitis (slight) .
Severe periodontitis (Advanced periodontitis)

Probing depth, attachment level and X-ray analysis indicate a unifor m loss (horizontal reabsorption) of bone tissue exceeding a third of the lengt h of the root. Probing to the bottom of the pocket causes bleeding .
Chronic adult periodontitis (severe) .
89
CHAPTER 2
Complicated periodontitis
This diagnosis is reached when angular (vertical) bone reabsorption is present, accompanied by 2nd to 3rd degree furcation involvement .
Chronic adult periodontiti s (complicated) with tooth mobility, damage to a number of furcations and angular bone defects.
Complicated periodontitis in an adult suffering from diabetes mellitus with tooth mobility, damage to all bifurcations and trifurcations and angular bone defects .
DISEASE DIAGNOSI S
Severe gingival inflammation and the accumulation of bacterial plaque can be observed .
CONCLUSION S Periodontal disease is diagnosed by means of a thorough assessment of th e patient based on clinical, instrumental and radiographic data . Only a correc t diagnosis can enable a suitable treatment plan to be drawn up .
91
TREATMENT PLANNIN G
The treatment of a patient with periodontal disease consists of thre e fundamental phases : 1) Complete removal, or at least control, of bacterial plaque, the etiologica l agent of the disease. 2) Surgical correction of alterations to the soft and hard tissues caused by th e disease . Restoration of functional form facilitates plaque control an d improves aesthetics. 3) Prevention of possible relapses with a personalized programme of follow up appointments .
Chronic adult periodontitis .
95
CHAPTER 3
TREATMENT PLANNING
0 Initial treatment plan 0 Presentation of alternative
plans
REEVALUATIO N
Hygienic treatment phas e 0 Treatment of carie s 0 Endodontic treatment 0 Extractions 0 Minor orthodontic s #> Construction of temporary prosthese s
Patient cooperatio n
40-
4
PERIODI C FOLLOW-UP APPOINTMENTS Supportive therapy
DEFINITIVE TREATMENT
o Periodontal surgery 0 Implant surgery o Peri-implant surgery 0 Construction of definitive prosthese s
TREATMENT PLANNIN G
Initial treatmen t
The aim of initial treatment is to eliminate, or at least control, bacterial plaque. It involves implementation of the following phases : 1) Oral hygiene instruction . The patient is instructed in correct home use of oral hygiene instruments an d attempts are made to motivate him or her towards positive
compliance .
Before scaling .
2) Scaling and root planing . These manual or mechanical operations enable bacterial plaque to be completel y removed from the crown and root surfaces of the tooth.
Immediately after scaling.
During initial treatment, other measures may be required. These include : 1)Removal and restoration of caries . 2) Endodontic treatment. 3) Extraction of hopeless teeth. 4) Minor orthodontics. 5) Construction of temporary prostheses .
Together, these measures neutralize the bacterial infection, eliminat e pain and re-establish a certain degree of masticatory, phonetic an d aesthetic functionality.
97
CHAPTER 3
Reevaluatio n
reasonable period of time (possibly several months) after the end of initial treatment, the patient undergoes a thorough examination to check th e state of gingival inflammation (which should have disappeared), periodonta l pocket depth and residual tooth mobility. The level of patient cooperatio n must also be verified . The examination covers every tooth and the result s determine the choice of definitive treatment .
Before initia l treatment .
At reevaluation .
nQ
TREATMENT PLANNIN G
Reevaluation: periodontal pocket and bleeding on probing .
Probing reveals a pocket (>6 mm .) between the first and second molars .
A modest degree of bleeding on probin g is present .
Raising a mucoperiosteal flap, bone reabsorption of the interdental septum can be observed .
99
CHAPTER 3
Definitive treatmen t
If the patient cooperates, surgical treatment can commence .
PERIODONTAL FLAP SURGERY to eradicate any periodontal pockets (>4 mm) still present after the hygienic phase .
BONE RESECTIVE SURGERY to eliminate intraosseous defects by resecting one or more bone walls .
1 nn
TREATMENT PLANNING
GINGIVAL RESECTIVE SURGER Y to eliminate hyperplastic gingival formations and pseudopockets and reconstruct a functional and aes thetically satisfactory gingival profile .
ROOT RESECTIVE SURGER Y involves the sectioning and removal of one or two roots of a multirooted tooth .
101
CHAPTER 3
BONE REGENERATIVE SURGER Y to regenerate bone tissue in angular defects using guided tissue regeneration (GTR) .
PRE-PROSTHETIC SURGERY to modify the length of the clinical crown, the shape and length of tooth abutments and the shape o f bone and soft tissues, enabling a functional and aesthetically satisfactory prosthesis to be constructed .
1r)
TREATMENT PLANNIN G
MUCOGINGIVAL SURGERY to reconstruct the gingiva, improve appearance and reduce root sensitivity .
DENTAL IMPLANT SURGERY to reconstruct dental elements in partially totally toothless patients .
103
CHAPTER 3
Surgical treatmen t of periodontitis
Modified Widman flap Apical flap Bone resective surgery Gingivectomy Root resection surgery
Provides access to roots and bon e defects Reduces or eliminates the pocket Facilitates plaque contro l Facilitates restorative and cosmetic dentistry
Increase in gingival recessio n Long term success not guarantee d without maintenanc e
Mucogingival surgery Free grafts Pedicle graft s Pedicle grafts + GT R
Improves aesthetic s Reconstructs gingival defects Reduces root, sensitivity
Clinical variability Results linked to surgical techniqu e
GT R Non-reabsorbable membran e Reabsorbable membrane
Significant increase i n attachment level s The best results are obtained with Class II mandibular furcations an d intraosseous defects
Results linked to surgical techniqu e
Autologous bone Increase in bone level The osteogenetic capacity of demin e alized bone grafts is variabl e Alloplastic bone (synthetic) Increase in bone level Synthetic grafts act as fillers withou t regeneratio n
(Modified from World Workshop in Periodontics 1996) .
If the patient is not cooperative or does not wish to or cannot undergo surgery, non-surgical treatment can be administered, followed by the maintenance phas e with a cycle of periodic follow-up appointments .
!!
TREATMENT PLANNIN G
Non-surgical treatment of gingivitis and periodontitis
Treatment
Indications
Contraindication s
Manual or mechanical scaling and root planing
Gingiviti s Periodontiti s
Non e
Chemical treatment of bacterial plaqu e Mouth washes Gel Irrigation
Gingivitis
No long term benefits in periodontitis
Topical antibiotics Tetracycline impregnated fibres
Periodontitis
Allergy Recessions Candid a
Systemic antibiotic s Tetracyclin e Metronidazol e Amoxicilli n Clavulanic aci d Clindamycin Spiramycin
Aggressive destructive periodontitis
Gingiviti s Adult periodontitis
(Modified from World Workshop in Periodontics 1996 )
Manual scaling . 105
Mechanical scaling .
CHAPTER 3
CLINICAL CASE
Male patient aged 48 fitted with two cardiac by-passes. The periodontal examination led to a diagnosis of chronic periodontitis . The clinical file reproduced below indicates tooth mobility, pocket depth and furcatio n involvement.
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TREATMENT PLANNIN G
TREATMENT PLAN
HYGIENIC PHASE
1 gross-scaling sessio n 4 scaling and root planing session s
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REEVALUATION
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SURGERY
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MAINTENANCE Periodical follow-up appointment s every three month s
10 7
CHAPTER 3
Maintenance
At the end of treatment, the patient is included in a programme of peri odic follow-up appointments formulated to prevent possible relapse . The appointment schedule is established in relation to the patient's ability to maintain a high standard of oral hygiene . Longitudinal studies have shown that a maintenance programme with appointments every three months is optimu m for preventing relapse in the majority of cases . During each session, oral hygiene is assessed and scaling is performed for the entire mouth, usually associated with polishing. If necessary, the patient is remotivated to maintain positive compliance . At least once a year, bone level should be assessed via X-ray analysis .
The image shows a cas e after a year in the maintenance phase (follow-u p appointments every fou r months) . Note the absence of periodontal pocket and inflammation.
Compliance The patient's behavioural response in relation to his/he r health and the means at his/he r disposal to maintain it .
ono
TREATMENT PLANNING
At the end of periodontal treatment, the patient is included in a pro gramme of periodic follow-up appointments .
Follow-up programm e After one mont h Subsequently every three month s Every three months Personalized (every 4-6 months )
CONCLUSION S
A treatment plan is a sequence of therapeutic measures aimed at healing o r halting periodontal disease. It is vital that the phases are applied according to this algorithm . Each play s a vital role in determining the success of the treatment. It is important to emphasise that it is impossible to prevent bacterial colo nization and thus avoid relapse of the disease without effective maintenance .
109
Chapter 4
Oral Hygien e Rehabilitation

'ow
':
111
ORAL HYGIENE REHABILITATIO N
The aim of Oral Hygiene Rehabilitation (OHR) is to eliminate bacteria l plaque infection by removing all local irritative stimuli . During this initial phase of periodontal treatment, the patient must be motivated and instructed in th e use of home oral hygiene instruments . The patient must be made aware of th e close relationship between his or her active participation and the successfu l outcome of the treatment .
Oral hygiene instruction Motivation

Toothbrush (manual, electric, sonic, interdental) Dental floss (floss, tape, super floss ) Toothpaste Antiseptics (chlorhexidroe) Manual instruments (curettes, scalers) I-Iyposonic and ultrasonic instrument s Rotary instruments Alternating movement instrument s
113
CHAPTER 4
BACTERIAL PLAQUE CONTROL

Bacterial plaque must be controlled daily (2-3 times) by the patient using a toothbrush and dental floss .
Toothbrush
None of the toothbrushes currently available on the market is better than th e others. The best brush is probably the one used with the most effective technique . The advantages of electric toothbrushes over normal toothbrushes are con fined to patients with reduced manual ability. Sonic toothbrushes (Sonicare 0) supplement the electrical movement with cavitating vibration and a water je t to facilitate removal of plaque and stains from the supragingival surface of the teeth.
Conventional toothbrush.
Electric toothbrush . Does not remove bacterial plaque more efficiently tha n conventional toothbrushes.
Brushing methods
Numerous brushing methods have been described, but none ha s proved more efficient than the others . The Bass Method effectively removes bacterial plaque from the supragingival and subgingival pericrevicular zone . The head of the toothbrush is placed on th e gingival margin at an angle of 45 with respect to the axis of the tooth and move d from the front towards the back, in association with short pulses of vibration . In the Charter Method, the bristles of the toothbrush are placed at an angle o f 45 in the interdental spaces and moved backwards and forwards with a rotat ing movement . This method is particularly effective in removing bacteria l plaque in the presence of open interdental spaces caused by papillary recession . Other techniques include: Roller Circular Vertica l Horizontal
115
CHAPTER 4
Too thbrushing
duration and sequenc e
The patient must learn to brush his or her teeth according to a sequence which must become automatic and routine . Toothbrushing starts in a vestibular position in the molar sector of one arc h (about 10 seconds for each sextant) and then proceeds to the lingual position . It continues with the other arch following the same sequence . The occlusal surfaces are the last to be brushed .
Toothbrushing techniqu e Step 1

The toothbrush is positioned at 45 to the axis of the tooth and the bristle s are pushed into the gingival sulcus .
Step 2
The toothbrush is moved in a mesial-distal or circulatory-vibratory directio n to remove bacterial plaque from the pericrevicular or inter-proximal areas .
Step 3
The same movements are repeated for th e other sectors of the mouth following an established sequence (about 10 second s for each sextant) .
Step 4
In the front palatal and lingual sectors, th e toothbrush must be held perpendicularly to the arch .
Step 5
To conclude, first the lower and then the upper occlusal surface s are brushed .
117
CHAPTER 4
Plaque disclosing dyes

Bacterial plaque, often difficult to detect, may be highlighted by usin g either single colour or two colour dyes . Two-colour plaque detectors differentiate between newly formed and less recently formed plaque . Dyes containing fluorescein can be used to make the plaque visible in ultraviolet light only. Plaque disclosing dyes are extremely useful during the initial phase of OHR to motivate the patient and indicate where it is necessary to brush correctly. They are also important to verify the home hygiene programme and monitor correc t removal of bacterial plaque .
SINGLE COLOUR PLAQUE DISCLOSING AGEN T
Plaque can be observed in the pericrevicular zone . Invisible to the naked eye , it is highlighted by the dye .
I1Q

TWO COLOUR PLAQUE DICLOSING AGEN T
Note the different gradation s of colour: the dark colouring identifies less recently formed plaque .
The same clinical case as i n the previous image treated with single colour plaqu e detector. Recent plaque canno t be distinguished from less recent plaque .
MARGINAL GINGIVITI S
. T.TT
Note the modest quantity of bacterial plaque in the pericrevicular region, highlighted b y single colour dye .
119
CHAPTER 4
PLAQUE DICLOSING AGENT WITH FLUORESCEI N This diclosing agent avoids staining the patient's mouth . When the surface is exposed to ultraviolet rays, the zones covered with bacterial plaque are fluorescent .
Flake Lite r equipment.
Complianc e The patient's behavioural response in relation to his healt h and the means at his disposal to maintain it .
ACTIVE PATIENT MOTIVATIO N
By placing a small quantity of bacterial plaque taken from the patient's mouth on a slide and using a phase contrast microscope, the composition and amoebic movements of the mobile life-forms in th e plaque can be displayed on a television screen . This method is effective in active patient motivation .
121
CHAPTER 4
Dental floss
Dental floss effectively removes bacterial plaque from between the teeth and under the papillae and is an indispensable part of the daily ora l hygiene programme . Various types are available : single thread, multi-thread, ribbon and super floss ; waxed or unwaxed and in various flavours .
Use of a toothbrush alone is not sufficient t o remove the bacterial plaque from the interdenta l spaces .
Using dental floss
Step 1
A length of dental floss approximately 30 cm lon g is taken and rolled around one finger of eac h hand, leaving about 20 cm free .
Step 2
For the maxilla, the index finger and thumb are used . For the mandible, the two index fingers are used .
Step 3
The floss is passed delicately acros s the contact point with a backwards an d forwards movement .
123
CHAPTER 4
Step 4
The floss is curved into a "C" around the tooth and moved delicately in an apical direction . Then with a single rapid movement, it is move d in an occlusal direction , scraping the plaque .
Step 5
Using clean sections of the floss, the operation is repeated for the othe r interproximal surfaces .
BLEEDIN G
If the floss is used correctly without damaging the epithelial attachment, any papillary bleeding ca n be attributed to the presence of plaque or subgingival calculus . 125
CHAPTER 4
Proxa- brush
Patients with papillary recession or with a prosthesis may effectivel y replace the dental floss with an interdental toothbrush (proxa-brush) to completely remove interdental plaque . Two shapes of proxa-brush exist, conical and cylindrical, the latter being avail able in various sizes .
CONICAL PROXA-BRUSH
After periodontal surgery, the space between the premolar an d molar is wider as a result of papillary recession . Use of a conica l proxa-brush is therefore recommended .
Its shape makes the conical proxa-brush ideal for removin g bacterial plaque from the interproximal spaces of a prostheti c reconstruction .

CYLINDRICAL PROXA-BRUS H
Access to the interdental spac e between the two roots of a hemi sectioned tooth can be obtained only by using a cylindrica l proxa-brush .
Only a small diameter cylindrical proxa-brush is able to penetrate the upper front interdental spaces of a temporary prosthesis which, for aesthetic reasons, are always very narrow . 127
CHAPTER 4
Toothpaste
Used in combination with the toothbrush, toothpaste makes brushin g more pleasant, facilitates bacterial plaque removal and may contain antisepti c substances, etc . Some toothpastes are more abrasive than others . The toothpaste should contain calibrated abrasion particles (75 RDA-25 RDA) to protect the enamel and, in the case of gingival recession, also the neck and root of th e tooth .
CONTROLLED ABRASION TOOTHPAST E 75 RDA* 25 RDA* Dental enamel Necks and roots
"Radioactive Dentine Abrasion .
Relation between bacterial plaque, inflammation and tissue destructio n

The ability of bacterial plaque to cause gingivitis and possibly peri odontitis has already been discussed in chapter one . If performed correctly and constantly, oral hygiene measures enable the gums to be maintained in a healthy state . This has been incontrovertibly demonstrated by numerous researchers .
Lindhe et al. (1975) eliminated gingival inflammation from the mouths of a group of beagles by applying a hygiene regime based on toothbrushin g twice a day and prophylactic polishing once a week . The group of dogs was subsequently divided into two sub-groups . The control group (dotted line) was kept free of local inflammation (zero plaqu e index) for a period offour years just by brushing twice a day . The dogs in the second group (test dogs) were left without oral hygiene . Bacterial plaqu e accumulated rapidly, followed immediately by gingival inflammation . After six months, the dogs began progressively to lose periodontal attachment . During the four year experiment, the test group lost a mean 2 .9 mm of attachment.
129
CHAPTER 4
SCALING AND ROOT PLANING

Scaling: involves the use of instruments to remove plaque and calculus fro m the supragingival and subgingival surfaces of the teeth . Root planing : involves the use of instruments to remove softened cementu m from the root surfaces . Scaling and root planing are usually carried out without incision an d therefore without a direct view of the deposits on the roots . The manual o r mechanical instruments used for these operations must have very fine point s and an extremely sharp cutting edge . In the case of single root teeth, irritative stimuli can be completely remove d and the roots planed . However, this is not possible with multi-root teeth an d scaling and root planing must therefore be completed with the tooth and roo t exposed during periodontal surgery . Calculus: hard, widely distributed calcareous deposit adhering tenaciously t o the surface of the teeth, formed by calcification of bacterial plaque by certai n groups of Gram+ bacteria . From a topographical point of view, it is divided into supragingival calculu s and subgingival calculus .
Supragingival calculus : yellowish and friable, it is located mainly on th e lingual and vestibular aspects of the mandibular sector of the mouth .
Subgingival calculus : dark and hard, it occurs everywhere in the mouth . Th e colour is caused by the deposit of hematic pigments resulting from ulceratio n of the soft wall of the periodontal pocket .
CHAPTER 4
Instruments
The instruments used for scaling and root planing include : Manual instruments (scalers - curettes ) Mechanical instruments (sonic, hyposonic ) Rotary instruments (burrs ) Alternating movement instrument s MANUAL INSTRUMENT S Manual instruments are made up of three parts : blade, shaft and handle . SCALER Triangular section instrument with two cutting edges, a back and a point . Its particular shape makes it strong and rigid enough to remove thick calculu s deposits. Scalers may be straight or curved . Use: supragingival scaling, shallow pockets .
Scaler M23 (Deppeler) Tl.

1Q

CURETT E Semicircular instrument with two cutting edges and a rounded point . The rounded back enables the instrument to be inserted into deep pocket s without damaging surrounding soft tissues . The particular curved blade of cer tain curettes ensures optimum adaptation of the instrument to the surface o f the tooth . Use : subgingival scaling, root planing .
Curette M23 A (Deppeler) TI
Scaler M23 (Deppeler) TI Curetta M23 A (Deppeler) TI
The ideal curette should have a very small blade enabling it to be inserted easil y into the pocket . It should also be shaped in such a way that it can be used in al l sectors of the mouth.
133
CHAPTER 4
Holding the instrument s

The way an instrument is held is crucial to stability, control and efficiency. The most common techniques are : Pen grip: the instrument is held between the thumb and index finger of th e operating hand and rested on the side of the middle finger . Modified pen grip : the instrument is held between the thumb and index finge r of the operating hand ; the fingertip of the middle finger is rested on the instrument in such a way as to act as a pivot . This grip is more powerful an d improves the instrument's stability during lateral movements .
Pen grip
Modified pen grip
1Qh
ORAL HYGIENE REHABILITATION
Resting the han d To maintain control of the instrument, a point must be found to res t the operator's hand, thus improving stability and efficiency while minimizin g the risk of damage to surrounding tissues . The hand is usually rested inside the mouth (teeth) as close as possible to the working area, using the fingertips of the ring and little finger . These fingers should be perfectly dry to avoid slippage .
Resting point in the same arch .
Resting point in the opposite arch . 135
CHAPTER 4
Mechanical instruments (ultrasonic - sonic)

Clinical research has consistently failed to demonstrate the superiority of manual instruments over mechanical instruments . Although the latter produce a rougher root surface, they enable the junctional epithelium to readapt perfectly to the surface of the root cementum . A number of studies (Leon et al . 1987 - Ainamo et al . 1991) have demonstrated the superiority of mechanical instruments over curettes in subgingival scalin g of multi-root teeth . The latest generation of mechanical instruments, hyposonic instrument s (2,300-6,300 cycles/second), produce a less rough root surface than ultrasoni c instruments (25,000-42,000 cycles/second) .
Titan-S
Note the point of the Titan-S a , similar in size to that of a very small curette (M23A-TI) . In the furcation area, the point of a soni c instrument removes bacterial plaque more efficiently via vibration and the cavitatin g effect of the water used for cooling .
Rotary instrument s
The use of diamond burrs mounted on rotary instruments to remov e residues of calculus and softened root cementum is confined to devitalize d teeth transformed into prosthetic abutments . This operation is carried ou t exclusively with the tooth exposed during pre-prosthetic surgery .
During the surgical preparation of abutments , calculus and softened root cementum residue s are removed using a diamond stone mounted on a rotary instrument .
137
CHAPTER 4
A lternating movement instruments

Alternating movement instruments are extremely useful in removing calculus and planing the approximal surfaces of the roots . They are also use d to remove the excess contours of iatrogenic interproximal fillings which wil l subsequently have to be redone to enable optimum control of bacterial plaqu e in the meantime.
DENTATUS EUA TIPS no . 4-3- 1 CONTRA-ANGLE EUA with TIP no. 20
Note the calculus deposit on the approxi mal surfaces of the molars and premolars . After calculus removal , root planing can easily be performed using alternating movement instruments.
DENTATUS EVA TIPS no . 4-3- 1
DENTATUS EVA TIP no . 20
Iatrogenic filling . The interproximal exces s contour must be remove d (EVA TIPS no. 20-21) fo r optimum hygiene i n these areas . 139
CHAPTER 4
Supragingival scaling
Definition : removal of all accretions (plaque, calculus, stains) fro m the supragingival surface of the teeth . Supragingival scaling can be carried out using manual instruments (curettes , scalers) and/or mechanical instruments (sonic, hyposonic) .
TECHNIQUE Manual instruments : the blade is rested on the tooth and adequate pressur e is applied . The instrument is then moved in a coronal direction with a movement repeated across the entire supragingival surface of the tooth until all visible accretions have been removed . Magnifying glasses (x 2-3) can be used to facilitate this operation .
Supragingival scaler DEPPELER M23.
Note the blade of the instrument resting on the surface of the tooth t o perform supragingival scaling .
14Q
Supragingival scaling . Mechanical instruments : the point of the instrument (sonic, hyposonic) is held flat on the surface of th e tooth with a very light pressure and moved backwards and forwards . To break very thick calculus concretions, the point of the instrument may be positioned perpendicularly to the surface of the tooth . If this is not successful, rather than persist, manual scalers should be used . The Titan- S 12 sonic instrument is also highly effective in tooth surface planing, using its rhomboid-sectio n point flat and performing brush-type movements .
If thick calculus concretions are present, th e point of the instrument may be positione d perpendicularly to the sus face of the tooth .
141
CHAPTER 4
Pre-hygienic phas e
Post-hygienic phas e
Note the considerable reduction i n recession after completion of the hygienic phase (supragingival scaling) . If the patient controls bacterial plaque adequately, mucogingiva l reconstruction of the central incisors can be avoided . l /,
Pre-hygienic phas e
On completion of the hygienic phas e (supragingival scaling), the local inflammation has receded, but the larg e recession is unaltered . In this case, reconstruction of the gingiva wit h mucogingival surgery is recommended. 143
CHAPTER 4
Subgingival scaling and root planing are presented together as they are both performe d at the same time . Subgingival work must be carefully targeted and performed under local anaesthetic following identification of pocket depths and the presence of subgingival deposits .
Subgingival scaling
Definition: removal of all accretions (plaque, calculus) from the sub gingival surface of the teeth . Subgingival scaling may be performed using manual instruments (curettes ) and/or mechanical instruments (sonic/hyposonic) .
Note that the subgingival concretion of calculus has bee n completely removed by the curette . During subgingival scaling, root planing is also completed .
Subgingival curette Deppeler M23 A Tl.
Root planing
Definition : involves the use of instruments to remove the final residues of calculus, the softened and infiltrated cementum and smooth th e root surface . Root planing is normally carried out using manual instruments (curettes) . Th e same result can also be obtained using certain hyposonic mechanical instruments (Titan-S) with a particular shaped point .
The very fine rhomboid-section point of the Titan-S enables it to be used for subgingival work .
Titan-S .
145
CHAPTER 4
Subgingival scaling and root planing technique Step 1

The pocket is probe d and the solid concretio n is identified .
Step 2
The curette is reste d on the tooth with th e rounded back toward s the gingiva.
Step 3
The curette is pushed under the gingiva, delicatel y moving the gingiva l tissue . If calculus i s encountered on the root, the curette is moved away fro m the tooth, shiftin g the soft tissues until the obstacle i s passed .
1hf
Step 6
When the sensation is of scrapin g a hard, smooth surface, roo t planing is complete .
Step 5
The apical-coronal movement o f the curette is repeated a numbe r of times to remove the softene d surface of the root cementum.
Step 4
When the depth of th e pocket has bee n reached, the blade of th e curette is engaged in th e root cementum an d moved with an apicalcoronal movement . This operation remove s the calculus and part o f the root cementum .
147
CHAPTER 4
Polishing
Polishing completes scaling, leaving the supragingival surfaces of th e teeth smooth and clean . It also removes any pigmentation left by smoke, food and drugs (chlorhexidine) . Polishing is carried out using a rubber cup mounted on a rotary instrument o r alternatively using air and water jet instruments with abrasive paste . RUBBER CUPS The rubber cups, used in association with variable grain size abrasive pastes (fine, medium, coarse), can be pushed under the gingiva using a ligh t pressure and moved in a coronal-apical direction . The friction of the cup produces heat and it is therefore advisable to polish two teeth at the same time . Both the vestibular and lingual and/or palatal aspects are polished .
Cups for prophylactic treatment.
Fine, medium and coarse grai n abrasive pastes .
Note the polishing of two teeth at the same time to increase cooling .
To polish under the gingival margin, the cup is positioned on the tooth, a light pressure is applied and th e micro-motor is activated . By sloping the cup apically and then moving it in a coronal-apical direction, i t can be inserted under the gingival margin . The cup should be held in that position for no longer than tw o or three seconds .
149
CHAPTER 4 WATER-JET INSTRUMENT S Air and water jet instruments (air flow) are highly effective in removing pigmentation from the tooth surface . They are normally used with highl y abrasive powders containing pumice grains . In the presence of gingival reces sion, use of less abrasive powders containing sodium bicarbonate is preferable. The jet of the instrument must never be directed into the sulcus and should no t hit the gingival margin.
1 g-n
Abrasive powder crystals .
151
CHAPTER 4
Antiseptics in Oral Hygiene Rehabilitatio n

For some years now, chemical control of bacterial plaque has been th e object of numerous research projects, but it has not yet been demonstrate d that mechanical hygiene can be replaced by chemical substances . One of the most effective anti-plaque agents is chlorhexidine . This is used only after completion of the mechanical part of treatment for short or medium ter m therapy during the hygiene phase . It can be used for subgingival irrigation, top ical application (gel) or ablution . Chlorhexidine is, however, more successful in preventing disease than in treating it .
It has been show n that a 0 .2% solutio n of chlorhexidine i s effective in preventing the formation of bacterial plaque o n clean tooth surfaces in the absence of periodontal pocket s (Loe and Schiott, 1970) .
The patient, unable t o use a toothbrush due t o the presence of painful marginal gingivitis, was given chlorhexidine treatment for a week . Note the dark pigmentation caused by the drug and the re d pigmentation due t o the plaque detector applied immediatel y after scaling .
11Q
The following substances are also used during OHR in support of mechanica l treatment . Hydrogen peroxide (12 vol) : used exclusively for subgingival irrigation . Active against anaerobic bacteria. Betadine (povidone iodine 1% tincture) : recommended in ulcerative gingivitis or acute infections .
H.202 has a direct bactericidal actio n on anaerobic flora and also an indirec t action, activating the myeloperoxidas e system of the leukocytes .
Povidone iodine solution (1%) (Betadine) is used during scaling and root planing in support of mechanical treatmen t in particularly severe forms of periodontitis .
153
CHAPTER 4
Antibiotics in Oral Hygiene Rehabilitation

In the majority of cases, mechanical treatment is sufficient to eliminat e the etiological agent of periodontal disease . In gingivitis, antibiotics are no t prescribed . In adult periodontitis, mechanical treatment is normally sufficient . However, in certain specific situations (progressive adult periodontitis, refractory periodontitis, juvenile periodontitis), topical chemotherapy and topical o r systemic antibiotics are administered to improve treatment efficacy . Antibiotics should be prescribed only on completion of mechanical treatment.
Treating periodontal disease s

Systemic antibiotic treatment Local antibioti c treatmen t
Mechanical treatment
Chemical treatment
Adul t periodontiti s - Advanced

- Progressive Amoxycil .+Clay. Ac . Clindamycin Ciprofloxaci n Metronidazole Metronidazole+Amoxycil . Amoxycil.+Clay. Ac .
Yes
Yes
Ye s
Yes
Ye s
Local antibiotic treatmen t

Well-defined sites which do not respond to mechanical treatment ca n be treated with locally-applied antibiotics . Monolithic ethylene vinyl acetate fibres impregnated with tetracyclin e hydrochloride (Actisite 't -Alza corp .), inserted in the periodontal pocket maintain a local antibiotic concentration of more than 1,000 mg/ml for more than 1 0 days. The fibres are not reabsorbable and must be removed . Multi-centre studies have demonstrated that mechanical treatment associate d with local treatment with tetracycline HCL impregnated fibres significantl y reduces the depth of treated pockets and bleeding on probing and increase s the attachment level for about a year after treatment (Goodson et al . 1991).
Tetracycline concentration in the crevicular fluid (CF) afte r application of the fibres . Note that the concentration is still high 240 hours after th e start of treatment.
Tetracycline impregnated fibres
155
CHAPTER 4
TETRACYCLINE IMPREGNATED FIBRE S Indications: sites not responding to mechanical treatment. Recurrent or localized disease . Refusal to undergo surgery.
Insertion technique
Step 1
After scaling and root planing , the pocket is thoroughly probed .
Step 2
Using tweezers, a fibre (23 cm long, 0 .5 m m diameter) is inserted in the pocket .
Step 3
A small spatula or curette is used to push th e fibre in such a way that they fold over each other , completely filling the periodontal pocket . An y excess fibres must be trimmed .
Step 4
After inserting the last segment of fibre under th e gingiva, several drops of cyanoacrylate based sealan t are applied to keep it in place .
Step 5
After about 10 days, the fibre is removed and th e patient may resume normal oral hygiene mea sures at this site .
157
CHAPTER 4
CLINICAL CASE 1 Female patient aged 15 .
Gingivitis
Note the presence of inflammation and edematous papillae . On probing, no periodontal pockets were found . There are pseudopockets in the front vestibula r sector of the maxilla .
X-ray examination: note the presence of crestal and radicular laminae dura . The bone tissue is normal .
ORAL HYGIENE REHABILITATION
As the patient complained of pain when toothbrushing, she was treated with a mouth was h containing 0.2% chlorhexidine for a week . The image shows the case immediately before scaling and after application of a bacterial plaque detector .
A WEEK AFTER supragingival and subgingival scaling performed
with manual and sonic instruments .
159
CHAPTER 4
AFTER A MONTH : the clinical signs of inflammation and papillary edema have disappeared . The patient demonstrates a high degree of positive compliance and scrupulously follows the home hygiene programme .
AFTER TWO MONTHS : the patient will now be included in a maintenance programm e with regular follow-up appointments every three months .
CLINICAL CASE 2 Male patient aged 50 .
Slight periodontiti s
Note the periodontal pockets (4-5 mm) located mainly in the front sector of the mouth and the hyperplastic reaction of the gingiva.
The case after a yea' : As a result of existing heart problems, the patient did not undergo periodontal surgery . At the end of OHR, only a fe w periodontal pockets remained . A maintenance programme followed, adhered to by the patient with scrupulous cooperation . 161
CHAPTER 4
CLINICAL CASE 3 Female patient aged 45 .
Moderately severe periodontiti s
There are 4-5 mm deep periodontal pockets .
The image shows the case a year after completion of OHR. The patien t refused surgical treatment and was included in a maintenance phase with follow-up appointments every three months .
CLINICAL CASE 4 Male patient aged 55 .
Periodontitis with complications
Periodontal pockets 4-5 mm deep and furcation involvement are present .
The case at the end of OHR. The patient is cooperative and has agreed t o surgical treatment .
163
CHAPTER 4
Sharpening
Instruments must be sharp in order to perform scaling and root planing efficiently. Blunt instruments increase operation time, tire the operator , smooth the calculus rather than remove it completely from the root surfac e and cannot be used to plane the root . The instruments on the previous pages (Deppeler M23-M23A TI) are extreme ly easy to sharpen as they have two lateral faces which can be sharpened b y resting them flat on an Arkansas stone . A bottle of sharpening oil (Sharpe n EZ -Hu Friedy) and a ceramic rod are also necessary to finish the curved cut ting sections.
Sharpening techniqu e
Cutting edge
Cutting edge
Subgingival curett e Deppeler M23A-Tl
Supragingival curett e Deppeler M23-Tl
Sharpening oi l (Sharpen EZ 1z -Hu Friedy)
Step 1
The stone is lubricated with a drop of oil and the excess is remove d with gauze.
Step 2/ A
Supragingival curette (M23-TI) : one of the two sides of the instrumen t to be sharpened is rested flat on the lubricated stone . Exerting slight pressure , it is moved backwards and forwards until the edge is sharp . Repeat for the other side .
': 165
CHAPTER 4
Step 2/B
Subgingival curette (M23A-TI) : sharpen using the same technique a s described for the supragingival curette . This curette has a rounded point which must be respected during sharpening .
Step 3
The internal part of these instruments is curved and must therefore b e finished with a cylindrical ceramic rod or Arkansas stone .
Protected back
Sharpening
Instruments must be sharpened each time they are used and before sterilization. If necessary, they may also be sharpened during scaling and root planing sessions.
Cutting edge of a stainless steel curett e after sharpening with Arkansas ston e (x 200) .
Cutting edge of a stainless steel curett e after 10 saturated steam sterilizatio n cycles at 132C.
Cutting edge of a stainless steel curett e after use for a scaling and root planin g operation (x 200) . Note the blunt cutting edge of the curette .
(Bartolucci-Parkes)
167
CHAPTER 4
Reevaluatio n
At the end of OHR, the patient must be reevaluated according to th e following parameters : Resolution of gingival inflammation . Reduction of probing depth . Reduction of tooth mobility. Evaluation of the patient's ability to maintain oral hygiene .
On reevaluation, th e clinical signs of inflammation are absent .
On reevaluation, probing does no t cause bleeding .
On reevaluation, uncooperative patients (low standard of oral hygiene due to lack of manual skills and/or motivation) will not be moved on to the sur gical phase of periodontal treatment, but will be included in a cycle of regular three-monthly follow-up appointments, after being clearly informed that th e periodontal disease is progressing relentlessly. When reevaluation reveals the persistence of deep periodontal pockets i n patients who have adopted correct hygiene standards, these patients will b e moved on to the surgical phase . Root access will enable scaling and root plan ing to be completed or remaining periodontal pockets to be eliminated . A limited number of patients with excellent hygiene standards and a massiv e reduction in pockets will not be moved on to the surgical phase, but will simply follow maintenance treatment .
Patient cooperation
L
NO
YES
L
REGULAR FOLLOW-UP APPOINTMENTS Maintenance pat h Non-surgical path Surgical path
CONCLUSION S
Inflammatory gingivitis and periodontitis are extremely widespread disease s which can be prevented by mechanically controlling supragingival bacteria l plaque. Treatment of these diseases is largely mechanical. Use of antiseptics an d antibiotics is necessary only in a small number of cases . Surgical treatment may follow initial treatment to improve it or to correc t alterations induced by the disease .
169
Chapter 5
Principles of Periodonta l Surgery
171
! PRINCIPLES OF PERIODONTAL SURGERY
The term "periodontal surgery" covers all the techniques employed to modify the disease-altered morphology of periodontal tissues .
Indication s
To eliminate periodontal pockets To create access to root and bone surfaces To functionally and aesthetically reconstruct gingival and bone anatomy . Absence of patient cooperatio n General medical reasons .
Contraindications
Periodontal Surger y
Gingivectomy
Pedicle Graft s
Positioned
Apically Coronall y Laterally
Free Graft s
Resective Surgery
Bone Surgery
Additive Surgery Regenerative Surgery
Bone grafts Bone implants

GTR
Autologous Homologou s Alloplastic
173
CHAPTER 5
SURGICAL TREATMENT
PATIENT SELECTIO N FACTOR S
LOCAL Oral access Chronic desquamative gingivitis Plaque contro l
BEHAVIOURAL Compliance Smokin g
SYSTEMI C
I
YES
CONTROLLABL
I
NO
SURGICA L TREATMEN T
MAINTENANCE
The patient has concluded the hygienic phase of periodontal treatment and is ready for the surgical phc
PRINCIPLES OF PERIODONTAL SURGER Y
DECLARATION OF INFORMED CONSEN T

The undersigne d confirms that the following have been clearly explained :
The details of the surgical operation The reasons for and objectives of the operation . The predictable consequences . The level of risk involved . The probability of success . The possibility of a subsequent operation. Possible alternative treatments .
He/she therefore consents to the proposed treatment and any othe r action which may be held necessary during the operation itself . Date
175
CHAPTER 5
Operating room fo r periodontal procedures.
Cardiac monitoring system for at-risk patients.
------------ -
c
Standard set of instruments for periodonta l flap surgery. The specifi c instruments for individual operations will be described in the relativ e chapter.
PRE-OPERATIVE INSTRUCTIONS FOR THE PATIENT Arrive on time dressed comfortably . Eat at least two hours before the operation . Remove contact lenses and earrings . Do not wear make-up If you are diabetic, do not interrupt treatment . If you are taking anti-coagulants, the treatment must be interrupted . Do npt take aspirin or drugs containing aspirin (acetylsalicylic acid ) for at least 10 days before the operation . Indicate any changes in your state of health .
Preparing the patien t Any mobile prostheses must be removed and the patient is instructed to put on a paper hat and waterproof cape, rins e his/her mouth with 0 .2% chlorhexidine for one minute and clean his/her face thoroughly with chlorhexidine foam . He or she is then placed in prone supin e position to proceed with the operation .
177
CHAPTER 5
LOCAL ANAESTHESI A
Two types of anaesthesia are used in periodontal surgery . Infiltration anaesthesia : an anaesthetic solution (with or without adrenaline) is injected into the sof t tissues surrounding the site of the operation . The anaesthetic penetrate s through the cribrose structure of the bone tissue . Regional or nerve blocking anaesthesia : anaesthetic is injected near a nerve trunk, preferably near the bone entry o r exit point . In operations involving the lower molar sectors, both the lingua l and buccal nerves must often be blocked .
Instruments
Cook-Waite syringe Aspirating syringe fo l intraoral anaesthesia .
Disposable needles of various lengths an d diameters .
Carpule of anaesthetic . To reduce local bleedin g to a minimum, th e anaesthetic is combine d with epinephrin e (1 :100,000 or 1 :50,000) .
FORTE
on ADRENALIN A
1 :100 .00 0
179
CHAPTER 5
Sensory distribution zone s

Maxillary arc h
Anterior superior alveolar nerve
Posterior superio r alveolar nerve
Palatine nerve
To administer anaesthesi a in the maxillary arch, the patient must be in a prone positio n with the head in hyperextension .
Mandibular arch
Lingual nerv e
To administer anaesthesi a in the mandibula r arch, the patien t must be in a semi-prone position with the hea d upright.
181
CHAPTER 5
Blocking the inferior alveolar nerv e

The ramus of the mandible is held in the left hand in such a way tha t the thumb is in the patient's mouth on the external oblique edge of th e mandible about 1 cm above the occlusal plane . The syringe is held parallel to the occlusal plane and brought into the mouth near the premolars of the opposite side . The needle is inserted in the mucosa of the inner face of th e ramus near the thumb of the left hand . The needle touches the bone almos t immediately. The syringe is rotated towards the left, then slowly inserted fo r about 20 mm. The point of the needle should be near Spix's spine, in other words, the point where the inferior alveolar nerve enters the mandibula r bone . After testing aspiration, 2-3 ml of anaesthetic solution are injected . This technique often blocks the neighbouring lingual and buccal nerves as well. Inferior alveolar nerve block is indicated for operations involving the mola r sector.
Anaesthesia blocking the inferior alveola r nerve.
Buccal nerve Inferior alveolar nerve Lingual nerv e
1 R2
PRINCIPLES OF PERIODONTAL SURGERY
Blocking the lingual nerve

In operations involving the lingual sector of the mandible, the lingual nerve must be blocked by depositing a small quantity of anaesthetic on the lingual side on a level with the gingiva of the third lower molar. As the right and left lingual nerves anastomose anteriorly, the nerve endings corresponding t o the canine must also be blocked in the lingual sector to obtain complete anaesthesia of the zone.
Anaesthesia blocking the lingual nerve .
Blocking the buccal nerv e

The buccal nerve crosses the external oblique margin of the mandible , reaching the vestibular section of the molars . To block this nerve, several millilitres of anaesthetic are injected into the submucosa in correspondence wit h the first and second lower molar .
Anaesthesia blocking the buccal nerve.
183
CHAPTER 5
Anaesthesia of the mental foramen

anaesthetise the premolar and canine region, after pulling th e cheek aside, the needle is introduced into th e mucosa near the premolars. The point is pushe d in for about 1 mm, injecting 1-2 ml of anaestheti c solution. For a complete effect, anaesthesia must also be performed in th e lingual sector.
To
Anaesthesia of the incisive nerve

anaesthetise the incisor region, a needle is inserted in th e extreme surface of the mucosa, injecting sever al millilitres of anaesthetic between the righ t and left mental fora mens of the symphysis . The anaesthetic spreads through the osseou s pores into the bone tis sue as far as the nerve . Anaesthesia of thi s region must always b e completed by blocking the mylohyoid nerve .
To
Infiltration anaesthesi a of the incisive nerve .

1Q1
Anaesthesia of the mylohyoid nerv e

This anaesthesia is required for operations involving the lower incisor region . The right and left mylohyoid nerves run through the floor of the mouth an d enter the mandibular bone through two holes, the inferior retromental foramen (IR) and the paramedian retromental foramen (P) . Before entering the bone, the two nerves anastomose . They are blocked by injecting 1-2 ml of anaesthetic to the right and left of th e paramedian line .
Variations in anastomosis
between the incisor and mylohyoid nerve s
Two forms of anastomosis involving the incisive and mylohyoid nerve s have been described . There is end-to-end anastomosis of the right and left incisive nerves . The right mylohyoid nerve communicates with the left incisive nerve after penetratin g the mandible through the inferior retromental foramen . The right and left incisive nerves do not anastomose . After penetrating th e mandible through the lower retromental foramen, the right mylohyoid nerv e innervates the right lateral incisor . From a clinical point of view, these individual anatomical differences explai n the need to complete regional anaesthesia by blocking the mylohyoid nerv e and the contralateral incisive nerve .
End-to-end anastomosis of the right and left inci- The right and left incisive nerves do not anastosive nerves. mose.
CHAPTER 5
distal to the second superior molar . The syringe is held at an angle of 45 to th e occlusal plane and the needle is pushed for about 25 mm near the posterio r part of the maxillary tuber. The needle must be held very near the bone t o avoid pterygoid venous plexus . After aspirating, about 2 ml of anaestheti c solution is injected . For operations involving the first, second and thir d molars, anaesthesia must be completed by blocking the palatine nerve on a level with the exit point (foramen) on the palate .
Anaesthesia of the posterior superio r alveolar nerv e To block this nerve, the needle is inserted vestibularly in the mucos a
Anaesthesia blockin g the posterior superio r alveolar nerve .
Note the depressio n on the bone corresponding to the path of the posterior superior alveolar nerve.
Anestesia al forame sottorbitari o
Anaesthesia o f the suborbital forame n Permeation of the anaesthesia through the bone makes blocking of th e suborbital forame n superfluous. It is therefore sufficient to inject 1/2 ml of anaestheti c solution into the zon e below the foramen at a distance of a few centimetres. The regional anaesthesia is complete d by injecting anaestheti c solution into the zone of the central incisors t o the right and left of th e median line. For operations in the sector between the right an d left canines, the regional block must be complete d by also injecting anaesthetic solution on the palatine side near the exit point of the nasopalatine nerve .
Infiltration anaesthesia of the incisor sector.

187
CHAPTER 5
Blocking the palatine nerv e

The palatine nerve emerges from the palatine bone through the greate r palatine foramen . It runs at a considerable depth through the gingiva of th e palate medially between the alveolar crest and the median line . Homolateral anaesthesia of the palate is obtained by injecting 2 ml of anaesthetic solutio n in front of the foramen near the third molar about 1 mm from the gingival mar gin. The palatine nerve can also be blocked anywhere along its path, obtainin g anaesthesia from the injection point towards the mesial part of the palate .
Anaesthesia blocking the palatine nerve.
Blocking the nasopalatine nerv e

The nasopalatine nerve emerges from the nasopalatine channe l through the incisive foramen, innervating the anterior third of the palate . Anaesthesia of this zone is obtained by injecting a small quantity of anaesthet ic near the incisive papilla, taking care to prevent the point of the needle fro m entering the incisive foramen . This could damage the nerve or result in intravessel injection.
Anaesthesia blocking the nasopalatine nerve .
189
CHAPTER 5
SURGICAL INCISIONS
Various types of incision are employed in periodontal surgery. Th e most common are the external bevel incision and the internal bevel incision .
External bevel incision

The external bevel incision is made with a surgical blade (no . 15-1 6 Kirkland scalpel) on the keratinized gingiva coronally to the mucogingiva l junction. The scalpel is held at an angle of about 45 in an apical-coronal direc tion and the incision terminates near the cemento-enamel junction . The bone tissue must always remain covered by a certain amount of connective tissue .
This incision is used in the presence of pseudopockets and t o eliminate gingival hyperplasia .
External bevel incision . /on
Internal bevel incisio n

The internal bevel incision is performed with a surgical blade (BardParker" no.15) on, or 1-2 mm apically to, the free gingival margin . If there is little keratinized gingiva or there are strong aesthetic reasons, it is preferable t o perform the incision within the crevicular sulcus . The scalpel is held paralle l to the long axis of the tooth or at an angle of 25 to 30 . The incision follow s the contour of the gingival festoon, attempting to respect the interdental papil lae as far as possible . If a full thickness flap is to be raised, a deep incision is made down to the osseous crest . If a partial thickness flap is required, the incision does not reach the bone tissue, leaving the latter covered with a certai n amount of connective tissue .
Indication s
This incision is used in the presence of periodontal pockets to eliln inate th e epithelium inside the pocket and to provide access to the deep planes .
A = intrasulcular incision B = crestal incisio n C = marginal incision

Internal bevel incision .
191
CHAPTER 5
Marginal incisio n
This is the most commonly employed incision in periodontal surgery. It is performed at a distance of 1-2 mm apical to the free gingival margin an d follows the contour of the gingival festoon, cutting around the interdenta l papillae which are preserved.
The marginal incisio n is pe7fo7ned about 1 mm from the free gingival margin.
Inc)
Intrasulcular incisio n
This incision is performed within the crevicular sulcus, usually in th e anterior-superior sector, when there is little keratinized gingiva or for aesthetic reasons.
The intrasulcular incision is performe d by inserting the blade into the sulcus .
In the presence of periodontal pockets limited to the interdental spaces , incision of th e papillae eliminate s the epithelium inside the pocket .
1,93
CHAPTER 5
Scalloped incisio n
The scalloped incision, performed in either the vestibular or palata l and lingual sectors, is employed in order to preserve the interdental papillae , following the contour of the gingival festoon and also obtaining healing by firs t intention in the interproximal area . This incision is performed in associatio n with the internal bevel incision .
Interrupted palatal scalloped incision.
Continuous palatal scalloped incision .
Note the interruption i n the palatal scallope d incision, starting an d stopping for each tooth . In comparison with th e continuous scalloped incision, this version is easier to perform.
This vestibular scalloped incision is continuou s and free from interruptions .
Near a furcation an d in the presence of a retracted flap, th e scalloped incision follows the anatom y of the mesial an d distal root of th e tooth.
195
CHAPTER 5
Linear incision
The linear incision is performed in particular situations and location s only. In the anterior-inferior lingual sector, the linear incision is preferable to the festooned incision . It would, in fact, be difficult to trace around the papil lae given the limited diameter of the interdental space in this zone . The incision may also be performed in edentulous and retromolar spaces.
The incision is performed with a scalpel (B.P no . 1 5 blade) positione d parallel to the axi s of the tooth at a distance of about 2 mm from the free gingival margin.
A scalloped incision can b e observed about 2 mm from the teet h in the palatal and vestibular sectors . The incision then continues linearly in correspondence with th e edentulous area.
Linear incision between the tw o maxillary canines .
Linear incision of a n edentulous area .
197
CHAPTER 5
Releasing incisio n A releasing incision facilitates access to the deep planes and enable s the size of the periodontal flap to be limited . This incision may be performe d mesially or distally to the primary incision . In the case of limited sectors (one or two teeth), both may be performed .
Note the pe?fect visibility and optimu m access to th e deep planes obtained with a realising incision.
1QQ
IF 4
Note the optimum access to a bone defect obtained with tw o realising incision s (mesial and distal) i n the zone concerned.
the presence of grade 2 (type A ) compromised furcation, a full thickness flap is lifte d after performing an intrasulcula r incision and a realising incision .
To position a GTR membrane in
199
CHAPTER 5
Interproximal incisio n
This incision is performed with an interproximal scalpel (Orban' s scalpel no . 1-2 ; Buck's scalpel no. 5-6) and continues into the interproxima l spaces to separate the col from the bone tissue . The triangular Buck's scalpe l is used in the narrowest interdental spaces (front sector) . The oval Orban' s scalpel is used in the widest interdental spaces (rear sector) .
No . 1-2 Orban's scalpel No . 5-6 Buck's scalpel
After elevating a vestibular flap and a palatal flap, an interproximal incision is performed on both sides of the col .
onn
FLAPS
Pedicle flap
Deli n i tion: section of gingival tissue separated from the surroundin g tissues except for at the base .
Free graft
surrounding tissues .
Definition: section of gingival tissue completely separated from the
201
CHAPTER 5
Dissected
flap
Definition : section of gingival tissue raised after incision using a scalpel. The dissected flap raised is partial thickness, leaving the periosteu m and a certain quantity of connective tissue on the bone surface .
Partial thickness flap : note the bone tissue covered by a layer of connective tissue .
Blood circulation in the gingival plexus : vascularization of the gingiva determined mainly by supraperiosteal vessels . During partial thickness flap dissection, these vessels are damaged .
Elevated flap
Definition: section of gingival tissue raised after incision using a periosteal elevator. The elevated flap is full thickness, leaving the bone surfac e exposed .
Full thickness flap : note the completely bare bone tissue .
Are dissected with a scalpe l Are elevated using a periosteal elevato r Consist of epithelium and part of th e connective tissu e Protect the bone tissu e Cause damage to the vascular apparatu s Can be sutured to the periosteum Consist of epithelium and all th e connective tissu e Maintain the vascular apparatus intac t Cannot be sutured to the periosteum
203
CHAPTER 5
Lifting the flap

periodontal flap can either be lifted minimally, as in the case of a modified Widman flap, or beyond the mucogingival junction, as in bon e surgery.
Modified Widman flap : note the minimal elevation of the flap .
Molt's periosteal elevator.
Flap for bone surgery: note the considerable elevation of the flap .
No . 3 Pritchard's periosteal elevator.
In the case illustrated, an exostosis must be removed . An internal bevel festooned incision is performed and a full thickness flap is elevate d using a no . 3 Pritchard's periosteal elevator.
Pritchard's periosteal elevator
In the case illustrated, osteoplasty and ostectomy were performed t o remodel the bone . The extremity of the Pritchard's periosteal elevator i s used to keep the flap raised and protected during bone surgery . 205
CAPITOLO 5
Bar-W ide Periosteal Elevator

The Bar-Wide" (dr. E. Bartolucci) periosteal elevator is a recently conceived surgical instrument used, on one hand, to lift full thickness flaps and , on the other, to separate and protect the flap during bone surgery and facilitat e flap suture . The instrument has a completely smooth handle with a dual non slip and hygiene function . Its smooth surface provides optimum grip to th e gloved hand of the operator and organic surgical residues can easily b e washed off .
Bar-Wide periosteal elevato r
The thin end of the instrument is used as a periosteal elevator to elevate full thickness flaps .
9n~
The wide end of the instrument is used to separat e and protect the flap during bone surgery and facilitate flap suture. While the flap is divaricate d using the Bar-Wide periosteal elevator, suturing can be performed by passing the needle through th e hole in the elevator.
Non-slip function.
207
CHAPTER 5
Secondary flap
Definition: residual tissue around dental elements after the primary flap has been elevated .
Removing the secondary flap

After lifting the primary flap, this tissue is removed by performing tw o incisions, the first at the base of the secondary flap perpendicular to the long axis of the tooth and the second within the sulcus . The secondary flap can then be removed using a sharp curette.
Internal bevel marginal incision .
Perpendicular (1 ) and intrasulcular (2) incisions.
Note the removed secondary flap.

orw
ROOT AND BONE CURETTAGE

Surface curettage of root and bone defects removes the etiologica l agent of periodontal disease and is therefore the most important phase of peri odontal surgery. To halt the infective process, it is fundamental to remove bac terial plaque, residues of subgingival calculus, softened and contaminate d cementum and granulation tissue . This operation can be carried out wit h either manual instruments (curettes, scalers) or mechanical ultrasonic or hyposonic vibration instruments .
No. 11-12 Gracey's curette.
Root planing with curettes .
Titan: hyposonic instrument.
The granulation tissue of intraosseous defects is easily and rapidl y removed with mechanical vibration instruments .
209
CHAPTER 5
Bone reshaping
If the bone tissue is deformed due to increased volume (exostosis) o r local reabsorption (intraosseous defects), before closing the periodontal flap the bone must be reshaped to allow optimum positioning of the flap and thu s functional recovery . For a description of these surgical techniques, see the respective chapters .
Note the altered parabolic profile of the vestibular bone .
Note the significant vestibular bone defect .
Note the altered bone profile and the presence of small intraosseou s defects of the alveola r bone in a vestibula r position .
Flap positioning and repositionin g

At the end of surgical, root and bone treatments, the periodontal fla p must be placed in the position established when planning the operation . Two possibilities exist: repositioned flap and positioned flap .
Returning the flap to the same position as before the operation .

Repositioned flap
If the gingival margin before the operation was at the cemento-enamel junctio n (normal), there is no reason to modify its position .
APICALLY POSITIONE D FLAP
LATERALLY POSITIONE D FLAP
LATERALLY POSITIONE D FLAP
CORONALLY POSITIONE D FLAP
Positioning the flap in a position other than its origina l position before the operation .
Positioned flap
The new position may be more apical, more coronal , mesial or distal . Reference will therefore be made to : Apically positioned fla p Coronally positioned flap Laterally positioned flap
211
CHAPTER 5 APICAL
REPOSITION ]
BIPAPILLARY FLAPS
CORONAL
OSITIONED FLAP
'LAP
LATERALLY POSITIONED FLAP S
'OSITIONED FLAP
CHAPTER 5
SUTURES After positioning the flaps as planned, the wound is sutured . The sutures should always be anchored in keratinized tissue . It is important to pre vent tension thus avoiding possible localized necrosis and to use a sufficien t (but not excessive) number of stitches .
Circular (0) interrupted suture in black silk .
Materials
Various types of material and suture needles are used in general surgery, only some of which are used in periodontal surgery .
MATERIALS Silk Dacron and PTFE (Gore-Tex") Ethibond (Exel) Simple catgut Chromic catgut Polyglycolic acid (Dexon') Polyglactin (Vicryl) Poliglecaprone (Monocryl)
GAUGE 3.0 - 4 .0 5.0 5.0 5.0 4.0 - 5.0 4.0 4.0 - 5.0 - 6.0 4.0 5.0 - 6.0
NEEDLE
FS2 v V5 RTI6 V DA1
Nonabsorbable
FS2v - P2 V FS2 V T5 - PRE2V - CE2 v FS2 v DA10- P3v
Absorbable
TAPERCUT NEEDLES
v REVERSE CUTTING NEEDLE S
"!
4-0
18
(2 .0 metric)
TEAR LEFT
PLAIN GUT
(45 cm)
/
CUTTING
7771
2'0 N C 46
Sterile, Absorbable Surgical Suture, U .S .P Type A Do Not ResterRize
IH
683
rt, a.
! u~
~$# r
41i ir
po
Clfbcl( c3a 6T l e rile ago
t~E
Easy Access
IX.. .?t !..3CERf
'S-2
Suture in black silk and simple catgut .
FS2 needles .
Types of suture
Various types of suture are used in periodontal surgery .
Interrupted
Circular Figure-of-eigh t Mattress (vertical - horizontal) Sling Suspended Spiral Blocked

(one flap - two flaps)
Continuous
Compression
21 5
CHAPTER 5
Instruments
In periodontal flap surgery, 15 cm long Crile-Wood forceps are commonly used . Accessibility with this needle holder is excellent, even in the posterior-lateral and retromolar sectors of the mouth, and large FS2 type needle s can be handled easily. For pedicle or free flaps, a needle holder with a different grip is preferable, the Castrovejo forceps . This more delicate instrument enables small V5, P2, DA1 needles to be handled more easily. Two version s exist, straight point or curved point . The latter is preferable for mucogingival surgery.
15 cm Crile-Woo d needle forceps .
Note the Crile-Wood needle forceps with an FS2 needle.
!"!
.el ru rejo needle Inrrcp (14 cm) . .
Correct pen grip of th e Castrovejo needle forceps . Observe the resting poin t obtained with the ring and little fingers .
658
6.
SUTURA
CM .
45
ZACERAR6 Easy Access
CATGUT NON
CROMICO ago P- 2
sterile
VaL t Reg. 199@9
P2 needle with non-chromic catgut.
217
CHAPTER 5
SUTURE TECHNIQUE S
Surgeon's kno t
This knot can be performed using either Castrovejo or Crile-Wood needle forceps .
Step 1
The needle forceps (Crile-Wood) ar e held with the thumb and middle figure of the operating hand .
Step 2
The needle is passed through the tissues . The needle end of the suture thread is held with the non-operating hand . The suture is pulled through the gingiva leaving about 2 cm of thread free at the end . The suture i s rolled twice clockwise around the needl e forceps .
Step 3
The free end of the suture i s gripped with the needle forceps .
Step 4
The free end of the suture is pulled with the needle forceps .
Step 5
The thread is rolled around the needl e forceps again in an anticlockwis e direction (opposite direction to step 2) . The end of the thread is gripped with the needle forceps .
Step 6
The free end of the thread is pulled , keeping the needle forceps stationary , until the second part of the surgeon' s knot is tight.
219
CHAPTER 5
Circular interrupted sutur e

This suture can be used for all periodontal flaps, particularly when th e intention is to join the two flaps without the interposition of suture threads .
In the case illustrated , the aim was to clos e the flaps with healing by first intention . A circular interrupte d suture was thus used .
Sep 3
The circular interrupted suture will enable healing by first intention .
221
CHAPTER 5
Figure-of-eight interrupted sutur e

This suture is used when the two periodontal flaps cannot be brough t into contact with each other as in the posterior interproximal sectors and i n some cases of pre-prosthetic surgery . In these cases, healing by second inten tion will take place .
Step 1
The two periodontal flaps could not b e brought into contact with each other in the interdental spaces . A figure-of-eigh t interrupted suture is therefore used .
222
With a figure-of-eight interrupted suture, only healing by second intention can take place.
223
CHAPTER 5
Mattress suture
This type of suture is indicated when optimum adaptation of the flap s to the deep planes is required . The stitches are anchored to the periosteum and leave a minimal amount of thread within the flap . There are two variations : Vertical mattress suture Horizontal mattress suture
V ertical mattress suture
Note the depth of penetration of the needle, anchoring in the periosteum .
Vertical mattress suture is often used t o adapt the papilla i n the interdental space .
9 911
Horizontal mattress suture
Horizontal mattress suture is used in th e vestibular and palata l sectors to obtain a high degree of fla p adaptation to the deep planes .
Note the thre e interdental papillae in the vestibular sector sutured wit h horizontal mattress suture.
titi< 225
CHAPTER 5
Simple suspended suture

Also known as a sling suture, this is used in the case of a flap raise d on one side and limited to a single tooth . The suture suspends the flap , anchoring to the two papillae and passing lingually or palatally around th e tooth.
Step 1
The first papilla is caught with the sutur e needle. In this phase, Corn's forceps are extremely useful, enabling the flap to b e supported while it is perforated in the precise position identified . The thread entry hole may be in the epithelial part (see drawing) or the connective part (see photograph) .
Step 2
The thread is passed lingually (or palatally ) around the tooth and catches the second papilla.
Step 3
The thread is passed around the tooth agai n and into the interproximal space, to retur n vestibularly.
Step 4
Once the flap is positioned, the suture thread s are held and the two ends are knotted with a surgeon's knot .
Note the two ends of the suture (Dacron - Ethibond) held under tensio n to position the flap at the cemento-enamel junction.
The sling (simple suspended) suture has bee n knotted . Note the knot positioned on the mesia l papilla of the flap. Three sutures in 5-0 simpl e catgut have been performed in the mesial an d distal edges of the flap .
227
CHAPTER 5
Continuous suspended suture

The continuous suspended suture is similar to the sling suture, but , unlike the latter, extends over a number of teeth . It is used when the flap ha s been suspended unilaterally or when the intention is to suspend the vestibula r and palatal or lingual flap at different levels .
Step 1
The first papilla of the flap is caught with the suture needle and a surgeon's knot is performed.
Step 2
The thread is passed around the tooth as fa r as the following interdental space, exitin g with the thread vestibularly. The secon d papilla is caught with the needle, followe d by the third, the fourth, etc .
Step 3
Once the surgical quadrant has bee n completed, a surgeon's knot is performe d as shown in the drawing.
c)6) o
Step 4
The flap is fixed in the required positio n with the continuous suture . If the lingual (or palatal) flap is also to be sutured , the procedure is repeated as for the vestibular flap .
Continuous suspend ed suture in 4- 0 black silk.
Continuous suspended suture in 4-0 simple catgut .
229
CHAPTER 5
Continuous spiral suture
The spiral suture is used in apicectomies, in pre-prosthetic surgery, t o suture long incisions in edentulous crest, or in mucogingival surgery to sutur e the site where the connective tissue graft has been taken from the palate . It is easy and very quick to perform .
Step 1
The suture begins at one end of th e incision with a circular stitch , performing a surgeon's knot.
Step 2
It continues by passing the needl e and thread about 3 mm away fro m the first stitch . The needle re-emerge s in a direction perpendicular to th e surgical wound.
9 9n
Step 3
The thread is now passed at 45 to th e surgical wound obtaining a continuou s spiral suture .
Step 4
The process is continued, keeping a constant distance between the stitche s and the thread under tension .
Step 5
At the end of the incision, a surgica l knot is performed to block the end with one end of the suture thread and a sli p knot with the last loop which is no t tightened .
231
CHAPTER 5
Continuous blocked suture

The indications for this type of suture are the same as for the continuou s spiral suture . It is more demanding, but also more stable than the previous version .
Step 1-2-3
The first two steps are identical to the continuous spiral suture . The needle i s then passed under the thread to block i t before performing another stitch about 3 mm away from the first .
Step 4- 5
The suture is continued, keeping th e end under tension . When the end of th e incision is reached, a surgeon's knot is performed with the end of the thread and a slip knot with the last loop whic h is not tightened .
Compression suture
This type of suture is used in association with free flaps for optimu m adaptation to the underlying bed . The objectives are to reduce the layer of fibrin between the free grafts and the receiving bed, prevent the formation o f hematoma and facilitate take of the graft . Compression sutures also anchor th e edge of the graft without perforating it, thus avoiding possible necrosis in th e perforation site . There are two variations : Vertical compression suture Horizontal compression sutur e
Vertical compressio n suture .
Horizontal compression suture .
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CHAPTER 5
THE PERIODONTAL PACK

The periodontal pack is applied to the surgical wound to protect i t from attack by food, keep the flaps well adapted to the deep planes an d improve post-operative patient comfort . It is indicated in extensive operations , free flaps and pedicle flaps. It is not indicated in cases with minimum flap elevation. The periodontal pack should be left in place for the time required (max . 10 days) for the organic union between the flap and the deep planes . Leaving it for longer would not be justified .
Materials
The most commonly used periodontal pack and the easiest to prepar e is the soft type (Coe-Pack ) . This consists of a basic paste containing zin c oxide, a fungicide and an accelerant containing carboxylic acids and a bacteriostatic agent .
Pack technique
Two parts of material of an equal length are placed on a mixing shee t and are mixed rapidly and thoroughly with a spatula for at least a minute t o obtain a rubbery paste. The pack is then immersed in a glass of warm water fo r 2-3 minutes . If cold, the water accelerates hardening of the pack .
Application techniqu e
With moist gloved hands, a small cylinder of pack is prepared an d applied directly to the surgical wound, after having dried the region concerne d with air and a surgical aspirator . Exerting a certain pressure, the pack i s spread apically and coronally on the surface of the teeth and, using a mois t instrument, is inserted in the interdental spaces . The pack is applied both vestibularly and palatally or lingually .
23 5
CHAPTER 5
POST-OPERATIVE MEASURE S
Periodontal surgery does not normally include antibiotic treatment . However, antibiotics are generally prescribed in guided regeneration wit h membrane and/or bone graft or implants. In these cases, amoxycillin (1 g twic e a day) is recommended . In the case of penicillin allergy, erythromycin or clin damycin is prescribed . Antibiotic treatment is almost always limited to very short periods . It is initiated two hours before the operation and continued throughout the followin g day. Association of amoxycillin (875 mg) with clavulanic acid (125 mg 1 cp . twice a day) is recommended . Antibiotic treatment may be short term, initiated two hours before the opera tion and continued for the two following days . Antibiotic treatment durin g surgical treatment of juvenile periodontitis, resistant periodontitis and periodontitis during diabetes mellitus is discussed in the relative chapters .
Local treatment of the surgical incision and treatment of post-operative pain: Anti-inflammatory and antalgic treatment using drugs such as Ipobrufene (100 mg x twice/day ) and/or Paracetamol or similar . If not protected by a periodontal pack, the incision must be spread with a 2% chlorhexidin e based gel two or three times per day. Only cold food should be eaten for the first day . No smoking for 3-4 days (prevents delays in healing of the incision) . Removal of suture stitches (if not absorbable) between 7 and 10 days after the operation .
Clinical case on the tenth day with the suture stitches stil l in place. Once removed, the patient must spread the operated area with a chlorhexidine based gel (0.2%) twice a day for a week .
POST-OPERATIVE INSTRUCTIONS FOR THE PATIEN T MEDICINES Take as prescribe d PAIN Take the prescribed medicine within an hour o f the operation, then, if necessary, continue as pre scribed. SWELLING If present, may persist for several days . Take the medicines as prescribed . BLEEDING A small quantity of blood may be found in the saliva during the first two days . Do not worry. If bleeding is excessive, telephone. ORAL HYGIEN E Begin oral ablutions several hours after the operation. Brush the hemiarch and/or arch not affected by the operation . During the first two days, only soft food should be eaten . Avoid hot food. For ten days, avoi d chewing on the part operated. Will be removed 7-10 days after the operation .
DIET
SUTURES
PACK If applied, will be removed together with th e sutures.

IN THE EVENT OF COMPLICATIONS, TELEPHONE
Clinical case with repositioned flap one month after the operation .
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STERILIZATION
Procedure aimed at destroying all forms of life, including spores . In periodontal surgery, it is vital to operate with sterile surgical instruments t o avoid cross infection. Three methods of sterilization are accepted (ADA 1974) : Saturated steam autoclav e Dry heat ove n Ethylene oxid e In the dentistry clinic, the autoclave and dry heat oven are preferable .
Saturated steam autoclave .
Dry heat oven.
Epidemiology of cross infection s

SURVIVAL INCUBATIO N
Respiratory viruse s Herpes Zoste r Herpes Simplex 1- 2 Parotitis viru s Hepatitis A viru s Hepatitis B virus Hepatitis C virus M. tuberculosi s Staph. Aureu s Pyogenic Staph . Pneum . mycoplasma Treponema Pallid . HIV virus
Saliva - secretion s Saliva - vesicle s Saliva - vesicles Saliva - secretion s Saliva - blood - faece s Saliva - bloo d Saliva - bloo d Saliva - expectorat e Saliva - skin - exudat e Saliva - secretion s Saliva - secretion s Contact with the lesio n Blood - sperm - vag . secy.
Hours Hours Minute s Hours Month s Month s Month s Days - weeks Days Hours - day s Seconds - minutes Second s Hours
1 - 14 days 2 - 3 weeks weeks 2 12 - 26 days 15 - 40 day s 1 .5 - 4 month s 4 - ? month s 6 month s 4 - 10 day s 1 - 3 day s 2 - 3 weeks 1 .5- 10 week s Years
Monitoring
It is absolutely vital to monitor correct sterilization . This is achieved by verifying destruction of bacterial spores, the most resistant of the viruses o r the bacteria themselves, exposed to the same conditions . Their destruction is proof of successful sterilization .
2 2
1
1
0 1
3 4
10
15
10
7s
20
Minute s -
Minute s
B. Stearothermophilus B. Sottilis
- - - B. Stearothermophilus B. Sottilis
Saturated steam sterilization . Bacillus Stearothermophilus spores are used i n the autoclave. They die in 15 minutes at 120 C .
Dry heat sterilization . Bacillus Sottilis spores are used in the dry oven . They die in 30 minutes at 160C .
Bacterial spores.
239
CHAPTER 5
Sterilization cycle
Sterile instruments before surgery
"
L.' -
Monitoring with spor
es
241
Chapter 6
Periodontal Flap Surgery
PERIODONTAL FLAP SURGER Y
The term "periodontal flap surgery" describes the techniques employe d to remove epithelium and inflamed connective tissue and to obtain access t o root and bone surfaces . Access allows optimum elimination of bacterial plaqu e and calculus from the root surfaces and elimination of granulation tissue fro m bone defects . Periodontal flap surgery includes a series of operations with different characteristics and indications : access flap, modified Widman flap, apically positioned flap, palatal flap and distal wedge .
Indication s
To completely eliminate bacterial plaque and subgingival calculus . To eliminate periodontal pocket .
Contraindications
Psychological reasons. General medical reasons .
SELECTING THE TYPE OF TREATMEN T
TYPE OF GINGIVA
EDEMATOUS
FIBROU S
HEIGHT OF GINGIVA
ADEQUATE
INADEQUATE
NECESSITY FOR ACCESS TO THE BONE
Not necessary
Necessary
HYGIENIC PHASE
GINGIVECTOMY
FLAP
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CHAPTER 6
L.
SURGICAL RATIONALE
In cases of periodontitis in which periodontal pockets > 4 - 5 mm persist after initial preparation, surgery is required to eliminate or reduce th e pocket as otherwise neither home hygiene not professional hygiene treatmen t would be capable of maintaining this pathological structure free from inflammation. The periodontal disease would inevitably reoccur, with further attach ment loss . Other conditions also suggesting periodontal flap surgery include the need for access to bone, pre-prosthetic surgery and cosmetic surgery .
Pocke t
Loss of connective attachment with bone reabsorption .
a = soft tissue surgery. b = hard tissue surgery.
MATERIALS FO R PERIODONTAL SURGER Y Sterile latex glove s Surgical mas k Sterile gauze Surgical blade s Needles for anaesthesia Carpule of anaestheti c Burrs for bone surgery Bite bloc k Cotton wicking s Dappen Suture threads
J
Surgical instruments
Instruments employed in periodontal flap surgery include :
Double-sided mirror to improve visibility. CP12 graduated periodontal probe for measuring and probing . Straight round scalpel for incisions. Bartolucci periosteal elevator (Bar-Wide) . No . 1/2 Orban interproximal scalpel for interproximal incisions . Universal curett e
to remove pieces of tissue and for the curettage of bone defects and roots .
No. 36/37 Rodhes chisel ,
useful in bone surgery, the distal wedge procedure and to remove th e periosteum . H3 curved Cocker Mosquito to remove pieces of tissue . Crile-Wood needle forceps (15 cm) for suturing. Dean scissors to cut the suture threads .
Cook-Waite syringe for anaesthesia. Columbia retractors to retract cheek and lip . LaGrange scissors to finish the flaps.
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CHAPTER 6
A) Access flap
Described for the first time by Kirkland in 1931, this flap is easy to per form . The aim is to obtain full access to root surfaces in order to complet e mechanical treatment and perform any chemical treatment necessary.
Indications:
Indicated in chronic adult periodontitis to complete root planing and reduc e pocket depth .
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Surgical techniqu e
Step 1 : Incision, flap elevatio n and curettage

The incision is performed vestibularly and palatally directly in the bot tom of the pocket . The flaps are raised using a periosteal elevator, exposin g the bone and root surfaces which undergo thorough curettage .
PERIODONTAL FLAP SURGERY
Step 2: Chemical root treatmen t

The root cementum is contaminated as a result of exposure of root surfaces to bacterial plaque . Scaling and root planing alone are not sufficient to completely remove the bacterial load . The root surfaces are therefore chemically treated with pH 1 citric acid for one minute, followed by immediate irrigation with sterile physiological solution .
A saturated solution is prepared by dissolving citric acid in hot water until precipitation forms on the bottom of the bottle. The pH is measured (it must b e highly acid, pH 1) . The citric acid is use d to sterilize the surfac e layer of root cementu m penetrated by bacteria l plaque.
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As an alternative to citric acid, a tetracycline hydrochloride based paste can be applied for three minutes (Terranova), followed by immediat e irrigation of the area with sterile physiological solution .
A capsule of Ambramycin is opene d in a dappen and the contents ar e diluted with sterile physiologica l solution until a stiff paste i s obtained.
The tetracycline paste is applied for about three minutes to the root surfac e of the teeth.
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To remove the tetracycline paste, the site of the operation is irrigated wit h sterile physiological solution.
Step 3: Flap suture

After any granulation tissue present has been removed from the inne r surface of the flaps and the epithelium has been eliminated from the pockets , the flaps are replaced in their pre-operative position and sutured with interrupted circular or figure-of-eight stitches . Absorbable thread can be used t o spare the patient the minor trauma of removal .
Post-operative imag e (after six months) .
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B) Modified W idman flap

In 1974, Ramfjord and Nissle modified the technique previousl y described by Leonard Widman in 1918 . Unlike the original Widman flap, th e objectives of the modified flap do not include apical positioning or resective bone surgery.
Widman flap
Initial incision perpendicular to the long axis of the tooth . The flap is complete reflected beyon d the mucogingival junction . The epithelial-connective collar i s removed with a scaler . Interproximal, adaptation of the flap s is not important . 1. 2. .i . 4.
Modified flap
Initial incision parallel to the lon g axis of the tooth . The flap is minimall y reflected . The epithelial-connective collar i s removed by means of three incisions . Perfect interproximal adaptation of the flaps is extremely important.
Definition :
Scalloped, internal bevel, mucoperiosteal flap reflected just enough to allo w access to the root and bone surfaces .
Objectives:
Performance of a minimally invasive operatio n Reduction of post-operative symptoms. Improvement of post-operative aesthetics .
Indications :
Moderate periodontitis (4-6 mm pockets) Front sectors of the mouth.
Contraindications :
None. Minimum surgical instruments : Scalpel Needle forceps (Crile-Wood) M23 Deppeler curette 2/4 Molt periosteal elevato r Interproximal scalpel (1/2 Orban) .
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Surgical techniqu e Step 1 : Incisions

After administering local anaesthesia with an anaesthetic containin g epinephrine (1:100,000), the incisions are performed using a Bard-Parker blad e (no . 15).
FIRST INCISIO N The first incision is made about 1 mm from the margin of the fre e gingiva, holding the blade parallel to the longitudinal axis of the tooth .
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CHAPTER 6 SECOND INCISIO N The flap is elevated minimally and an incision is made in the botto m of the gingival sulcus as far as the osseous alveolar crest, holding the blad e parallel to the longitudinal axis of the tooth .
PERIODONTAL FLAP SURGERY THIRD INCISIO N This incision is performed holding the blade perpendicularly to th e longitudinal axis of the tooth .
Once the secondary flap has been eliminated, the col is removed using a 1/2 Orban interproximal scalpel .
CHAPTER 6
Step 2: Bone and root curettage
Root planing removes softened and infiltrated cementum. Curettage of any bone defects present is then performed to remove all granulatio n tissue.
Step 3: Irrigation and aspiration
The operation is concluded by irrigating the site with sterile physiological solution and the n aspirating the irrigatio n liquid, together with any pieces of granulation tis sue, specks of calculu s and bacterial plaque .
Step 4: Suture
Circular suture .
At the end of the surgical operation, the palatal and vestibular flaps ar e repositioned and sutured in the pre-operative site . The suture is performe d with silk thread or simple catgut .
Step 5: Periodontal pack

A pack is not required with the Widman flap, but if used, it should b e removed after 3-4 days.
Post-operative image (after six months) . The incision performed several millimetres from the gingival margi n has altered the final aesthetic result . Where aesthetics are a priority, th e operation can be varied, making the first incision directly in the crevicular sulcus . 257
CHAPTER 6 INTRACREVICULAR INCISION Where aesthetics are a priority, the first incision is performed directl y in the crevicular sulcus as far as the osseous crest .
Post-operative image (after one month) . The final aesthetic result is clearly better after an intracrevicular incisio n than after a margina l incision.
PERIODONTAL FLAP SURGERY BONE RESHAPING
Ramfjord did not describe resective bone surgery in the Widman modified flap . However, in some cases, ostectomy and osteoplasty may be used to improv e adaptation of the flaps and obtain better interproximal closure .
Before bone surgery Note the altered bone profile .
Ochsenbein chisel (no . 1-2) i n ostectomy .
After bone surgery.
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CHAPTER 6
CLINICAL CASE 1
Male patient aged 42 with moderately severe periodontitis . At the end of the hygienic phase, 4-5 mm pockets are still present, largely in the inter proximal sectors . It was decided to use the modified Widman flap technique with intracrevicula r incision to reduce crown lengthening to a minimum .
Pre-hygienic phase : presence of periodonta l pockets with an averag e depth of 4-5 mm.
Post-hygienic phase : the case at the end of the hygienic phase and immediately before the surgical phase .
Incision : note the first incision pel for med i n the crevicular sulcus .
A,
Elevating the flap: the flap is raised using a Pritchard periosteal elevator ; avoiding going beyond the mucogingiva l junction . Root and bone curettage is carried out without reshaping the bone .
Suture : the vestibular and palatal flaps are repositioned in their pre-operative site and sutured with 4-0 blac k silk and an FS2 needle using interrupted circular stitches . 261
CHAPTER 6
Post-operative phase : the case six months after the operation . Note the excellent healing and aesthetics.
CLINICAL CASE 2
Male patient aged 50 with moderately severe periodontitis (4-5 mm) . However, in the upper canine zone, there are pockets compatible wit h advanced periodontitis (6-7 mm) . It was therefore decided to use the modifie d Widman flap technique to preserve aesthetics as far as possible following th e specific request of the patient .
Incision : the first incision is performed a millimetre from the gingival margin , holding the scalpel almost parallel to the longitudinal axis of the tooth . A continuous internal bevel scalloped incision is performed .
Elevating the flap : a mucoperiosteal flap is delicatel y elevated without going beyond th e mucogingival junction.
Interproximal incision : the second and third incisions hav e already been performed. The operatio n continues with the interproximal incisio n (1/2 Orban scalpel) to remove the col .
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When the flap has been elevated, it can be seen that the vestibular sectors of the incisors are free fro m bone reabsorption . However, in the vestibular sectors of the canines, there are small bone defects . Thorough curettage of these defects is performed, but without bone reshaping .
Post-operative phase : the case six months after the operation .

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the vestibular and palatal flaps are repositioned in thei r pre-operative site and sutured with 4-0 black silk and a n FS2 needle using interrupted circular stitches .
Suture :
Clinical case courtesy of : Dr. llilton Israelson Dallas, Texas - USA .
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CHAPTER 6
C) Apically positioned flap

This flap was described for the first time by Nabers in 1954 . Later, i n 1962, Friedmann called it the "Apically Repositioned Flap", thus emphasisin g the fact that the keratinized gingiva alveolar mucosa is moved in an apica l direction after bone surgery. We will name this flap "apically positioned " because the gingival tissues are moved in a new position .
An internal bevel incision is performed, the secondary flap is removed an d the full thickness primary flap is elevated beyond the mucogingival junctio n and positioned apically to cover the osseous crest .
Definition :
Mucoperiosteal flap, elevated beyond the mucogingival line an d apically positioned.

Objectives :
To obtain full access to the deep planes . To eradicate periodontal pockets .

Indications :
Periodontitis with deep pockets (>6 mm). Clinical crown lengthening. Resective bone surgery . Pre-prosthetic bone surgery. Aesthetic - after the operation, there is always clinical crow n lengthening .
Contraindications :
Pre-operative phase Before the operation, the gingival margin is positioned at the cemento-enamel junction .
Post-operative phase After the operation, the gingival margin of the flap is positioned apically to cover th e osseous crest .
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CHAPTER 6
Surgical technique
Pre-hygienic phas e Note the edematous and reddened gingival tissues.
Post-hygienic phas e At the end of the hygienic phase , the edema and reddening of th e gingiva have disappeared . The patient is being treated wit h 0.2% chlorhexidine .
Step 1 Incision
An internal bevel scalloped incision is performed at the gingival margin . It is then deepened as far as th e osseous crest .
Step 2 Elevating the flap

Once the secondary flap and col have been removed, a mucoperiosteal flap is elevated beyond th e mucogingival junction to expose the osseous crest and any bon e defects present . If necessary, resective bone surgery is performed .
Step 3 Suture
The vestibular and lingual flap s are positioned apically and sutured to cover the osseous crest with 4-0 black silk sutures and a n FS2 needle .
Step 4 Stabilization
In the event of massive bone reabsorption with reversal of th e crown/root ratio causing perma nent tooth mobility, stabilizatio n may be indicated .
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CHAPTER 6
CLINICAL CASE 1
Female patient aged 46 with advanced chronic periodontitis . Periodontal pockets, an average of 6-7 m m deep, are present . At the end of the hygienic phase, a surgical operation is performed to eradicate th e pockets.
Pre-osseou s
Note the predominantly horizontal bone reabsorption .
Suture : the flaps are sutured a t the osseous crest using a simple catgut suture .
Post-surgical phase:
Bone reabsorption is predominantly horizontal and evenly distributed . Conservative resective bon e surgery is therefore performed to avoid impairing the stability of the teeth which already have a reverse d crown/root ratio .
Post-osseous
Note the conservative nature of the bone resection to avoid worsening th e crown/root ratio .
Suture : the flaps are sutured at the osseous crest using simpl e catgut suture.
the case six months after the operation .
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CHAPTER 6
CLINICAL CASE 2
Female patient aged 55 with moderately severe chronic periodontitis (5-6 mm pockets) . The treatment plan involves extracting th e incisors and constructing a fixe d circular prosthesis including th e two canines and four premolars . It involves an apically positioned flap and resective bone surgery.
Note the teeth transformed into abutments for insertion of a temporary prosthesis .
Incisio n Flap elevatio n Bone surgery An internal bevel scallope d incision has been performe d and a mucoperiosteal flap has been elevated . After curettage of the root an d bone surfaces, resective bone surgery is carried ou t to re-establish the paraboli c profile of the bone.
Suture: the flaps are positioned apicall y and sutured at the crest with Dacron sutures using interrupte d circular stitches . Post-operativ e image on removal of the suture s (12 days) .
Post-operative phase : the case a month after th e operation .
The case three months after th e operation with the temporary prosthesis in situ . The tissues are mature and the case is ready fo r preparation of the definitiv e prosthesis.
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CLINICAL CASE 3
Male patient aged 32 with root caries near the cemento-enamel junction of the right mandibular canin e and premolars. Reconstruction of these lesions would be difficult and would be either too near the gingival margin o r below it. The surgical treatment plan includes an apically positioned flap elevated vestibularly only. On healing, the therapeutic programme provides for aesthetic reconstruction of the caries .
PRE-OPERATIVE IMAGE
Note the caries near th e gingival margin.
INCISION AND FLAP ELEVATION
An intracrevicular incision i s made as far as the osseous crest . Using a Pritchard periosteal elevator, a full thickness flap is raised beyond the mucogingiva l junction.
9'7h

BONE SURGERY
Modest ostectomy and osteoplasty are performed, moving th e bone margin vestibular to the caries apically by about 1-2 mm . The dentine and softened cementum are removed and a temporary filling is performed . POST-OPERATIVE IMAG E
The case three months after the operation. Note the perfectly healed gingival tissue positioned apically to the caries . The case is ready for cosmetic reconstruction .
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D) Palatal Flap
When an apically positioned flap is performed in the vestibular sec tion, once elevated beyond the mucogingival junction, the tissue can usually b e moved without difficulty. However, in the palatal sector where the flap consists exclusively of connective tissue, the lack of elasticity prevents it bein g apically positioned.
Definition :
The term palatal flap describes a particular surgical technique enabling th e palatal connective tissue to be incised, elevated, thinned and positione d apically.
Objectives :
To provide access to the root and bone surfaces . To obtain apical mobility of the palatal flap .
Indications :
Periodontitis . Clinical crown lengthening . Resective bone surgery. Pre-prosthetic surgery.

Contraindications :
Too narrow and/or low a palate would make thinning of the flap difficult . Care must be taken to avoid damaging the palatine artery.
Multiple bone reabsorption in the palatal secto r
CLINICAL CASE 1
In this clinical case i t was necessary to posi tion the vestibular and palatal flaps apicall y for prosthetic reasons . Note the short clinical crowns . With apically positioned flaps an d resective bone surgery , the clinical crowns are lengthened and prosthe sis retention is thus improved.
PRE-OPERATIVE IMAGE S
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Surgical techniqu e
Step 1 : Intracrevicular incisio n

This is performed with a no. 15 Bard-Parker blade inserted directl y into the crevicular sulcus as far as the osseous crest .
Step 2: Flap elevation

A mucoperiosteal flap is elevated using a Pritchard periosteal elevator . After exposing the bone tissue (for possible bone surgery) , the length of the flap is measured .
Step 3: Paramarginal incision.

An internal bevel incision is performed at a distance from th e gingival margin determined by the need or otherwise t o shorten the flap .
Step 4: Thinning the flap

If necessary, the flap is further thinned using a new blade .
Step 5: Suturing the flap

The flap is closed, covering the osseous crest, with a continuous suspended suture or vertical/horizonta l mattress suture .
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Note the intracrevicular an d paramarginal incisions . The incisions are also extended t o the retromolar region and th e mesial edentulous ridge .
After removal of the secondary flap and further thinning of th e primary flap, the latter i s positioned at the osseous cres t (resective bone surgery is performed) and sutured with interrupted figure-of-eight stitche s and horizontal mattress stitches . The margins of the flap positioned in correspondence with the edentulous ridge are sutured wit h interrupted circular stitches .
After the operation, the clinica l crowns appear longer. In this typ e of operation, a periodontal pack i s always indicated . It is removed after about a week .
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CHAPTER 6
CLINICAL CASE 2
Male patient aged 48 with chronic periodontitis. Pocket an average o f 6-7 mm deep and horizontal bone reabsorption are present. Probing performe d after anaesthesia (bone sounding) revealed the need to shorten the palatal flap by about 3 mm .
The first internal bevel incision (no . 15 B.P.) is performed about 3 mm from th e gingival margin to thin and shorten the flap . The incision is extended to th e retromolar area .
After elevating the primary flap, the secondary flap can be clearly seen .
The secondary flap is removed after making a second incision in the sulcus (no . 1 5 B.P.) and a third interproximal incision (no . 1/2 Orban) at the base of the col . Thorough root and bone curettage is performed together with bone reshaping . Note the thinned palatal flap .
The palatal flap is adapted to the bone planes and held under compression) with a gauze moistened with physiological solution for 2-3 minutes . This minimizes the fil m of fibrin and encourages coagulation . Immediately afterwards, the flap is closed wit h continuous suspended suture using 4-0 black silk .
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CHAPTER 6
CLINICAL CASE 3
Female patient aged 35 with amelogensis imperfecta . The crown enamel is completely destroyed and the clinical crowns must therefore be lengthened to allow for prosthetic reconstruction of the teeth .
After bone sounding, two incisions are performed, the firs t intracrevicular to the osseous crest, the second 6-7 mm from th e gingival margin .
A full thickness primary flap is elevated . The secondary flap is then removed and an ostectomy performed to obtain crown lengthening .
The palatal flap is positioned apically in the osseous crest and sutured with interrupted mattres s stitches . Now seeming considerably longer, the teeth are then prepared for optimum reception of firs t the temporary prosthesis, then the definitive prosthesis .
The case six months after the operation with a temporary prosthesis in situ .
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CHAPTER 6
E) The Distal Wedg e

The retromolar gingival mucosa zone of the mandible and maxill a often present variations - sometimes bulbous and keratinized, sometimes fla t and without keratin . In the majority of cases, there is a limited amount of keratin in this area . The treatment of any periodontal pockets in the distal sector of the last mola r may be complicated by poor accessibility and the local anatomy. The operation to reduce retromolar pockets was described by Robinson i n 1966 in his article, now a classic, "The Distal Wedge Operation" . In the presence of a pocket in the retromolar zone together with completel y keratinized tissue, the pocket eradication operation consists of a simple gingivectomy. However, if the tissue consists of a keratinized zone and a zone of mucos a only, and access to the deep planes (bone and root surface) is required, the preferred operation is the distal wedge procedure .
Definition :
The term distal wedge is applied to a particular surgical technique employe d to eradicate retromolar pockets and reduce the extent of retromolar tissue .
Objectives :
To eradicate retromolar pockets . To reduce the volume of the retromolar area . To create access to the deep planes .
Indications:
Periodontal pockets . Clinical crown lengthening . Retromolar bone surgery. Pre-prosthetic surgery.
Contraindications :
None.
Surgical techniqu e
The retromolar zone may be surgically reduced by means of : A) Gingivectomy B) Distal wedge procedure . GINGIVECTOMY This operation is indicated exclusively in the case of moderately sever e gingival hyperplasia . In these cases, a section perpendicular to the axis o f the tooth is sufficient to completely eradicate a pocket or the gingiva l hyperplasia.
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DISTAL WEDG E The flap incisions to reduce the retromolar zone can be performed in thre e different ways : I) Triangular incisio n II) Parallel incision s III) Page incision I) TRIANGULAR INCISION
A triangular incision is made angled from th e median part towards the exterior so as t o obtain a thinned flap . The incision is then continued along the intracrevicular line a s far as the interproximal space between th e last two molars.
Two full thickness flap s are elevated, isolatin g the distal wedge whic h is removed by firs t gripping it with a Cocker Mosquito an d then detaching it from the deep osseous planes with an Ochsenbei n chisel.
c)
Curettage is performe d and the area is irrigat ed with physiologica l solution . If there is a n intraosseous pocket , this is treated by means of bone surgery (resec tive or regenerative).
At the end of the operation, the flaps ar e sutured with 4-0 black silk . Alternatively, an absorbable suture material can be used .
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II) PARALLEL INCISION S
Pre-operative image.
Two parallel incisions are made in the keratinized retromolar gingiva terminating in the mucosa . The incisions are undercut by sloping the scalpel . The result is two thinned flaps . The incisions are then extended around th e last two molars and may either be intracrevicular or 1-2 mm from the gingival margin . This depends on whether epithelium needs to be remove d from within the periodontal pocket .
After elevating the two mucoperiosteal flaps, the block of intermediate tissu e is removed with the help of an Ochsenbein chisel .
The bone tissue and root surfaces of the two molars are exposed and curet tage is performed . The area is then irrigated with physiological solutio n and, if necessary, bone surgery (resective or regenerative) is performed.
The flaps are adapted accurately to the deep planes and sutured with interrupted circular stitches, using 4-0 black silk in order to obtain healing b y first intention .
289
CHAPTER 6 III) PAGE INCISIO N This variation on the standard procedure in which one flap is obtaine d instead of two is indicated when there is a very large intraosseous pocket i n the retromolar zone requiring regenerative or additive surgical treatment . The suture is eccentric and thus interferes less with the membrane and th e bone graft . This flap is also indicated in the presence of an edentulous ridge wit h intraosseous pocket.
The incision is begun in a palatal-vestibular direction and continues wit h an angle of 90 on the vestibular edge, ending on the distal edge of th e tooth. It is then continued intracrevicularly as far as the palatal zone . Finally, a periosteal elevator is used to raise a flap which will be thinne d with a further incision .
Curettage of the root su7faces and bone defect is performed, followed b y irrigation with physiological solution . If necessary, bone surgery (regenerative - additive) is performed .
The flap is carefully adapted to the deep planes and sutured with interrupted circular stitches .
291
CHAPTER 6
Smoking and the outcom e of treatment

Cigarette smoking is recognized as having a negativ e influence on the outcome of surgical and non-surgica l treatment (Kaldahl, 1996) . In addition, it had previously been demonstrated (Bergstrom, 1987) that smoking had a negative effect on bone reabsorption, even in patient s with a high standard of hygiene .
Reabsorption of alveolar bone height with respect to age : study car ried out on smoker and non-smoker patients .
Smoker patien t Eighteen months previously , the patient underwen t periodontal flap surgery. The photographs were take n during a routine professiona l scaling session (every thre e months) . Note the enormous quantity of black pigmentatio n (nicotine and tar) and gingival inflammation .
292
Healing of the operation site
Modified Widman flap A) B) C) Curettage is performed on the bone which is then covered with the flap . During the healing phase, bone reabsorption takes place together wit h bone regeneration widthways . A long junctional epithelium is interpose d between the regenerated tissue and the root surface . During tissue maturation (6-12 months), moderate apical migration of th e gingival margin occurs .
Apically positioned flap A) B) C) Bone reshaping is performed and the flap is positioned at the crest. The bone continues to be reabsorbed and there is attachment loss . During tissue maturation (6-12 months), a certain amount of regeneration of the bone and coronal attachment apparatus occurs.
CONCLUSION S Longitudinal studies have shown (1st European Workshop on Periodontology, 1993) that the various surgical methods are equally effectiv e in reducing periodontal pocket depth and controlling the progression o f chronic adult periodontitis . Post-operative control of bacterial plaque is, however, the most important fac tor in determining the long term success of periodontal surgery, regardless of the technique used . These observations reduce the significance of the traditional differentiatio n between surgical techniques indicated to reduce pocket depth (access flap an d modified Widman flap) and surgical techniques indicated to eliminate th e pocket (apically positioned flap and gingivectomy) .
293
Chapter 7
Resectiv e Bone Surgery
RESECTIVE BONE SURGERY
The term "resective bone surgery" is applied to all procedure s employed to eliminate craters and angular defects caused by the bone reabsorption typical of periodontal disease . The principles of resective bone surgery were set out by Schluger in 1949 and again by Goldman in 1950 . These authors described the direct relationship between the gingival profil e and the shape of the underlying bone . Elimination of craters and osseou s angular defects is therefore vital to obtaining an optimum gingival profil e and maintaining shallow pockets after periodontal surgery.
Normal bone profil e Normal bone architecture consists of a festooned bone profile with into proximal septa locate d coronally to the radicular bone . The bone and the cemento-enamel junction are about 2 mm apart .
297
CHAPTER 7
Almost normal bone profile Note the greater distance between the bone and the cemento-enamel junction, although the paraboli c profile and shape of the interdental alveolar septa are conserved.
Pathological bone profile Note the much greater distance between the bone and the cemento-enamel junction . The parabolic profile and shape of the interdental alveolar septa are completely altered .
Bone defects
Bone defects consist of localized reabsorption of the osseous alveola r crest around the tooth . They are also known as intraosseous defects as the y are formed within the bone mass and are classified according to the number o f constituent walls . Bone defects may occur in various sites around the same tooth and are usually located in the interproximal space . However, they may also occur in th e vestibular and/or palatal and lingual bone tissue . If they occur in the bone tissue of a root furcation, there may also be som e degree of reabsorption between the roots, in the severest cases, establishing communication between the vestibular and palatal or lingual sectors .
One wall (hemiseptum)
Two walls
299
CHAPTER 7
Crater A bone defect is defined as a crater whe n the two surviving bone walls are th e vestibular and lingual or palatal walls .
Three walls
Circumferential
Resective bone surgery is not indicated for very large bone defect s which are more effectively treated by regenerative or additive bone surgery (or a combination of both) .
ADDITIVE
Bone grafts Bone implants Guided tissu e regeneration (GTR)
REGENERATIVE
301
CHAPTER 7
Resective Bone Surgery

INDICATIONS Bone reshaping Elimination of small bone defects Creation of a physiological profile TECHNIQI IE Osteoplasty CONTRAINDICATION S Non e
Ostectomy
Degree 2-3 toot h mobility Bone reabsorption of >50% Degree 2-3 tooth mobilit y
Osteoplasty Ostectomy
OSTEOPLASTY
The term osteoplasty was introduced by Friedman in 1955 . The aim o f this technique is to reshape the bone to create a physiological form withou t removing the supporting bone (tissue connected to the tooth via periodonta l fibres) .
Surgical techniqu e
After elevating a full thickness flap, osteoplasty is performed using mediu m grain diamonds mounted on a turbine or micromotor . The operation site must be abundantly irrigated with cold (4-5C sterile salin e solution). Initially, the diamond is moved in a coronal-apical direction to reduce th e thickness of the bone . The surface is then finished with the same diamon d used with a brush-type movement in a mesial-distal direction . During the operation, great care must be taken to avoid touching the root surfaces with the rotating diamond.
Diamonds fo r osteoplasty .
Before the Osteoplast y
Bone reabsorptio n caused by periodonta l disease has modifie d the bone architecture . After elevating a full thickness flap, it wa s therefore decided to reshape the bon e architecture b y osteoplasty .
A fter Osteoplasty
After osteoplasty, th e bone margin is thinner and the ledge has bee n eliminated withou t removing the supporting bone .
303
CHAPTER 7
OSTECTOM Y
Ostectomy describes the surgical procedure employed to remove th e supporting bone tissue (bone connected to the tooth by means of periodonta l fibres). This technique is used to re-establish the physiological contour of bone tissu e altered by periodontal disease.
Before Ostectom y
The physiologica l architecture of the bon e has been completel y altered by bone reabsorption caused b y periodontal disease .
A fter Ostectomy
Ostectomy (removal of the supporting bone) has been performed . This operation has recreated the physiological architecture of the alveolar bone. The interproximal bone is now more tapere d and located more coronally to the radicular bone . This type of con tour is defined as `parabolic".
Qni,
RESECTIVE BONE SURGER Y
Ostectomy requires a number of specific instruments in addition t o the standard set for flap surgery :
a\ c'
No. 1 Ochsenbein chise l No. 2 Ochsenbein chisel:
designed for ostectomy in, respectively, the mandibular and maxillar y arches and to finish the parabolic bone profile . The curved side of th e chisel can also be used to shape the bone . with backwards hoe-like action . for finishing the osseous crest in the interdental spaces .
c' N
No. 36/37 Rhodes chisel :
a\
No. 1S/2S Sugarman file :
No . 1 Ochsenbein chise l No . 2 Ochsenbein chise l No . 36/37 Rhodes chisel
No. IS/2S Sugarman file
305
CHAPTER 7
Using Chisels
Bone chisels are used to remove vestibular and palatal support bone and to give the bone profile a parabolic (festooned) shape capable of supporting a similar gingival architecture .
Normal bone profile
The vestibular bone profile is paraboli c with a physiologica l architecture and interdental peak s positioned coronall y to the festoons.
Pathological bone profile
Following periodonta l disease, bone reabsoi p tion has taken place . The bone profile has been completely altered .
RESECTIVE BONE SURGER Y
To modify the bone profile, no . 1 and no. 2 Ochsenbein chisels and a no. 36/37 Rhodes chisel are used .
No . 1 Ochsenbein chisel
No. 2 Ochsenbein chisel
No. 36/37 Rhodes chisel
CHAPTER 7
Using files
Interdental files are used to remove small pieces of connective tissu e from the interradicular bone while at the same time filing the surface . The sides of the files are not sharp so as to avoid damaging the surface of the tooth during the operation .
No. 1 S/2S file
The sides of the fil e (Sugarman 1 S/2S) are flat to avoid damaging the root surface of the teeth during filing.
SURGICAL CORRECTION OF INTERPROXIMAL CRATER S

The guided tissue regeneration technique can be used to treat dee p interproximal craters . Ostectomy is, however, the preferred treatment for craters no deeper than 3- 4 mm, especially if located in a vestibular position . To remove the vestibular wall or the bone walls of the defect, first medium sized diamonds, then chisels and files are used as described previously .
Pre-operative Post-operative
Pre-operative 309
Post-operative
CHAPTER 7

Resective bone surgery uses both osteoplasty and ostectomy t o reshape the bone tissue . The aim is to obtain bone architecture with a physiological parabolic shap e with the interproximal septa positioned coronally to the festoons .
Phases of resective bone surgery

Step 1 : Preparation of vertical groove s Step 2: Preparation of festoons Step 3 : Margin definition Step 4 : Parabolization
Hunan maxilla : vestibular vie w Note the altered bone architecture .
FUNDAMENTAL RULES OF BONE SURGERY
o Always elevate full thickness flaps . o The scalloping of the flap should anticipate the anatomy of the underlyin g bone after surgery. Osteoplasty should always precede ostectomy. If possible, surgery should always finish with positive bone architecture . Micromotor or turbine mounted burs or diamonds must never come int o contact with the teeth and must always be used under an abundant spra y of cold water.
SURGICAL TECHNIQUE - VESTIBULAR, SECTION
Step 1 : Preparation of vertical grooves

After elevating a mucoperiosteal flap and exposing the bone surface, a rounded bur (no . 8) is used to cut vertical grooves in the interdental spaces , starting from the coronal part and extending apically . These grooves indicate the quantity of bone to be removed .
311
CHAPTER 7
Step 2: Preparation of festoons

Using the same bur with a horizontal brush movement, the grooves are joined together, reducing the thickness of the bone at the margins to obtain a physiological shape .
?1)
Step 3: Margin definitio n

Using a smaller diamond, a small grove is traced delicately near th e bone margin . This enables definition of the quantity of bone tissue to be removed with the chisels to obtain a parabola shaped crest .
Step 4 : Parabolizatio n
Bone chisels are used to obtain the definitive contour.
313
CHAPTER 7
The definitive architecture is festooned, thin and with interdental crests situate d more coronally to the vestibular bone profile .
SURGICAL TECHNIQUE - PALATAL SECTOR

Resective bone surgery can also be performed in the palatal sector . After elevating a mucoperiosteal flap and exposing the bone surface, the procedure proceeds as for the vestibular sector .
Human maxilla : palatal view Note the perfect bone architecture .
vertical grooves in the interdental spaces, starting from the coronal part an d extending apically. These grooves indicate the quantity of bone to be removed .
Step 1 : Preparation of vertical groove s A turbine or micromotor with a round diamond (no . 8) is used to cut
Vertical grooves hav e already been cut using a round diamond .
315
CHAPTER 7
Step 2: Preparation of festoons

Using the same diamond with a horizontal brush movement, th e grooves are joined together, reducing the thickness of the bone at the margins .
Step 3-4 : Margin definition Parabolizatio n

After defining the quantity of bone to be removed, bone chisels ar e used to obtain a parabolic contour as indicated for the vestibular sector .
The definitive architecture i s festooned and th e osseous crest i s positioned more coronally to the palatal profile .
.q 16
CLINICAL CAS E
Patient suffering from chronic adult periodontiti s Premolar and molar periodontal pockets are present in the rear maxillary sec tion with an average depth of 6-7 mm . The hygienic phase reduces the depth of the pockets (average 5-6 mm) . The surgical treatment involves elevation of a mucoperiosteal flap and reshap ing of the bone to eradicate the pockets and obtain an anatomy suitable fo r patient maintenance of a healthy periodontium .
Before bone surgery

An internal beve l incision has been performed, a full thickness flap has been elevated and th e secondary flap ha s been removed . The physiologica l bone contour has been altered by bon e reabsorption caused by the periodontitis . The alterations can be corrected b y resective bon e surgery .
317
CHAPTER 7
A fter bone surgery
Note the festooned profile of the bon e with the interdenta l sectors positione d more coronally to th e vestibular bone .
The vestibular an d palatal flaps will b e positioned so as t o cover the osseous cres t and sutured independently with continuous suspended suture.
Clinical case six months after th e operation. Note th e elegant architectur e of the gingival tis sues, perfectly adapt ed to the underlying bone structure .
Maintenance
This new architecture facilitates bacterial plaque control and thu s maintenance of a healthy periodontium . The patient will be included in a cycl e of regular follow-up appointments for professional prophylaxis .
CONCLUSION S Resective bone surgery is by definition destructive and does not in itself cur e periodontitis as this is an infectious disease . This type of surgery is performed exclusively in the case of minor alteration s in the bone architecture which, in association with periodontal pockets , facilitate the progression of periodontal disease .
319
Chapter 8
Resectiv e Gingival Surgery
321
RESECTIVE GINGIVAL SURGER Y
Increases in gingival volume may be caused by a range of factors an d can be divided into two forms : Gingival hyperplasia : abnormal multiplication or increase in the number of cells in the gingival tissue, leading to an increase in the volume of the gingiva . Gingival hypertrophy : an increase in the volume of the cells in the gingiva , leading to an increase in the volume of the gingiva . Gingival hypertrophy usually disappears if the etiological factor causing it i s treated . On the other hand, once present, gingival hyperplasia does not regress , even if the etiological agent is eliminated . Resective Gingival Surgery is used above all to treat gingival hyperplasia .
Gingival Enlargements
GENERALIZED LOCALIZED
*Hereditary Gingival Fibromatosi s Mucopolysaccharidosis Aspartylglycosaminuri a Donahue's Syndrom e Pfeiffer's Disease
Angiokeratoma Corporis Multiple Hamartoma Sturge Weber's Angiomatosi s
Acute Myeloid Leukemi a Preleukemia Aplastic Anemi a *Drug s

(Diphenylhydantoin, Cyclospori n Ca Channel Blockers)
*Fibroepithelial Epuli s *Giant Cell Tumour *Hormonal Epulis Sarcoidosis Multiple Myeloma Langerhans' Cell Tumour *Chronic Inflammatory Hyperplasia
*Diseases treatable by resective gingival surgery.
323
CHAPTER 8
CHRONIC
INFLAMMATORY
HYPERPLASIA
Bacterial plaque hyperplasia : the accumulation of bacterial plaqu e induces a chronic inflammatory condition which predisposes the patient liabl e to gingival fibrosis .
Open mouth breathing hyperplasia : during the night, adenoidal patients with labial incompetence breathe with their mouths open . The continued alternation of damp and dry conditions on the surface of the gingiva l mucosa induces an inflammatory condition which predisposes the patient t o gingival fibrosis .
HORMONAL HYPERPLASIA
During puberty or pregnancy, hormonal alterations may cause localized hyperplasia .
PREGNANCY EPULIS
325
CHAPTER 8
HEREDITARY FAMILIAR FIBROMATOSIS
HYPERPLASIA DURING DIABETES MELLITUS
In patients with juvenile diabetes there is often a hyperplastic gingiva l response resulting from suppression of the typical activity of the macrophage s which normally phagocyte the damaged collagen fibres .
()i
RESECTIVE GINGIVAL SURGERY
Collagen fibres of the gingival connective tissue .
In diabetics, the gingival connective tissue tends to increase due to the abnormal stability of the mature collagen, insensible to normal turnover . 327
CHAPTER 8
DIPHENY LHY DANTOIN HY PERPLASIA
A common type of gingival hyperplasia frequently occurs during the chroni c assumption of certain drugs such as diphenylhydantoin, cyclosporin etc .
PATHOGENIC HYPOTHESIS
Salivary Gland s
Gingival Connective Tissue
Serum
The diphenylhydantoin taken by epileptics passes from the plasm a serum to the salivary glands, building up in the bacterial plaque . It has been shown (Steinberg A .D. et al, J.Perio Res . 1976) that bacterial plaque diphenylhydantoin is reabsorbed through the sulcular epithelium and deposited in th e underlying connective tissues where it is added to the diphenylhydantoin o f hematic origin. 329
CHAPTER 8
SURGICAL JUSTIFICATIO N
In cases of gingival hyperplasia, surgery must be performed to eliminate the pseudopocket and re-establish a physiological contour.
Pocke t
Connective attachment loss with bon e reabsorption.
Pocket caused by gingival hyperplasia withou t connective attachment loss or bone reabsorption.
Pseudopocke t
The instruments used in Resective Gingival Surgery include:
Double-sided mirror :
for improved visibility. for measurements and probing .
CP12 graduated periodontal probe :
G'N Goldman-Fox right and left pocket marker: forceps to establish pseudopocket depth .
Straight round scalpel :
for excising the hyperplastic tissue . for incising the hyperplastic tissue. for removing pieces of tissue and root planing. for removing pieces of tissue .
No. 15/16 Kirkland scalpel: Universal curette :
H3 curved Cocker Mosquito : Surgical Forceps Columbia retractor:
to retract cheeks and lips .
Cook-Waite syringe for anaesthesi a LaGrange scissors :
to finish gingival tissue .
331
CHAPTER 8
SURGICAL TREATMENT
Step 1 : Measuring the pseudopocket s

The first surgical phase involves measuring the depth of th e pseudopockets to establish the amplitude of the surgical excision . A periodontal probe is used first to measure the pseudopocket and then t o reproduce the measurement externally with a bleeding point. Alternatively, this can be done using Goldman-Fox pocket marker forceps .
Minimum instruments necessar y for gingivectom y CP 12 Periodontal Prob e no. 7/8 Younger-Good Curett e LaGrange Scissors no. 15/16 Kirkland Scalpe l right and left Goldman-Fox Pocke t Marker Forceps
Goldman-Fox Pocket Marker Forceps .
333
CHAPTER 8
Step 2: Incisio n
The initial incision is made slightly on the apical side of the bleedin g points with a no . 15 Bard-Parker blade or a no. 15/16 Kirkland scalpel . The instrument should slope in an apical-coronal direction and the incision shoul d reach the bottom of the pseudopocket .
No. 15/16 Kirkland scalpel.
Step 3: Excisio n
After the hyperplastic tissues have been incised, they are remove d using a no . 1/2 Orban interproximal scalpel. The operation is completed with the help of a curette .
No . 5/6 Buck interproximal scalpel.

Qh,
Step 4: Gingivoplasty
The definitive gingival profile and shape are obtained using LaGrang e scissors. In some cases, a coarse grain turbine-mounted diamond may also b e used for gingivoplasty.
Step 5: Hemostasis
The raw gingival surface is covered with a strip of Surgicel' to control post-operative hemorrhage and then with a soft periodontal pack . The pack is left in situ for about a week .
Surgicel"
335
CHAPTER 8
Post-operative treatmen t
Once the periodontal pack has been removed, topical 0 .2% chlorhexidine treatment (gel) is continued for a week . At the same time, normal ora l hygiene procedures are gradually resumed . Drug-induced gingival hyperplasia tends to reoccur. Post-operative treatment therefore involves a rigid pro gramme of follow-up appointments (every three months) . During the professional prophylactic sessions, the following operations are performed : 1) Reinforcement of patient compliance . 2) Scaling and polishing . 3) Minor and localized gingivectomy (if necessary) . 4) Topical chemotherapy.
Post-operative image (after two months) . Note the excellen t aesthetic an d functional results .
Post-operative imag e (after two years) . The patient continues the diphenylhydantoin therapy. Note the moderate hyperplasia starting to re-form in correspondence with the interdental papillae, perhaps caused b y reduced plaque contro l by the patient.
,`.
Pre-operative imag e
Post-operative image (after two months) . 337
CHAPTER 8
CLINICAL CASE 1
Puberal Hormonal Hyperplasia
During puberty, hormonal alterations may induce localized gingival hyperplasia .
Localized gingival hyperplasia in a female patient aged 13 .
The first incision is performed with a Kirkland scalpel sloping in an apical-coronal direction (4 ,
After excising th e hyperplastic tissue , a gingivoplasty i s performed .
A small quantity of Avitene is applied as a hemostatic .

000
Post-operative image (after one month) .
Histologic examinatio n reveals an epithelial hyperyplasia in the fibrou s mass removed. The basal layer is normal.
339
CHAPTER 8
CLINICAL CASE 2
Diphenylhydantoin-induced hyperplasi a
Diphenylhydantoin-induced generalized gingival hyperplasia in an epileptic male patient aged 25, in an institution for many years . As a result of poor bacterial plaque control, the hyperplasia is associated with hypertroph y caused by local accumulation of fluids due to the inflammation present . Afte r completing the hygienic phase, gingivectomy was performed first in the maxillary arch and then in the mandibular arch .
eh,n
341
CHAPTER 8
A strip of Surgicel" was placed on the surgical wound to obtain hemostasis.
The variation in colour indicates successful hemostasis . The periodontal pack will be positioned on the strip of Surgicel"
Pre-operative image.
Post-operative imag e (after six months) .
CONCLUSION S Resective gingival surgery is the preferred treatment for gingival hyperplasia . However, these conditions have a specific etiology and therefore tend to relapse if the etiological agent is not eliminated. In order to maintain the result obtained, it is therefore necessary for thes e patients to adhere meticulously to a rigid programme of follow-up appointments .
343

Periodontology Bartolucci One

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Enrico G .

Chapter 1 0 MUCO -GINGIVAL SURGERY

The mechanis m of periodonta l destruction

THE MECHANISM OF PERIODONTAL DESTRUCTION

--------------------------Epithelial attachment 0 .97 mm Biologic width 2 .04 m i

HEALTHY GINGIVAL CONDITION (PRISTINE GINGIVA)

A healthy gingival condition (known as "pristine gingiva") is an ideal sit -

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

BACTERIAL COLONIZATION OF THE CREVICE

Anaerobic ! Subgingival - not adheren t

Gingival crevice : interior view.

! Intact tissue s ! Exudation ! Phagocytosis ! Immune respons e

! PMN defect s ! Hypersensitivity reactions ! Systemic disease s

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Impairment of the Sulcular Epitheliu m

Bacterial plaque enzyme s Hyaluronidase Collagenas e Proteas e Elastas e

Collecting crevicular fluid with blotting paper .

Crevicular leukocyte s ~--- Crevicular fluid

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Epithelial cells . Ground substance.

Destroy the mucopolysaccharides o f the ground substanc e

Polymorphonuclear Leukocytes (PMNs)

Polymorphonuclear leukocytes in th e non-migratory phase . 10

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Animal histologic preparation .

Epithelial attachment and connective attachment .

Polymorphonuclear leukocytes in diapedetic phase . 11

Phagocytosis of a bacterium by a polymorphonuclear leukocyte .

HISTOPATHOLOG Y A number of neutrophil s Slight infiltrat e

Considerable increas e in infiltrat e

Considerable increas e in infiltrat e (> 50% plasma cells)

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Grain- rod-shaped microbes

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Formation of Gingival Recession

Bacterial plaque recession

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Traumatic toothbrushing recessio n

MACROPHAGE {Activates the B-cell s Memory-cells- Killer-cells Mitogenic for T-cells .

marro w Memory cell s T-suppressors

*Killer cell s Spleen

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Homologous receptor s T! a few hundre d B! 50 .000 - 150 .000

In periodontitis, the majority of lymphocytes present are B lymphocytes .

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Phagocytosis of the connective tissue .

Connective fibre during digestion .

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

acrophage phagocyte s microorganism 2) Activation of the T-helper an d bonding with a macrophag e

THE LYMPHOKINE CASCADE

THE MECHANISM OF PERIODONTAL DESTRUCTION

The activated osteoclasts cause bone reabsorption .

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

B) Liberation of prostaglandins (PGE2)

Alternative pathway Bacterial plaque Bacterial endotoxi n Proteolytic enzyme s

Edema Chemotaxis Cell damage

Chronic adul t periodontitis .

Presence of periodontal pocket .

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Severe form of periodontitis.

THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Degranulation of th e mast cells .

Mast cell in degranulation phase.

Pathogenesis of periodontal disease

a! MI MI s -_ a1 a a 1 ." a mm ai, ma NMI -_ t, a " ~ ~ ~ ~ _ " . ~ M ai,a 11111 as ~-" a