You are on page 1of 334

Enrico G .

Bartolucci
first volume
RIOD O
Text - .das

by

'co Bart
CONTENTS Volume I

Chapter 1
THE MECHANISM OF PERIODONTAL DESTRUCTION page 1
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

Chapter 2
DIAGNOSIS page 3 9
Classification of Periodontal diseas e
Clinical examinatio n
Periodontal probing
Tooth mobilit y
Clinical chartin g
Radiographic analysi s
Diagnosis

Chapter 3
TREATMENT PLANNING page 9 3
Initial treatment planning
Reexaminatio n
Definitive treatment plannin g
Non surgical treatment
Surgical treatment
Maintenance therap y

Chapter 4
ORAL HYGIENE REHABILITATION page 11 1
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

VI
Chapter 5
PRINCIPLES OF PERIODONTAL SURGERY page 17 1
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 page 24 3
Indications and controindication s
Access flap
Modified Widman flap
Apically positioned flap
Palatal flap
Distal wedg e
Smoking and surgical therapy

Chapter 7
RESECTIVE OSSEOUS SURGERY page 29 5
Osseous defects
Osteoplasty
Ostectomy
Surgical instruments
Surgical technique s
Clinical case

Chapter 8
RESECTIVE GINGIVAL SURGERY page 32 1
Gingival hyperplasi a
Gingivectomy
Surgical instruments
Surgical technique s
Clinical cases

VII
CONTENTS Volume I I

Chapter 9
SURGERY OF FURCATION-INVOLVED TEETH page 345
Anatomy
Diagnosis
Radiographs
Classificatio n
Treatment of degree I
Treatment of degree II
Treatment of degree II I

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 page 46 9
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

Chapter 1 2
PREPROTESIC SURGERY page 535
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

VIII
Chapter 1 3
JUVENILE PERIODONTITIS page 61 1
Localized Juvenile Periodontitis
Generalized Juvenile Periodontiti s
Batteriology
Immune responce
Treatment
Clinical case s

Chapter 1 4
PERIODONTITIS AND JUVENILE DIABETES page 63 1
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

Chapter 1 5
DESQUAMATIVE CHRONIC GINGIVITIS page 653
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

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 inflam-
matory 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).

3
CHAPTER 1

HEALTHY GINGIVAL CONDITION (PRISTINE GINGIVA)

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


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 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, modi-
fying its qualitative
characteristics .

4
!

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 Supragingiva l
Anaerobic 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 Positive Response
!Intact tissue s
! Quantity of plaqu e !Exudation
! Quality of plaqu e !Phagocytosis
! Plaque retainin g ! Immune respons e
factor
! Bacterial product s 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 .

6
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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 junc-
tional 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 junc-
tional 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
28 35 Days can be observed .

8
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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.

9
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 epitheli-
um and the sulcus, pe'iforming their phagocytic function .

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 Phagocytosis of a bacterium by a


in diapedetic phase . polymorphonuclear leukocyte .

11
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

J . Y.CIIO
Marginal gingivitis
Note the plaque in the pericrevicular zone and the red and edematous gingival margin .

definition according to
PAGE and SCHROEDER 1976 HISTOPATHOLOG Y

Histologic perfectio n A number of neutrophil s

Normal healthy gingiva Initial lesion Slight infiltrat e


(Mon. Mac) : Lymph. Neutr )

Increase in infiltrat e
Early gingiviti s Early lesion (appearance of a number
of plasma cells)
Stable lesio n Considerable increas e
Stable gingivitis (without bone loss or apica l in infiltrat e
migration of the epithelium ) (10-30% plasma cells)
Stable lesio n Considerable increas e
Periodontitis (with bone loss and apica l in infiltrat e
migration of the epithelium) (> 50% plasma cells)
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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

PERIODONTITIS

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 .

. Viscosu s
H 30-40'% AA . Naeslundi
Grain- rod-shaped microbes
II Spirochete s
X PMN s
Plasma cells

J . Y.CIIO

14
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Traumatic toothbrushing recessio n

Brushing traumatically or with an unsuitable brush (too hard or


without rounded points) may cause surface abrasion of the gingival epithe-
lium. In a thin gingival morphotype, persistent trauma or the onset of inflam-
mation 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 lympho-
cytes) 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 lympho-
cytes 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 a marro w
Lymph nodes —..B lymphocytes
Memory *Killer cell s Spleen
cell s -0-B and T lymphocyte s
Thymus --!T lymphocytes
T-suppressors

T-helpers ONk
n /
IgA -v Secretor y
Ig D
- ~ Ig G
Ig M
Bursa equivalents I IgE.-Mast cells
PLASMA CELL

18
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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 func-
tions, 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 (gingivi-
tis) as the macrophages phagocyte the hydrolytic enzymes produced by th e
PMNs, reducing cell damage . They also phagocyte the altered cells of the con-
nective tissue .
Macrophages are also important in the advanced phase of the disease (peri -
odontitis) when they interact with the B lymphocytes, thus maintaining the lat-
ter in a strategic position to identify and neutralise large quantities of antigens .
However, they are above all important for the interaction with the lymphocyte T-
helper 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
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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 B) Transformatio n C) Blastogenesis


activation
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 B) Transformatio n C) Blastogenesis


activation

22
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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 T-
helpers 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


THE MECHANISM OF PERIODONTAL DESTRUCTION

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
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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 progres-
sion 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 hyper-
emia 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
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Vasodilatatio n
T Permeability

Degranulation of th e
mast cells .
A) Sensitization B) Antigen C) Degranulatio n
fixation
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 Destructio n
vascular system of gingival
collagen

Proliferation
of junctional
epithelium Formatio n
of granulation
tissue
THE MECHANISM OF PERIODONTAL DESTRUCTION

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 destruc-
bone tissue has been reabsorbed . tion of the attachment system and bone tissue .
THE MECHANISM OF PERIODONTAL DESTRUCTIO N

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 Early onset (EOP )


Pre-pubera l Chronic
Localized (LIP) Severe (SAP )
Generalized (JP) 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 JP EOP SAP REF


A. Actinomicetemcomitans • • • • •• •• •• •

P. Gingivalis • • •• • • • • •

P. Intermedi a

B. Forsythus • • •• • • • • •

Fusobacterium spp

Peptostreptococcus spp

Campylobacter rectus • • • • •

Spirochetes •• •• • • • • • • ••

(Loesche et al . 1985; Slots and Rams 1990; Van Steenberger 1991)

Bone reabsorption in chronic adult periodontitis .


THE MECHANISM OF PERIODONTAL DESTRUCTIO N

Gingival recession caused by bacterial plaque.

CONCLUSION S
To eradicate periodontal infection, the microorganisms causin g
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 .

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 conve-
nience the diseases are therefore divided into inflammatory and non-inflam-
matory conditions .

Classification of periodontal diseas e

Chronic gingiviti s
Allergic gingivitis
Gingival Eruptive gingiviti s
Herpetic gingivitis
Ulcerous-necrotic gingiviti s
INFLAMMATORY
CONDITIONS
Prepuberal periodontitis
Juvenile periodontitis
Early onset periodontitis
Periodontal
Chronic adult periodontiti s
Refractory periodontitis
Gingival recession due to plaqu e

Puberal gingiviti s
Pregnancy gingiviti s
Vitamin C deficit gingiviti s
Gingival Desquamative gingiviti s
Leukemia-associated gingivitis
NON-INFLAMMATORY Drug-related hyperplasia
CONDITIONS Hereditary hyperplasi a

Caused by occlusal traum a


Atrophy caused by lack of use
Periodontal
Gingival recession caused b y
toothbrushing

41
CHAPTER 2

EXAMINATION OF THE PATIENT

Medical and stomatologic histor y


To obtain a standardized assessment of the condition of organs o r
apparatus possibly involved in periodontal disease or influencing the defini-
tion of pharmaceutical or surgical treatment, a questionnaire is submitted t o
the patient .

Medical history

Have you ever had : YES N O Are you taking or have you YES N O What kind of toothbrus h YE S N O

taken drugs such as:

Hepatitis or liver problems Antibiotics


Prolonged bleeding Aspirin Do you use a water pick ?
Rh ('/1 ma tie fever Anticoagulant s Do your gums bleed ?
Heart murmur Cortisone Do you breath wit h
High/low pressure
Chest/shoulder pain ve drug s Do you grind you r
Glaucoma Have you ever suffere d teeth at night ?
Contact lenses adverse reactions to drugs ? Do you have bad breath ?
Kidney problem s Which ones ? Is your mouth painfu l
Diabetes when you wake ?
TB Do you suffer from allergies ? Othe r
Emphysema/asthm a To what ?
Ulcer
Cancer
Epileps y If you are female :
Venereal disease Are you pregnant ?
Anaemi a Are you taking contraceptives ?
Blisters in the mouth Are you taking other
Ulcers in the mouth hormonal drugs? _
Are you in the menopause ?
If yes, specify

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 gin-
giva 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 Stippling


The healthy gingiva is pink, the papillary con - Diagrammatic representation of the epitheliu m
tour is flat and the marginal contour is fes- (E) with the collagen fibres (C) and anchorag e
tooned . The gingival margin is located at th e fibrils (A) .
cemento-enamel junction . The latter give the epithelial surface of a health y
The interincisal papilla have a characteristi c gingiva a stippled appearance .
"stippled" appearance . If edema is present, the stippling disappears .
Probing identifies the presence of a gingival sul-
cus about 1 .5 mm deep .

Position of the gingiv a Toothbrushing abrasio n


In the case illustrated, the gingival margin is located apicall y A small toothbrushing abrasio n
to the cemento-enamel junction . can be observed on the gingiva l
This is probably caused by incorrect toothbrushing with a dam - margin vestibularly to the centra l
aging toothbrush . 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 support-
ing 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 inflamma-
tion 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 :
:1\2
of irritatative-masticatory origin . nI~ORi~0~6ipiiV i tZ N' •~j,4

Histologic examination after removal reveale d


increased keratinization of the epithelial tissue ,
while the other malpighian layers were normal . etit l
~. a ca J #

.1
ry,ryAgll»•

uJes,
,f v
41 ' i
. 1. ~ Se' ' •rA "
tey
.
i *ear
.•j. . . ; f .j•~\ ti

47
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 bacteri-
al 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 peri-
odontal lesion to be verified simply and immediately .
A periodontal probe can be used to reveal :

1. The depth of a periodontal pocke t


2. The depth of a pseudopocke t
3. The height of the keratinized gingiv a
4. The height of the attached gingiv a
5. The quantity of attachment loss
6. The depth and width of recession
7. The presence or absence of bleeding .

Periodontal prob e
University of Michigan .

Periodontal probing Periodontal prob e


The sulcus is about 3 mm deep. 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 penetra-
tion depth of the probe into the pocket .

POCKET
> 3 mm.

Periodontal pocke t The periodontal pocke t


Note the periodontal pocket (4 mm) and the tissu e is about 6 mm deep.
edema, indicated by the mark (fovea) left by th e
probe on the gingiva .

51
CHAPTER 2

A pathological condition is known to cause proliferation of the junc-


tional 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 epitheli-
um as far as the roo t
cementum .

Junctional epitheliu m Probing dept h


Diagrammatic representation of the structure of the junctional epitheliu m In the presence of
adhering to the surface of the enamel via hemidesmosomes . inflammation, the
In drawing 1, the yellow line corresponds to the basal lamina and denta l probe penetrates as far
cuticle . In drawing 2, note the cemento-enamel junction with a small are a as the first health y
of afibrillar cementum (A), the beginning of the root cementum (C), the fibres of the connective
dentine (D) and the enamel (E) . attachment apparatus .
DISEASE DIAGNOSIS

Force applied to the prob e


In 1967, Glavind and Loe demonstrated that application of a non-stan-
dardized 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 mea-
surements 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, TPS Probe Vivacare "


the probe should be held parallel to Calibrated pressure probe .
the long axis of the tooth .

Probe angle

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 accompa-
nying 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 suc-
cession 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 .

Maxillary arc h

: ,
2
1 air r r r r ~r s aj g

Yft
MI MI MU
Cs-r'.
.
a
MI•
10a.r 1111I
' !

/ BIM
7
! IM WI MIN
Vestibular

WI/ W = =
. i
w

12 '1 1 21 ®D
1q 13
t8 V 28
R 26 L

-
--,,- _ -! s==-
Lingual a p-/- -
~ -•i-- - -
MI !i - MI - MI MI " - -
MIll
Mll MI IM 111I 111tMItIM A NMI
i-• a . .r " • " • _ ', a • •
t r • r r • 111 • • . t r V VIM
krilimhihd

1 . f; in 66 .6} 6 . 9 ' . ID.I

2
3

Mandibular arc h

3
2
1 r ~6~6
mr
WI I s aI A a .
VI
. a •
sw
o!
MI U"a! MI MI s
ow
m a m m ma ma
-_ a1 a a 1
m ma ma
a a& II
m

--. _
Vestibular a ." a mm ai, ma NMI -_ a
M • ai,a
. MI AM t,
!rr N MI of ,a " ~ ~ ~ ~ _ " .
~
AM MIN as ~~~-"~~ a •11111

CIOO 00 .00
AmI
a s !!~i "~ i
Lingual i
A
" ia -
// a S !i
a a_
111I
a~ a s a-
w ~a IW
~ S
% a
% VW 1
II

L. AMM
asl.
A—
I aW - a! !i it al _
a "" a ~MM mm .-_
a, MIM a_
"_ a
a_ _ =
—a
nMIIIL
i
J

1 E 3'~6~~
:
6`6 ~6j6 ill 3~G M31ML'IE~LAG 6
2

1 = probing at 1st examination.


2 = probing at the end of the hygienic phase (reevaluation) .
3 = probing six months after the surgical phase .

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 iden-
tify the mucogingival
junction. The height of
the keratinized gingiv a
from the free gingival
margin to the mucogin-
gival 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 mea-
sure the height of th e
keratinized gingiva
and depth of the sulcus .
The latter is subtracted
from the former to cal-
culate the quantity of
attached gingiva .

59
CHAPTER 2

Measuring gingival recession


The term gingival recession describes the apical migration of the gin-
gival 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 peri-
odontal 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 Absent

Degree 1 Tooth mobility in a vestibular-lingual direction by up to 1 m m

Degree 2 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


Degree 3 and/or depressibility in the alveolus .

Classification criteria of dental mobility .


!

DISEASE DIAGNOSIS

Tooth mobility
Occlusion traum a
Ingravescent:
Presence of disease in progress Bone reabsorption caused by excessive occlusal
(Occlusion trauma) •
(Inflammatory) • accompanied by attachment loss .
(Glossary of Periodontic terms . American
Stabilized : Academy of Periodontology, 1986 )
Poor bone support .

Orthodontic trauma
Mono-directional forces exerted on individual teeth produce pres-
sure 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 reor-
ganized and the tooth becomes stable in its new position.

ressure zone Tension zon e


Tightened ligament . 0 Stretched ligament.
Thrombosis, hemorrhage, 0 Bone apposition.
collagen destruction . ©Dilated vessels .
Bone and cementum reabsorption . 0 Torn periodontal fibres .

67
CHAPTER 2

Jiggling trauma
The combined effect of pressure and tension forces in the periodon-
tal tissues causes thrombosis, hemorrhage, collagen destruction and reab-
sorption 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 demon-
strated 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 periodon-
tal 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 Junctional epitheliu m
more rapidly. in the migratory phase

Occlusio n
trauma-derived
bone lesio n

0
DISEASE DIAGNOSI S

CLINICAL CAS E

The clinical case illustrates a typical diagnostic and therefore thera-


peutic 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


All clinical and instrumental data and the patient's medical histor y
should be gathered together in a clinical record .

Maxillary arc h

3
2
1

Vestibular
• f t t • • • • I 1 / I I

13 12 11 21
1g 14
R f8 17 1'6• ® 23 24 25 26_ , 37- 2S

Lingual

1
2
3
Mandibular arch
3
2
1

Vestibular

Lingua l

1
2
3
##"!!!!
""

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
T
3
2
1 9B~ ~F6;L55?4S Sy'555'S"6l y 6545i~{4C1 i44 ~b ;Si

. - A i A
1101510twoo-ifraloia::.i .vOlOIE
yrwateavx
Vestibular
~ . ~r ~ live-war ~
wiry -
11 22 .
900 ® 23
R ®.m 9s

A A
.
Lingual 14' air
.- . s a*
.tqt!g

1 Jo1, b 4666 54s ' S1~55t5'545545 545,543 345! 55 b1~ Ia 5 5'


2
1 1
3 1. i

Mandibular arc h

3
-T
2
-- -

'a
----------
6 ,1. 7- 6 ` ~9~j66S_ 555 ;5455451565 5651565 b

! ^am
u ~7 .3s ~ ~ r~-ti
Vestibular

4Z11 Ma .4 'gm

®m
P t
47 46 43 33
R 42 41 31 32 L

Lingual
Uri-...i i,,,,A
*viol
A

air a
ayaj : pvk.-kWale &Ak"!i
tv‘t twit&
1 13 6 'bfifi 17*6 X666 1 45. 4'4553-seD 4s‘ cc .1,44c.
4 4 4
2
3 i 1 I i l I

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-dimen-


sional representation of three-dimensional structures . To reach a correct diag-
nosis, 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 posi-
tioned 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 Y I

••tVw H
1 1 1

X-ray equipment with


1 extension cone.

ad o

Seated patient protected


with lead apron an d
colla:
WW1
DISEASE DIAGNOSIS

Positioner for intraoral X-ray s

Rear right positioner with collimato r Collimator .


mrnwted on the target, . 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 Position between :
DF-56 no .1 1 - 2 right and left
(from the front) 3 - 4 right and left

Four X-ray films horizontally Position between : c


DF-58 no . 2 5 - 6 right and left
(from the rear) 7 - 8 right and left

Mandibular arch
Four X-ray films vertically Position between :
DF-56 no .1 1 - 2 right and left
(from the front) 3 - 4 right and left

Four X-ray films horizontally Position between


DF-58 no .2 5 - 6 right and left
(from the rear) 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 interin-
cisor 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 Diseased
The crestal and radicular laminae dura are The crestal laminae dura of the premolars are
intact. The trabeculae are in the norm . decalcified . Calculus can be observed on the roo t
surfaces.

81
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 Diseased
The crestal and radicular laminae dura ar e Note the deep distal bone reabsorption corre-
intact. The trabeculae are in the norm . sponding to the first molar and the intraosseou s
pocket identified by probing .
#
DISEASE DIAGNOSIS

X-RAY ANALYSIS OF THE MANDIBULAR ARCH

Front sector

G
I ,iI ..-_J
rrrt . _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 lami-
na dura has disap -
peared . An accumula-
tion of calculus can b e
observed on the roo t
surfaces.

8
CHAPTER 2

Lateral sector
In the premolar sector, the positioner bite should be inserte d O
between the two premolars, first on the right, then on the left .

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 Disease d
Calcification of the crestal laminae dura is Bone reabso'iption prevents identification of the
normal. crestal laminae dura. A large quantity of
calculus can be observed on the root su ifaces.

Normal Diseased
Calcification of the crestal laminae dura is Considerable bone reabsorption can be observe d
normal. 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 lam-
ina dura and the
cemento-enamel junc-
tion of the two neigh-
bouring teeth . In a nor-
mal situation, the cre-
stal lamina dura i s
always parallel to th e
line between the cemen-
to-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 SYMPTOM S

Inflammatory infiltrate Bleeding on probing


above the transseptal fibres No pocke t

Bone reabsorption limite d


Slight to the coronal third of the
root only

Bone reabsorption Bleeding on probin g


Periodontitis Severe extended beyond the Pocket
coronal third Possible tooth mobilit y

Bleeding on probin g
Angular bone reabsorptio n
Pocket
Complicated and 2nd or 3rd degree
Possible tooth mobility
furcation involuement
Furcation involvement

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 periodonti-
tis in an adult suffering
from diabetes mellitus
with tooth mobility, dam-
age 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

Hygienic treatment phas e


0 Treatment of carie s
0 Endodontic treatment
0 Extractions
0 Minor orthodontic s
#> Construction of temporary
prosthese s
REEVALUATIO N

Patient cooperatio n

40- o Periodontal surgery


0 Implant surgery

4
DEFINITIVE
o Peri-implant surgery
TREATMENT
0 Construction of definitive
prosthese s

PERIODI C
FOLLOW-UP
APPOINTMENTS

Supportive therapy
TREATMENT PLANNIN G

Initial treatmen t
The aim of initial treatment is to eliminate, or at least control, bacteri-
al 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
A 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 Provides access to roots and bon e


defects
Apical flap Increase in gingival recessio n
Reduces or eliminates the pocket
Bone resective surgery
Facilitates plaque contro l Long term success not guarantee d
Gingivectomy without maintenanc e
Facilitates restorative and cosmetic
Root resection surgery dentistry

Mucogingival surgery
Improves aesthetic s
Free grafts Clinical variability
Reconstructs gingival defects
Pedicle graft s Results linked to surgical techniqu e
Reduces root, sensitivity
Pedicle grafts + GT R

Significant increase i n
GT R attachment level s
Non-reabsorbable membran e The best results are obtained with Results linked to surgical techniqu e
Reabsorbable membrane Class II mandibular furcations an d
intraosseous defects

Autologous bone
Increase in bone level

The osteogenetic capacity of demin e


alized bone grafts is variabl e

Alloplastic bone (synthetic) Synthetic grafts act as fillers withou t


Increase in bone level 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 Gingiviti s


Non e
i scaling and root planing Periodontiti s

Chemical treatment
of bacterial plaqu e
No long term benefits
Mouth washes Gingivitis
in periodontitis
Gel
Irrigation

Allergy
Topical antibiotics
Periodontitis Recessions
Tetracycline impregnated fibres
Candid a

Systemic antibiotic s
Tetracyclin e
Metronidazol e Aggressive destructive Gingiviti s
Amoxicilli n
Clavulanic aci d periodontitis Adult periodontitis
Clindamycin
Spiramycin

(Modified from World Workshop in Periodontics 1996 )

Manual scaling . Mechanical scaling .

105
!

CHAPTER 3

CLINICAL CASE

Male patient aged 48 fitted with two cardiac by-passes. The periodon-
tal examination led to a diagnosis of chronic periodontitis . The clinical file
reproduced below indicates tooth mobility, pocket depth and furcatio n
involvement.
Maxillary arc h

9 i. — 6- '_6 t551 ciiLt5 555 65. y 65-54S14r44 X45637-,25i g51


s
!!k Vestibular

. IIMII'IHI V INV
R
Lingual

lo?.c1 16661 54ss45501545 54s_ .54Yi543 !34Si `5'S? 6Hq9~ ~~! 1

1! i! i! I I! ! 2
3
Mandibular arc h

45C 67i-. T*6 466 65665555686 ~S6C5~ f6671666

Medical alert: aorta-coronary by-pas s

Diagnosis : complicated chronic periodontitis


i
#

TREATMENT PLANNIN G

TREATMENT PLAN

1 gross-scaling sessio n
HYGIENIC PHASE 4 scaling and root planing session s

8 78
ex
8 8

6 6
end o
76 7

temp . prosth .
76 . 4 5 . 7

REEVALUATION

1
SURGERY

APF+B .S. MWF APF+B.S .+R S

APF+B .S.
APF APF+B.S .+GTR
+hemisections

4 6
def . prosth .
76 . 4 5 . 7

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 main-
tain 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 re-
motivated 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 main-
tenance 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 tech-
nique .
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.
ORAL HYGIENE REHABILITATIO N

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 .
ORAL HYGIENE REHABILITATIO N

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 differen-
tiate between newly formed and less recently formed plaque .
Dyes containing fluorescein can be used to make the plaque visible in ultravi-
olet 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
ORAL HYGIENE REHABILITATIO N

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 bac-
terial plaque are fluorescent .

Flake Lite r equipment.


ORAL HYGIENE REHABILITATIO N

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 .

w
ORAL HYGIENE REHABILITATIO N

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 .
ORAL HYGIENE REHABILITATIO N

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 com-
pletely 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 pap-
illary recession . Use of a conica l
proxa-brush is therefore recom-
mended .

Its shape makes the conical proxa-brush ideal for removin g


bacterial plaque from the interproximal spaces of a prostheti c
reconstruction .
ORAL HYGIENE REHABILITATIO N

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 pene-


trate the upper front interdental spaces of a temporary prosthe-
sis 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 tooth-
paste 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* Dental enamel


25 RDA* Necks and roots

"Radioactive Dentine Abrasion .


ORAL HYGIENE REHABILITATIO N

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 demon-
strated 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 con-
trol 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 .
ORAL HYGIENE REHABILITATIO N

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
ORAL HYGIENE REHABILITATIO N

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 effi-
ciency.
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 instru-
ment 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 superiori-
ty of manual instruments over mechanical instruments . Although the latter
produce a rougher root surface, they enable the junctional epithelium to re-
adapt 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 .
ORAL HYGIENE REHABILITATIO N

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.
ORAL HYGIENE REHABILITATIO N

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 move-
ment repeated across the entire supragingival surface of the tooth until all vis-
ible 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
ORAL HYGIENE REHABILITATIO N

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 con-
cretions, 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 /,
ORAL HYGIENE REHABILITATIO N

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.
ORAL HYGIENE REHABILITATIO N

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 instru-
ments (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
ORAL HYGIENE REHABILITATIO N

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 apical-
coronal 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 pro-
duces 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 .
ORAL HYGIENE REHABILITATIO N

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 remov-
ing 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 prefer-
able.
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 chlorhexi-
dine 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
ORAL HYGIENE REHABILITATIO N

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 gin-


givitis 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 solu-


tion (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, refrac-
tory 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 Local
Mechanical Chemical
antibiotic antibioti c
treatment treatment
treatment treatmen t

Adul t
periodontiti s
- Advanced
- Progressive

Amoxycil .+Clay. Ac .
Yes Yes Clindamycin Ye s
Ciprofloxaci n

Metronidazole
Yes Metronidazole+Amoxycil . Ye s
Amoxycil.+Clay. Ac .

C
ORAL HYGIENE REHABILITATIO N

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 main-
tain 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 .
ORAL HYGIENE REHABILITATIO N

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 - Gingivitis

Female patient aged 15 .

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 .
ORAL HYGIENE REHABILITATIO N

CLINICAL CASE 2 - Slight periodontiti s

Male patient aged 50 .


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 - Moderately severe periodontiti s

Female patient aged 45 .

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 .
ORAL HYGIENE REHABILITATIO N

CLINICAL CASE 4 - Periodontitis with complications

Male patient aged 55 .

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 plan-
ing 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 Supragingival curett e


Deppeler M23A-Tl Deppeler M23-Tl

Sharpening oi l
(Sharpen EZ 1z -Hu Friedy)
ORAL HYGIENE REHABILITATIO N

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
ORAL HYGIENE REHABILITATIO N

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 132°C.

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 .
ORAL HYGIENE REHABILITATIO N

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 sim-
ply follow maintenance treatment .

Patient cooperation
L

NO YES

REGULAR FOLLOW-UP Maintenance pat h


APPOINTMENTS 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 .
Contraindications
Absence of patient cooperatio n
General medical reasons .

Periodontal Surger y

Gingivectomy

Pedicle Graft s Apically


Positioned Coronall y
Laterally

Free Graft s

Resective Surgery

Bone Bone grafts Autologous


Homologou s
Surgery Additive Surgery
Bone implants Alloplastic

Regenerative Surgery GTR

173
CHAPTER 5

SURGICAL TREATMENT

PATIENT SELECTIO N

FACTOR S

LOCAL BEHAVIOURAL I SYSTEMI C

Oral access Compliance


Chronic desquamative gingivitis Smokin g
Plaque contro l

I CONTROLLABL I
E I
YES NO

SURGICA L MAINTENANCE
TREATMEN T

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.
PRINCIPLES OF PERIODONTAL SURGER Y

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 ANAESTHESIA

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 .
PRINCIPLES OF PERIODONTAL SURGER Y

Disposable needles of
various lengths an d
diameters .

Carpule of anaesthetic .
To reduce local bleedin g
to a minimum, th e on ADRENALIN A
anaesthetic is combine d FORTE 1 :100 .00 0
with epinephrin e
(1 :100,000 or 1 :50,000) .

179
CHAPTER 5

Sensory distribution zone s


Maxillary arc h

Anterior superior
alveolar nerve

Posterior superio r
alveolar nerve

To administer anaesthesi a
in the maxillary
Palatine nerve arch, the patient must
be in a prone positio n
with the head in
hyperextension .
PRINCIPLES OF PERIODONTAL SURGER Y

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 lin-
gual 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 anaes-
thesia 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 mil-
lilitres 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


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

Anaesthesia of the incisive nerve


To anaesthetise
the incisor region, a nee-
dle is inserted in th e
extreme surface of the
mucosa, injecting sever -
al millilitres of anaes-
thetic 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 .

Infiltration anaesthesi a
of the incisive nerve .

1Q1
!

PRINCIPLES OF PERIODONTAL SURGER Y

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 fora-
men (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 anasto-
sive nerves. mose.
CHAPTER 5

Anaesthesia of the posterior superio r


alveolar nerv e
To block this nerve, the needle is inserted vestibularly in the mucos a
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 blockin g
the posterior superio r
alveolar nerve .

Note the depressio n


on the bone corre-
sponding to the path
of the posterior
superior alveolar
nerve.
PRINCIPLES OF PERIODONTAL SURGER Y

Anestesia al forame sottorbitari o

Anaesthesia o f
the suborbital forame n
Permeation of the anaes-
thesia through the bone
makes blocking of th e
suborbital forame n
superfluous. It is there-
fore sufficient to inject
1/2 ml of anaestheti c
solution into the zon e
below the foramen at a
distance of a few cen-
timetres. 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 opera-
tions in the sector
between the right an d
left canines, the regional
block must be complete d
by also injecting anaes-
thetic 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.
PRINCIPLES OF PERIODONTAL SURGER Y

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 intra-
vessel 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
PRINCIPLES OF PERIODONTAL SURGER Y

Internal bevel incisio n


The internal bevel incision is performed with a surgical blade (Bard-
Parker" no.15) on, or 1-2 mm apically to, the free gingival margin . If there is lit-
tle 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 inci-
sion 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)
PRINCIPLES OF PERIODONTAL SURGER Y

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 aesthet-
ic 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.
PRINCIPLES OF PERIODONTAL SURGER Y

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 inci-
sion 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.
PRINCIPLES OF PERIODONTAL SURGER Y

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 inci-
sion.

1QQ
PRINCIPLES OF PERIODONTAL SURGER Y

To position a GTR membrane in

IF 4
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 .

Note the optimum


access to a bone defect
obtained with tw o
realising incision s
(mesial and distal) i n
the zone concerned.

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 inci-


sion is performed on both sides of the col .
onn
PRINCIPLES OF PERIODONTAL SURGERY

FLAPS

Pedicle flap
Deli n i tion: section of gingival tissue separated from the surroundin g
tissues except for at the base .

Free graft
Definition: section of gingival tissue completely separated from the
surrounding tissues .

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 .
PRINCIPLES OF PERIODONTAL SURGERY

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
Consist of epithelium and all th e
connective tissu e
connective tissu e
Protect the bone tissu e
Maintain the vascular apparatus intac t
Cause damage to the vascular apparatu s
Cannot be sutured to the periosteum
Can be sutured to the periosteum

203
CHAPTER 5

Lifting the flap


A 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 .
!

PRINCIPLES OF PERIODONTAL SURGERY

No . 3 Pritchard's In the case illustrated, an exostosis must be removed . An internal bevel


periosteal elevator. festooned incision is performed and a full thickness flap is elevate d
using a no . 3 Pritchard's periosteal elevator.

Pritchard's periosteal In the case illustrated, osteoplasty and ostectomy were performed t o
elevator 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 con-
ceived 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~
PRINCIPLES OF PERIODONTAL SURGER Y

The wide end of the instru-


ment 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 pass-
ing 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
PRINCIPLES OF PERIODONTAL SURGER Y

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 Root planing with curettes .


curette.

Titan°: hyposonic The granulation tissue of intraosseous defects is easily and rapidl y
instrument. 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 .
PRINCIPLES OF PERIODONTAL SURGER Y

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 LATERALLY
POSITIONE D POSITIONE D
FLAP 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
PRINCIPLES OF PERIODONTAL SURGERY

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 GAUGE NEEDLE

Silk 3.0 - 4 .0 FS2 v


Non- Dacron 5.0 V5 •
absorbable and PTFE (Gore-Tex") 5.0 RTI6 V
Ethibond® (Exel) 5.0 DA1 •

Simple catgut 4.0 - 5.0 FS2v - P2 V


Chromic catgut 4.0 FS2 V
Absorbable Polyglycolic acid (Dexon') 4.0 - 5.0 - 6.0 T5• - PRE2V - CE2 v
Polyglactin (Vicryl®) 4.0 FS2 v
Poliglecaprone (Monocryl®) 5.0 - 6.0 DA10- P3v

• TAPERCUT NEEDLES v REVERSE CUTTING NEEDLE S


"!

PRINCIPLES OF PERIODONTAL SURGERY

TEAR LEFT
4-0 (2 .0 metric) / 7771
/ 2'0 f
® PLAIN GUT 46

18° (45 cm) CUTTING - N


F
IH
Sterile, Absorbable N
Surgical Suture, U .S .P„ Type A C
Do Not ResterRize

po
683 u ~! ~$#
r 41i
ir
IX..
!..3CERf.?t
Easy Access
rt,
t~E
c3a 6T l e
Clfbcl(

a. rile ago 'S-2

Suture in black silk and simple catgut . FS2 needles .

Types of suture
Various types of suture are used in periodontal surgery .

Circular
Figure-of-eigh t
Interrupted Mattress (ver°tical - horizontal)
Sling

Suspended (one flap - two flaps)

Continuous Spiral
Blocked

Compression

21 5
CHAPTER 5

Instruments
In periodontal flap surgery, 15 cm long Crile-Wood forceps are com-
monly used . Accessibility with this needle holder is excellent, even in the pos-
terior-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 differ-
ent 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.
!"!

PRINCIPLES OF PERIODONTAL SURGER Y

.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 SUTURA CM . 45 ZACERAR6


Easy Access

CATGUT NON CROMICO


6.
V
c
VaL
sterile

t Reg. 199@9
ago P- 2
I

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 .
PRINCIPLES OF PERIODONTAL SURGER Y

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 .
PRINCIPLES OF PERIODONTAL SURGER Y

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
PRINCIPLES OF PERIODONTAL SURGERY

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
PRINCIPLES OF PERIODONTAL SURGER Y

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.

225
titi<
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.
PRINCIPLES OF PERIODONTAL SURGER Y

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 The sling (simple suspended) suture has bee n
(Dacron - Ethibond®) held under tensio n knotted . Note the knot positioned on the mesia l
to position the flap at the cemento-enamel papilla of the flap. Three sutures in 5-0 simpl e
junction. 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
PRINCIPLES OF PERIODONTAL SURGER Y

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
PRINCIPLES OF PERIODONTAL SURGERY

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 .
PRINCIPLES OF PERIODONTAL SURGER Y

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 fib-
rin 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 .

233
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 ele-
vation. 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 bacte-
riostatic 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 .
PRINCIPLES OF PERIODONTAL SURGERY

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 initi-
ated 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 peri-
odontitis 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 oper-
ated area with a chlorhexidine based gel (0.2%) twice a
day for a week .
PRINCIPLES OF PERIODONTAL SURGER Y

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 oper-
ation. Brush the hemiarch and/or arch not
affected by the operation .
DIET During the first two days, only soft food should
be eaten . Avoid hot food. For ten days, avoi d
chewing on the part operated.
SUTURES Will be removed 7-10 days after the operation .
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 .

237
CHAPTER 5

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 Saliva - secretion s Hours 1 - 14 days


Herpes Zoste r Saliva - vesicle s Hours 2 - 3 weeks
Herpes Simplex 1- 2 Saliva - vesicles Minute s 2 weeks
Parotitis viru s Saliva - secretion s Hours 12 - 26 days
Hepatitis A viru s Saliva - blood - faece s Month s 15 - 40 day s
Hepatitis B virus Saliva - bloo d Month s 1 .5 - 4 month s
Hepatitis C virus Saliva - bloo d Month s 4 - ? month s
M. tuberculosi s Saliva - expectorat e Days - weeks 6 month s
Staph. Aureu s Saliva - skin - exudat e Days 4 - 10 day s
Pyogenic Staph . Saliva - secretion s Hours - day s 1 - 3 day s
Pneum . mycoplasma Saliva - secretion s Seconds - minutes 2 - 3 weeks
Treponema Pallid . Contact with the lesio n Second s 1 .5- 10 week s
HIV virus Blood - sperm - vag . secy. Hours Years
!

PRINCIPLES OF PERIODONTAL SURGERY

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 .

0 0
1 Z 3 4 s 10 15 s 10 7s 20

Minute s Minute s

- - • — B. Stearothermophilus — • - - - B. Stearothermophilus
B. Sottilis B. Sottilis

Saturated steam sterilization . Dry heat sterilization .


Bacillus Stearothermophilus spores are used i n Bacillus Sottilis spores are used in the dry oven .
the autoclave. They die in 15 minutes at 120 °C . They die in 30 minutes at 160°C .

Bacterial spores.

239
CHAPTER 5

Sterilization
cycle

Sterile instruments
before surgery
"

PRINCIPLES OF PERIODONTAL SURGER Y

L
1 L.' -

es
Monitoring with spor

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 charac-
teristics and indications : access flap, modified Widman flap, apically posi-
tioned 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 I

NECESSITY
FOR ACCESS
TO THE BONE Not necessary Necessary

HYGIENIC PHASE I GINGIVECTOMY FLAP

245
!
CHAPTER 6

L. SURGICAL RATIONALE

In cases of periodontitis in which periodontal pockets > 4 - 5 mm per-


sist 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 inflam-
mation. 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
PERIODONTAL FLAP SURGER Y

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.

247
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 .

mwmmfwtmmwwmr-
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 sur-
faces to bacterial plaque . Scaling and root planing alone are not sufficient to
completely remove the bacterial load . The root surfaces are therefore chemi-
cally treated with pH 1 citric acid for one minute, followed by immediate irri-
gation 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.

249
CHAPTER 6

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.
PERIODONTAL FLAP SURGER Y

f
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 inter-
rupted 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) .

251
!!

CHAPTER 6

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 Modified flap

Initial incision perpendicular to the 1. Initial incision parallel to the lon g


long axis of the tooth . axis of the tooth .
The flap is complete reflected beyon d 2. The flap is minimall y
the mucogingival junction . reflected .
The epithelial-connective collar i s .i . The epithelial-connective collar i s
removed with a scaler . removed by means of three incisions .
Interproximal, adaptation of the flap s 4. Perfect interproximal adaptation of
is not important . 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) 4..0s,400001' 00*0000'''

M23 Deppeler curette


2/4 Molt periosteal elevato r
Interproximal scalpel (1/2 Orban) .
PERIODONTAL FLAP SURGERY

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 .

253
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 con-


cluded by irrigating the
site with sterile physio-
logical solution and the n
aspirating the irrigatio n
liquid, together with any
pieces of granulation tis -
sue, specks of calculu s
and bacterial plaque .
PERIODONTAL FLAP SURGERY

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 crevic-
ular 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 mod-
ified 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 Ochsenbein chisel (no . 1-2) i n


Note the altered bone profile . ostectomy .

After bone surgery.

259
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, n
PERIODONTAL FLAP SURGERY

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.
PERIODONTAL FLAP SURGERY

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 : Interproximal incision :


a mucoperiosteal flap is delicatel y the second and third incisions hav e
elevated without going beyond th e already been performed. The operatio n
mucogingival junction. continues with the interproximal incisio n
(1/2 Orban scalpel) to remove the col .

263
CHAPTER 6

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 .
F /,
PERIODONTAL FLAP SURGERY

Suture :
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 .

Clinical case courtesy of :


Dr. llilton Israelson
Dallas, Texas - USA .

265
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.
Contraindications :
Aesthetic - after the operation, there is always clinical crow n
lengthening .
PERIODONTAL FLAP SURGERY

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 .

267
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 .
PERIODONTAL FLAP SURGERY

Step 2
Elevating the flap
Once the secondary flap and col
have been removed, a mucope-
riosteal flap is elevated beyond th e
mucogingival junction to expose
the osseous crest and any bon e
defects present . If necessary, resec-
tive 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 .

269
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:
PERIODONTAL FLAP SURGERY

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 .


271
CHAPTER 6

CLINICAL CASE 2

Female patient aged 55 with mod-


erately 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.
PERIODONTAL FLAP SURGERY

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.

273
CHAPTER 6

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
PERIODONTAL FLAP SURGERY

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 tempo-
rary 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 .

275
CHAPTER 6

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 con-
sists 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.
PERIODONTAL FLAP SURGERY

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 PRE-OPERATIVE IMAGE S
positioned flaps an d
resective bone surgery ,
the clinical crowns are
lengthened and prosthe -
sis retention is thus
improved.

277
CHAPTER 6

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 .

9 '7Q
PERIODONTAL FLAP SURGERY

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 .

279
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 .
PERIODONTAL FLAP SURGER Y

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 .

281
CHAPTER 6

CLINICAL CASE 3
Female patient aged 35 with amelogensis imperfecta . The crown enam-
el is completely destroyed and the clinical crowns must therefore be length-
ened 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 .
PERIODONTAL FLAP SURGERY

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 .

283
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 gin-
givectomy.
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.
PERIODONTAL FLAP SURGERY

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.

285
CHAPTER 6

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 interproxi-
mal 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)
PERIODONTAL FLAP SURGERY

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 .

287
CHAPTER 6

II) PARALLEL INCISION S

Pre-operative image.

Two parallel incisions are made in the keratinized retromolar gingiva ter-
minating 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 gin-
gival margin . This depends on whether epithelium needs to be remove d
from within the periodontal pocket .
PERIODONTAL FLAP SURGERY

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 inter-
rupted 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 .
PERIODONTAL FLAP SURGERY

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 inter-
rupted 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
PERIODONTAL FLAP SURGERY

Healing of the operation site

Modified Widman flap


A) Curettage is performed on the bone which is then covered with the flap .
B) 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 .
C) During tissue maturation (6-12 months), moderate apical migration of th e
gingival margin occurs .

Apically positioned flap


A) Bone reshaping is performed and the flap is positioned at the crest.
B) The bone continues to be reabsorbed and there is attachment loss .
C) 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 reab-
sorption 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 .
RESECTIVE BONE SURGERY

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 usual-
ly 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
RESECTIVE BONE SURGERY

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) .

Bone grafts
ADDITIVE
Bone implants

Guided tissu e
REGENERATIVE
regeneration (GTR)

301
CHAPTER 7

Resective Bone Surgery

INDICATIONS TECHNIQI IE CONTRAINDICATION S

Bone
Osteoplasty Non e
reshaping

Elimination of small Degree 2-3 toot h


Ostectomy
bone defects mobility

Creation of a Osteoplasty Bone reabsorption of >50%


physiological profile Ostectomy Degree 2-3 tooth mobilit y

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 (4-5°C 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 sur-
faces with the rotating diamond.

Diamonds fo r
osteoplasty .
RESECTIVE BONE SURGERY

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 physiolog-
ical architecture of the
alveolar bone.
The interproximal bone
is now more tapere d
and located more coro-
nally to the radicular
bone . This type of con -
tour is defined as `par-
abolic".

Qni,
RESECTIVE BONE SURGER Y

Surgical instruments
Ostectomy requires a number of specific instruments in addition t o
the standard set for flap surgery :
a\ No. 1 Ochsenbein chise l
c' 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 .
c 'N No. 36/37 Rhodes chisel :
with backwards hoe-like action .
a\ No. 1S/2S Sugarman file :
for finishing the osseous crest in the interdental spaces .

No . 1 Ochsenbein chise l
No . 2 Ochsenbein chise l No. IS/2S Sugarman file
No . 36/37 Rhodes chisel

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 support-
ing 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.
!

RESECTIVE BONE SURGERY

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 Post-operative

309
CHAPTER 7

RESECTIVE BONE SURGERY

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.
RESECTIVE BONE SURGERY

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)
RESECTIVE BONE SURGERY

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 .
RESECTIVE BONE SURGERY

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 pro-
cedure proceeds as for the vestibular sector .

Human maxilla :
palatal view
Note the perfect bone
architecture .

Step 1 : Preparation of vertical groove s


A turbine or micromotor with a round diamond (no . 8) is used to cut
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 .

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
RESECTIVE BONE SURGERY

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 indepen-
dently with continuous
suspended suture.
RESECTIVE BONE SURGERY

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 Angiokeratoma Corporis
Aspartylglycosaminuri a Multiple Hamartoma
Donahue's Syndrom e Sturge Weber's Angiomatosi s
Pfeiffer's Disease

*Fibroepithelial Epuli s
Acute Myeloid Leukemi a *Giant Cell Tumour
Preleukemia *Hormonal Epulis
Aplastic Anemi a Sarcoidosis
*Drug s Multiple Myeloma
(Diphenylhydantoin, Cyclospori n
Ca Channel Blockers)
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 con-
tinued 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 .
RESECTIVE GINGIVAL SURGER Y

HORMONAL HYPERPLASIA

During puberty or pregnancy, hormonal alterations may cause local-


ized 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 .
RESECTIVE GINGIVAL SURGERY

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 diphenyl-
hydantoin 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 elimi-


nate the pseudopocket and re-establish a physiological contour.

Pocke t
Connective attachment loss with bon e
reabsorption.

Pseudopocke t
Pocket caused by gingival hyperplasia withou t
connective attachment loss or bone reabsorption.
RESECTIVE GINGIVAL SURGER Y

Surgical instruments
The instruments used in Resective Gingival Surgery include:
Double-sided mirror :
for improved visibility.
CP12 graduated periodontal probe :
for measurements and probing .
G'N Goldman-Fox right and left pocket marker:
forceps to establish pseudopocket depth .
Straight round scalpel :
for excising the hyperplastic tissue .
No. 15/16 Kirkland scalpel:
for incising the hyperplastic tissue.
Universal curette :
for removing pieces of tissue and root planing.
H3 curved Cocker Mosquito :
for removing pieces of tissue .
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 .
RESECTIVE GINGIVAL SURGERY

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,
RESECTIVE GINGIVAL SURGER Y

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% chlorhexi-
dine 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 profes-
sional 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 mod-
erate hyperplasia start-
ing to re-form in corre-
spondence with the
interdental papillae,
perhaps caused b y
reduced plaque contro l
by the patient.

,`.
RESECTIVE GINGIVAL SURGERY

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 The first incision is performed with a Kirkland
patient aged 13 . 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
RESECTIVE GINGIVAL SURGERY

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 max-
illary arch and then in the mandibular arch .

eh,n
RESECTIVE GINGIVAL SURGER Y

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"
RESECTIVE GINGIVAL SURGERY

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