OUTLINES OF PERIODONTAL THERAPY

AHMED Y. GAMAL. PROF. OF PERIODONTOLOGY .

2011
The main rational of periodontal therapy is that it interrupts a sequence of events that leads to final loss of teeth, which can disrupt and destroy complete dentition (scaling and root planing, conservative non surgical approach), in addition to the reconstruction of the periodontal tissues that has been previously destroyed by periodontal disease (advanced surgical approaches). Periodontal reconstruction or regeneration is defined as restoration of the lost supporting tissues including new alveolar bone, new cementum, and a new periodontal ligament.

To get predictable amount of regeneration we have to:

1. Control infection: through the removal of local irritants by either closed or opened debridement, chemical adjunctive therapy either systemically or locally at a site, and oral self care. 2. Control apical migration of epithelial attachment: by the use of guided tissue materials with or without bone fillers. 3. Maximum recruitment of the periodontal tissues, namely PDL and bone cells to repopulate the destroyed periodontal tissues by the use of biologic enhance modifiers. 4. And finally to render the root surface more biocompatible for PDL and bone cell colonization. Steps of periodontal Treatment: All forms of gingivitis or periodontitis almost follows a similar general periodontal coarse:

Following periodontal examination and determination of the case diagnoses and prognoses the patient will pass into the following phases:

1- Initial therapy (Phase 1) 1. Oral hygiene instruction (Patient motivation) for either mechanical or chemical plaque control. 2. Supra-gingival plaque removal, together with the removal of eitrogenic (poor restorations, fillings, ortho. wires) or naturally occurring (ledges, craters.) plaque retentive areas.

1 - Initial therapy (Phase 2)

Sub-gingival plaque and calculus removal (scaling, root planing and sub-gingival curettage).

2- Re-evaluation: To get definitive prognoses and definitive treatment plane, whether we will consider scaling and root planing are final treatment or the case needs further periodontal procedures. 3- surgical therapy (corrective phase). In deep inaccessible areas or if reevaluation following initial, non surgical therapy indicates that inflammation and infection are not resolved, and disease progression has occurred, a clinician decision must be made regarding the reasons of non response, and the need for further therapy including surgery. 4- Maintenance therapy (recall visits)

Check for pocket activity. If there is no pocket activity, the patient needs to be re-motivated. If there is pocket activity, plaque and calculus removal and treatment of a recurrent disease should be done.

* Non-surgical approach: Is defined as Plaque removal, plaque control, Supra- and sub- gingival scaling, root planing, and the adjunctive use of chemical agents. Scaling, root planing and sub-gingival curettage: Scaling: refer to the removal of calculus, bacteria and their products from the crown and root surfaces or lying free in the pocket. Root planing: refer to the removal of calculus, bacteria and their products, and contaminated cementum and dentine from the root surface, rendering the root surface more biocompatible for periodontal ligament fibroblasts adhesion, and smooth enough to prevent plaque retention and subsequent re-infection (A. Gamal definition). Curettage: refers to scraping of the inner surface of the gingival wall of the periodontal pocket to clean out, separate and remove diseased soft tissue.

Indications: 1. Pocket reduction: Shallow and moderately deep pockets could be completely debrided by scaling and root planing, complete debridement for deep pockets could not be achieved for two reasons: 1. Scaling and root planing are extremely difficult for deep pockets without direct vision, since the root surface exhibit a wide variety of irregularities and grooves, in other words the morphology of the roots rather than the probing depth determines the limitations of closed sub-gingival scaling. 2- Heavy instruments (scalers, hoe) could not be used for sub-gingival curettage, as it does not get to the bottom of the pocket. * The amount of pocket reduction induced by non-surgical approach depends on:

The original depth of the pocket The amount of the oedematous fluid in the tissue. The amount of the fibrous connective tissue. The thoroughness of root preparation.

* Pocket reduction following scaling and root planing occur through a combination of: 1. Tissue shrinkage: due to reduction in gingival inflammation. 2. Re-adaptation of the gingival connective tissue to the root surface decreasing retractability of the soft tissue from the tooth surface. 3. New attachment by long junctional epithelium. (Why) Pocket epithelium migrate rapidly since it requires two factors to migrate: 1. Vascular CT for nutrition. 2. Substratum (fibrin strands) as contact guidance. But the CT of the PL is slower in his rate of growth because: 1. Slow angiogenesis of avascular root and periodontal ligament. 2. Early differentiation of progenitor cells delays its proliferation. 3. Limited surface area of the periodontal ligament structure.

These resulted in epithelium that proliferate apically on the root surface before the other supporting tissues reach the area, with only longer junctional epithelium will form. 2. Pre-surgical preparation of tissue: (deep pockets) * The main objectives of pre-surgical preparations are to: 1st- Render the tissue easier to handle during surgery. 2. Decrease bleeding and increase visibility during surgery. 3. Decrease postoperative pain , and infection. 4. Some degree of pocket reduction which my render surgical outcome unnecessary. 3. Treatment of compromise situations: 1. Patients psychologically unwilling to accept surgical manipulation of their tissue. 2. Systemic and medical problems may render the patient not be able to undergo more extensive surgery (Ex, Leukemia, hemophilia, heart failure, uncontrolled diabetes.). 3. When scaling and root planning was intended as a pre-surgical preparation but after that the patient and or the therapist decide to discontinue treatment because of the dramatic improvement of the periodontal condition. 4. Maintenance of the treated patients: Repeated scaling and root planing and soft tissue curettage is necessary to prevent recurrence of disease in a previously treated areas.

Periodontal surgical approach:

While nearly all-periodontal treatment techniques are surgical in nature, by common usage the term periodontal surgery is applied only to procedures, which require incisions or excisions of periodontal tissues. It is aimed at treatment of the unresolved periodontal pockets, advancing loss of attachment, or need for regenerative procedures. Objectives of periodontal surgery: 1. Deep pocket reduction: root cleaning and smoothing with direct vision. Deep pockets are areas which are difficult to be cleaned by closed scaling and root planing, it is : * Difficult to be self-cleansed.

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

3. Dental contraindications and precautions 1. Inadequate plaque control: Individual who will not keep etiologic factors under control will not benefit from periodontal surgery. 2. Root exposing surgery in anterior region. 3. Restoration of periodontal health by closed mechanical debridement. *Surgical modalities could be classified as follows: 1. Resectional surgery ( Gingivectomy and gingivoblasty). 2. Surgical sub-gingival curettage ( Excesional new attachment procedure ENAP)) 3. Periodontal flap procedures . 4. Muco-gingival surgeries. 5. Re-constructive modalities.

Gingivectomy and gingivoblasty:

Gingivectomy is the complete removal of the soft tissue wall of the pocket. Indications: 1- Presence of supra-bony pockets >5mm which persist despite repeated sub- gingival curettage and root planning, and where gingivectomy would leave adequate amount of attached gingiva. 2- presence of dense and fibrous gingival enlargement. 3- presence of furcation evolvement (without associated osseous defects) where there is a wide zone of attached gingiva. 4- A gingival abscess entirely contained in the soft tissue. 5- A peri-coronal flap. Advantages: 1. Total pocket eradication. 2. Good visibility to the root surface 3. Fast and simple procedure.

Disadvantages: 1. It creates an open wound, which heal by secondary intention. 2. Tissue is wasted which could be used to close the wound and obtain healing by primary intention. 3. Alveolar bone defects are not exposed and therefore it is contraindicated in the presence of intrabony lesions. 4. The zone of attached gingiva my be eliminated. 5. The clinical crown my be lengthened. 6. Exposed roots my be sensitive and liable to caries. 7. Some loss of CT attachment my occur during healing. Gingivoblasty: Is a term used when gingivectomy is done in the absence of pockets with the sole purpose of recontouring the gingiva, as in cases of rolled gingival margins, craters, and bulbous interdental papillae. 2- Surgical subgingival curettage:

Excisional new attachment procedure (ENAP) ( Mini flap, Open curettage):

* It is essentially a sub-gingival curettage performed by a knife, with an internal bevel incesion started from the gingival margin to the apical end of epithelial attachment. Such clean difinitive excesion of the junctional epithlium offer greater probability of new clinical attachment. * Tissue elevation is not a part of this procedure, that is why it is restricted to suprabony pockets whose apical extent lies within the keratinized gingiva. * New attachment refer to embedding of new PDL fibers into new cementum and formation of a new gingival attachment in an area previously degenerated by periodontitis ( Caranza 1996) , Reattachment refers to reattachment of periodontal tissues in an area not previously exposed to the pocket, ex. Reattachment that follows periodontal surgery or following access to periapical lesion. Advanteges: -The procedure permits through soft tissu preparation. -Secure good access to the root surface. Disadvanteges: -Limited scope -Limited attachment gain

3. Access periodontal flap procedure: Flap procedure are indicated in cases of periodontitis with active pockets 5-6 mm deep or greater that do not respond to initial therapy. The main reasons for doing periodontal flap are 1. To secure access for root planing and to the underlying intraosseous defects. 2. To facilitate removal of the lining epithelium and granulation tissue that may interfere with healing. 3. To facilitate attempts to reestablish new CT attachment (reconstructive procedures). The modified Widman flap (Ramfjord technique) (Partial flap reflection): The primary objective of the procedure is not pocket elimination per se, but maximum healing of periodontal pocket with minimum loss of tissue. The flap consisted of three basic incisions: 1. Initial internal bevel incision begun 0.5 to 1mm from the free gingival margin ( supra-crestal internal bevel incision) to the alveolar crest, followed by reflection of a full thickness flap that exposes 1 to 2 mm of alveolar bone. The aim of this incision is to separate the pocket epithelium and inflamed C.T. ( cervical wedge) from the flap. The incision should follow the scalloping of the free gingival margin to get complete coverage of the interdental areas after suturing. 2. The second incision made from the base of the pocket to the bone crest. 3. The third one is a horizontal incision made from the crest of the bone to the tooth surface, to allow the cervical wedge to be removed easily. * Difference between the original Widman and modefied Widman flap: Modefied widman described by Ramfjord and Nissle in 1974 is consederd more conservative than that originally described by Widman (1916):

Widman flap envolve raising of a full thickness flap without internal beviling . Less bone is exposed in modefied flap. Sharp knifes rather than curettes are used to separate the cevical wedge in modified widman Modified technique maintain bony pocket walls , whereas the original procedure included removal of osseous defects.

Advanteges: A-Optimize accesses to the root surface and intra-bony lesions. 2. Optimize postsurgical adaptation of healthy CT and epithelium to the root surface. 3. Allow optimal soft tissue coverage to the root surface which gives a good esthetic, less post operative sensitivity or caries. 4. Because the alveolar bone is minimally exposed there is a decreased post operative pain and bone resorption Disadvantages: Interdental tissue architecture is poor immediately following removal of the dressing, by meticulous oral hygiene the interdental tissue regenerates over few monthes. These craters developed because of the minimal reflection of the muco-periostium that did not allow for complete coverage of the interdental tissues.

4 - reconstructive procedures:

Bone grafts:

Attempts to obtain some fill-in of the bone defects and reattachment by simple curettage of the bone defect are an unpredictable procedure. Multiple factors must be consederd when attempting regeneration, they include: 1. Implant materials with varieng osteoginic potential. 2. Need for endotoxin free root surface. 3. Control of epithelial migration into the root surface. 4. Induction of a new cementum and incorporation of connective tissue fibers. 5. Host response factors. The essential requirements of the graft materials are: 1. It should be immunologically acceptable (non-antigenic). 2. It should have osteoginic potential. 3. Non toxic 4. Stable after sterilization. 5. Inexpensive.

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

.Freeze dried deminirelized bone allograft (FDDBA). Bone matrix contains bone inductive proteins as BMP2 and 7, and other bone derived growth factors. It may be combined with collagen to facilitate its retention.

Lyophilization: is the process of freeze drying that permits storage within a vacuum for an indefinite shelf life and also markedly reduces the antigenicity of the graft.

Sample (ex. Shaft of long bone) taken from cadaver within 24 h of death. The donor should be free from viral, bacterial, contagious diseases, malignances, long half-life isotops, long term medications that known to affect bone (corticosteroid).

Sample frozen in liquid nitrogen. All cancellus bone and marrow elements removed and discarded, studies showed that cortical bone is superior to cancellus bone when used as a freeze- dried allograft, the opposite may be true in autogenous grafts.

The cortical plates were reduced in size to approximately 1 to 2 cm. The bone chips were lyophilized in freeze-drying chamber. At the end of about 2 weeks at least 95% of the total water content had been removed.

The lyophilized bone was ground under sterile condition through a sterile sieve with 400 um openings.

3. Xenograft: Bone from different species treated with EDTA to remove the organic compounds and antiginic fraction.( Bio-oss. and Bio-guide, Bovine bone menial and collagen) 4. Grafts of bone substitutes and synthetic materials ( Alloplastes) : Are biocompateble materials that are used to fill osseous defects, but they are not an Osteoinductive materials a- Porous and non- porous Hydroxylapatite (periograf, or durapatite): Porous hydroxylapatite has a uniform pore size , which facilitate vascular ingrowth and subsequent new bone formation b- Tricalcium phosphate ceramics( Synthograft). c- Hard tissue replacement polymer (HTR) Is a non- resorbable microporous biocompatible composite of Polymethylmethacrylate (PMMA) and polyhydroxyethylmethacrylate(PHEMA) . This materials has been used in the fabrication of contact lenses, prothetic heart valves and has no inflammatory or immune responses.

PMMA beads are 550 - 880 um diameter with pores of 50-300 um form the core of the material. These are coated with liquid PHEMA , then the composite beads coated with calcium hydroxide / calcium carbonate. Thus the actual surface interface with bone is the calcium surface layer and both fibrous tissue and bone can form on and attach to this layer. Advantages of alloplasts: -Unlimited amount of materials negating the need for human donor. - Biocompatible . -reduce any tiny risk of disease transfer by infected allogenic bone. Possible mode of actions of re-constructive materials: 1. Implants my promote osseous repair by there ability to act as matrix (scaffold) around which bone is formed (osteo-conductive). 2. Theoritically Ca phosphate ceramics becomes rapidly encapsulated in collagen and act as an enhancer for new bone growth. 3. Ions from the implant dissolve in tissue fluids and increase the local concentration of Ca and Phosphate ions which are the most common stimulus for the differentiation of pleuripotential cells to differentiate into osteoblastes. D- The most accepted theory is that the implant act only as a space filler in the defect preventing the flap from collapsing into the bony defect, thus retarding reepithelialization until true regeneration occur (mechanical barrier). Disadvantages:

Partial or complete exfoliation. Closure of the defect occure by long junctional epithelium. Limited new attachment. Not improving tooth mobility. Some inflamatory reactions my occure. Autogenous materials need donor tissue and additional surgry. There is a potential of root resorbtion of fresh materials.

Guided tissue regeneration (GTR):

Regeneration is the growth and differentiation of new cells and intercellular substances to form new tissues . Regeneration takes place by growth from the same type of tissue that has been destroyed or from its precursor ( Caranza 1996b). For that reason recruitment of PDL and bone cells are important steps in regenerating the periodontium.( It differs from repair or healing by scar, restore the tissue but does not necessarily restore the original architecture or function)

GTR is a technique used to increase the chance of obtaining a new CT attachment, by which surgical procedures are designed to mechanically prevent the epithelial attachment and gingival CT which has no potential to provoke formation of new CT from reaching curreted root surface by a membrane, at the same time to allow time for population of the curreted root by cells arising from the periodontal ligament.

Sometimes the procedure called osteopromotion because it is a more general term not restricted to only placement of a membrane for guidance, as it could be of a value in regeneration, neogeneses, improving bone graft results.

- It protects the blood clot and favours its adherence to the root surface by its mechnical supportive effect (scaffold). For that reason the membrane should be firm to the extent of not ristricting the space of bone and PL. -Locally concentrate growth stimulatory factors derived from bone, periodontal ligament and cementum.( Bone morphogenitic protein, PDGF, cementum derived growth factor). - Stimulatory properties of the membrane: *The surface of the membrane my be osteoconductive i.e.: act as a guidance for osteogenic cells. * ePTFE is permeable to tissue fluids and macromolecules , thus allowed nutreins to pass while unwanted cell types are kept out. Types: 1. Non- resorbable: Plytetrafloroethyline mem. (teflon mem.) (Gore-tex) * It consists of a narrow, open microstructure margin which is designed to allow C.T. penetration to produce a seal at the coronal margin of the root, as well as an occlusive membrane. * It is adapted to fit over th intrabony defect and the root of the tooth, extending from 2-3 mm below the bone margin to just below the C.E.J on the root.

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

-Cargile Mem. (4-8 weeks). -Calcium sulfate

Root conditioning agents in promoting connective tissue attachment: (Acids)

1.

Citric acid: (20% for 3 minutes) 1. Demineralization and exposure of collagen from the superficial portion of dentine where CT attachment occur by integration of new and old collagen fibers. 2. Stop apical migration of epithelial attachment through early fibrin linkage. 3. Exposing inducers of cementoblastes and osteoblastes by exposing collagen fibers . 4. It my act as a solvent for endotoxins. 5. Bacteriocidal property of low PH on microbes. Tetracycline HCL: 1. Collagen exposure. 2. Good substantivity: react with dental hard tissue, from which it slowly released in an antibiotically active form. 3. Anticollagenolytic activity; antienzymatic effect that retard collagen breakdown 4. Promote fibroblast adhesion and growth. EDTA (prefgel 24%) * It exerts its demeniralizing effect through chelating divalent cation at a neutral PH. Which in contrast to etching at low PH preserve tissue vitality. * In contrast to etching at low PH it does not alter the structure of dentin associated collagen * it is as effective as low PH with respect to smear removal and superior in exposing root associated collagen. * Expose and widen the orifices of dentinal tubules which favor periodontal ligament fibroblasts adhesion to the root surface. b- (Extracelllular matrix) Fibronictin is an extracellular matrix protein provide attachment of fibroblasts to diseased root. Laminine: promote epithelial cell proliferation.

c- (Growth factors): The most important factors determining periodontal regeneration are:

Excluding epithelium: GTR seeks to produce these condition by excluding epithelial down-growth and thus proving an anatomical environment for the coronal migration of these cells.

Stimulation of cells of periodontal ligament and alveolar bone populated the healing tissue coronal to the residual alveolar bone. Bone grafts with its contained growth factors and growth factor application seems to stimulate cells capable of regeneration. The most related and most studied growth factors in periodontal regeneration include: PDGF , IGF , BMP , TGF .

Platelet derived growth factor(PDGF): Have a potent effect on proleferative activety of periodontal ligament fibroblastes(PDL). Chemotactic for PDL cells Promote collagen and total protein syntheses. Improve adhesion of PDL cells to the root surface( Gamal et al 1998) Can reduce the inhibitory effects of lipopolysaccaride on gingival fibroblast proleferation. Promote fibroblastes proleferation under an expanded GTR membranes increase metalloproteinase syntheses from PDL cells. Insulin growth factor (IGF-1): Chemotactic for cells derived from PDL. Have an influential effect on PDL mitogeneses and protein syntheses. Synergestic effects are observed on mitogeneses of PDL cells when IGF-1 is combined with PDGF.

Platelet rich plasma:

Is exactly what its name suggests. The substance is a by-product of blood (plasma) that is rich in platelets. Platelets are our primary mechanism for hemostasis. They circulate in our bodies looking for exposed endothelium. They then aggregate to the site of injury and further platelet degranulization occurs. Platelets rich plasma perform many functions, including: 1. formation of a blood clot Platelet gel mimics the final stages in the clotting cascade. The platelet rich plasma in the presence of thrombin activates platelets, converts fibrinogen to fibrin and stimulates further platelet aggregation

2. and release of growth factors (GF) into the wound. These GF (platelet derived growth factors PGDF, transforming growth factor beta TGF , and insulin-like growth factor ILGF) function to assist the body in repairing itself by stimulating stem cells to regenerate new tissue. The more growth factors released/sequestered into the wound, the more stem cells stimulated to produce new host tissue. Autologous platelet rich gel has several advantages:

eliminated the risk of disease (viral transmission) related to donor blood products. Cost effectiveness: Since PRP harvesting is done with only 55 cc of blood in the doctors office, the patient need not incur the expense of the harvesting procedure in hospital or at the blood bank.

Ease of use: PRP is easy to handle and actually improves the ease of application of bone substitute materials and bone grafting products by making them more gel-like. (Calcium chloride is added to counteract the anticoagulant citrate, rapidly forming gelatinous, platelet-rich glue.)

Emdogain
A recently developed biologically based product represents a new way of thinking in periodontal regeneration. It is an enamel matrix protein( amelogenin) that applied as a gel directly into the tooth root during periodontal flap surgery . Its key component (amelogenin) naturally produced by the ameloblastes during tooth development, this protein is involved in the formation of tooth supporting tissues. Once applied, emdogain is naturally absorbed by the body , leaving only a residue of enamel matrix protein on the debrided root surface, this natural and insoluble surface layer encourages the migration of cementum forming cells from the surrounding tissues , following cementum formation the PL is established creating true CT attachment to the tooth . 4- Muco-gingival techniques in periodontal surgery: Many techniques have been attempted to correct abnormal topographic relations between gingiva and alveolar mucosa that interfere with the elimination of periodontal pockets or favor the recurrence of gingival inflammation. The term Mucogingival Surgery was proposed by Friedman in 1957 to indicate any surgery designed to preserve attached gingiva, to remove frena or muscle attachment, and to increase the depth of the vestibule. The aim of this type of surgery was to maintain an adequate amount of attached gingiva and to prevent continuous loss of attachment. This philosophy was supported by many horizontal observations in humans that confirmed the need for a certain band of attached gingiva to maintain periodontal tissue in a healthy state. Subsequently, clinical and experimental studies by Wennstrm and Lindhe (1983) demonstrated that

as long as plaque buildup is kept under careful control there is no minimum width of keratinized gingiva necessary to prevent the development of periodontal disease. More recently the Consensus Report of the American Academy of Periodontology (1996) defines Mucogingival Therapy as non surgical and surgical correction of the defects in *morphology ( Recession, papillary loss, crown lengthening) *position ( pocket at the mucogingival area, frenum, teeth not likely to erupt ). *and/or amount of soft tissue and underlying bone ( inadequate attached G , ridge augmentation, prevention of ridge collapse). This assigns importance to non-surgical therapy and to the bone condition because of its influence on the morphology of the defects. In this respect the Mucogingival Therapy includes: 1- Pockets extend at or below the mucogingival line. 2- Insufficient attached gingiva without pocket formation. 3- Isolated gingival recession. (Gingival augmentation). 4- Frenum insertion in or close to the gingival margin. 5- Augmentation of the edentulous ridge. 6- Crown lengthening. 7- Teeth that are not likely to erupt. 8- Prevention of ridge collapse associated with tooth extraction. 9- Loss of interdental papilla which presents an aesthetic and/or phonetic problem. 1. Treatment of pocketing below the muco-gingival junction: A number of surgical procedures have been proposed to solve muco-gingival problems of this type . All have the common aim of: 1. The removal of the disease. 2. The production of a periodontal anatomy which allows effective plaque control , and therefore prevent disease recurrence.

Deep pocketing of this type may be treated by partial or full thickness apically repositioned flaps Apically repositioned flap: The apically repositioned flap achieves pocket elimination by moving the flap in an apical direction converting the pocket wall into an attached gingiva. Procedure: 1. Incisions: Two parallel vertical releasing incisions to bone at either ends of the operative area extending to the base of the vestibule to get an adequate mobility of the flap. An inverse bevel incision start 1mm. from the gingival margin to the alveolar crest. This will separate the pocket lining from the inner wall of the flap. This tissue is left on the surface of the tooth when the flap is raised and is referred to as the cervical wedge (or secondary flap). 2. Full thickness flap reflection and removal of the cervical wedge together with scaling and root planning. 3. Apical repositioning: The flap is reflected to the base of the vestibule, once released the flap tend to contract and fold up so that apical positioning often takes place spontaneously. One should ensure that the flap is displaced apically so that its edge just covers the alveolar crest. 4. Suturing: It is important to make sure that the flap is not pulled coronally when suturing Sutures should be made first near to the margin of the free flap with loose interdental interrupted or suspensory sutures and apically in the affixed tissue to ensure the degree of apical repositioning,. 5. Placing the periodontal dressing: It helps in prevention of coronal displacement so it should extend to the base of the vestibule 6. Treatment of insufficient attached gingiva: The term-attached gingiva refer to gingival tissue that is bound to the tooth and underlying bone. The attached gingiva starts at the base of sulcus or free gingival groove to the mucogingival junction. Its width varies from one to nine mm. It was originally believed that a minimum width of attached gingiva required to maintain gingival health and to prevent recession. The width of attached gingiva is considered functionally adequate if it can dissipate the pull of the frena and muscle of the lip and cheeks. It has been observed that following removal or in the absence of the attached gingiva, the remaining tissue namely,

alveolar mucosa will * curl * will not respond to treatment * and will not withstand the rigors of mastication or oral physiotherapy However several longitudinal studies have demonstrated that the lack of or presence of minimal amount of attached gingiva does not necessarily result in progression of soft tissue recession. Therefore, the term adequate attached gingiva should describe the amount of tissue that is conductive to gingival health in the clinician's opinion. Indications: There are factors to help guide the clinician in determining the need for surgery when there is 1mm of attached gingiva or less; 1. Recession becomes an esthetic concern to the patient. 2. Sites exhibit progressive recession. 3. Sub-gingival restorative margins are continuos source of irritation to the gingiva and require at least 5mm gingival width to maintain its health. 1- Free grafts: I- Full thickness free gingival graft. I- Full thickness free graft: Is the procedure of relocation of keratinized palatal epithelium and connective tissue from its original site to a remote donor tissue. Indications: 1. Increase width of keratinized gingiva. 2. Treatment of gingival recession. Procedure: A- Preparation of recipient site : II- Connective tissue graft.

1. Muco-gingival incision in case of increasing the width of attached gingiva or a horizontal incision at the base of the papillae, which continued around the recession area for treatment of gingival recession. 2. Two vertical incisions delineate the flap. 3. Dissection of split thickness flap to leave connective tissue bed over bone to nourish free graft. B- Preparation of donor site : Three-mm deep incision is made on the palate opposite the premolar- first molar area to dissect a split thickness graft from the underlying deeper connective tissue. C- Placement of the graft : The flap should be placed and trimmed quickly to maintain its vitality. The flap raised at the recipient site can be cut off at this point as it is no longer needed, and the graft can be sutured in place by papillary and apical stretching sutures. For free graft we can use simple interrupted suture for the corners, and a periosteal sling suture. A space between the graft and underlying CT. will prevent the donor tissue from becoming vasculerized , which will result in necroses and sloughing of the graft. D- Healing of the graft: Vascularization of gingival graft takes place from the underlying CT bed. Capillary buds grow from the underlying connective tissue into the graft. Because nutrition to the graft is minimal during the first 2-3 days, the surface layer degenerate and desquamate. A layer of new epithelium is present after 4-5 days.

II - Subepithelial connective tissue graft: This procedure was introduced by Langer and Langer (1985) as a method of :

Gaining root coverage in Cases of sever gingival recession involving isolated or multiple teeth. Increasing the zone of attached gingiva.

This type of graft has a number of advantages over the free epithelial graft: 1. Closed plalatal wound healing by primary intention which involve less postoperative pain. 2. Closer color blend avoiding patchy healing of the free G.G. 3. There is a better blood supply from the periostium (partial thickness flap around the defect and underside of the covering flap).

Procedure : 1. Preparation of the donor tissue:

Three incisions to a depth of 3 to 4 mm. Are made in the palate adjacent to the 1st. and 2nd. Premolar area (one horizontal and two vertical).

Approximately 1mm. of epith. is dissected from the underlying CT. With epithelial trap door reflected, the CT. can now easily visualized. A fourth incision is made through the CT. at the base of the trap to free the donor CT. Donor CT. of about 2mm. thick is sharply dissected from the exposed palatal tissue. The trap door is replaced and a finger pressure applied for 10 minutes. Another approach is done by making two parallel horizontal beveled incisions 2mm apart from each other, and 3mm. from the gingival margin using a No. 15 blade. It is made from the canine to the 1st. molar area since the CT. is thicker and better vascularized in this area and the rugae area of no concern because the graft is taken internally. A split thickness flap is raised with or without mesial and distal vertical relieving incisions. A wedge of CT. of about 1.5 mm. thickness along its thin border of epithelium is carefully dissected out. Care should be taken to avoid the palatine vessels but staying anterior to the first molar should avoid this problem. The procedure leaves the outer epithelialized flap to be replaced for primary intention wound healing.

A special scalpel handle has been devised to accept two blades 1.5 mm. Apart for use in obtaining a suitable CT. graft ( 1.5mm double scalpel knife). This was designed by Harris 1992 . ( I met Haris in Boston AAP meeting 1998) 2. Root preparation: Root planning of the exposed roots is carefully carried out . Additional preparation with citric acid or tetracycline may also carried out. C - Preparation of the recipient site:

Elevating a partial thickness envelope flap (without vertical incisions) around the denuded root (It could be done by vertical incisions).

The size of the CT. graft is determined by the size of the recipient base and its height and length are measured.

The CT. then placed beneath the partial thickness flap and over the exposed root at or 1mm. coronal to the CEJ. (Sub-epithelial CT graft).

Without coronal displacement the replaced partial thickness flap cover 50% of the donor CT. No sutures usually required to the donor tissue. ( it may be sutured by resorbable sutures).

2- Apical repositioned flap. (See treatment of insufficient attached gingiva) 3- Treatment of gingival recession: Classifications:

Sullivan and Atkins classified gingival recession into four morphologic categories: (1) Shallow and narrow (2) shallow wide (3) Deep narrow (4) Deep wide.

Miller expanded this classification as follows:

Class I: Marginal tissue recession that does not extend to the muco-gingival junction. There is no loss of bone or soft tissue in the inter-dental area. This type of recession can be narrow or wide (Group 1 or 2 in Sullivan and Atkins classification) Class II: Marginal tissue recession that extends to or beyond the muco-gingival junction. There is no loss of bone or soft tissue in the inter-dental area. This type of recession can be sub-classified into wide and narrow, corresponding to Group 3 and 4 of Sullivan and Atkins classification. Class III: Marginal tissue recession that extends to or beyond the muco-gingival junction , in addition , there is bone and/ or soft tissue loss inter-dentally or there is mal-positioning of the tooth. Class IV: Marginal tissue recession that extends to or beyond the muco-gingival junction with sever bone loss and soft tissue loss inter-dentally and / or sever tooth mal-positioning.

1- Pedicle grafts and its modifications:

Is a flap of tissue connected to its origin by a stalk.

Lateral repositioned flap. Sub-marginal laterally repositioned flap. Coronal repositioned flap. Double papillae repositioned flap. CT graft with double papillae flap. Subpidecle CT graft. Partial full rotated flap.

Laterally repositioned flap (LRF): The exposed root is covered by mobilizing a pedicle graft from a suitable adjacent area which then slide laterally to cover the defect.

Indications of LRF: It is suitable to treat *single tooth * narrow areas of gingival recession *with adequate interdental bone height *and an adjacent donor area with an adequate zone of attached gingiva. Contraindication of LRFs: 1-Generally it is not suitable for treating isolated wide areas of recession . 2-Multiple recessions. 3-Inadequate attached gingiva, or interproximal bone in the donor area. 4. presence of deep interproximal pocket. 5. Excessive root prominence. 6. Deep abrasion or erosion. Advantages of LRF: 1. It is a one stage procedure whereby a pedicle flap is elevated by a split or full thickness from an adjacent area of keratinized gingiva. 2. The blood supply that nourishes the flap over the avascular root surface is supplied by the wide base of the pedicle flap and from the perostium over the bone surrounding the denuded root. 3. The color blend and root coverage are excellent in well chosen cases. Procedure of LRF: 1. root surface preparation, to remove necrotic cementum and to reduce prominent convexity of the root. 2. A number 15 scalpel blade is used to make a V shaped incision about the denuded root , removing the adjacent epithelium and CT . The V shaped incision should be beveled out on the opposite side from the donor area, permitting overlap and increase vascularity for the donor tissue. 2. Partial or full thickness flaps 1 wider than the recipient area. Vertical incision should extend to far apically to the mucosal tissue so that the tissue can be placed on the recipient bed without tension. A

small cut back incision to facilitate rotation was suggested. However this incision rarely are necessary if the outline incision are angled toward the base of the deficiency to be corrected. Double papillae repositioning flap: The donor tissue is mobilized from the adjacent papillae rather than from the adjacent teeth . it is designed to achieve adequate zone of attached gingiva and or coverage of a denuded root surface. Indications: 1. When the interdental papilla adjacent to the mucogingival problem are sufficiently wide. 2. When the attached gingiva on an approximating tooth is insufficient to allow for laterally positioned flap. 3. when periodontal pockets are not present. Advantages: 1. The risk of loss of alveolar bone is minimized because the interdental bone is more resistant to loss than is radicular bone . 2. The papilla usually supply a greater width of attached gingiva than radicular surface of a tooth . 3. There is less exposure of donor site . Disadvantage: 1-Two small flaps have to join in such a way that they act as a single flap over avascular root surface 2-Proximal papillae must be of sufficient bulk. Procedure:

A V shaped incision to remove a wedge of gingiva over the root. It should extend far enough apically to prevent bunching of the tissue when the flaps are brought together. The V section is then removed and the root surface scaled. The periosteum has been retained.

Lateral releasing incision at the mesio-facial and disto-facial line angles of adjacent teeth , these should not encroach upon the radicular surface because these expose radicular bone

Horizontal incisions across the tops of the papillae to allow better placement of the flap. Mucosal flaps are reflected leaving the periostium. Suturing of the double flap, with care to avoid separation of the flap By both sling and periosteal suture complete fixation is accomplished.

CT graft with double papilla flap : In both free graft and CT graft , the graft over the root surface depends on the collateral circulation in their nutrition. In this modification proposed by Harris(1992) the graft is covered over the root surface with tissue brought together by a double papillae type flap. The graft gets its blood supply both from the underling periostium , mesial , distal and apical to the exposed root , and from the covering double papillae pedicle flap. Sub-pedicle CT graft : A pedicle flap cover a CT autograft to get more blood supply to the pedicle flap. Partial full rotated flap: Which allow full thickness flap to cover the recession and partial thickness flap to cover the exposed bone, using 2 teeth at one side - the first one is full and the second partial. 2 - Free gingival graft. (see above). 3. Subepithelial CT graft (See above). 4. free rotated papillae autograft:

Partial thickness envelop flap. De-epithelialization of the adjacent papillae and removed in full thickness and placed at the recession were the bases at the CEJ and the apices at the base of the recession.

The CT papillae then covered by the partial thickness flap with some coronal displacement.

Advantages: Single surgical site with no palatal discomfort. 5. GTR barrier mem. Covered by a coronally repositioned buccal flap. The mem. Placed at the CEJ covered by a full or partial thickness buccal flap coronally repositioned to the CEJ. 4 weeks later the mem was removed and the flap was sutured to cover the newly formed tissue healing was found to occur by new CT attachment while that without the mem. Occur by long junctional epith. 4. Treatment of pocketing below the mucogingival junction: * apically repositioned flap. ( See above)Hgamal1@hotmail.com Ahmed Y Gamal
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