Rational and objectives Nikhil Dubey BDS Intern,GDC Raipur

1. periodontal surgery Rational and objectives Nikhil Dubey BDS Intern,GDC Raipur

2. Non surgical periodontal therapy. Surgical periodontal therapy. Periodontal therapy

3. Rational *Why do we do periodontal surgery? *To provide access and direct vision of the root surfaces for thorough debridement. Because in some situation non –surgical therapy is not enough to clean the environment.

4. Surgical periodontal therapy seeks to • Improve the prognosis of teeth. • Improve aesthetics.

5. Purpose of surgical pocket therapy • To eliminate the pathological changes in the pocket walls. • To create a stable, easy maintainable state. • May promote periodontal regeneration .

6. Objectives • To gain surgical access to deep pockets for adequate cleaning and smoothening of the root surfaces. • To facilitate plaque control by reduction or elimination of potential plaque retention areas(correction of morphologic defects).

7. Objectives, cont. • To provide an environment for an adequate prosthesis. • For periodontal regenerative therapy. • To correct cosmetic abnormalities.

17. Indications for periodontal surgery • Areas with irregular bony contours or deep craters. • Pockets on teeth in which a complete removal of root irritants is not considered clinically possible. (molars). • In cases of grade II or III furcation involvement. • Infrabony pockets in distal areas of last molars. • Persistent inflammation in areas with moderate to deep pockets may require a surgical approach.

18. Contraindications • Patients who do not exhibit good plaque control. • Uncontrolled or progressive systemic disease (uncontrolled diabetics,leukemia ect.). • Patients taking large doses of corticosteriods may have reduced resistance to stress associated with surgery .. • Patients with imminent terminal disease who are debilitated are not candidates for surgery.

19. Results of pocket therapy • Conversion of an active pocket to inactive pockets and heal by long junctional epithelium with or without gain of attachment. • Pocket elimination or reduction. • Improved gingival attachment promotes restoration of bone height, with reformation of periodontal ligament fibers and layers of cementum.

20. Surgical instruments

27. Classification of periodontal surgery

28. Introductory points: • Pocket is a pathological deepening of the sulcus. • Initially ------Pocket (8mm) • Re-evaluation------Pocket(6mm) • We need to gain access for thorough cleaning. • However, some time we add bone and some time we resects bone.

29. Classification of periodontal surgery • Resective Procedures. • New attachment procedures. • Regeneration procedures.

30. Resective procedures • It is the procedure that means to eliminate or reduce the pocket, by excising or amputating the tissue constricting the pocket wall. • (in this case we remove bone).

32. New attachment procedures • It is the reunion of connective tissue by formation of new cementum with inserting collagen fibers on root surface that has been deprived of its periodontal ligament.

33. Regeneration procedures • Are surgical procedures aimed at Reproduction or reconstruction of lost or injured periodontium. • Aim is to restore the periodontium to the normal physiologic levels. We have new bone and periodontal ligament formation

34. Resective procedures includes: • Gingivectomy, Gingivoplasty. • Apically positioned flap without osseous surgery. • Apically positioned flap with osseous surgery (Osteoplasty, Osteoctomy). • Root resection.

35. Gingivectomy,Gingivoplasty • Gingivectomy:Excision of soft tissue wall of periodontal pocket. • Basic rational is pocket elimination to allow access for root instrumentation. • Gingivoplasty:To restore gingival contours.(not commonly used now days). • External bevel incision is done to remove excess gingiva and healing is by secondary intention.

38. Apically positioned flap without osseous surgery • The idea is to move the gingival margin Apically and not to excise the gingiva. • Indications: • Deep supra and infra bony pockets. • Crown lengthening procedures with minimal attached gingiva. • Increase the zone of attached gingiva.

43. Contra-Indications (Apically positioned flap without osseous surgery) • Anatomical reasons:due to location of the pocket.(e.g.. Anterior oblique ridge in the mandible in the 3rd molar area. • Esthetic and cosmetic reasons: Anterior area with high lip line. • Severely compromised Alveolar bone support.

44. Apically positioned flap with osseous surgery • We remove bone to have normal architecture by doing Osteoplasty or Osteoctomy. • Indications: • Pre-restorative periodontal procedures(exposure of crown). • Active pockets with mild or moderate infrabony defects where the base of the pocket is apical to crest of the bone.

45. Contraindications(Apically positioned flap with osseous surgery) • Anatomical limitations,poor crown\root ratio. • Presence of excessive tooth mobility.

46. Osteoctomy: Removal of some alveolar bone, thus changing the position of crestal bone on tooth surface. Osteoplasty Reshape the bone by thinning it and not to reduce from its height therefore gingiva can adapt nicely. Definitions

47. Root Resection Therapy • In cases of multirooted teeth with infrabony deep pockets and root proximity. • In case of furcation grade III. • The bone around the area will be thin, therefore affected root can be removed.

48. Objectives of Resective procedures • Pocket elimination or reduction. • A physiological gingival contour,tightly adapted to alveolar bone and apical to pre surgical site. • A clinically maintainable condition.

49. Requirements for Resective procedures • Access proper root instrumentation. • Access for underlying alveolar crest. • Maintain adequate band of attached gingiva. • Heal in rapid fashion. • Minimize the alveolar crest height. • Maintain levels of clinical attachment on a long term basis. • Reduce probing on a long term basis.

50. New Attachment Procedures Closed curettage. Excisional new attachment procedure (ENAP). Open flap curettage. Modified widman flap procedure.