Reconstructive Periodontal Surgery

7/21/2019 Reconstructive Periodontal Surgery

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! reconstruct or reconstitute all gingival andosseous structures lost through disease.



!

Repair

! Healing of a wound by tissue that does not fullyrestore the architecture or function of the part, asin the case of a long junctional epithelium or

ankylosis.



! The reunion of connective tissue with ahealthy root surface on which viableperiodontal tissue is present without newcementum, as in the case of trauma or after asupracrestal fiberotomy.



! The reunion of connective tissue with anunhealthy or previously diseased root surfacethat has been deprived of its periodontalligament. This reunion may or may not occurby formation of new cementum with insertingcollagen fibers, as in the case of GTR.



! Reproduction or reconstitution of the lost orinjured parts by restoration of new bone,cementum, and a periodontal ligament(reunion of connective tissue) on anunhealthy or previously diseased rootsurface.

! Ideally, complete restoration would also

restore total function



! non–bone graft–associated new attachment

! bone graft–associated new attachment.

Many procedures combine both approaches.



! the removal of the junctional and pocket epithelium;

! the prevention of their migration into the healing areaafter therapy;

! clot stabilization, wound protection, and space creation;

! guided tissue regeneration;

! the biomodification of the root surface;

! selection of the proper graft materials;

! biologic mediators (growth factors) and enamel matrixproteins to enhance or direct healing; and finally

! the combination of graft materials, membranes, andbiologic mediators used to enhance new attachmentand bone growth.



! 1. Plaque control

! 2 Underlying system disease (eg, diabetes)

! 3. Root preparation

! 4. Adequate wound closure

! 5. Complete soft tissue approximation

!

6. Periodontal maintenance, short and long term

!

7. Traumatic injury to teeth and tissues

! 8. Defect morphology

!

9. Type of graft material

!

10. Patient’s repair potential



1. Removal of plaque, calculus, softened

cementum, and the junctional epithelium fromthe root surface

2. Removal of all granulation tissue from the bonydefect

3. Removal of all connective tissue and periodontal

ligament fibers covering the bone

4. Decortification of dense or sclerotic bone



! Periodontal reconstruction without the use ofbone grafts in meticulously treated three-walldefects (intrabony defects) and in periodontaland endodontic abscesses.



Periodontalpocket with

angular boneloss

Fullthicknessflap

reflected.

Flap is closedwithout a

membrane

Flap closedwith

membrane inplace.

. Only bone and PDL cells can occupy the defect



! The graft simply delays the epithelium fromproliferating into the healing area



! The method for the prevention of epithelialmigration along the cemental wall of thepocket and maintaining space for clotstabilization



! nonresorbable membranes!

polytetrafluoroethylene (PTFE)! titanium-reinforced expanded polytetrafluoroethylene

(ePTFE)

! resorbable membranes!

OsseoQuest (Gore),! a combination of polyglycolic acid, polylactic acid, and

trimethylene carbonate that resorbs at 6 to 14 months;

!

BioGuide (Osteohealth),! a bilayer porcine-derived collagen;

!

Atrisorb (Block Drug)!

a polylactic acid gel; and

! BioMend (Calcitech),! a bovine Achilles tendon collagen that resorbs in 4 to 18 weeks



! 1. Increase the bone level! 2. Reduce crestal bone loss! 3. Increase the clinical attachment level! 4. Reduce probing depth when compared with open

flap surgery!

5. Increase clinical attachment level and reduceprobing depth when combined with guided tissueregeneration (GTR) compared with grafts alone

! 6. Support formation of a new attachment apparatus! a. autogenous bone grafts!

b. demineralized freeze-dried bone allografts(DFDBA)!

c. xenografts (Bio-Oss®, Osteohealth,Uniondale, New York)! d. enamel matrix derivative (Emdogain® Straumann, Basel,

Switzerland).



!

(1) autografts! are bone obtained from the same individual;

! (2) allografts!

are bone obtained from a different individual of thesame species;

! (3) xenografts! are bone from a different species.



Reentry 6 months later

Osseous defect mesial to a second premolar



BEFORE AFTER 6 MONTHS



incipient involvement into a fluteof furcation with suprabonypockets and no interradicularbone loss

Grade II: any involvement of theinterradicular bone without a

through-and-through ability toprobe



through-and-through loss ofinterradicular bone

through-and-through loss ofinterradicular bone, with totalexposure of furcation owing togingival recession



loss of interradicularbone less than orequal to one-third

loss of interradicular bonegreater than one-thirdbut not through andthrough

through-and-through loss ofinterradicularbone



! Scaling and Curettage, Gingivectomy,Odontoplasty

!

Furcation Plasty—Odontoplasty andOsteoplasty

!

Grafting

!

Tunnel Preparation

! Root Resection



Glickman

1958)

I II III or IV

Lindhe(1983)

- I II III

Tarnow

(1984)

- A, B, or C A, B, or C A, B, or C

Treatment Scaling and rootplaning;Gingivectomy;Odontoplasty

Odontoplasty;Osteoplasty

OdontoplastyOsteoplasty;Grafting;GTRFlap and CaTunnelpreparationRoot resection

RootSectioning;tunnelpreparation;GTR



Osteoplasty and odontoplasty



! The furcation area is characterized by defects,the walls of which are primarily of toothstructure.

! Therefore, although the area is capable of

holding a graft, it has little or no vascularity tosupport one. For this reason, the success ofgrafts is limited in furcations

! Grafts are indicated where destruction of the

furcation is only partial (grade I or II) or wheredeep vertical lesions have still left some bone onthe inner aspect of the roots



deep grade II furcation

Xenograft (Bio-Oss) placed

Resorbable membrane positioned andsutured

Reentry 12 months later



! Tunnel preparation is the surgical exposureof the furcation, which is indicated foradvanced grade II and III lesions in whichresection is not possible

!

It requires roots that are long and divergentand is generally indicated for the mandibularmolars. It often fails because of decay in thefurcation area



Grade III furcation prior to correction Tunnel preparation completed

Small interdental brush isinserted into and through thefurcation to show that theinner portion of the furcationcan be cleaned

Reconstructive Periodontal Surgery

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