Periodontal surgery

Periodontal surgery.

1. Introduction :

Most forms of periodontal disease are disorders related to the bacterial biofilm, so surgical treatment can only be considered as an adjunct to etiological therapy. Therefore, various surgical methods should be judged on the basis of their ability to contribute to plaque control and long-term preservation of the periodontium.

2. Reminder on the healthy periodontium
3. Periodontal health: according to CLAUD BERNARD “Stable stage over time of each of the four periodontal tissues which adhere and/or attach to the entire surface of the dental root”.

NB: any periodontal condition that deviates from this definition may be considered pathological.

2. Periodontal disease: Periodontal diseases include all conditions affecting the superficial and deep periodontium.

Gingivopathies: are conditions affecting the superficial periodontium “gum” without destruction of the deep periodontal structures. (False pocket).

Periodontal diseases: are conditions affecting the deep periodontium with irreversible destruction of the supporting tissues of the tooth. (True pocket).

3. Etiologies of periodontal diseases: Weski triad (local, constitutional, general factors).
4. General information on periodontal surgery:
5. Definition of periodontal surgery:

Periodontal surgery means any surgical procedure involving the periodontal soft tissues and alveolar bone. 

2. Place of periodontal surgery in the treatment plan:

Periodontal surgery occupies a valuable place in the treatment plan. After initial therapy and sanitation of the oral cavity, then passing through a reassessment phase, a decision will be made to move on to surgical therapy in the corrective phase.

3. Classification of periodontal surgery:

• KRAMER classification:

• Keratinized area: periodontal curettage, gingivectomy, gingivoplasty.
• Mucosal area: frenectomy, flaps, gingival grafts.
• Bone area: osteotomy, osteectomy, osteoplasty, bone grafts, substitutions.
• DEPENDING ON THE TYPE OF SURGERY: 

• Restorative by incision.
• Reductive by excision.
• ACCORDING TO THE THERAPEUTIC CHRONOLOGY:

Immediate hot, or after etiological treatment.

• DEPENDING ON THE TYPE OF HEALING

• Reattachment by repair: long junctional epithelium, epithelial or connective tissue adhesion, no neocementum or neoligament, may be new bone; gingivodental sulcus deeper than normal.
• New attachment by regeneration: short junctional epithelium, neocementum, neoligament, new bone, short gingivodental sulcus.

4. Objectives of periodontal surgery:

• Better access to root surfaces in deep pockets especially where inflammation persists after initial periodontal treatment.
• Regeneration of the periodontal system destroyed by periodontal disease
• Pre-prosthetic correction of periodontal sites for the development of an environment compatible with restorative dentistry procedures and prosthetic reconstructions 
• Correction of iatrogenic acts.
• Improved aesthetics 

5. Indications for periodontal surgery:

• Creating better access for root planing 
• Difficult access areas for HBD (inter-radicular damage, gingival peculiarities).
• periodontal preparation before prosthetic restoration, pre-prosthetic surgery 
• Correction of certain iatrogenic acts
• Muco-gingival problems (hypertrophic frenum, gingival hypertrophy).

6. Contraindications of periodontal surgery:

• Uncooperative patient.
• Relative contraindications

• Medium or low risk cardiovascular disease: hypertension, angina pectoris, treatment with anticoagulants (favorable opinion of the treating physician)
• hematological disorders: moderate or compensated forms of anemia
• hormonal disorders
• Diabetes mellitus: unbalanced patients (irregular diet, inadequate insulin treatment)
• Absolute contraindications 

•  high-risk cardiovascular diseases (valve prostheses, valvulopathies – congenital heart diseases)
•  hematological disorders (acute leukemia – agranulocytosis-lymphogranulomatosis)
•  neurological disorders (multiple sclerosis-Parkinson). Cervico-facial radiotherapy.

7. General principles of periodontal surgery:

Preparation during initial therapy should be completed by: 

• A blood test
• Psychological preparation of the patient
• Medical preparation
• Compliance with asepsis rules

The general principles of the different surgical techniques are to proceed:

• Anesthesia: local or locoregional (with or without vasoconstrictor)
• Incision.
• detachment: delicately (risk of tearing)
• Perfect removal of pathological tissues   
• Sutures: no traction or tearing of tissues 
• Use of periodontal dressing (wound protection)
• drug prescription 
• Post-operative advice.

8. Different types of surgical procedures:

1. Pocket surgery:
2. Periodontal curettage:

Debridement and excision using a curette of the granulation tissue constituting the internal part of the gingival wall of the pocket as well as the junctional epithelium and the inflamed supracrestal connective tissue. The curettage is accompanied by root planing. 

Indications: Becoming Rare

• Shallow pockets (extension of root planing)
• Preparation for deeper surgery in complex cases 
• In case of periodontal abscess, curettage accelerates healing.   

Contraindications:

• Deep pockets 
• Gums of fibrous consistency 

2. Gingivectomy:

The oldest surgical technique, its main objective is to remove the soft tissues constituting the walls of the periodontal pocket. Gingivectomy is intended to reshape the gum to give it an aesthetic and functional morphology. 2 types of gingivectomy depending on the type of incision: GBE-GBI.

 Directions:

• Gingival hyperplasia and hypertrophy (inflammatory-hormonal-drug-respiratory-congenital)
• Hyperplasias associated with shallow suprabony periodontal pockets.

Contraindications:

• Infrabony pockets 
• Suprabony pockets extending beyond the mucogingival line
• Insufficient attached gingiva 
• Soft gums 
• Bone defects.

Periodontal surgery.

3. ENAP (EXCISIONAL NEW ATTACHMENT PROCEDURE):

DEFINITION:

• Periodontal curettage performed with a scalpel blade (described by YUKNA 1976)
• Intermediate between blind curettage and open curettage 

Indication  

• Shallow pockets especially in the anterior sector (limits recessions).

4. FLAP INTERVENTIONS:

DEFINITION :

Flap surgery involves lifting a tissue flap released by incisions in order to access the underlying root and bone structures; its base remains attached to the underlying tissues and ensures vascular supply.  

• It can involve the epithelium, the chorion and the periosteum and we will speak of a muco-periosteal flap (full thickness)
• Or be dissected into the thickness of the connective tissue and is then called a mucosal or partial thickness flap. 

Directions:

• Have sufficient accessibility to the root surfaces for proper debridement to be performed 
• Elimination of pockets larger than 5mm that do not respond sufficiently to initial treatment
• Infrabony pockets
• Significant thickening of the bone rim (treatment of bone lesions)
• Dental hemisection with treatment of adjacent structures (treatment of interradicular lesions.

Contraindications:

• Gingival swelling and hyperplasia 
• Very unfavorable clinical coronary-radicular report
• Loose teeth with significant attachment loss
• Difficult access

5. APICALLY REPOSITIONED FLAP:

Incision is internally beveled and moved apically relative to its initial position. Sutures performed on the bony crest or slightly coronally.

 Indication: Keratinized gingival height equal to or less than 3 mm; Shallow periodontal pockets.

Contraindications:

• Periodontal pockets in aesthetic sectors 
• Deep intrabony defects 
• Patients at high risk of caries 
• Severe hyperesthesia 
• Teeth with significant mobility and loss of attachment
• Very unfavorable clinical coronary-radicular report NEUMANN FLAP (1926)

6. PALATE ACCESS FLAP 

It concerns the upper incisor-canine block and aims to provide access to the very frequent palatal lesions at this level. Intrasulcular vestibular and interdental incisions as well as palatal semilunar incisions allow the lifting of the interdental gingival tissue.

2. MUCCO-GINGIVAL SURGERY:

DEFINITION: Mucogingival surgery is defined as “all periodontal surgical techniques aimed at correcting defects in the morphology, position and/or quantity of the gingival tissue bordering the tooth.” 

1. Frenotomy/frenotomy:

Definition 

   Frenulumectomy is the total removal of the frenulum followed by detachment of the muscle fibers.  

  Freinotomy is the partial removal of the frenulum, it is the dissection of the frenulum from the apex to the base.

2. Vestibuloplasty: 

Definition:

Increasing the depth of a shallow vestibule in order to remove any tension at the marginal gingiva and obtain sufficient height of attached gingiva thus facilitating hygiene and adequate brushing.

Indications:

• Practiced exclusively in the lower incisor-canine sector and sometimes extending to the premolars
• Short vestibule associated with a generalized brevity of the attachment system without significant root exposure.
• FLAP TECHNIQUES:

1. Laterally displaced flap:

Definition: surgical technique intended to cover and/or stabilize root denudations. The gum is moved (rotational movement) and sutured to the area to be treated 

Indication:

• Aesthetic damage
• Hyperesthesia
• Progressive lesion 
• Lack of adherent gingiva

Contraindications:

• Presence of inflammation 
• Improper hygiene 
• No aesthetic problem 
• Absence of hyperesthesia 

2. Bipapillary flap:

Definition: Technique described by Nelson in 1987, 

It is a double lateral translation flap associated or not with the use of a connective graft.

3. Coronally displaced flap:

Definition:

Intervention which consists of moving in a coronal direction the gingival tissue present apically to the site to be treated.

Periodontal surgery.

4. Semi-lunar flap:

Definition:

This technique was described by Tarnow in 1986. It is a variant of the coronally displaced flap.

• GRAFT TECHNIQUES:
  1. EPITHELIOCONJUNCTIVE GRAFTS:

Definition :

It is the autogenous transplantation of mucosal tissue from a donor site to a recipient site. Technique described by BJORN in 1963 which consists of the placement at the level of the area to be treated of an epithelial-connective graft taken from the palate.

2. CONJUNCTIVE GRAFTS FOUND:

Definition :

Surgical intervention consisting of graft removal from the thickness of the palate or maxillary tuberosity, which will be fixed under a flap. Technique based on the specificity and induction of connective tissue.

Historically, the use of connective tissue grafts has been proposed to improve the aesthetic results of interventions compared to those obtained with epithelial-connective tissue grafts.

• ADVANCED TECHNIQUES:

1. GUIDED TISSUE REGENERATION:

Goals:

Guided tissue regeneration aims to reconstitute the entire attachment system, unlike other techniques which promote repair, with the creation of a long junction epithelium in contact with the root surface.

Directions:

The use of a membrane limits this technique to single recessions, in the presence of thick tissues that can be pulled coronally. The objective is therefore twofold: regeneration of the attachment system and recovery of the recession.

3. BONE SURGERY:

 1. Definition: The term bone surgery refers to surgical procedures performed on bone with the aim of reshaping or restoring it; it aims to correct bone lesions caused by periodontal disease or by anatomical deformation.

2. Goals of bone surgery:

Surgical interventions on the bone, seeking an ideal bone architecture resulting in a physiological anatomy of the bone and even gingival tissues as well as a drastic reduction in the depth of the pockets, better control of personal oral hygiene.

3. Different therapeutic techniques:
4. SUBTRACTION TECHNIQUE (RESECTIVE BONE SURGERY):

•  Resective techniques include osteoplasty and osteotomy, which involve remodeling of the alveolar bone with removal or elimination of supporting bone, 
• unlike osteoplasty which does not require the removal of bone and therefore allows harmonization of contours while sparing bone tissue.

2. RECONSTRUCTION OR FILLING TECHNIQUES:

Without contribution  : Regenerative techniques involve debridement and curettage of lesions.

   PRICHARD demonstrated that certain bone lesions were likely to regenerate without surgical intervention but by simple curettage of the lesion.

With contribution  : The principle consists of depositing, after curettage of the lesion, a filling material capable of increasing the regeneration potential of periodontal tissues in order to promote bone reconstitution and the formation of a new attachment .

** RTG + bone graft association:

• Prevent membrane collapse in the lesion 
• maintaining a significant scar space. 
• new bone formation could be improved 

**Guided Bone Regeneration (GBR):

In ROB, bone defects are covered with a membrane that is precisely adapted to the bone surface. Non-bone cells are excluded. Osteoblasts from the periosteum and bone are driven to the bone surface to facilitate new bone formation.

4. the sutures:

Definition: 

The suture is the means by which the thread passes from one point to another, the point being the one at which the needle enters into contact with the tissue by piercing it (Pasqualini and Gallini, 1989)

Its objectives are to:

• cover the alveolar, interdental or crestal bone with soft tissues
• bring your mucous membranes closer together to promote healing and reduce your postoperative complications 

5. healing: According to Bouchard and Etienne 1993: The healing of a wound represented by all the biological phenomena, which lead to the repair of the tissue concerned, achieving its continuity, with restitution of its morphology and its function. 

Periodontal surgery.

5. Conclusion :

Practitioners must be aware of the different indications and contraindications of surgical techniques in order to be able to decide on the best approach to follow for each case and avoid failures in unfavorable cases.

Periodontal surgery.

  Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.
 

Periodontal surgery