Perio Sheet #5 By Amani Al-Rabab'a

by **Sura** 22/10/2012, 9:08 pm

http://www.4shared.com/office/u3nW0TY2/perio_5_amani.html

by **Shadi Jarrar** 12/11/2012, 9:20 pm

بسم الله الرحمن الرحيم
Management of osseous defects/Osseous Surgery

► Reasons to rise up a flap :

1- accessibility , for meticulous scaling and root planning

2- Regenerative technique, i.e. bony defects . we have to model or fill the defect with bone grafting in harmony with bony architecture , by this you should know about : how much resorption you have and type of bony defect preoperative .

►Once we decided to go for a flap for regenerative technique , how to know if this is indicated or not .

Note : Periodontal Regenerative Surgery : A bone graft is used to recreate bone and soft supporting tissues lost due to gum disease.

►Tooth with pocket requires : - modified widman flap ; access flap

- or pocketing with the measured depth more than 5mm , say 7, 8, 9 mm , which indicates bone resorption . how to manage such pockets ; with bone resorption??? That is what we will know in this lec.

►Osseous defect : is a concavity or defect in the alveolar bone involving one or more teeth , this certain the idea that 'periodontitis' is a site specific disease . so once you open a flap you might see bone deformity on one site and the adjacent doesn’t have .

So we have : - convexity - concavity - deformity

Regarding concavity in the bone , usually uniform in which bone resorption has occurred in similar periods .

But deformity , severe bone loss which is irregular .

' we will learn how to manage each one'

►Osseous surgery : recontouring and irradication of irregular bony defect and crater , since these defects are thin , un-supported and susceptible for fracture ; regenerative technique .

►Morphology of bony defect :

It is important before any osseous surgery to identify and classify the bony defect as quick as possible .

Bone resorption identified by measured probing depth :

- less than or equal to 5mm , no resorption

- more the 5mm , bone resorption .

so the probe : measure , identify the sites where resorption occurred , but it can not predict the shape of resorption .

This way ;using probe , to estimate defect before osseous surgery is called : Topography in a single plane , in which we insert the probe in the pocket from above in a perpendicular manner , which is a useless way , it tells you that there is a bony defect but can not tell you to decide to open a flap or not .

Another way being used : radiographs in which we use radiopaque material , same principal in root canal obturation using gutta percha. ((There is another material used for obturation of root canal , plasticized material which is a liquid material with specific temperature once inserted in the canal it will fill the main canals and collateral canals , seal the apex with no chance of future perapical lesions J ))

In perio , radiopaque materials used : silver points or H –feil pauls??? "I can not hear it will" :( This material is flexible , used instead of probe , once it is inserted in the pocket it will take the shape of bony defect .

Limitation of silver points : used in single site probing depth , even if you use more than one in each site still inaccessible to many areas and can not be penetrated , even it is flexible . it can not give you the whole picture of how the bone has resorped, it give us an idea of resorption but can not achieve the goals .

►All previously mentioned methods give us a spatial vision ; existing and in a space ! so they are topographic ways tell you if there is or there is not resorption

So what is the best way to know exactly amount of bone loss , architecture , where is crater , deformities and un-supported bone . using surgery to identify mentioned objectives is not possible and illogical way to open a flap for every patient and see every thing in the naked eye .

►Tooth mobility classification :

Class O	Complete tooth stability.
Class I	Tooth moves 1/2 mm buccally and 1/2 mm lingually.
Class II	All degrees between Class I and Class III mobility of up to 1mm in any direction.
Class III	Tooth is terminally mobile. Greater than 1 mm in any direction and is depressible in the socket.

لالالالالالا

Class I < due to occlusal trauma , beginning of periodontal disease . we all know the treatment J! I think just scalling and root planning . prognosis is high

Class II < we have to assess the entire condition : level of gingival attachment , type of disease and the patient is free from any systemic disease . Tx is problematic but still there is a solution .

Class III < Tx :extraction

►According to previous data , we decide to do or not to do a flap surgery for regenerative technique : - grade of mobility

- oral hygiene of the patient - gingival recession

►Infrabony defect : a periodontal pocket in which the base is apical to the crest of alveolar bone .

It is misconception " alveolar crest is intact and pocket is found apical to it " .

SO what does occur: resorption usually starts vertically then transformed into horizontal direction in the chronic disease , and the crest of the alveolar bone will shifted downward; apically .

►Types of bony defect :

1- three walls 2- two walls 3- one wall

Details :

1- three walls : 3 remaining walls are intact and one is missing in one site in the pocket not around the tooth surface . The resorped wall in the pocket is not restricted to specific side , i.e. the resorped wall might be the facial wall and extending all around the tooth = circumferentially bony defect , but stills 3 walls bony defect . we called this intrabony defect , within the bone of the pocket.

Surface area of bone resorption : in horizontal dimension : wide or narrow . in depth deep or shallow .

Eg: #narrow opening of the pocket with shallow depth : tx OHI , proper scalling , meticulous root palning and using chemicals for detoxification

# wide and deep pocket : you have to open a modified widman flap then bone grafting .

►We treat the tooth :

- which is not having severely inflamed surrounding periodontium

- less than grade II mobility , and no mobility teeth

- measured probing depth surrounding the tooth in all sites less than 3mm except in one site depth more than 5mm .

2- two walls bony defects : like intradental bony defect , between two teeth = crater which is the most prevalent bony defect among all classifications .

3- one wall bony defect : 3 walls lost and one is intact

"dr was asking on a diagram identify the type of bony defect and which wall has been lost "

4- combined bony defect : cup like appearance . it is not possible to be combined <3walls bony defect + any other type > !!! . but it must be one defect + any other type ' 2 walls or 3 walls' ????

So by knowing the type of bony defect , you can put your tx plan .

In three walls bony defect "one is lost and 3 intact " and it was deep , only solution is bone grafting .

But if 3 walls are lost and only one is intact , we do bone grafting + guided tissue regeneration because the bone and connective tissues are lost , so this will guide the growth of PDL , which is not a problematic but difficult . results will be challenging if the patient doesn’t continue the oral hygiene practice so end up with failure L

►What do we achieve from osseous surgery :

1- crown lengthening , easy just cut the gingival all around . sometimes the alveolar bone is thick ,and if you cut part of the gingiva , you might end with bone exposure , so what you should do : open a flap to perform osteoplasty to recontour and remove from the thick bone ,so the healing will be primary.

2-to create a contour of the bone that is parallel to the contour of the gingival margin , related to the biologic width !!

3- to create a contour that permits the patient to accomplish effective plaque control .

►Choices for resolving osseous defect :

1- osteoplasty : -crown lengthening - un-supported bone

- to recontour the bone and reduce the thickness.

2- osteoctomy :remove tooth supporting bone , there are certain indications we will take next week

3- regeneration using bone grafts which do : - osteoinduction

- osteoconduction - regenerative

Grafted bone acts as template , and it also induces natural bone growth = known as bone redeposition .

Case : multirooted tooth , one root with good amount of surrounding bone and the other one has bone resorption :

- endo tx for root with bone surrounding

- amputation of the root with resorped bone .

►By frequent scalling , root planing and using local drugs , the 3 walls bony defect " one wall is resorped " with shallow and narrow pocket , this defect should be left as it is , no need to expose the patient for surgery to correct that defect . so we just encourage oral hygiene and frequent visits to maintain and fix the defect so not to develop to further stages .

►Osseous surgery :like impacted tooth we do a flap surgery .

►Biological width :

There is an intimate relation between gingiva and tooth surface , this relation is controlled by

1-subclinical 3 variables : sulcus – junctional epithelium – connective tissue attachment . we say probing depth or sulcus depth in biological width = sulcus space , ranges from 1-3mm and it varies from between patients.

2-clinically, scalloped gingiva the contours are controlled by physiologic rules , since the gingiva follows the CEJ , also the scalloping is related to skeletal pattern . for example : pointed chin , then scalloped marginal gingiva is sharp and high interdental gingiva .

Wide chin , wide scalloped marginal gingiva and shallow interdental .

►Osseous ressective surgery osteoplasty and or ostectomy !!! are techniques aimed to achieve physiologic contour in the bone during surgery that permits anticipated for surgical procedures !!!

Which means :

:a- we open a flap for regenerative surgery , neither replace ' flap is closed in the same original position ' nor modified widman flap ' just luxate and open' . so we want a displaced flap either apically or coronaly positioned

b- perform osteotomy where required and osteoctomy where required , then fill the gap , ending by straight line border of bone no irregularities or defects .

c- now to replace the flap , if the gingival margin is not parallel to bone , then during healing the gingival margin tries to go inside the sulcus to achieve recontouring !! then changes in contour .

measured sulcus space using computerized probe = 0.69 mm

biological width : junctional epithelium + connective tissue = 2.04mm . in the past biological width was measured ; 1mmsulcus , 1mm J.E , 1mm C.T , TOTAL 3MM

choices if the gingival margin is not parallel to the bone :

1- sulcus depth increase , C.T decrease , instead of having sulcus depth 1mm , you will have 4 or 5mm , end with re-pocketing and the disease will come back again

2- healing by long junctional epithelium , so weak attachment , no C.T which is the major attachment

why we have to restore the biological width : because it is the first defense line , any food accumulation in sulcus the body will control the inflammation from zero .

perio

dr . Nicola

17-10

Done by : Amani Rababa'h

( it is better to read the chapter related to the lecture )J

Perio Sheet #5 By Amani Al-Rabab'a

Perio Sheet #5 By Amani Al-Rabab'a

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