Periodontal Surgical Techniques Research Articles

Different managements for surgical approaches in the aesthetic and functional treatment of type IB altered passive eruption

Aesthetics has been one of the most discussed and explored subjects in today’s dentistry. Therefore, the search for procedures aimed at facial harmonization has been more frequent in dental offices. The gingival smile is characterized by excessive gingival exposure to the smile being one of the main complaints of the patients who seek a dental surgeon in order to obtain facial aesthetics, being able to present different causes. It is extremely important to correctly diagnose each case so that the correct etiology is stable and successful in the treatment to be performed. Objective: In the present paper, two clinical cases of patients with complaints of gingival smile and short teeth were reported in which the etiology of both was type IB altered passive eruption. Case report: Due to the individual characteristics of each patient, each case was solved with different surgical approaches. In the first case, the patient had a thick periodontium and therefore the clinical crown lenghtening procedure was performed through the internal bevel gingivoplasty with osteotomy and osteoplasty. In the second case, the patient had a thin periodontium, and it was possible to perform a clinical crown lenghtening using the flapless technique. Conclusion: Therefore, although both cases present the same etiology, different periodontal surgical techniques were used, which allowed for satisfactory results for the patients.

Advances in the periodontal surgical flaps techniques to preserve gingival papilla

Papilla preservation in periodontal surgery is not only beneficial to maintain postoperative aesthetics and good oral hygiene but also contributes to obtaining good periodontal regeneration outcomes. Various periodontal flaps have been designed to preserve the gingival papilla, which constitutes the clinical basis for periodontal open flap debridement and periodontal regeneration surgery. A comprehensive understanding of their design purpose, indications, and technical key points will help clinicians to choose the optimal surgical plan, and thus improve the clinician's treatment levels, and obtain good clinical outcomes. Therefore, this article aims to introduce the design background, indications, and technical key points of various surgical flaps, such as papilla preservation technique, modified papilla preservation technique, simplified papilla preservation flap, etc.

Preclinical teaching of periodontal surgical concepts using common instructional models: A comparative assessment.

Some commonly used models utilized for teaching periodontal surgical techniques to dental students include pig mandible and periodontal typodonts. Currently, no study compares the learning and teaching outcomes following the use of one model to the other. This study is aimed at evaluating the effectiveness of the preclinical laboratory component on student understanding of concepts taught in the periodontal surgical course and assessing students' and faculty members' satisfaction with the instructional models. As part of the surgical periodontics course, 98 students took the final exam, with eighty students participating in only the pig mandible session and twenty-three students participating in both the pig jaw mandible and an additional session utilizing periodontal typodonts under the supervision of ten periodontal faculty members. Examination scores of students attending or not attending the laboratory session were analyzed by a two-sample t-test. A questionnaire evaluating the effectiveness of both models was given to faculty members and students who participated in both laboratory sessions. These results were analyzed by paired t-test. Participation in the laboratory sessions did not significantly impact the final exam scores (p=0.722). Students who had better didactic performance in the course performed better in the final exam, irrespective of laboratory participation. Both students and faculty members preferred typodont to the pig mandibles in learning or teaching periodontal surgical concepts, but both felt gaining flap management and flap refection experience to be better with the pig mandible model without statistical significance (p=0.119 and p=0.070, respectively). Within the limitations of this study, we can conclude that laboratory sessions did not significantly improve student performance on the exam. Students and faculty members generally gave positive feedback on both instructional models. Periodontal typodont could be an alternative model for teaching dental students, periodontal surgical concepts.

A Comparative Clinical Study to Assess the Role of Antibiotics in Periodontal Flap Surgery.

Introduction:Periodontitis is a multifaceted disease that results from the intricate interplay of infectious pathogens and host factors. Periodontal surgical techniques may be required in moderate to severe cases of chronic periodontitis. As a result of the potential for postoperative infection to have a substantial impact on the surgical outcome, an attempt will be made in the study to assess the role of antibiotics in periodontal flap procedures in minimizing postoperative infections.Methodology:From the Department of Periodontics and Oral Implantology, 30 patients (male and female) with moderate to severe chronic periodontitis were chosen. Amoxicillin 500 mg three times a day for 5 days following surgery was given in the therapeutic group (15 patients). Antibiotics were not provided to the control group (15 patients) after surgery. Both groups were administered analgesics and antiseptic mouthwash. On the seventh day after suture removal, patients were assessed for pain (measured on a visual analogue scale [VAS]), modified gingival index, wound healing index, swelling, fever, ulceration, and delayed wound healing.Results:The VAS reported in the control group was 2.67, while the VAS recorded in the therapeutic group was 2.20. The mean modified gingival index score in the control group was 0.94, while it was 0.67 in the therapeutic group. The mean Wound Healing Index score in the control group was 3.80, whereas it was 3.97 in the therapeutic group. When antibiotics were administered to patients, they reported less pain and faster wound healing. Following flap surgery with or without antibiotics, however, there were no statistically significant variations in all clinical measures.Conclusion:The findings of our study imply that antibiotics for the sole goal of avoiding postsurgical infections may not be beneficial.

Cirurgia periodontal de retalho de Widman modificada no sextante anterior: caso clínico

Introduction: The treatment of periodontal disease is considered complex, including, in the first phase, a non-surgical therapy, and then, eventually, a surgical therapy. The modified Widman flap presents itself as a technique that allows a decrease in the probing depth of the pockets with maximum preservation of the periodontal tissue, indicating when aesthetics is an important factor. Descrition of the case report: A 53-year-old female patient was diagnosed with periodontitis stage IV grade B. Non-surgical periodontal treatment was started, using root planing. In the revaluation consultation, it was found that the depth of probing of the pockets did not reach normality. Treatment was continued using the Widman flap periodontal surgical technique modified in the anterior sextant. Conclusions: The modified Widman flap surgical technique proved to be a treatment option, achieving stability and periodontal health.

Utilização das técnicas cirúrgicas em periodontia: Revisão da literatura

A cirurgia periodontal é uma parte importante do tratamento periodontal e deve ser levada em consideração quando a terapia convencional não elimina o problema periodontal. Também apresenta-se indicada em alguns casos estéticos ou casos em que seja necessário melhorar o acesso à determinada área para dessa forma realizar o correto plano de tratamento. O objetivo do presente estudo é apresentar as principais indicações das técnicas cirúrgicas periodontais e detalhar os procedimentos apresentados na literatura. Trata-se de uma revisão de literatura, utilizando como base livros e artigos científicos presentes no PubMed, Scielo e Google Acadêmico. É importante salientar que a terapia periodontal não cirúrgica preceda o tratamento periodontal cirúrgico. A associação entre a cirurgia mucogengival e enxertos, demonstrou resultado positivo no tratamento de recessões gengivais, assim como a cirurgia regenerativa com uso de biomateriais apresentou eficácia no tratamento de defeitos ósseos periodontais. A cirurgia periodontal pode ser empregada como uma importante ferramenta no tratamento de diversos problemas periodontais.

Use of the Free Gingival Grafting Technique for soft tissue reconstruction after excision of a Peripheral Ossifying Fibroma

The Peripheral Ossifying Fibroma is a benign tumor that develops from a hyperplastic tissue reaction, usually related to traumatic stimulus that are responsible for triggering inflammatory reactions of the connective tissue. Histologically, it is a nodular mass characterized by a dense connective tissue, surrounded by stratified squamous epithelium. Surgical removal in these cases is indicated, and for reconstruction of soft tissue in the region, some periodontal surgical techniques are recommended, such as free gingival grafting. Thus, the present study aims to report a clinical case submitted to the free gingival graft technique for tissue reconstruction after the surgical removal of a fibroma. A total excision of the lesion was performed, later sent to a histopathological report where it was diagnosed as Peripheral Ossifying Fibroma, after the removal of the lesion the region was left with the periosteum exposed and then the free gingival graft was performed to cover the region and promote keratinized gum augmentation. This technique proved to be efficient for reconstruction of soft tissue in the region after surgical removal of the Peripheral Ossifying Fibroma, returning aesthetics, function and periodontal health.

Minimally Invasive Surgical Strategies in Regenerative/Reconstructive Periodontal Therapy.

After a quick overview on the original principles of guided periodontal regeneration (GTR), the aim of this paper focuses on the advantages of minimally invasive surgical techniques for periodontal regeneration/reconstruction. The specific clinical question to answer is: Are there new clinical parameters useful to choose the best minimal invasive surgery approach for each periodontal defect? An update of the decision trees is to propose after highlighting some clinical parameters deemed relevant for the choice of the most suitable minimally invasive surgical approach and which therefore are considered by us having a place in the new decision trees. Starting from the paper of Evian dated 1985 until that of Aslan in 2017, we have analyzed the minimal periodontal surgical techniques proposed for the periodontal regeneration. In addition to the parameters set in the various flowcharts, we have highlighted the following additional parameters: papilla height loss; supra bone component of the defect; Δ Bone Sounding; width of keratinized tissue. The decision-making chart improved with the new clinically relevant factors may serve as a useful guideline for dentists, but to definitively validate it, further studies need to be developed in the future. In order to clarify the proposed flow chart, the authors present two different clinical cases.

USO DE HIPERPLASIA GENGIVAL FIBROSA EM REGIÃO DE TUBER COMO ALTERNATIVA PARA CORREÇÃO DE DEFEITO ALVEOLAR: RELATO DE CASO

The various preprosthetic periodontal surgical techniques proposed currently, provide a future prosthetic work with better aesthetic results and functional.The objective of this study was to report a clinical case of periodontal surgery for correction of the defect in the alveolar border, by means of the subepithelial connective tissue graft. Patient presented fibrous hyperplastic growth, in the region of the maxilla túber and lip defect in the region of the upper central incisor. After planning the event,were carried out, concomitantly, two plastic surgeries prosthetic periodontal lunches. In the first surgery, a connective tissue graft was removed from the donor area, the maxila túber and then was adapted in the anterior region, receiving area where the defect of flange. Thoughtout a postoperatory period of 45 days, that the choice of surgical technique, the type of graft used for correction of the defect of rim, were pre-requisites for the future success in aesthetic and functional prosthetic rehabilitation.

Acellular dermal matrix and gingival connective in the treatment of periodontal recessions – comparative clinical evaluation in humans

ABSTRACTDifferent periodontal surgical techniques have been proposed for the treatment of periodontal recessions. Among these, the graft of gingival connective tissue stands out for the high predictability of success. This work compared the clinical outcomes of treatment of periodontal recessions, using the gingival connective tissue grafts and acellular dermal matrix. A total of 72 recessions constituted the sample, divided equally into 2 groups. Group 1: treated with acellular dermal matrix graft (MDA) associated with the displaced: Group 2: treated with gingival connective tissue graft, also associated with the flap offset coronally. We evaluated the clinical parameters of probing depth, insert, clinical periodontal recession towards coronal-apical diameter mesio-distal of recessions, keratinized and mucosa thickness flap and influence of grafts in relation to root coverage. The initial measures were compared to those obtained with 45, 90 and 120 days after surgery. No statistically significant differences were found between the groups in terms of reduction of periodontal recessions, keratinized and mucosa flap thickness and of grafts in relation to root coverage. The Group 2 (CG) showed statistically significant reduction in the depth of drilling and clinical level of insertion, compared to group 1 (MDA). However, these differences were not clinically relevant. It was concluded that both the gingival connective tissue graft as the acellular dermal matrix can be used in the treatment of periodontal recessions, with a high predictability of success.Keywords: Gingival recession, connective tissue graft, acellular dermal matrix, periodontal surgery, gum recession, root coverage.

Er:YAG Laser as an Advanced Periodontal Surgical Technique

Lasers were introduced into the field of dentistry as they performed work more precisely and effectively with less discomfort to the patient by minimizing pain and recovery time. Every discipline of dentistry has been positively affected with the use of laser technology including Oral Medicine, Oral surgery, Pediatric and Operative Dentistry, Periodontics and Oral Implantology, Prosthetic Dentistry. Treatment with lasers provides a hope of overcoming the disadvantages of conventional dental procedures. In this paper, a brief history of the mechanism and uses of the Erbium-doped:Yttrium-Aluminium-Garnet (Er:YAG) laser is presented, which is the most commonly used tool in Periodontics and Oral Implantology.

Orthodontic–periodontics interdisciplinary nonsurgical approach to manage infrabony osseous defect

Clinicians often encounter infrabony osseous defects that are usually best treated by periodontal surgical techniques, including bone grafting and guided tissue regeneration, with a goal of establishing a new connective tissue attachment. On occasion, infrabony osseous defect proximal to a central incisor with extrusion and large midline diastema may present an opportunity to consider a resolution by orthodontic–periodontic interdisciplinary approach. Orthodontics has been used as an adjunct to periodontics to increase connective tissue support and alveolar bone height. In modern clinical practice, the orthodontic–periodontic interdisciplinary approach is essential for optimized treatment outcomes. The purpose of this case report is to highlight the importance of orthodontic–periodontic interdisciplinary approach in clinical practice and to improve the level of cooperation between dental practitioners. The authors decided to treat an advanced case of periodontitis, with extrusion and pathological migration of a maxillary central incisor, using orthodontic–periodontic interdisciplinary approach. After the nonsurgical conventional periodontal therapy, the orthodontic movement was started, and the incisor was repositioned using an intrusive mechanism. There was a significant clinical decrease in the probing depth values, and radiographs showed a remarkable reduction of the infrabony osseous defect.

Minimally invasive surgical techniques in periodontal regeneration

There are recent advances in periodontal surgical techniques, from resection to regeneration, the focus of surgical access has shifted to regeneration of lost tissues. To achieve goals of periodontal surgical therapy, minimal invasive surgery can be considered as a potential future for the treatment of periodontal disease with the concept of being minimal in our treatment approaches. This article reviews the various techniques, its applications, and future prospects of minimal invasive periodontal surgery.

Pig Mandible as a Valuable Tool to Improve Periodontal Surgery Techniques

Clinical education in dental practice is a challenge for professionals and students. The traditional method of clinical training in Periodontology usually is based on following the procedure and practicing under supervision, until achieving proficiency. However, laboratory practice is required before direct care in patients. Specific anatomic plastic models can be useful, but animal cadaver models provide better similarity to human tissues. The objectives of this study are to describe a model for training periodontal surgical techniques in a pig mandible model and evaluate the effect of the program on student’s progress. Several surgical procedures were critically analyzed and trained with graduate students, including: gingivoplasty/gingivectomy, distal wedge procedure, frenectomy, internal bevel incision, total/partial flap, furcation access, gingival grafts and suture techniques. These procedures were theoretically reminded before laboratory practice. A questionnaire was applied concerning aspects of the laboratory and students provided their concepts and impression. The majority of the students scored positive aspects related to laboratory practice. Based on the questionnaire answers, we observed that the practical laboratory helped in the assimilation of the theoretical content and improved skills in the practice of periodontal surgical techniques. Graduate students were also more confident in performing these surgical procedures directly on the patient. Another positive aspect is the similarity of pig teeth and gingival tissues to human correspondent, being especially appropriate for surgical demonstration and training with excellent reproducibility. The laboratorial practice with pig mandible for graduate students was a valuable tool to improve periodontal surgical techniques.

Dealing with gingival recession associated with non-carious cervical lesion

Gingival recession is a very common problem and can affect 100% of the individuals older than 50 years. Almost 50% of these cases, gingival recession is associated with a noncarious cervical lesion and together, they form a combined lesion that requires multidisciplinary approach to properly deal with this condition. When the combined lesion is treated by only a restorative procedure, the position of the gingival zenith is kept more apically due to the persistence of the gingival recession, which would lead to a longer tooth and consequently to a possible esthetic disharmony in case of recession greater than 2 mm. On the other hand, if the surgical procedure for root coverage is individually performed, the coronal portion of the non-carious cervical lesion may not be covered with the periodontal flap after the healing period. It happens because, in most cases, the non-carious cervical lesions affect the enamel above of the cemento-enamel junction, and this zone of the tooth crown cannot be covered, which gives the impression that the procedure was unsuccessful. In order to overcome these limitations, some randomized clinical trials evaluated the clinical outcome of different multidisciplinary approaches that combined restorative materials, such as resin-modified glass ionomer and composite resin, with periodontal surgical techniques for root coverage. These approaches restored the entire length of the cervical lesion and placed the flap/graft on top of it. After a healing period, good clinical outcome was achieved; the root zone of the restorative material was coverage by a healthy soft tissue, and good esthetic outcome could be observed. However, questions began to arise: What if the restoration fail? Do we need to reopen the flap and do it all over again? Despite some studies showed good clinical outcome after some years, other therapeutic options need to be tested. Some case reports suggested that partial restorations of the cervical lesion (just the coronal zone) may be a valid option. However, clinical trials are needed to test this option. In addition, no guideline that takes in account the anatomy of the cervical lesions is available. Ergo, we are still evolving our knowledge regarding the best way to deal with this combined lesion and clinicians should be aware of what will come next. Mauro Pedrine Santamaria

Gingival biotype and its clinical significance – A review

Abstract Gingival biotype has a significant impact on the outcome of restorative and regenerative therapy. The disparity in treatment outcome is possibly because of the difference in tissue response to trauma. Hence in clinical practice identification of the periodontal biotype is significant. Gingival thickness can be assessed by various invasive and non invasive methods. Thick and thin tissues often respond differently to inflammation and trauma. Periodontal surgical technique can improve the tissue quality and treatment outcome. This review paper highlights the general aspects of gingival biotype, methods to assess gingival thickness, response to treatment, techniques to improve tissue quality and its clinical significance.

Surgical Treatment Options for Grafting Areas of Gingival Recession Association with Cervical Lesions: A Review

Gingival recession (GR) is a highly prevalent dental problem that may be associated with dentin hypersensitivity and aesthetic complaint. Furthermore, GR is often complicated by dental cervical wear of substance, such as erosion, abrasion, or abfraction lesions, as well as initial or more extensive carious involvement of the cervical area, which worsen the symptoms and make the treatment of this periodontal condition more challenging. To provide an overview of surgical treatment options presented in the literature for sites affected by GR with carious cervical lesions (CCLs) or non-carious cervical lesions (NCCLs). The Medline database was searched for items dealing with GR and its treatment options, especially on GR associated with CCLs or NCCLs. Several periodontal surgical techniques have shown good potential for treating GR over the years. Specifically, considering GR associated with CCL or NCCL, an assessment of both hard (dental) and soft (gingival) tissue characteristics of the involved site is recommended in selecting the surgical procedure. For GR associated with CCL or NCCL, hard and soft tissue characteristics of the involved site have to be carefully evaluated in order to choose the most appropriate surgical procedure. A structured decision-making process, considering both hard and soft tissue characteristics of the involved site, is recommended in choosing the most appropriate surgical procedures to treat GR associated with CCL or NCCL defects. The restitutio ad integrum of the dento-periodontal unit is an essential condition to restore the tooth to its original function and esthetics.

Immunological and microbiological findings after the application of two periodontal surgical techniques: a randomized, controlled clinical trial

To examine microbiological and immunological alterations following two periodontal surgical techniques, over a 6-month period. A total of 30 chronic periodontitis patients participated in the present randomized controlled clinical trial and were randomized in two groups. Modified Widman flap (MWF) was applied in the control group and apically positioned flap (APF), without intervention to the bone, in the experimental group. Gingival crevicular fluid samples and subgingival plaque samples from the operated sites were collected at baseline, 6th, 12th and 24th post-operative week. No major differences were noticed in immunological and microbiological profile of patients receiving either modified MWF or APF, for a period of 6 months. The choice of the periodontal surgical procedure does not seem to affect the immunological and the microbiological profile of patients with chronic periodontitis.

Crestal bone resorption after the application of two periodontal surgical techniques. A randomized, controlled clinical trial

To radiographically assess, by means of digital subtraction radiography, crestal bone loss following two periodontal surgical techniques, over a period of 6months. A total of 30 chronic periodontitis patients participated in this randomized controlled clinical trial and were separated into two groups. Modified Widman flap was applied in the control group and apically positioned flap, without intervention to the bone, in the experimental group. Clinical measurements (plaque index, gingival bleeding index, probing pocket depth and clinical attachment level) were recorded at baseline, 6weeks, 3 and 6months after surgery. Digital radiographs were taken at baseline, 1, 3, 6weeks, 3 and 6months after surgical treatment and subtracted digitally in pairs. Both groups showed statistically significant improvement of clinical parameters. Statistically significant differences between the two groups were observed only in probing pocket depth (PPD) at 6weeks interval, where the test group showed more reduction (smallest statistically significant differences observed, SSSDO=0.64). Both groups showed the same rate of crestal bone resorption. Bone resorption of the alveolar crest is a phenomenon that is observed as a consequence of periodontal surgical treatment without significant differences between the two techniques. Furthermore, both surgical techniques lead to satisfactory clinical results, indicating that bone removal during periodontal surgical treatment is not always necessary.

Periodontal and Prosthetic Biologic Considerations to Restore Biological Width in Posterior Teeth

The biologic width is an essential dental space that always needs to be maintained to ensure periodontal health in any dental prosthetic restorations. An iatrogenic partial fixed prosthesis constructed in lower posterior teeth predisposed the development of subgingival caries, which induced violation of the biologic width in involved teeth, resulting in an uncontrolled inflammatory process and periodontal tissue destruction. This clinical report describes a periodontal surgical technique to recover a violated biologic width in lower posterior teeth, by crown lengthening procedure associated with free gingival graft procedure, to ensure the possibility to place a modified partial fixed prosthesis in treated area. The procedure applied to recover the biologic width was crown lengthening with some modifications, associated with modified partial fixed prosthesis to achieve health in treated area. The modified techniques in both surgical and prosthetic procedures were applied to compensate the contraindications to recover biologic width by osteotomy in lower posterior teeth. The result, after 4 years under periodic control, seems to achieve the projected goal. Treating a dental diseased area is necessary to diagnose, eliminate, or control all etiologic factors involved in the process. When the traditional methods are not effective to recover destructed tissues, an alternative, compensatory, and adaptive procedure may be applied to restore the sequelae of the disease, applying a restorative method that respects the biology of involved tissues.