Professional Documents
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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a b
Fig 1 (a) Baseline clinical image (frontal view) revealing heavy plaque and calculus accumulation, gin-
gival inflammation and severe teeth migration in the second sextant. (b) Twelve years later the complete
recovery of the gingival health as well as the spontaneous dental repositioning were achieved by nonsur-
HJDBM QFSJPEPOUBM UIFSBQZ, PDDMVTBM BEKVTUNFOU BOE TVQQPSUJWF UIFSBQZ XJUI SFDBMMT FWFSZ 4 NPOUIT. 5IF
anterior teeth were stabilized by means of extracoronal splintings. (Courtesy Dr Mariani.)
a b
Fig 2 3BEJPHSBQIJD JNBHFT PG UIF DMJOJDBM DBTF QSFTFOUFE JO 'JH 1 BU CBTFMJOF (a) BOE 12 ZFBST MBUFS
(b). A complete recovery of the periodontal health was evident together with the appearance of the lamina
dura. The correct relocation of the anterior teeth in the alveolar process was accompanied by the coronal
migration of the alveolar bone crest.
and ultrasonic devices. Tooth scaling is tum. When patient enters the mainte-
a key component in treating gingivitis, nance therapy the SRP can be replaced
while scaling combined with root planing by the periodontal debridement in which
(SRP) is the gold standard for the non- the removal of root cementum is not
surgical management of periodontitis.14 longer necessary.
The objective is to provide a root sur- Narrative and systematic reviews
face compatible with periodontal health have documented the efficacy of SRP in
by removing adherent and unattached the treatment of periodontitis. 15-18 It re-
bacterial plaque, microbial toxins, de- sults in reductions in bleeding on prob-
posits of calculus and contaminated ing (BoP), probing depth (PD), subgin-
cementum. Due to its strict adherence gival bacterial loads and gains in clinical
to the root cementum it is impossible to attachment level (CAL). Another param-
remove effectively subgingival calculus eter to be considered, in spite of the lack
without removing the underlying cemen- of scientific evidence, is the reduction in
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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the degree of tooth mobility, as clinically Clinical studies reported that subgin-
experienced. gival instrumentation failed to eliminate
Nonsurgical periodontal treatment DBMDVMVT JO 10% PG QFSJPEPOUBM QPDLFUT
can also lead to spontaneous reposi- XJUI B EFQUI PG < 5 NN, JO 23% PG QPDLFUT
tioning of pathologically migrated teeth XJUI B EFQUI PG 5 UP 6 NN BOE JO 35% PG
('JHT 1 BOE 2) BOE UP DMPTVSF PG EJBTUF- QPDLFUT > 6 NN EFFQ, JO 10% PG TJOHMF-
mas.19 Control of infection and inflam- SPPUFE UFFUI BOE JO 30% PG NVMUJ-SPPUFE
mation, elimination of abnormal occlusal teeth.30,31 ('JH 3) 3FDFOUMZ, UIF JNQSPWF-
forces and reorientation of supracrestal ments in ultrasonic devices, mainly with
collagen fibers play an important role in the modifications of the working tips,
the repositioning of teeth.20 have increased the effectiveness of ul-
The reduction in PD following mechan- trasonic scalers to reach deeper into
ical instrumentation results from both the periodontal pockets or furcation areas.32
shrinkage of the pocket soft tissue wall, Some studies suggest less cementum
manifested as recession of the gingival removal and less operative discomfort
margin, and the gain in clinical attach- compared to manual SRP but these find-
ment.21 The magnitude depends on the ings are not universally demonstrated. 33
initial PD. A review by Cobb reported It is our opinion that a combined in-
a mean PD reduction and CAL gain of strumentation approach is indicated to
1.29 NN BOE 0.55 NN, SFTQFDUJWFMZ, GPS optimize the treatment outcomes and
JOJUJBM 1%T PG 4 UP 6 NN BOE PG 2.16 NN the choice of the treatment modality
BOE 1.19 NN, SFTQFDUJWFMZ, GPS QPDLFUT should be based on the periodontal an-
JOJUJBMMZ ö 7 NN EFFQ.22 In general, clin- atomic features and the individual pa-
icians should evaluate post-SRP heal- tients’ needs.
JOH BU 4 UP 6 XFFLT GPMMPXJOH USFBUNFOU. When analyzing the SRP outcomes it
"GUFS 6 XFFLT, NPTU PG UIF IFBMJOH IBT is important to take in account the long-
taken place but soft tissues maturation term maintainability of deep periodontal
NBZ DPOUJOVF GPS BO BEEJUJPOBM 9 UP 12 pockets, and the risk of disease recur-
months or longer.23 rence. Post-treatment residual pockets
The limitations of SRP are well recog- exhibiting BoP and more than 5 mm
nized. The efficacy of the SRP seems deep are related to lower clinical stability
to be directly related to the professional XJUI BO PEET SBUJP NPSF UIBO 10 GPS EJT-
skill and the anatomical features but not ease progression. 34 Besides anatomical
to the modality of debridement as ultra- damage from previous periodontal dis-
sonic devices have achieved similar re- ease will persist and inverse architecture
sults than hand instrumentation. 24,25 The of soft tissue may impair home plaque
results are dependent on local factors, removal. The choice between non-sur-
such as deep and tortuous pockets and gical therapy alone and combined non-
furcations, as well as on patient’s factors surgical and surgical therapy has to take
such as smoking habits, uncontrolled di- in account the medical history, expecta-
abetes mellitus and poor self-performed tions, psychological profile and degree
plaque control which may limit the clinic- of compliance (full mouth plaque score
al outcomes.26-29 <'.14> < 20%) PG UIF QBUJFOU, BOE UIF m-
254
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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AIMETTI
a b c
Fig 3 Electron scansion microscopic images of microbial plaque on the root surface of a hopeless tooth
extracted at the completion of hand and ultrasonic instrumentation at magnifications of (a) ¨48, (b) ¨155,
and (c) ¨1,600. ($PVSUFTZ %S 4DJQJPOJ.)
nal purpose of the treatment. If a patient tion by periodontal pathogens of the al-
requires a prosthetic rehabilitation it is ready treated periodontal sites from the
necessary to surgically correct the ana- remaining untreated pockets and from
tomical defects caused by the disease intraoral bacterial reservoirs, such as
and to achieve postoperative PDs less tongue, tonsils, and other mucous mem-
UIBO 4 NN BOE BCTFODF PG #P1 UP PQUJ- branes, that could lead to a disease re-
mize the long-term prognosis. currence.36,37
In an attempt to improve subgingival Based on these premises the Leu-
instrumentation new treatment proto- ven research group proposed the one-
cols, the adjunctive use of systemic an- stage full-mouth disinfection protocol
timicrobials, and new technologies have (OSFMD) which consisted of full-mouth
been suggested. SRP combined with a disinfection of all
intraoral niches by means of the topi-
cal application of chlorhexidine, within
Advances in non-surgical 24 IPVST (VTVBMMZ JO 2 TFTTJPOT PO 2
consecutive days). 38 They reported
treatment protocols
clinical and microbiological advan-
Traditionally, SRP was carried out ei- tages compared to the CSD therapy in
ther quadrant- or sextant-wise in ses- chronic and aggressive periodontitis
sions usually scheduled at weekly inter- patients.39-41
vals (conventional staged debridement Other researchers proposed the treat-
[CSD]).35 0WFS UIF MBTU 10 ZFBST, NBOZ ment protocol of the full-mouth SRP (FM-
clinical trials have been carried out in SRP). The supra- and subgingival instru-
an effort to assess whether it would be NFOUBUJPO XBT DPNQMFUFE JO 24 IPVST PS
advantageous to change the stand- less with no adjunctive use of antiseptics
BSE 4- UP 6-XFFL QFSJPE PG OPOTVSHJDBM agents.42 When the FMSRP was com-
periodontal treatment to a full-mouth pared to the standard approach neither
24-IPVS BQQSPBDI. 5IF SBUJPOBMF GPS UIF clinical nor microbiological differences
latter strategy was to prevent reinfec- were detected.43,44
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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a b
Fig 4 Clinical images of ulcero-necrotic gingivitis treated by the administration of antimicrobials and an -
tiseptics, and then by the ultrasonic instrumentation (a). Care was taken not to damage the marginal peri-
odontal tissues. In spite of the destructive features of the pathology, this procedure and the thick gingival
biotype made it possible to limit the soft tissues contraction and to preserve the interdental papillary height
in the second sextant (b). (Courtesy Dr. Mariani.)
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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conditions, the light scarification of the Fig 5 Miller’s Class I recession type defect lo-
DBUFE BU UPPUI 1.3 USFBUFE CZ SPPU QMBOJOH BOE QPM-
interdental gingival tissues, according to
ishing (a). The coronal displacement of the gingival
the technique proposed by Shapiro et margin and the almost complete root coverage were
BM,53 DPNCJOFE XJUI BO BEFRVBUF IPNF achieved by both the detoxification and the gentle
and professional plaque control may reduction of the root convexity (b).
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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b c
d e f
Fig 6 Angiomatous neoformation between the upper central incisors in frontal (a), lateral (b) and overall
frontal (c) view. The neoformation even involved the fornix and the skin surface on the maxillozygomatic
area. The patient underwent two surgical sessions to remove the neoformation. Due to the relapse of the
lesion she was advised to extract the upper incisors. The histological analysis of a tissue specimen excised
during the nonsurgical instrumentation confirmed the diagnosis of lobular capillary hemangioma of the
interdental papilla. One year later, following the nonsurgical periodontal treatment and frequent sessions of
motivation and instructions in proper home plaque control measures, the complete recovery of the gingival
architecture was achieved without loss of interdental soft tissue (d and e). 'SPOUBM WJFX 17 ZFBST MBUFS (f).
258
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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a b
c d
e f
Fig 7 28-ZFBS-PME $BVDBTJBO XPNBO QSFTFOUFE XJUI UIF DIJFG DPNQMBJOU PG EJGmDVMUJFT JO TQFFDI BOE
mastication due to advanced mobility of several teeth. Good general health, amount of microbial plaque
inconsistent with the severity of periodontal tissue destruction, familiar aggregation supported the diagnosis
of generalized aggressive periodontitis. Clinical images at baseline (a, c, e) BOE 16 ZFBST MBUFS (b, d,
f). The patient underwent the OSFMD in according to the protocol by Quirynen et al 38 in association with
TZTUFNJD BOUJCJPUJD JOUBLF. 5IF TVQQPSUJWF QFSJPEPOUBM UIFSBQZ XBT QFSGPSNFE FWFSZ 3 NPOUIT. 5IF QBUJFOU
EJTQMBZFE B HPPE DPNQMJBODF XJUI B QMBRVF JOEFY TDPSF < 10% BOE BO PQUJNBM UJTTVFT SFTQPOTF (b, d,
f). The left upper central incisor was extracted during the etiological therapy and the crown was splinted
to the neighboring teeth as provisional treatment. The patient refused the implant rehabilitation and the
whitening treatment. At present the splinting is still in place.
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Fig 8 Buccal view of the first, third, fourth and the sixth sextants. You can observe the optimal patient’ self-
performed oral hygiene, the healthy condition of the marginal periodontal tissues and the partial recapture
of the interdental papillary tissue.
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