Professional Documents
Culture Documents
Dr shabeel pn
Contents
Introduction Classification of failure Pre Therapeutic Therapeutic Surgical
Non surgical
INTRODUCTION
Classification
Pretherapeutic Therapuetic Post Therapuetic
Pretherapeutic
Incorrect Patient Selection Age Socio economic status and nutritional deficiencies
s
Systemic disease:
Diabetes Mellitus Blood Dyscrasias : leukemia, Cyclic neutropenia Immune deficiences : Neutrophil monocytic chemotactic defects, AIDS Genetic disorders : Downs syndrome, Papillion Lefevre syndrome, hypophosphatasia , Chediak Higashi Syndrome) ; Vitamin deficiences
Pretherapeutic
Pretherapeutic
Therapeutic
Non-Surgical
Scaling Root Planing Splinting Occlusal therapy Local Drug Delivery
Surgical
Curettage Gingivectomy Abscess Drainage Flap Surgery Bone Grafts GTR procedures Root coverage procedures Implant Aesthetic surgeries
Scaling
Obviously recognized by remnants of calculus Causes: 1. Incorrect instrumentation & Poor condition of instruments. 2. Burnishing Calculus. 3. Induced Bleeding. 4. Prescription of Gum paints. 5.Assessment of calculus ratio.
Root Planing
Rough root surface and persistence of inflammation. Inadequate RPdetection of caries. Over instrumentation..hypersensitivity Presence of developmental grooves.Use of rotary instruments to smoothen as far as possible
Splinting
Failures could be: Inflammation in the area Breaking of splint Increased plaque accumulation.
How to Prevent?
Diagnose whether a temporary or permanent splint is required. Contouring the splint Proximal cleaning aids to be prescribed. Should be clear of occlusal interferences. Margins of splint should be flush with tooth surface
Occlusal therapy
Diagnosis of occlusal abnormalities. occlusal scheme of pt., plunger cusps, or other occlusal Interference. Assessment of tooth wear and judgement whether it can be corrected by selective grinding or a full fledged occlusal rehabilitation procedure is needed. Fremitus Test.
Occlusal therapy
Correction of worn out teeth must be done prior to invasive periodontal surgery. Patients with other oral habits like tongue thrust, occupational habits must be either advised to quit or forced to quit before attempting any periodontal therapy. Gross malocclusion must be corrected following basic therapy.
Surgical
Improper treatment sequencing :
Role of interdisciplinary dentistry is today unquestionable and this helps in sequencing Not only the removal of primary etiological factors is important need to eliminate the secondary complicating and confounding factors. Malocclusion, occlusal interferences, mild mobility, faulty restorations, open contacts, etc and so on and so forth.
Improper selection of technique: Design of surgery or procedure, right from types of incisions to the required modification Improper selection of technique could be a primary trigger that leads to a cascade of events precipitating in failure. Incomplete treatment: Incomplete debridment Improper asepsis: Improper primary closure:delays healing
Curettage
Persistence of inflammation after procedure Causes: 1. Diagnosis per se 2. Procedural errors; instrumentation when to stop 3. failure to irrigatetags of tissue 4. Suture a curetted area. granulation
Gingivectomy
Defined by recurrence of lesion either immediately within a few weeks or by destruction of the periodontal apparatus.
Wade (1954) outlined 15 reasons why gingivectomy fail: 1. Unsuitable case selection. Cases underlying
osseous or intrabony defects. 2. Incorrect pocket markings 3. Incomplete pocket elimination 4. Insufficient beveling of the incision 5. Failure to remove tissue tags, resulting in excessive tissue 6. Failure to remove etiologic factors calculus and plaque 7. Beginning or terminating the incision in a papilla
8. Failure to eliminate or control the predisposing factors 9. Inaccessible interdental spaces 10. Loose dressings 11. Lost dressings 12. Insufficient use of dressings 13. Failure to prescribe stimulators or rubber tip for interproximal use 14. Failure to use stimulators or rubber tip 15. Failure to complete treatment
Abscess Drainage
Defined by the recurrence of abscess/ resultant increase in periodontal destruction. 1. Identification of source/ origin.tortousity of pocket & complexity of the tooth . 2. Removal of entire abscess wall.remenant tags act as a nidus. 3. Chronic abscesses tend to show more recurrence. 4. Systemic/ Local drug delivery is mandatory; if its a periodontal abscess.
Elimination of inflammationRemoval of depositsimproves tissue tone & texture Failure to remove the entire pocket lining Recurrence of the pocket epithelium. Failure to correct bony ledges.improper maintenance, periodontal infections & attachment loss Incomplete debridement of granulation tissue and deposits. Excessive reflection can cause increased postoperative surface resorption.
Regenerative Techniques
Bone grafting Procedures
GTR Procedures
iv. Maintenance of vascular continuity.. Alloplasts & xenograftsosteoconductive.only act as a scaffold. Establishment of vascular continuity Clot.should preferably arise from bone.penetrations of cortical plate is reqd to enhance blood flow from marrow..trephinationaid in neovascularization.
v. Flap margin bleed ..persistent bleeding on flap surface results in clot forming from the flap involving graft.fibrous encapsulation. vi. Postoperative infection control.antibiotics & antibacterial mouthrinse.. vii. Graft sterilizationmost commonly overlooked aspects viii.Primary closure with no intervening graft
GTR Procedures
Adaptation of membrane.to provide adequate space to the periodontal ligament cells to migrate Prevention of collapse..use in conjunction with bone graft. Trimmed membrane..should cover at least 2mm of adjacent alveolar bone, no sharp edges Membrane exposuretension free flap,
Barrier-Independent Factors
Poor plaque control Smoking Occlusal trauma Sub optimal tissue health (i.e. Inflammation persists) Mechanical habits (e.g.. Aggressive tooth
Barrier-Independent Factors
Surgical technique
improper incision Traumatic flap elevation and management Excessive surgical time Inadequate closure or suturing
Barrier-Independent Factors Post surgical factors premature tissue challenge #Plaque recolonization #Mechanical insult Loss of wound stability (loose sutures, loss of fibrin clot).
Graft handling could be one of the reasons for failure. Squeezing of the graft leads to leakage of the plasmatic fluid ..dessication Size of the graft should be adequate. ideal size should be 1.25 1.5 mm The presence of clot between the graft and root surface. Compression of graft against root surface Root conditioning is a must; esp in soft tissue graft procedures
Rotated flaps
Intra surgical considerations:
Horizontal incision; mandatory to maintain viability of papilla.
Rotated flaps
Coronally displaced flaps fail most often because they are either secured in tension and are not stable; thus vertical incisions play a critical role in success of this procedure. These procedures show limited success if
Epithelialized grafts
Reasons for failure. Langer & Langer 1992 Recipient bed too small Flap perforation Inadequate graft size Inadequate coronal positioning of flap Too thick a CT graft Poor root preparation Poor papillary bed preparation
Implants
Inadequate union of bone and implant at the time of surgical insertion. Improper biomaterials a) Use of dissimilar materials b) Bio incompatible materials Contamination of the implant surface & infection Surgical overheating of bone Structural design that does not transmit forces evenly to the bone Premature loading with occlusal forces prior to healing phase Increased periodontal pocket activity
Post Therapeutic
Instruction & Motivation Preservation of the periodontal health requires as positive programme If periodontist follows a very good therapeutic procedures..pt does not maintain or not under PD,tooth loss etc. proper recall visits.signs of failure bone loss Motivation + reinforcement of OHI. Failure to continue with treatmentconscious or unconscious decision
Unsupervised healing: Absence of supervision Professional cleaning of supragingival area periodically Failure to assess OH status Inbility to monitor nutritional status Persistent or reintroduction of certain microorganisms Failure to eliminate certain microorganisms..A.a.persistence or recurrence. Some remain in the DEJresistant to antibioticsrecurrence.
New Disease:
CONCLUSION
References
Dr.Ramaswamy. Causes of failure of periodontal treatment. JISP 1995; 19:23 24. Gerald Kramer. Dental failures associated with periodontal surgery. DCNA 1972;16:13 31. Leon Lefer. Failures in motivation of dental home care. DCNA 1972;16:1:pg3. Bradley RE. Periodontal Failures related to improper prognosis & treatment planning.DCNA 19726:1:pg33 43. Wang HL, MacNeil RL. GTR. DCNA1998; 42:509.
Recent advances
AlloDerm is an acellular dermal matrix derived from donated human skin that undergoes a multi step proprietary process that removes both the epidermis and the cells that can lead to tissue rejection. AlloDerm has been used in a wide variety of soft tissue grafting procedures such as root coverage, soft tissue augmentation and guided bone regeneration with a consistent record of excellent results.1 7
Advantages compared to the connective tissue autograft from the patients palatal surgery palate: Eliminates the need for
Removes palatal harvesting limitations from treatment planning considerations Reduces patient reluctance to follow through with surgical treatment Consistent quality Provided in multiple convenient sizes Available in two thickness ranges for use in different procedures: 0.9 to 1.6 mm AlloDerm for root coverage, soft tissue ridge augmentation, etc. 0.5 to 0.8 mm AlloDerm GBR for guided bone regeneration and barrier membrane function
Acellular Dermal Matrix for Mucogingival Surgery: A Meta-Analysis. Gapski R, Parks CA and Wang HL. J Periodontol 2005;76(11):1814-1822.
Root Coverage
References
Management of Gingival Recession by the Use of a Acellular Dermal Graft Material: A 12-Case Series. Santos A, Goumenos G and Pascual A. J Periodontal 2005;76(11):1982-1990. Subpedicle Acellular Dermal Matrix Graft and Autogenous Connective Tissue Graft in the Treatment of Gingival Recessions: A Comparative 1-Year Clinical Study. Paolantonio M, Dolci M, Esposito P, DArchivio D, Lisanti L, Di Luccio A and Perinetti G. J Periodontol 2002;73(11):1299-1307. Clinical Evaluation of Acellular Allograft Dermis for the Treatment of Human Gingival Recession. AichelmannReidy ME, Yukna RA, Evans GH, Nasr HF and Mayer
Predictable Multiple Site Root Coverage Using an Acellular Dermal Matrix Allograft. Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer MJ, Goldsmith LJ and Rebitski G. J Periodontol 2001;72(5):571-582. Surgical therapies for the treatment of gingival recession. A systematic review. Oates TW, Robinson M and Gunsolley JC. Ann Periodontol 2003;8:303-320. Root coverage of advanced gingival recession: A comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. Tal H, Moses O, Zohar R, et al. J Periodontol 2002;73:14051411. The clinical effect of acellular dermal matrix on gingival