l22_phase ii therapy

8/17/2019 L22_Phase II Therapy

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Periodontal Therapy:

Phase II

Rikko Hudyono


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The Concept of PeriodontalTherapy

to eliminate infammation


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‘no one can clean calculus completely’


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Interdisciplinary cooperation



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ing an oral environment that is conducive to maintaining the padentition in a healthy com!orta"le and !unctional esthetic state and

#hen !easi"le to regenerate and preserve the periodontal attachmen


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Periodontal Therapy$e%uences

Phase I:&on $urgical Peridontal Therapy

Phase I:

(aintenance

Phase II:$urgical Peridontal

Therapy

Phase III:Restorative Phase

)mergency Phase

* h y +


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*hy is phase II come

a!ter the phase I+

(ost o! periodontal diseases are pla%ue,associated disorders

&on,$urgicalPeriodontal

Therapy

Pla%ue

Periodontal-reakdo#n

(otivational

Intervie#ing $upra.ingivalPla%ue/ontrol

&on,surgicalroot

de"ridement

$urgical 0Reconstructive

Therapy


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3"5ectives

The surgical phase o! periodontaltherapy has the !ollo#ing maino"5ectives:

12 Improvement o! the prognosiso! teeth and theirreplacements2a2the pocket #hich esta"lished an environment

conducive to progression o! periodontal disease #aseliminated and

"2the root sur!ace #as made accessi"le !or scaling and!or sel!,per!ormed tooth cleaning a!ter healing2

42 Improvement o! esthetics2


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11/64at #e do +


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*hat do #e do in surgicalphase+

• /ontrolling or eliminatingperiodontal disease2

• /orrecting anatomic conditions

that may !avor periodontal diseaseimpair esthetics or impedeplacement o! the correct prostheticappliances2

• Placing implants to replace lostteeth and improving theenvironment !or their placement

and !unction2


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Indications !or Periodontal$urgery12 =reas #ith irregular "ony contours deep craters and

other de!ects

42 Pockets on teeth in #hich a complete removal o! root

irritants is not considered clinically possi"le2

;2 In cases o! !urcation involvement o! grade II or III


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• )sthetic cro#nlengthening

• $o!t tissue gra!ting• Papilla reconstruction

• -iopsy o! enlargement• Treatment o! a"scess

• /ro#n lengthening• .ingival

augmentation• Ridge augmentation• Tori reduction• Tu"er reduction• esti"ulopasty• Implant $urgery

• =ccess to osseous de!ect• Regeneration• Resective

PocketReducti

on

Prosthetic

$urgery

Plastic

$urgery

3ther

$urgery

Periodontal $urgery


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/ontra,Indications

12 Poor Pla%ue control

42 High caries rate

;2 ?nrealistic patient e@pectation or desire


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/ontra,Indications

Uncontrolled medical conditions:

1. Patient cooperation

. Cardiovascular disease

!. Organ transplantation

". #lood disorders

$. %ormonal disorders

&. 'eurologic disorders

(. Smo)ing


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Access to osseous defect

• Visibility

• Effective SRP

• Less trauma

•

Maintenance


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Osseous defect modification

• Resection

• Augmentationes ta " l is

h

p h ys io log ic


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No biologic architecture of hard tissue


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Last molar problem


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$ome cases in #hich periodontalsurgery may "e indicated

a2/reating accessi"ility !or properpro!essional scaling and root planing

"2)sta"lishing a gingival morphology #hich!acilitates the patient’s sel!,per!ormed

in!ection control2

/onclusion o! purpose o! periodontal surgery:


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*hen #e do +

! " months interval

#hat are $e $aiting for%

& 'true( soft tissue and poc)et*& +irm and resilient tissue,& Evaluate the self maintenance


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$urgical Phase

The surgical phase consists o!

12 Pocket reduction surgery

42 /orrection o!anatomicBmorphologic de!ects7mucogingival de!ects8

In many cases procedures are com"ined so thatone surgical intervention !ullls "oth o"5ectives2


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Poc)et

*eductionSurgery


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*hy Pocket Therapy+

.ingivalinfammati

on

Pocket

deepening

Pla%ue=ccumulati

on

The e9ectiveness o! periodontal therapy is predicated on success incompletely eliminating calculus pla%ue and diseased cementum !rom the

tooth sur!ace2 6eeper pocket makes everything more diCcult2


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Periodontal Pockets

Dalse Pocket

True Pocket


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Periodontal Pockets


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$urgical Pocket Therapy

• )liminating the pathologic changes in the

pocket #allsE• /reating a sta"le easily maintaina"le

stateE

•

Promoting periodontal regeneration7i! possi"le8

Purpose:


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Targets mainly on:

access surgery to ensure the removal o!irritants !rom the tooth sur!ace or elimination

reduction o! the depth o! the periodontalpocket


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-y surgical therapies #e can:

• increase accessi"ility to the root sur!acemaking it possi"le to remove all irritantsE

• reduce or eliminate pocket depthmaking it possi"le !or the patient tomaintain the root sur!aces !ree o!

pla%ueE and• reshape so!t and hard tissues to attain a

harmonious topography2


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Pocket reduction surgery seeks toreduce pocket depth "y either

• Resective surgery – gingivectomy

– apically displaced fap

– undisplaced fap #ith or #ithout osseous reduction

• Regenerative surgery – faps #ith gra!ts mem"ranes etc

• /om"ination o! "oth methods


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T#o !actors are taken intoconsideration:

718the character o! the pocket #allE

and

748the accessi"ility o! the pocket2


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(ethods o! Pocket Therapy

• &e# =ttachment Techni%ue

ideal therapy

• Removal o! the Pocket *allRetraction or shrinkage: $caling and rootplaning

$urgical removal: gingivectomyundisplaced fap

=pical displacement: =pically repositionedfap


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Result o! Pocket Therapy

= periodontal pocket can "e

• =ctive state2 In an active pocketunderlying "one is "eing lost

• Inactive state or %uiescence2


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The possi"ility o! the treatmen


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$pecial /onsideration

The pocket #all can "e either edematous or "rotic2

• Edematous tissue shrinks a!ter the elimination o!local !actors there"y reducing or totallyeliminating pocket depth2 There!ore scaling androot planing are the techni%ue o! choice in thesecases2

• Pockets #ith a fbrotic #all are not apprecia"lyreduced in depth a!ter scaling and root planingEthere!ore they are eliminated surgically2


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6o #e need to Remove all Periodontal

Pocket+

Pocket )liminationsPocket (aintenance


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+ucogingivalSurgery


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(ucogingival $urgery

Purpose

• /orrecting the anatomic morphologicde!ects that may !avor pla%ue accumulation

and pocket recurrence or impair esthetics2

It is important to understand that theseprocedures are not directed to treat disease "utaim to alter the gingival and mucosal tissues tocorrect de!ects that may predispose to disease2


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+ucogingival Surgery

• Plastic surgery techni%ues to #idenattached gingiva 7!ree gingival gra!tsother techni%ues etc8

• )sthetic surgery 7root coverage re,creationo! gingival papillae8

• Preprosthetic techni%ues 7cro#n

lengthening ridge augmentation andvesti"ular deepening8

P i d t l !


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Periodontal surgery !orImplant

Placement o! dental implantsincluding techni%ues !or sitedevelopment !or implants

• guided "one regeneration

• sinus gra!ts

• FateraliGation o! mandi"ular nerve

• Ridge augmentation

• *idening the attached gingiva

R l ti ! Ph I


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Re,evaluation o! Phase I Therapy• 1 ; months and sometimes as

much as months a!ter thecompletion o! Phase I therapy2

• Dull,mouth repro"ing2

• The presence o! calculus root cariesde!ective restorations and signs o!

persistent infammation should also"e evaluated2

/ iti l J i P k t


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/ritical Jones in Pocket$urgery=reas that shall "e evaluated inchoosing the proper therapy:

• The so!t tissue pocket #all

• Tooth sur!ace

• ?nderlying "one and

•

=ttached gingiva2


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• Zone 1: Soft Tissue Pocket Wall

• the morphologic !eatures

• thickness

• topography o! the so!t tissue pocket

#all• persistence o! infammatory changes

in the #all2


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• Zone 2: Tooth Surface

• the presence o! deposits

• alterations on the cementum sur!ace

• determine the accessi"ility o! the

root sur!ace to instrumentation2Phase I therapy should have solved many i! notall o! the pro"lems on the tooth sur!ace2)valuation o! the results o! Phase I therapy

should determine the need !or !urther therapy


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• Zone 3: Underlying Bone

• the shape and height o! the alveolar "one

ne@t to the pocket #all through care!ulpro"ing and clinical and radiographice@aminations2

• -ony craters horiGontal or angular "one

losses and other "one de!ormities areimportant criteria in selection o! thetreatment techni%ue2


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/riteria !or (ethod


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/riteria !or (ethod$election12 /haracteristics o! the pocket: depth relation to "one and

conguration2

42 =ccessi"ility to instrumentation including presence o!!urcation involvements2

;2 )@istence o! mucogingival pro"lems2

2 Patient cooperation including a"ility to per!orm e9ectiveoral hygiene2 $mokers must "e #illing to stop their ha"it2

A2 =ge and general health o! the patient2

L2 3verall diagnosis o! the case: various types o! gingivalenlargement and types o! periodontitis 7e2g2 chronicmarginal periodontitis localiGed aggressive periodontitisgeneraliGed aggressive periodontitis82

M2 )sthetic considerations2

2 Previous periodontal treatments2


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Therapy !or $light


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Therapy !or $lightPeriodontitis• In slight or incipient periodontitis a small

amount o! "one loss has occurred and pocketsare shallo# to moderate2

• In these patients the conservative approach#ith good oral hygiene #ill generally suCce tocontrol the disease2

• Incipient periodontitis that recurs in previouslytreated sites may re%uire a thorough analysis o!the causes !or the recurrence2 3ccasionally asurgical approach may "e re%uired to correctthe pro"lem2


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Th ! ( d t t $


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Therapy !or (oderate to $everePeriodontitis in Posterior =rea

• Treatment !or premolars and molarsusually poses no esthetic pro"lem "ut!re%uently involves diCcult

accessi"ility2• The purpose o! surgery in the posterior

area is either enhanced accessi"ility or

the need !or denitive pocket reductionre%uiring osseous surgery2 It can "eregeneration or resective surgery2


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Remem"er that 2222

• Phase II therapy is used to surgically treatresidual periodontal pockets and "one

de!ects remaining a!ter Phase I therapy2• =ll patients treated surgically need to have

a preoperative history o! ade%uatepla%ue control #ith 4NO or more o!

the tooth sur!aces !ree o! pla%ue a!ter oralhygiene procedures2


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Remem"er that 2222

• (ost types o! surgical therapy #illresult in some postsurgical gingivalrecession and so they are not use!ul

in the anterior segments o! the mouthin those patients in #hom theesthetic shape o! the gingiva is

visi"le2• This patient may "est treated #ith

non,surgical procedure


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Remem"er that 2222

• Ho#ever ne# innovativeregeneration surgical techni%uesusing modied papilla preservation

approaches together #ith minimallyinvasive procedures o!ten coupled#ith a "asis o! microsurgery are

sho#ing promising results inmaintaining and even improvingpapillary and la"ial tissue levels2


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Thank you

l22_phase ii therapy

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