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FAILURES IN PERIODONTAL THERAPY

FAILURES IN PERIODONTAL THERAPY. Dr shabeel pn. Contents. Introduction Classification of failure Pre Therapeutic Therapeutic Post Therapeutic Summary & Conclusion. Surgical. Non surgical. INTRODUCTION. Dentist related failures Patient related failures. Dentist related failures.

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FAILURES IN PERIODONTAL THERAPY

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  1. FAILURES IN PERIODONTAL THERAPY Dr shabeel pn

  2. Contents • Introduction • Classification of failure • Pre Therapeutic • Therapeutic • Post Therapeutic • Summary & Conclusion Surgical Non surgical

  3. INTRODUCTION

  4. Dentist related failures • Patient related failures

  5. Dentist related failures • Gathering data • Improper diagnosis • Improper investigations • Inadequate motivation • Improper treatment sequencing • Incomplete treatment • Irregular follow-ups.

  6. Patient Related Factors • Maintenance • Smoking • Systemic Diseases. • Poor healing potential. • Psychological component – probably the least studied and the most critical aspect in periodontics.

  7. Classification • Pretherapeutic • Therapuetic • Post Therapuetic

  8. Pretherapeutic Incorrect Patient Selection • Age • Socio-economic status and nutritional deficiencies

  9. s Systemic disease: Diabetes Mellitus Blood Dyscrasias : leukemia, Cyclic neutropenia Immune deficiences : Neutrophil-monocytic chemotactic defects, AIDS Genetic disorders : Down’s syndrome, Papillion Lefevre syndrome, hypophosphatasia , Chediak Higashi Syndrome) ; Vitamin deficiences

  10. Pretherapeutic Incomplete diagnostic procedure or misdiagnosis • Improper Clinical diagnosis • Radiological interpretations • Microbiological interpretation • Biochemical interpretation • Immunological interpretation Inappropriate or improper dental restorations or prosthesis • Overhanging Class II , overextended crowns & bridges. Failure to carry out assoc. Prosthetic-restorative procedure

  11. Pretherapeutic Morphology of tooth surfaces : Lateral accessory canals, dev. Grooves, resorption lacunae – act as “Guide plan”for bacterial penetration….. Habits Occlusal corrections or teeth preparation: TFO…prevent proper adaptive remodelling of periodontium

  12. Therapeutic Surgical Non-Surgical Curettage Gingivectomy Abscess Drainage Flap Surgery Bone Grafts GTR procedures Root coverage procedures Implant Aesthetic surgeries Scaling Root Planing Splinting Occlusal therapy Local Drug Delivery

  13. 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”.

  14. Root Planing • Rough root surface and persistence of inflammation. • Inadequate RP……detection of caries. • Over instrumentation…..hypersensitivity • Presence of developmental grooves….Use of rotary instruments to smoothen as far as possible

  15. Splinting • Failures could be: • Inflammation in the area • Breaking of splint • Increased plaque accumulation.

  16. 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

  17. 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”.

  18. 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.

  19. 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.

  20. 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

  21. Curettage Persistence of inflammation after procedure Causes: 1. Diagnosis per se 2. Procedural errors; - instrumentation - when to stop 3. failure to irrigate…tags of granulation tissue 4. Suture a curetted area.

  22. Gingivectomy Defined by recurrence of lesion either immediately within a few weeks or by destruction of the periodontal apparatus.

  23. 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

  24. 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

  25. 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 it’s a periodontal abscess.

  26. Flap Surgical Techniques • Failures could be recurrence of pockets, flabby tissue, abscess formation, gingival recession, cleft formation, loss of interdental papilla. • In most situations, some amount of gingival tissue recession and loss of papilla occurs, accepted to such an extent that we do not consider it a failure anymore.

  27. Elimination of inflammation…Removal of deposits…improves 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.

  28. Regenerative Techniques • Bone grafting Procedures • GTR Procedures • Growth Factor usage

  29. Bone grafting Procedures • Pre-surgical considerations….decision to place a bone graft…. • Assessment of defect morphology: interproximal well supported 3 or 2 walled defects & Furcation Involment. • Technique of placement …increments, compacted not condensed. Pore size or distance between particles….significant.

  30. Maintenance of vascular continuity….. • Alloplasts & xenografts…osteoconductive….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…..trephination…aid in neovascularization. • Overfilling the defect … • lead to fibrous encapsulation of the graft

  31. Bone grafting Procedures • “Flap margin bleed” …..persistent bleeding on flap surface results in clot forming from the flap involving graft….fibrous encapsulation. • Postoperative infection control….antibiotics & antibacterial mouthrinse….. • Graft sterilization……most commonly overlooked aspects • Primary closure with no intervening graft particles.

  32. 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 exposure…tension free flap, bacterial accumulation..hampers healing • Membrane suture… sling suture

  33. Barrier-Independent Factors • Poor plaque control • Smoking • Occlusal trauma • Sub optimal tissue health (i.e. Inflammation persists) • Mechanical habits (e.g.. Aggressive tooth brushing)

  34. Barrier-Independent Factors • Overlying gingival tissue • Inadequate zone of keratinized tissues. • Inadequate tissue thickness • Surgical technique • improper incision • Traumatic flap elevation and management • Excessive surgical time • Inadequate closure or suturing

  35. Barrier-Independent Factors • Post surgical factors • - premature tissue challenge • Plaque recolonization • Mechanical insult • - Loss of wound stability (loose sutures, loss of fibrin clot).

  36. Barrier – Dependent Factors • Inadequate root adaptation (absence of barrier effect) • Non sterile technique • Instability (movement) of barrier against root. • Premature exposure of barrier to oral environment and microbes. • Premature loss or degradation of barrier.

  37. Growth factor usage • Method of draw… various techniques …blood bank draw technique..superior viable platelet conc. • Shelf life….24 hours, chair side equipment. • Use of thrombin; and its ratio…released during surgery is enough, ratio 1:7 • Aspiration technique…platelets fragile • When used alone will invariably fail to show desired results. • Prevent standing of PRP….premature bursting

  38. Root Coverage Procedures • Rotated flaps • Soft tissue grafts

  39. Root Coverage Procedures • Presurgical considerations…. depends on the position of the tooth, the extent of malocclusion if present, the thickness of the gingiva present in the adjacent area • The etiology of the recession must be corrected. • Depth of the vestibule , width of attached gingiva .

  40. 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

  41. Rotated flaps • Intra-surgical considerations: • Horizontal incision; mandatory to maintain viability of papilla. • Cut-back incision; prevents tissue ledges. • Partial thickness is desired as this may prevent donor site recession.

  42. 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 inter-proximal recession is also present.

  43. Laterally positioned flap • Common reasons for failure • Tension…. Distal incision • Pedicle too narrow • Exposure of bone at radicular surface • Poor stabilization

  44. Double papilla flap • Common reasons for failure • Non union of component flaps • Full tickness flap…..Dehiscence or fenestrations • Inadequate attached gingiva in the papillary area • Proper placement of the flap on periosteal bed • Adequate fixation of the flap to prevent shifting

  45. Free Soft tissue grafts • Epithelialized grafts • Sub-epithelial Connective Tissue Grafts

  46. Epithelialized grafts • The sutured graft should always be either at the level or higher than the level of adjacent recipient bed but never below; this leads to graft rejection (Chiranjeevi 1989). • Recipient bed preparation should be beveled and broader at the base.

  47. Sub epithelial Connective Tissue • 2 techniques of procurement; separation of full thickness yields more C.T. and easier. • Grafts have to be trimmed and the lipid layer has to be removed. • Tunnel technique gives only marginal recession coverage as opposed to pouch technique

  48. 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

  49. Implants • Inadequate union of bone and implant at the time of surgical insertion. • Improper biomaterials • Use of dissimilar materials • 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

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