Periodontal treatment planning: extracting or treating questionable teeth

• As obvious it sounds, don’t do something to your patient that you wouldn’t do to yourself!
• Establish patient expectations initially – what do they really want?
• Treatment planning establishing a tooth by tooth prognosis – good, fair, poor. However, the parameters to define this are difficult and changing.
• Your treatment plan should have distinct phases e.g. initial therapy, functional therapy, orthodontics, implant therapy, restorative treatment.
• Elimination of black triangles by composite bonding without preparation – conservative treatment.
• There is a difference in approach between Europeans and Americans!
• Use implants to save teeth, not to replace teeth. Implants are not the final solution! Achieving a perfect aesthetic outcome with implants is difficult. All on 4 may not be such a good idea! Angulation abutments can increase the risk of peri-implantitis. Current evidence for this is only through case reports (lowest level of evidence).
• It is also important to consider implant maintenance. Often we create prosthesis/superstructure which are extremely difficult to clean! People are living longer, dexterity will decrease and there will be huge problems. Therefore we need to ensure that we create a superstructure that can be cleaned easily. For example, an alternate to 4 locators could be 2 locators + 2 telescopic crowns.
• Predictable aesthetics with implants is only possible when replacing one tooth. Periodontium on the neighbouring teeth will define the height of the papillae. When you lose an adjacent tooth you will lose the papillae and therefore aesthetics become unpredictable.
• Most important radiograph during implant therapy is that taken 1 year after placement. It takes a year for the crestal bone to adapt therefore this should be taken as baseline. Following this, if probing depths increase, you will require another radiograph to check for bone loss. Bone loss will indicate peri-implantitis. Platform switching is not recommended as it doesn’t allow probing.
• Biological driven implant placement means that you can probe all around the implant, the patient can clean all the way round, the mucosa around the implant is attached and does not exceed more than 4 mm in the functional region.
• Useful reference: Evidence based medicine working group. J Dent Educ 1994; 58;648-653.
• Evidence based dentistry is based on: external evidence (literature), internal evidence (your competence) and the patient’s expectations/demands. Implant treatment – highly dependent on internal evidence.
• We are extracting more teeth than we should! Don’t forget we became dentists to maintain and save teeth! Why should we try and save teeth? We know much more about treating periodontitis than peri-implantitis. At the moment, peri-implantitis is being treated with internal evidence.
• Splieth 2002 – 37% of the teeth that were extracted at an attachment level of 50-70% and these were extracted for periodontal reasons!
• Predictors of tooth loss during long term maintenance – Chambrone 2010 – 26.1% of those teeth that were originally classified as irrational to treat were actually extracted over at least 10 years. Problems with parameters?
• Peri-implantitis progresses faster than periodontitis. Need to also be clear with patients that implants can also get periodontitis which actually progresses faster than teeth with periodontitis.
• Extraction of a tooth is a huge decision and great loss for the patient.
• The evidence shows that the maintenance of teeth is better than replacing with implants, especially with single rooted teeth.
• Always try and save teeth especially in the aesthetic zone. If teeth are mobile, you may need to splint before scaling and any surgery.
• Always try and gain time.
• Key message: Implants are a good treatment option but they should be used to save teeth not replace teeth.

Tunelling techniques to optimise aesthetics and predictability

• Blood supply in papillae is less. Therefore the less you cut through – the better the predictability. Cutting reduces wound healing capacity.
• Covering recession – coronal advancement vs tunelling.
• Tunelling is not easy technically and is time consuming.
• Tunelling and connective tissue graft is a predictable treatment option.
• Important considerations – magnification, illumination, instruments. Microsurgery is imperative.
• Always create tension-free flaps. It’s a good idea to use 7-0 sutures to help you with this. A 7-0 suture will pull through the flap if it is not tension-free – if this happens you need to change the flap design. Sutures are to adapt the flap not to bring the tissues together. Tie loose knots! Remember, wound healing can be influenced by the operator.
• Other important considerations include systemic and local factors. Systematic factors – smoking (no reconstructive surgery in smokers, should have stopped for 1 year – huge impact on blood supply), age, general health, medication. Local factors – blood supply (understand locally), wound stability (when possible do not extend past mucogingival junction as this will increase flap mobility), defect anatomy, plaque control.
• Technique as described well in the literature – incisions and undermine tissue. Connective tissue can be harvested from different sites (palatal anterior, palatal posterior, maxillary tuberosity). You may also harvest from different layers (free gingival graft, connective tissue) – all of these have different features.
• What’s the evidence? Study looking at the stability of a soft tissue graft was only 3.5 months in duration!
• Incorporation of the graft – new vessels finds old vessel system in the graft and attach to them. Clinical implications – this means if you leave a graft exposed it may integrate better? Also there are more vessels sub-epithelial – should you use this as it is likely to integrate better? Exposed lamina propria will necrose.
• At the moment we discuss quantity of cover for recession defects but we also need to consider quality e.g. it is important to avoid scar tissue.
• Rebele – tunnel vs CAF + EMD – measuring coverage using casts/superimposition of digital impressions (3d analysis, 0.1 mm accuracy) rather than a probe (at least +- error 0.5 mm). Tunneling showed better coverage and achieved greater thickness. Thicker tissue had better coverage – 1.44 mm is optimal. Therefore if thin biotype then maybe thicken, if thick biotype you may not need graft.
• We can use this technique in implant therapy to increase predictability of coverage.
• Double cross suture – Zuhr 2009 – Brings flap coronally and places papilla in the right position.
• Spatula needle can be useful.
• Uncovering implants – de-epithelialise area, U-shaped papilla, roll flap technique but use tunneling to mobilise area.
• Remember, if you add volume buccally, the papillae will flatten. Tinti 1995 – coronally positioned of palatal flap – release palatally. Combine with tunelling.

Managing extraction sockets and techniques for socket preservation

• Controversial topic
• Consider aesthetic zone versus functional zone
• How do we evaluate our aesthetic outcome? Pink aesthetic scores? E.g. Furhauser 2005 PES. There are too many. Can’t compare studies and all essentially two dimensional. The extraction socket is not 2 dimensional!
• Impossible to maintain full volume of socket following extraction.
• 3 dimensional analysis – impressions
• Dimensional changes of the alveolar ridge contour after different socket preservation – Fickl 2008 – looking at the outside.
• Extraction socket – 85% socket filled with bone 1963 Schroder. We know this!
• Many techniques e.g. Tarnow’s ice cone technique and Landsberg’s describes the use of bovine bone and free gingival graft. It makes sense to place bovine bone in the socket as it can prevent a little bit of resorption. But can only prevent in part. Some consider expanding the buccal bone plate and placing bovine bone/FSG in extraction socket.
• At the moment there is no method to prevent complete resorption
• Just as patients have different wound healing capacities, they have different resorption capacities and we cannot predict this.
• If there is no buccal bone and then you place bovine bone – you should not then then place an implant.
• When analysing cases as a general point, we need to always look in 3 dimension and train eyes to look in detail.

Clinical procedures and surgical techniques for an aesthetic outcome

• Only place immediate implants when there is existing buccal bone.
• Navigation is helpful
• Try a desmotome for extracting retained roots.
• The bundle bone belongs to the tooth and therefore when you extract a tooth, the fibres that insert in this are lost. Therefore you always lose bone when you extract a tooth.
• With immediate implant placement may add bovine bone but won’t be able to prevent resorption completely.
• Insertion torque – feel bone, measure last torque.
• Implant system and surface – need to know microtechnology, nanotechnology and pollution of surface. Surface can determine torque.
• Removable partial denture and individualised healing abutment for each case.
• Tuberosity tissue good to use for grafts around implants.
• Loose sutures always! Tissue will swell and so if the sutures are too tight, they will cut through the tissue and this will lead to scarring.
• Small titanium abutment – small screw head
• Immediate vs delayed?
• Immediate better for papilla but more demanding procedure
• Don’t remove connective tissue attachment
• Always try to understand the biology!

Periodontology