Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations 1999 Gingival and Periodontal Disease Classification In The Esthetic Zone Nick Caplanis DMD MS Private Practice Periodontics and Implant Surgery Mission Viejo, California Nick@drcaplanis.com Assistant Professor Loma Linda University Armitage GC. Ann Periodontol 1999;4:1-6 Classification of periodontal disease and conditions Periodontal disease classification “ Key Changes” Previous Current • Previous classification • Current classification • No section on gingival diseases • Entire new section on gingival diseases – 1989 world workshop – 1999 international workshop • “Adult” Periodontitis • “Chronic” Periodontitis • “Early-onset” Periodontitis • “Aggressive” Periodontitis • “Refractory” Periodontitis • Additions • A standard classification provides a framework for the – Periodontal abscess scientific study of disease etiology, pathogenesis and – Perio-endo lesions – Acquired deformities and conditions treatment as well as a standard mean of communication Armitage GC. Ann Periodontol 1999;4:1-6 Weakness of 1989 classification Classification of periodontal disease and conditions • Chronic periodontitis • Criteria for diagnosis unclear – Typical adult onset plaque induced • Disease categories overlapped – Previously referred to as “adult” perio • Too much emphasis on age of disease onset and rate of • Aggressive periodontitis progression which are difficult to determine – Previously known as pre-pubertal, juvenile perio, localized juvenile perio, rapidly progressive perio, early onset perio • No classification for diseases limited to gingiva Armitage GC. Ann Periodontol 1999;4:1-6 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 1
Nicholas Caplanis DMD MS 6/4/2012 Gingivitis Classification of periodontal disease and conditions Chronic and Aggressive Periodontitis • Clinical Signs • Treatment – Distribution – Severity – Gingival erythema – Scaling/Prophy with • Localized < 30% sites • Slight 1-2mm CAL – Edema OHI • Generalized > 30% sites • Moderate 3-4mm CAL – Bleeding on probing – Phase I Re-eval – PPD’s up to 3mm (unless pseudo – 4-6 mo PST • Severe > 5mm CAL pocket) – Soft tissue contour changes – Increased GCF Armitage GC. Ann Periodontol 1999;4:1-6 – No attachment loss Systemic Connections Slight Periodontitis • Periodontal disease increases CRP levels • Clinical Signs • Treatment • Link between Periodontal disease and – Gingival erythema – SRP + behavior mod cardiovascular disease; MI, CVA – Edema – Periostat • Link between periodontal disease and the delivery of – Bleeding on probing – Phase I Re-eval premature, underweight babies – Slight attachment loss – 3-6mo PST • Link between Periodontal disease and Diabetes – Pocket depths 4mm • Recent link with Alzheimer’s disease • Periodontal Pathogens are transmissible Moderate Periodontitis Biofilm and inflammation management • Clinical Signs • Treatment – SRP + behavior mod – Gingival erythema – Edema – Rx Periostat – Phase I Re-eval – Bleeding on probing – Additional RP + Arrestin – Moderate attachment loss – Pocket reduction surgery – Slight furcation invasion if needed – Pocket Depths 5mm – Phase II Re-eval – 3-4 mo PST Periodontal and Peri-Implant Considerations in Esthetic Dentistry 2
Nicholas Caplanis DMD MS 6/4/2012 Severe Periodontitis 56y/o male generalized chronic severe periodontitis • Treatment • Clinical Signs – SRP + behavior modification – Severe Attachment Loss – Phase I Re-eval – Pocket Depths >6mm – Pocket Elimination Surgery – Moderate to Advanced – Phase II Re-eval Furcation involvement – Bacterial Culture and Sensitivity – Inflammation, BOP – Localized and Systemic Antibiotics – 3mo PST Prior to treatment Jan 2002 Manual vs. Powered tooth brushing for oral health 56y/o male generalized chronic severe periodontitis Materials and Methods Results and conclusions • 42 trials involving 3855 participants • Powered brushes removed plaque included in review and reduced gingivitis more effectively than manual brushes Robinson PG, et.al. Cochrane Database 2005;18(2):CD002281 Post Perio, Restorative and Ortho Treatment Jan 2007 The efficacy of interdental brushes on plaque and parameters of 56y/o male generalized chronic severe periodontitis periodontal inflammation: a systematic review Materials and Methods Results and conclusions • 218 Medline-PubMed and 116 Cochrane • As an adjunct to brushing interdental brushes papers identified remove more plaque than brushing alone. • 9 studies met eligibility criteria • Clinical improvements noted in PI, BOP, PD • Improvement in PI better than using floss Jan 2011 Slot DE. Dorfer CE, et.al Int J Dent Hyg 2008;6(4):253-64 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 3
Nicholas Caplanis DMD MS 6/4/2012 Tooth vs. Implant Histology Periodontal Biotype • Tooth • Implant Thin Thick – Sulcus – Sulcus Long Tapered teeth • Short square teeth • – Epithelial Attachment – Epithelial Adhesion Thick robust gingiva • Thin friable gingiva • – Connective Tissue Attachment – No Connective Tissue Attachment Long pointy papilla • Wide blunted papilla • – Bone Attachment via Sharpy’s – Direct Bone to Implant Union LM Resistant to recession • Susceptible to recession • fibers (Osseointegration ) Peri-implant biologic width Dimensions of the Dentogingival Junction in Humans • Gingival sulcus ~ 1mm T Sulcus O • Sulcus O T • Junctional Epithelium ~ 1mm H • Junctional Epithelium • Connective Tissue Sulcus • Connective Tissue Attachment ~ 1mm JE Junctional Epithelium Connective Tissue CT Garguilo AW, Wentz FM, Orban B. J Perio 1961;32:261-267 Periodontal Biologic Width Peri-implant Histology • Sulcus • Junctional Epithelium • Junctional Epithelium – Presence of hemidesmosomes • Connective Tissue Attachment – James R, Shultz RL JOI 1973 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 4
Nicholas Caplanis DMD MS 6/4/2012 Peri-implant Histology Esthetic Crown Lengthening Techniques • Connective Tissue • Gingivectomy – Parallel Fiber arrangement around smooth titanium • Gingivectomy with osseous surgery – Perpendicular fiber arrangement can be found around – with flap elevation or without rough surfaces • Apically repositioned flap with or without osseous surgery – Adhesion • Orthodontics – Fiber dense Camargo PM, Melnick PR, Camargo LM. CDA Journal 2007;35(7):487-98 Peri-implant probing Esthetic crown lengthening – case 1 • Probe extends to base of connective tissue • Deep pockets difficult to maintain • Deep pockets increase risk for bone loss • Over contoured restorations will prevent accurate probing • Deep pockets around implants do not necessarily represent bone loss Understanding Biologic Width is Important to Avoid Gingivectomy using Ellman™ Radiosurgery Complications with Restorative Dentistry Periodontal and Peri-Implant Considerations in Esthetic Dentistry 5
Nicholas Caplanis DMD MS 6/4/2012 Esthetic crown lengthening – flapless osseous reduction Esthetic crown lengthening – Osseous surgery w flap Esthetic crown lengthening – case 1 Esthetic crown lengthening-case 2 Esthetic crown lengthening-case 2 Esthetic crown lengthening- case 3 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 6
Nicholas Caplanis DMD MS 6/4/2012 Root coverage procedures Esthetic crown lengthening – Gingivectomy guided by stent Esthetic crown lengthening – osseous flap surgery Placement of interpositional CT graft guided by stent Esthetic crown lengthening-case 3 Root coverage procedures Periodontal and Peri-Implant Considerations in Esthetic Dentistry 7
Nicholas Caplanis DMD MS 6/4/2012 Miller Recession Classification Mucogingival surgery – interpositional CT graft Clinical Presentation Expectation Success rates Class I Recession above MGJ – No AL Complete root coverage 100% Class II Recession to or beyond MGJ – No AL Complete root coverage 100% Class III Recession to or beyond MGJ – Minor Partial root coverage to the 50-70% interproximal AL height of interproximal tissues Class IV Recession to or beyond MGJ –Severe Unpredictable root coverage < 10% interproximal AL Miller, PD. A classification of marginal tissue recession. Int J Perio Rest Dent 1985; 5(2):8-13 Treatment of Gingival Recession Mucogingival surgery – interpositional CT graft Purpose • To evaluate the outcome of various gingival grafting techniques to assess which provides optimal results Materials and Methods • Review of controlled clinical trials Kassab MM, Cohen RE. JADA 2002;133(11):1499-1506 Mucogingival surgery – interpositional CT graft Treatment of Gingival Recession • Results and Conclusions – Autogenous connective tissue grafts in conjunction with a coronally repositioned flap is most effective in achieving predictable root coverage Kassab MM, Cohen RE. JADA 2002;133(11):1499-1506 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 8
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