Treatment of Infrabony Pockets.pptx

treat the pockets for optimum health

1. TREATMENT OF INFRABONY POCKETS DR. RINISHA SINHA MDS PART II POSTGRADUATE TRAINEE

2. INTRODUCTION The Periodontal Pocket is defined as a pathologically deepened gingival sulcus; may be due to coronal movement of gingival margin or due to apical displacement of gingival margin or a combination of both . The pocket had to be classified on the basis of the location of the bottom of the pocket in its relationship to the alveolar crest . The suprabony pocket is defined as a pathological sulcus where the base of the pocket is coronal or occlusal to the alveolar crest. the infrabony pocket is defined as a pathological sulcus where the bottom of the pocket is apical to the alveolar crest.

3. Suprabony vs infrabony pockets Suprabony Infrabony Base of pocket is coronal to the level of alveolar bone 1. Base of pocket apical to crest of alveolar bone 2. Horizontal pattern of bone destruction 2. Vertical pattern of bone destruction 3. On facial & lingual surfaces, PDL fibers beneath pocket follow their normal oblique course. 3. They follow angular pattern 4. Transseptal fibers are arranged horizontally 4. Transseptal fibers are ararnged obliquely

4. An infrabony defect may be subdivided to intrabony defect when the subcrestal component involves the root surface of only one tooth and crater when the defect affects the root surfaces of two adjacent teeth on an equal extent. The proposed classification of the infrabony pocket is on a morphologic basis and is dependent on the location and number of osseous walls remaining about the pocket . The first group of infrabony pockets described have three osseous walls in the Interdental Areas where one finds an Intact Proximal Wall as well as the Buccal and Lingual walls of the alveolar process Trough-like defects may be shallow with a broad orifice to the osseous part of the pocket or may be narrow and deep occasionally on the lingual surfaces of maxillary and mandibular teeth where the lingual plate is intact as well as both proximal walls Two wall infrabony pockets may be seen in the interdental areas If the buccal and lingual walls are intact, but the proximal wall has been destroyed, the lesion is commonly referred to as an intraosseous interproximal crater . Because the base of the pocket is apical to either the buccal or lingual wall , this falls into the classification as an infrabony pocket. The two walls remaining are the buccal wall and the proximal wall or the lingual wall and the proximal wall . One osseous wall infrabony pockets is usually seen in the interdental area. This can be detected clinically by probing or passing a needle through the soft tissue ; radiographic examination may also be helpful. It is much less common to find the buccal wall intact with loss of the proximal and lingual walls or to have a lingual wall intact with the loss of the proximal and buccal. The Etiology, Diagnosis and Treatment of the Intrabony Defect by J O H N F. P R I C H A R D. 1967-1968 (Goldman and Cohen, 1958)

5. CLASSIFICATION Defects in interalveolar bone usually can be classified by their morphology as intrabony defects, hemisepta or craters . According to Henry Goldman and Walter Cohen (1957)

6. ETIOLOGY Visualization of the topography of the infrabony pocket is an essential for its clinical management, but equally important is an understanding of its causation , for therapy without consideration for correction of the etiologic factors will probably not yield favorable results. Therefore, a detailed clinical examination is obligatory. Tooth anatomy as well as tooth position should be inspected. Thus, the position of the tooth in respect to the alveolar housing and buccal bone, the contact points between teeth and the tilting of teeth must be considered.

7. With these two factors operating an infrabony pocket will result once the gingival and original transseptal fibers have been destroyed by the continuing inflammatory process.

8. Etiopathogenesis of infrabony pocket Glickman’s concept Waerhaug’s concept The Infrabony Pocket and its Relationship to Trauma from Occlusion and Subgingival Plaque by jens WaERHAUG . July 1975

9. DIAGNOSIS The determination of the position as well as the number of osseous walls is of concern to the clinician during his examination procedures.

10. CLINICAL EVALUATION

11. TREATMENT Therapy of the infrabony pocket must be directed towards the elimination of the signs and symptoms. For consideration of the elimination of the causation of the infrabony pocket, the following factors should be recognized and corrected, if possible:

12. In all periodontal therapeutic techniques for pocket elimination

13. SPLINTING

14. SELECTION OF THERAPEUTIC PROCEDURE The objective of treatment is to eliminate the pocket and establish a crevice with as near zero depth as possible . Two major methods of therapy for the infrabony pocket have been developed Treatment of Intrabony Defects by Different Surgical Procedures. Lars Laurell et al. 1998

15. TREATMENT OF THE INFRABONY POCKET WITH THREE OSSEOUS WALLS Curettage-gingivectomy operation for new attachment

16. Step II : Remove the contents of the pocket by using any curette or scaler Step III : Focus the attention on the tooth Step IV : A trough is created after curettage is complete  affirm the trough Step V : Packing is done.

17. TREATMENT OF THE INFRABONY POCKET WITH ONE OR TWO OSSEOUS WALLS OSTEOECTOMY-OSTEOPLASTY TO ELIMINATE LESION

18. TREATMENT OF THE COMBINATION TYPE OF INFRABONY POCKETS

19. Guided tissue regeneration The term guided tissue regeneration (GTR) includes procedures attempting to regenerate lost periodontal tissues when barrier materials are used to exclude the epithelial and connective gingival tissues from the root and bone surface. The barrier materials in GTR must, therefore, fulfill five main criteria : Tissue integration, Cell occlusivity , Clinical manageability, Space-making ability maintained long enough for both PDL and bone cells to proliferate into the defect and Biocompatibility (non-toxic, nonantigenic and induce no or little inflammation) An overview of periodontal regenerative procedures for the general dental practitioner M. Siaili , D. Chatzopoulou . 2017

20. An overview of periodontal regenerative procedures for the general dental practitioner M. Siaili , D. Chatzopoulou . 2017 Bone Replacement Grafts for the Treatment of Periodontal Intrabony Defects Philip J. Hanes. 2016

21. ALLOPLASTIC GRAFTS These materials function primarily as bone fillers Synthetic grafts are available in particles of 300–500  μm of diameter and may offer the advantages of unlimited quantity , no risk for disease transmission and no additional surgical site . Tricalcium phosphate (TCP) The most commonly used form of this material is β-tricalcium phosphate (β-TCP) A partially resorbable material that initially acts as a scaffold for bone formation . A number of studies have indicated beneficial results in periodontal reconstruction with the use of tricalcium phosphate. Other studies however, have highlighted the tendency of the particles of this material to be encapsulated by fibrous connective tissue. 3rd World Workshop in Periodontics 1996 Cutright et al., 1972, Stein et al., 2009 Baldock et al., 1985 Other Alloplastic Grafts : Polymers, Hydroxyapetite , Bioactive Glass

22. PLATELET-RICH PLASMA Platelet-rich plasma (PRP) is an autologous volume of plasma with a four- to five-fold increased platelet concentration above baseline and a well-documented source of growth factors , which has been used to improve wound healing and to increase the rate of bone deposition and bone volume in combination with bone grafts during bone augmentation procedures .13-15 The positive effects of PRP on bone healing could be attributed to the angiogenetic, proliferative, and differentiating effects on osteoblasts of transforming growth factor (TGF)-b and PDGF that are present in PRP in high concentrations. PRP combined with different grafting materials, barrier membranes, or an enamel matrix protein derivative has also been used in regenerative periodontal therapy with varying degrees of success. In most studies, a barrier membrane was used to cover the defects, and thus, the effects of PRP may have been masked by the effects of the barrier. However, the data from controlled clinical studies evaluating the additional effect of PRP when used in combination with different grafting materials are also somewhat controversial. Although some studies have indicated significantly higher improvements in terms of probing depth (PD) reduction and CAL when PRP was combined with a grafting material , others have failed to demonstrate significant differences. Marx RE, Carlson ER et al. Platelet-rich plasma. Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85:638-646. To¨zu¨m TF, Demiralp B. Platelet-rich plasma: A promising innovation in dentistry. J Can Dent Assos 2003;69:664. Sanchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. Int J Oral Maxillofac Implants 2003;18:93-103. Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-496. Okuda K, Tai H, Tanabe K, et al. Platelet-rich plasma combined with a porous hydroxyapatite graft for the treatment of intrabony periodontal defects in humans: A comparative controlled clinical study. J Periodontol 2005;76:890-898. Do¨ri F, Husza´r T, Nikolidakis D, Arweiler NB, Gera I, Sculean AA. Effect of platelet-rich plasma on the healing of intra-bony defects treated with a natural bone mineral and a collagen membrane. J Clin Periodontol 2007;34:254-261

23. Treatment of intrabony defects

24. Periosteum Autogenous periosteum with a layer of connective tissue as an alternative to the existing barrier membrane and this meets the requirements of an ideal material and is biologically acceptable. The periosteum is composed of two tissue layers: The outer fibroblast layer that provides attachment to soft tissue and the inner cambial region that contains undifferentiated mesenchymal cells, osteogenic progenitor cells that support bone formation. Under specific conditions, periosteal cells secrete extracellular matrix and form a membranous structure. The periosteum has the potential to stimulate bone formation when used as a graft material in animal and human studies. In an animal study , free grafts of periosteum taken from the tibia in rabbits were able to initiate bone and cartilage formation when placed in the anterior chamber of the eye and in the capsule of the kidney. Bone formation was also seen when periosteal grafts were placed in the midline sutures of rabbit mandible. In human studies , the use of periosteum in furcation defects,interproximal defects, gingival recession, and periradicular area showed evidence of bone fill as well as improvement in pocket depths and CAL. The advantages of using an autogenous periosteal membrane are that it Paolantonio M et al. Autogenous periosteal barrier membranes and bone grafts in the treatment of periodontal intrabony defects of single‑rooted teeth: A 12‑month reentry randomized controlled clinical trial. J Periodontol 2010

25. Procedure for Treatment

26. Article No. 1

27. Postoperative care The patients were prescribed Amoxicillin 500mg every 6 h for 7 days, flurbiprofen 100 mg every 8 h if necessary and 0.12% chlorhexidine gluconate mouth rinse twice daily for 4 weeks. Sutures were removed 2 weeks after surgery and the patients were instructed not to perform mechanical oral hygiene procedures consisting of brushing and interdental brushing or flossing at the surgical area for 4 weeks after surgery. Postoperative visits were scheduled weekly up to 1 month and then once a month. Patients showing evidence of noncompliance with oral hygiene measures during any of the visits were reinstructed in oral hygiene measures and a follow-up appointment was given to determine sufficient plaque control. No subgingival clinical instrumentation was performed during the postoperative 6 month period. Conclusion The addition of PRP to b-TCP for the treatment of intrabony periodontal defects failed to enhance the results when compared with a b-TCP graft alone.

28. Article No. 2

29. References