Jan Lindhe. Clinical Periodontology

Подождите немного. Документ загружается.

TREATMENT PLANNING • 425

Fig. 19-13. Case K.A. Periodontal chart from recordings

made 8 years after treatment. (Fig. 19-12).

Concluding remarks

The result of the treatment is shown in Fig. 19-11a-c

(clinical status 5 years after initial treatment), Fig.

19-12 (radiographs 8 years after treatment) and Fig.

19-13 (periodontal chart 8 years after treatment).

There was no recurrence of destructive periodontal

disease during the period of maintenance.

The planning of the overall treatment and the se-

quence of the different treatment procedures used in

this case were selected for presentation in order to

illustrate the following principle:

In patients exhibiting

generalized advanced breakdown of the periodontal tissues,

but with an intact number of teeth, considerable efforts should

be made to maintain all teeth.

Extraction of one

single

tooth in such a dentition will frequently also call

for the

extraction of several others for "prosthetic

reasons".

The end result of such an approach thus

includes an

extensive, prosthetic rehabilitation which,

if the

treatment planning had been properly done,

would

have been entirely unneccessary.

Patient B.H. (female, 40 years old)

Initial examination

The periodontal status (pocket depths, furcation in-

volvements, tooth mobility, radiographs) from the in-

itial examination is shown in Fig. 19-14a,b. The data

obtained from this examination disclosed essentially

shallow pockets in most parts of the dentition except

for isolated areas (the region 11-24) where some sites

exhibited probing depths varying between 4 and 7

mm. It should be observed that, particularly in the

maxillary front region, pronounced gingival reces-

sions prevailed. This means that even the moderate

probing depth values obtained reflected advanced

loss of the supporting tissues. This was further con-

firmed by the severe loss of alveolar bone (see radio-

graphs: Fig. 19-14) in this region where, in addition,

some of the teeth exhibited increased mobility (tooth

11: degree 2 in combination with elongation; tooth 23:

degree 3 and tooth 24: degree 2). In the posterior tooth

regions there was a loss of periodontal tissues varying

between

and

of the length of the roots. In the

mandibular front tooth region the destruction was

severe, particularly around tooth 31. This tooth was

found to be non-vital and exhibited a mobility of

degree 2. The plaque and gingivitis scores were 25 and

30%, respectively.

Treatment

In discussing with the patient different treatment al-

ternatives, it was first suggested that tooth 23 was to

be extracted. Not more than 2-3 mm of the apical

portion of the root was still invested in supporting

bone. The tooth exhibited a degree 3 mobility in con-

junction with premature occlusal contact in the inter-

cuspal position and on laterotrusive movement of the

mandible. The question arose, however, what cons-

quences extraction of tooth 23 would have for the

overall therapy. For instance: the neighboring teeth (22

with advanced periodontal destruction at the distal

aspect, and 24 with severe loss of supporting tissue

including increased mobility) could not be considered

proper abutment teeth for a 3-unit bridge replacing

tooth 23. The demand for proper abutment teeth

would therefore require a further extension of the

bridge to include teeth 21 and 25 (following extraction

also of 24). This extension of the bridge implies, how-

ever, that tooth 11 will be the first nonsplinted neigh-

boring tooth. Considering the small amount of perio-

dontium which persisted around this tooth, it may

from a prosthetic point of view be reasonable to extract

11 as well, and to extend the bridge to tooth 13, since

tooth 12 may also be considered improper as the

terminal abutment.

From this discussion, it is apparent that extraction

of one single tooth (23) in this dentition will lead to

extraction of a number of additional teeth to exclude

their incorporation in the permanent reconstruction.

The result is, thus, an extensive bridge therapy which

can be avoided if only the critical tooth (23) can be

426 • CHAPTER 19

Fig. 19-14a. Case B.H. (40-year-old female patient). Radiographs from the initial examination.

Fig. 19-14b. Periodontal chart relating to case B.H. (Fig.

19-14a).

maintained. Therefore it was decided to treat all teeth

and postpone the decision of tooth extractions until

the result of the periodontal treatment could be prop-

erly evaluated.

Initial (cause-related) therapy

Oral hygiene instruction and plaque control evalu-

ation. Scaling and root planing. Occlusal adjustment

of 11, 23 and 24. Correction of improper amalgam

restorations.

Additional therapy (following re-evaluation)

Periodontal surgery in the region of 11-24. Extraction

of 28 and 48 (semi-impacted molars). Endodontic

treatment of 31.

Six months following this part of the corrective

treatment, a new evaluation disclosed that no pathol-

ogically deepened pockets were present and that the

mobility had decreased in all initially hypermobile

teeth (11: from degree 2 to 1; 23: from degree 3 to 2; 24:

from degree 2 to 0; 31 from degree 2 to 1). All teeth

could, thus, be maintained and there were no indica-

tions for additional tooth extractions. The treatment

was completed with a crown restoration in tooth 25.

Supportive therapy

During the first year after completion of the corrective

therapy, the patient was enrolled in a maintenance

care program with recall appointments once every 3

months and thereafter once every 6 months.

The result of the treatment (12 years after) is shown

in Fig. 19-15a-c (clinical status) and Fig. 19-16 (radio-

graphs). No further loss of supporting tissues had

occurred during this observation period.

TREATMENT PLANNING • 4

Fig. 19-15a-c. Case B.H. Clinical status 12 years after treatment.

Fig. 19-16. Case B.H. Radiographs obtained 12 years after active therapy. Note that no loss of alveolar bone has

occurred during the 12 years of maintenance. Compare with Fig. 19-14.

Patient P.O.S. (male, 30 years old)

Initial examination

The clinical status of this patient is illustrated in Fig.

19-17a-c and the periodontal status (pocket depths,

furcation involvements, tooth mobility, radiographs

and diagnoses) from the initial examination in Fig.

19-

18. The dentition was characterized by severe de-

struction of the supporting apparatus, including ad-

vanced loss of the interradicular periodontal tissues

all molars and the two first maxillary premolars.

Most teeth were markedly mobile, particularly the

incisors in both jaws. The plaque and gingivitis scores

were close to 100%.

Treatment planning

A thorough analysis of the periodontal conditions in

this patient revealed that certain teeth could no longer

be treated and maintained but had to be extracted.

Hence, it was decided to extract teeth 14 and 24 (fur-

cation involvement of degree 2 from both mesial and

distal aspects) and 12, 11, 21, 22 (loss of the supporting

428 • CHAPTER 19

Fig. 19-17a-c. Case P.O.S. (30-year-old male patient). Clinical status prior to surgery.

Fig. 19-18a. Case P.O.S. Radiographs from the initial examination.

tissues to a level close to or beyond the apices in

combination with a mobility of degree 3). In the man-

dible, 42, 41, 31, 32 and 37 could not be maintained.

The overall treatment of this patient, therefore, had to

include prosthetic replacement of a number of teeth.

Alternative 1

Mandible:

In the planning phase, it was anticipated

that the prosthetic rehabilitation of the mandibular

dentition should not involve any technical difficulties

since 33 and 43 as well as 34, 35 and 44, 45 were

available for periodontal therapy and, hence, could be

used as abutment teeth for a cross-arch fixed bridge. It

did not seem reasonable to maintain the furcation-

involved 47 and 38. Hence these teeth were scheduled

for extraction. In this context it should be understood

that if 47 and 38 were to be maintained, the treatment

would have included not only endodontic measures

but also root separation and periodontal surgery, pro-

duction of posts and cores, and the incorporation of

the preserved roots as abutments in the cross-arch

bridge construction.

TREATMENT PLANNING • 429

Fig. 19-18b. Periodontal chart relating to case P.O.S.

(Fig. 19-18a).

Maxilla:

The maxillary dentition presented more diffi-

cult therapeutic problems. If the patient was to be

restored with a fixed bridge, it was considered perti-

nent to maintain the two maxillary canines (teeth 13

and 23) and at least one tooth in the premolar (molar)

regions on both sides of the jaw (15 and 25) and one

or more roots of 17,16 and 27.

Definitive

prosthetic

treatment of the maxillary dentition by means of a

Fig. 19-19. Case P.O.S. Clinical status of the front tooth

region at completion of the initial, cause-related treat

ment.

removable, partial denture was not considered appro

priate since the various abutment teeth for such a

denture displayed a markedly increased mobility. For

the same reason, it was considered inappropriate to

temporarily

replace the extracted teeth by means of a

provisional, removable partial denture. The provi-

sional prosthesis had to be fabricated in the form of a

fixed bridge in order to enable proper stabilization

(

splinting) of the hypermobile 13, 23 and 25 prior to

periodontal surgery. In the present case the temporary

bridge did not include tooth 15 and the maxillary

molars. Tooth 15 was to be left uncovered in order to

facilitate endodontic therapy and the preparation and

insertion of a post and core. In addition, the maxillary

molars had to be accessible for periodontal therapy

including endodontic treatment and root separation.

In order to facilitate the surgical procedures and also

to avoid the risk of a further increase of the tooth

mobility, the extraction of 14, 21 and 22 and the

insertion of the temporary bridge had to be carried out

prior to the start of the surgical phase of treatment.

Alternative 2

The alternative treatment to the

one

outlined above is

complete denture in the maxilla and a removable

partial denture in the mandible with the use of 45, 44,

43 and 33, 34, 35 as abutment teeth.

Treatment

The clinical and radiographical symptoms of the ad-

vanced disease as well as the therapeutic alternatives

were thoroughly discussed with the patient. This dis-

Fig. 19-18c. Pre-therapeutic risk assessment made for patient P.O.S. described in Figs. 19-17 and 19-19a,b.

430 • CHAPTER

Fig. 19-20a-b. Case P.O.S. The abutment teeth used for a maxillary (a) and a mandibular (b) bridge.

Fig. 19-21a-c. Case P.O.S. Clinical photographs illustrating the result of treatment after 8 years of maintenance.

cussion included a detailed explanation of the role of

optimal plaque control for the long-term good prog-

nosis. The treatment was performed according to

al-

ternative 1

and in the following sequence:

Initial (cause-related) therapy

Instruction regarding oral hygiene measures. Scaling

and root planing. Evaluation of the ability of the pa-

tient to maintain a high standard of oral hygiene.

Extraction of 14, 12, 11, 21, 22. Temporary acrylic

bridge 14, 13, 12, 11, 21, 22, 23, 24, 25; (24 was tempo

rarily maintained in order to ensure proper stability

the temporary bridge).

Extraction of 47, 42, 41, 31, 32, 37, 38. Temporary

acrylic bridge 44, 43, 42, 41, 31, 32, 33, 34, 35; (45:

because the tooth was non-vital it was not incorpo

rated in the temporary bridge to facilitate endodontic

treatment). Endodontic treatment 15, 45. The clinical

status at the completion of the initial treatment is seen

in Fig. 14-19.

Additional therapy

Periodontal surgery around the teeth which at the

re-

evaluation after initial therapy still exhibited pathol-

ogically deepened pockets which bled on probing. The

palatal roots of 17 and 27 were maintained and the

buccal roots were extracted following separation.

Extraction of 16 and 24. Following healing after

surgery, posts and cores were inserted in 17, 15, 27 and

45 (Fig. 19-20a,b) and permanent fixed bridges were

designed and fabricated with the following outline:

TREATMENT PLANNING • 431

Fig. 19-22. Case P.O.S. Radio-

graphs obtained 8 years after com-

pletion of active therapy. Note

that

no further loss of alveolar

bone has

occurred during the 8

years of

maintenance.

Maxilla:

17 (palatal root), 16, 15, 14, 13, 12, 11, 21, 22,

23, 24, 25, 26, 27 (palatal root).

Mandible:

46, 45, 44, 43, 42, 41, 31, 32, 33, 34, 35, 36.

Supportive therapy

After completion of active treatment this patient was

enrolled in a maintenance care program including

recall

appointments once every 3 months. Clinical

photographs (Fig. 19-21a-c) and radiographs (Fig. 19-

22) illustrate the result of the treatment at the 8-year

control. No further loss of supporting tissues occurred

during the maintenance period.

REFERENCES

Lindhe, J. & Nyman, S. (1975). The effect of plaque control and

surgical pocket elimination on the establishment and mainte-

nance of periodontal health. A longitudinal study of peri-

odontal therapy in cases of advanced disease.

Journal of Clini-

cal Periodontology 2,

67-79.

Nyman, S. & Lindhe, J. (1979). A longitudinal study of combined

periodontal and prosthetic treatment of patients with ad-

vanced periodontal disease.

Journal of Periodontology

50, 163-

169.

Nyman, S., Lindhe, J. It Rosling, B. (1977). Periodontal surgery

plaque-infected dentitions.

Journal of Clinical Periodontology

240-249.

Nyman, S., Rosling, B. & Lindhe, J. (1975). Effect of professional

tooth cleaning on healing after periodontal surgery.

Journal of

Clinical Periodontology 2,

80-86.

Rosling, B., Nyman, S. & Lindhe, J. (1976a). The effect of system-

atic plaque control on bone regeneration in infrabony pock

ets.

Journal of Clinical Periodontology 3,

38-53.

Rosling, B., Nyman, S., Lindhe, J. & Jern, B. (1976b). The healing

potential of the periodontal tissues following different tech-

niques of periodontal surgery in plaque-free dentitions. A

year clinical study.

Journal of Clinical Periodontology 3,

233-

250.

CHAPTER 20

Cause-Related

Periodontal Therapy

HARALD RYLANDER AND JAN LINDHE

Objectives of initial, cause-related

periodontal therapy

Means of initial, cause-related periodontal

therapy

Scaling and root planing

Removal of plaque-retention factors

Healing after initial, cause-related therapy

Clinical measurements

Structural measurements

Evaluation of the effect of the initial,

cause-related therapy

The overall treatment of patients with caries and peri

odontal disease, including associated pathologic con-

ditions (e.g. pulpal and periapical lesions, tooth mi-

gration, tooth loss) can he divided into three different

but frequently overlapping phases (see Chapter 19):

The phase of initial, cause-related therapy is

aimed at

bringing caries and gingivitis under control and at

arresting the further progression of periodontal tissue

destruction.

The phase of additional therapy is

aimed at restoring

function and esthetics.

The phase

f supportive therapy is

aimed at preventing

recurrence of caries and periodontal disease.

OBJECTIVES OF INITIAL, CAUSE-

RELATED PERIODONTAL THERAPY

The measures used in initial, cause-related periodon-

tal therapy aim at the elimination — and the prevention

of their recurrence — of supra and subgingivally lo-

cated bacterial deposits from the tooth surfaces. This

is accomplished by:

•

motivating the patient to understand and combat

dental disease

(patient information)

•

giving the patient

instruction

on how to properly

clean his/her teeth

(self-performed plaque control

methods),

see Chapter 21

•

scaling and root planing

•

removal of additional

retention factors

for plaque such

as overhanging margins of restorations, ill-fitting

crowns, etc.

MEANS OF INITIAL, CAUSE-

RELATED PERIODONTAL

THERAPY

Scaling and root planing

Definitions

Scaling is

a procedure which aims at the removal of

plaque and calculus from the tooth surface. Depend-

ing on the location of the deposits, scaling is per-

formed by supragingival and/or subgingival instru-

mentation.

Root planing

denotes a technique of instru

mentation by which the "softened" cementum is re-

moved and the root surface is made "hard" and

smooth". Subgingival scaling and root planing can

performed as either

closed

open

procedures and

often under local anesthesia. The

closed

procedure

implies subgingival instrumentation without inten-

tional displacement of the gingiva. The root surface is,

thus, not accessible for direct visual inspection. The

open

procedure calls for exposure of the affected root

surface by measures which displace the gingival tis-

sue. The gingiva is thus incised and reflected or re-

sected to facilitate access and visibility in the field of

operation.

CAUSE-RELATED PERIODONTAL THERAPY • 433

Fig. 20-1. A double-ended hand

instrument with col-grip. The

cutting edges of the blades are

centered over the long axis of the

handle.

Instruments and instrumentation

Instruments used for scaling and root planing are

classified as:

Hand instruments

Ultrasonic and sonic instruments

Rotating instruments

Reciprocating instruments

5. Laser instruments

Hand instruments

A hand instrument is composed of three parts: The

working part

(the blade), the

shank

and the

handle.

The

cutting edges of the blade are centered over the long

axis of the handle in order to give the instrument

proper balance (Fig. 20-1). The blade is often made of

carbon steel, stainless steel

tungsten carbide.

Curettes

(Fig. 20-2): Curettes are instruments used for

both scaling and root planing. The working part of the

curette is the spoon-shaped blade which has two

curved cutting edges. The two edges are united by the

rounded toe. The curettes are usually made "double-

ended" with mirror-turned blades. The length and

angulation of the shank as well as the dimensions of

the blade differ between different brands of the instru

ment (Fig. 20-3).

Sickles

(Fig. 20-4): The sickle is manufactured with

either a curved or a straight blade which has a trian-

gular cross section and two cutting edges. The "facial"

surface between the two cutting edges is flat in lateral

direction but may be curved in the direction of its long

axis. The "facial" surface converges with the two lat-

eral surfaces of the blade. The sickles are mainly used

for supragingival debridement or scaling in shallow

pockets.

Hoes

(Fig. 20-5): The hoe has only one cutting edge.

The blade is turned at a 100° angle to the shank with

the cutting edge beveled at a 45° angle. The blade can

he positioned at four different inclinations in relation

to the shank: facial, lingual, distal and mesial. The hoe

is mainly used for supragingival scaling but is an

excellent instrument to use for root planing during

periodontal surgery.

Instrumentation

Supragingival scaling:

The debridement of the denti-

tion of a patient with periodontal disease often starts

with supragingival scaling. Supragingival calculus

and gross overhangs of restorations are removed (Fig.

20-6). This initial phase of the debridement can be

performed with the use of hand instruments or ultra-

sonic instruments (see below). When hand instrumen

tation is preferred for the initial debridement, a curette

or a sickle is often used to simply split off calculus

from its attachment to the enamel and/or the exposed

part of the root. Following hand instrumentation the

clinical crowns should be polished using rubber cups

and first pumice and subsequently more fine-grained

(

grainsize of 2-4tm) polishing pastes. In many cases

the

supragingival scaling effort can be completed in one

session. This will allow the patient, without further

delay, to implement the new and "improved" self-per-

formed plaque control program.

Fig. 20-2. Schematic illustration of the design of the

blade of a curette.

434 • CHAPTER 20

Fig. 20-3. Curettes with different lengths and angulations of the shank. (a) and (b) are curettes used for supragingi

val and (c) and (d) curettes for subgingival instrumentation. Increased angulation of the shank (b and d) of the cu

rettes permits proper instrumentation in posterior tooth regions.

Fig. 20-4. Schematic illustration of the cross section of

the blade of a sickle. Note the positions of the cutting

edges.

Subgingival scaling and root planning:

Performed with

hand instruments, these treatment procedures aim at

removing not only soft and hard deposits from the

root

surface but also small amounts of tooth sub-

stance.

Root cementum and also root dentine are re-

moved in

the shape of small chips which carry the

Fig. 20-5. The cross section of a hoe. Note the position

of the cutting edge.

deposits and which during the cutting operation are

curled up at the front side (in the cutting direction) of

the blade of the instrument. This method of instru-

mentation is denoted "orthogonal cutting", which im-

plies the removal of tooth substance by means of an

edge which to a varying extent penetrates the hard

substance of the root. The result of the cutting opera-