Surgical extrusion technique for clinical crown lengthening

Int J Periodontics Restorative Dent. 2004 Oct;24(5):412-21.

Surgical extrusion technique for clinical crown lengthening: report of three cases.
Kim CS, Choi SH, Chai JK, Kim CK, Cho KS.
Department of Periodontology, Research Institute for Periodontal Regeneration, Oral Science Research Center, College of Dentistry, Yonsei University, Seodaemun-Gu, Seoul, Korea.

Although a number of techniques have been proposed for clinical crown lengthening procedures, all have some limitation in terms of function and esthetics. This report presents the clinical and radiographic results of a surgical extrusion technique for clinical crown lengthening. Atraumatic surgical extrusion using a specially designed instrument (Periotome) was performed in three cases in which it was expected that extensive resective osseous surgery would have to be used for crown lengthening. Full-thickness mucoperiosteal flaps were raised both labially and palatally. The tooth was carefully luxated and extruded to the desired position without damaging the marginal bone area or root apex. No rigid splint was applied. Clinical examinations performed for more than 1 year after surgery revealed probing depths < or =" 3">@ Clinical procedure for CLP with surgical extrusion


@ Orthodontic Extrusion for CLP (PDF from U. Ohio)

The Vector™ System: an Ultrasonic Device for Periodontal Treatment

Several years ago the Vector system was introduced to the European market for ultrasonic periodontal treatment. The manufacturer claimed that the system removed root cementum and periodontal soft tissues less aggressively than hand instruments. Furthermore, the treatment with the Vector system was claimed to be less painful than treatment with conventional systems, as vibrations applied horizontally to the root surface were avoided by a specific oscillation pattern. In addition, by changing the different insert tips of the handpiece, it is possible to use the device not only for periodontal treatment but also in restorative dentistry (i.e. minimal invasive preparation). Several studies assessed the properties of the device, and evaluated its possible benefits especially for periodontal debridement and supportive periodontal care.

*Efficiency of subgingival calculus removal with the Vector™-system
*Treatment of peri-implantitis by the Vector® system: A pilot study

News from Durr's Company:
Dürr Vector System
- Periodontal Treatment Breakthrough
More than 60% of all adults in the industrial world suffer from Periodontitis. With the Dürr Vector System you gain control of this disease. The Dürr Vector removes biofilm, plaque, calculus, endotoxins and eliminates the causal bacteria quickly and reliably. With Vector you work ergonomically and with a sensitive touch right into the last corner, even in pockets more than 5, 9 or 11 mm deep.
Many dentists tend to view the use of sonic and ultrasonic equipment sceptically, especially when working in subgingival areas. There is too great a danger that instruments, whatever their shape, that are oscillating or swaying in an undifferentiated manner, do more harm than good in the pocket. This is not the case with Vector.
Vector converts the ultrasonic dynamics of 25,000 Hz in such a way that you as a dentist can work in a completely relaxed and non-traumatic manner. Quickly and effectively.
The actively oscillating ring of the Vector functions in a similar way to a hula-hoop. If it is pressed into the horizontal position it moves with exactly 90° deflection vertically.
It is a question of allowing the instruments to oscillate exactly linearly, parallel to the surface of the tooth, without circling, swaying or knocking. With the Vector method you can do practically nothing wrong.

Available soon.
For further information contact
Angela Young - Product Manager
Ivoclar Vivadent Pty Ltd
1-5 Overseas Drive, Noble Park North Vic 3174
Ph: (03) 9795 9599 Email: angela.young@ivoclarvivadent.com.au

Clinical Experience by Perio:
1. More precice to contact root surface,
2. Straight working to the deep pocket,
3. More power to remove the deposit of root,
4. Insert tips too long to approach posterior area,
5. Irrigator liquid too expensive...

Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects

Emdogain® is the biology-based and scientifically proven solution to promote the predictable regeneration of hard and soft tissues lost due to periodontal disease like intrabony defects, class II mandibular furcation and recession defects. ReliableMore than 40 clinical studies, involving 1500 intrabony periodontal defects in 1200 patients, have demonstrated that Emdogain is effective in stimulating the formation of new periodontal attachment in soft and hard tissue. 60-70% defect fill was measured as a gain of radiographic bone one year following treatment with Emdogain. Simple treatment with Emdogain requires little or no preparation time; no mixing and no specialized products or equipment are necessary. It is convenient and effective to use in areas difficult to treat such as interproximal areas, defects distal to the second molar, defects located under bridgework and wide defects. No second surgery is required.VersatileThe possibility for the use of Emdogain in periodontal defects is expanding.
It is indicated for:
1-,2-,3-wall defects
Recession defects
Class II mandibular furcation defects

Cochrane Review>>>

By mimicking the biological processes of natural tooth development, Emdogain forms an insoluble three dimensional matrix, which allows for the selective colonization of cells. Through cellular interactions, a cascade of events initiates increased cell proliferation, growth factor synthesis and cell differentiation resulting in the formation of necessary hard and soft tissues such as cementum, periodontal ligament and alveolar bone.
1. Attachment – Mesenchymal cells attach to the formed matrix.
2. Proliferation and growth – The cells spread and populate the surface.
3. Cementum formation – The cells start to produce cementum with insertingcollagen fibers.
4. Alveolar bone – Along the treated root surface, and at a certain distance, a condensation of fibrous tissue indicates the region where new alveolar bone is forming.

Post Surgery one wk:

>>>>>PostSx 2wks>>>>>

**Above Clinical Photo present by @Perio^^^
^How to control the bleeding before your application of Emdogain? Dr. Sculean's suggestions from his Taiwan's lecture!

1. Completely remove all infammations (hard/soft tiss);

2. Rinse with normal Saline frequently;

3. Apply Emdogain from apex to crown;

4. Presuture (Mod. Mattress suture);

5. Premixture with bone graft before applied into defects.

>>Suture Technique Review from eMedicine.com>>

Can the Emdogain help to Peri-implantitis ??? (Dr. Sculean et al.)

Modified Papilla Preservation Technique (MPPT)

The modified papilla preservation technique(1996). A new surgical approach for interproximal regenerative procedures. A modification of the papilla preservation technique has been applied to achieve primary closure of the interproximal tissue over barrier membranes placed coronal to the alveolar crest. Cortellini et al. study:Fifteen patients with deep intrabony interproximal defects were treated. Defects had a probing attachment level loss of 9.9 +/- 3.2 mm and a recession of the gingival margin of 1.7 +/- 1.6 mm. The depth of the intrabony component was 5.5 +/- 2.9 mm; while the suprabony component was 5.9 +/- 2.0 mm. Titanium-reinforced teflon membranes were placed 1.3 +/- 0.7 mm from the cemento-enamel junction, 4.5 +/- 1.6 mm coronal to the interproximal alveolar bone crest. Primary closure over the interproximal portion of the membrane was obtained in 93% of cases. In 73% of the cases complete coverage of the membrane was maintained until its removal at 6 weeks. These data indicate that the modified papilla preservation technique can be successfully applied to obtain primary closure of the interdental space in regenerative procedures with barrier membranes.
J Periodontol. 1995 Apr;66(4):261-6.
Int J Periodontics Restorative Dent. 1996 Dec;16(6):546-59.
Figure Enlarge>>>

Simplified Papillae Preseved Technique(SPPT)

Figure Enlarge>>>
Microsurgical Approach to Periodontal Regeneration. Initial Evaluation in a Case Cohort
Dr. Pierpaolo Cortellini and Maurizio S. Tonetti

The use of a microsurgical approach was associated with very high ability to obtain and maintain primary closure of the interdental tissues over the barrier membranes. The procedure resulted in clinically important amounts of CAL gains and minimal recessions. J Periodontol 2001;72:559-569.

SPPT procedures: Archives of Oct.>>>

Glass Ionomer filling into severe furcation invlovement of Molar tooth

Treatment of Class III furcation has historically been less than predictable. Long-term studies have demonstrated poor survival rates of teeth with advanced furcation involvement. Although multiple treatment modalities have been attempted to retain teeth with severe furcation invasion, clinical success has not been predictable. Treatment attempts range from non-surgical therapy, furcation obliteration,surgery to increase access to the furcation, root resections, tunnel procedure, guided tissue regeneration, and a combination of graft materials, membranes, and coronally positioned flaps. Regenerative techniques that have been successful in the treatment of Class II mandibular furcation involvements have been less predictable when performed in Class III situations. In the past restorative materials have been used to obliterate furcation; the goal was to improve plaque control by eliminating the anatomic niches within the furcation where bacteriacan accumulate. Also, in the past polymericreinforced zinc oxide-eugenol (IRM), amalgam,glass ionomer, and resin ionomer restorative materials were utilized to fill Class III furcation invasions.

@Potential advantages of an occlusive barrier such as glass ionomer include:
• Ease of placement
• Does not require a suture for stability
• Elimination of a second stage procedure for retrieval of the membrane since it is permanently bonded
• Long junctional epithelial attachment to the glass ionomer
• Does not require complete coverage by the gingival flap
• Bacteriostatic due to fluoride release
• Lower cost

The use of a glass ionomer to regenerate the attachment apparatus in the treatment of advanced furcation involvement was not the goal of the treatment. There was no intention to regenerate any tissue, hard or soft. The goal of selecting this mode of therapy was simply to retain hopeless molars with advanced furcation defects.

A case report for filling Fuji II LC into Mandibular Cl III molar FI and final procelain to metal crown restoration: Surgery by Dr. Perio
@PostSx 4 months....

Diabetes and periodontal disease: A complex, two-way connection

Dental visits among dentate adults with diabetes--United States, 1999 and 2004.
MMWR Morb Mortal Wkly Rep. 2005 Nov 25;54(46):1181-3.
Centers for Disease Control and Prevention (CDC).

One of the major complications of diabetes is periodontal disease, a chronic infection of tissues supporting the teeth and a major cause of tooth loss. Adults with diabetes have both a higher prevalence of periodontal disease and more severe forms of the disease, contributing to impaired quality of life and substantial oral functional disability. In addition, periodontal disease has been associated with development of glucose intolerance and poor glycemic control among adults with diabetes. Regular dental visits provide opportunities for prevention, early detection, and treatment of periodontal disease among dentate adults (i.e., those having one or more teeth); moreover, regular dental cleaning improves glycemic control in patients with poorly controlled diabetic conditions. One of the national health objectives for 2010 is to increase the proportion of persons with diabetes who have an annual dental examination to 71% (revised objective 5-15). To estimate the percentage of dentate U.S. adults aged > or =18 years with diabetes who visited a dentist within the preceding 12 months, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) surveys for 1999 and 2004. This report describes the results of that analysis, which indicated that, in 2004, age-adjusted estimates in only seven states exceeded 71% and estimated percentages for four states and District of Columbia (DC) increased significantly from their levels in 1999. The findings underscore the need to increase awareness and support for oral health care among adults with diabetes, including support for national and state diabetes care management programs.

What is the Link Between Diabetes and Periodontal Disease?

Diabetic Control.
Like other complications of diabetes, gum disease is linked to diabetic control. People with poor blood sugar control get gum disease more often and more severely, and they lose more teeth than do persons with good control. In fact, people whose diabetes is well controlled have no more periodontal disease than persons without diabetes. Children with IDDM (insulin-dependent diabetes mellitus) are also at risk for gum problems. Good diabetic control is the best protection against periodontal disease.
Studies show that controlling blood sugar levels lowers the risk of some complications of diabetes, such as eye and heart disease and nerve damage. Scientists believe many complications, including gum disease, can be prevented with good diabetic control.
Blood Vessel Changes.
Thickening of blood vessels is a complication of diabetes that may increase risk for gum disease. Blood vessels deliver oxygen and nourishment to body tissues, including the mouth, and carry away the tissues' waste products. Diabetes causes blood vessels to thicken, which slows the flow of nutrients and the removal of harmful wastes. This can weaken the resistance of gum and bone tissue to infection.
Bacteria.
Many kinds of bacteria (germs) thrive on sugars, including glucose -- the sugar linked to diabetes. When diabetes is poorly controlled, high glucose levels in mouth fluids may help germs grow and set the stage for gum disease.
Smoking.
The harmful effects of smoking, particularly heart disease and cancer, are well known. Studies show that smoking also increases the chances of developing gum disease. In fact, smokers are five times more likely than nonsmokers to have gum disease. For smokers with diabetes, the risk is even greater. If you are a smoker with diabetes, age 45 or older, you are 20 times more likely than a person without these risk factors to get severe gum disease.

> Free Article from JCDC >The Relationship Between Diabetesand Periodontal Disease
http://www.cda-adc.ca/jcda/vol-68/issue-3/161.pdf

Third molars may have a negative impact on periodontal health

The finding of more severe periodontal conditions associated with visible third molars in these middle-aged and older adults indicates that third molars may continue to have a negative impact on periodontal health well into later life. The relationship between third molars and periodontal disease pathogenesis deserves further study using longitudinal data... More>>>

A consensus development conference on Removal of Third Molars was held at the National Institutes of Health on November 28-3O, 1979. More than 200 practicing dentists and scientists, representing all disciplines within the profession, met in an effort to reach general agreement on when and under what circumstances third molar extraction is advised and to identify areas where further research is needed.
Summary :
The conference participants carefully examined the long-established practice of third molar removal. A number of clinical procedures were endorsed; others were controversial but identified as subjects for additional research. A number of well-defined criteria for the removal of third molars emerged. They are, in part, infection, nonrestorable carious lesions, cysts, tumors, and destruction of adjacent teeth and bone. There is less morbidity associated with removal of these teeth in the young than in the older patient.
The effectiveness of removal of third molars to prevent crowding of lower incisors is not borne out by the studies currently available. Third molar bud removal in youngsters, based on predictive studies, is not currently an acceptable practice in view of available knowledge. Clinical experience suggests that morbidity and serious complications may be reduced if impacted teeth are removed at an early age. The observation is not disputed by available data, but there is enough question about the life-cycle of impacted third molars to suggest the need for well-designed prospective studies of the subject.
Full Report>>>

*Severe infrabony defect caused from impacted 3rd molar >> regeneration surgery with Emdogain + Dynagraft --- Case report by Dr.Perio

How Predictable Are Periodontal Regenerative Surgery?

Periodontal regeneration has become one of the primary objectives of periodontal therapy.The resulting scientific endeavours have elucidated modes of periodontal wound healing, the growth of periodontal cells and their association with the surrounding matrix, and growth-promoting factors. The periodontal regeneration industry is producing better and more expensive devices, but the criteria for evaluating their success have not progressed to the same extent. Although clinical measurements of attachment level and probing depths, along with radiography, are good methods of evaluating tooth survivaland prognosis, they do not indicate true biological regeneration. In addition, there generation industry may encourage the overuse of allografts and alloplasts which may serve as an impediment to simple wound healing. This review is a critical assessment of the clinical use of various regenerative tools, specifically bone replacements and membranes.The future of the regeneration industry may depend on the merging of various technologies and biological concepts, including the possible use of biological barriers, variousbone and periodontal growth inducers, and artificial matrices that will attract or carry the cells necessary for regeneration.
Oct. Archives>>>

Crown Lengthening Procedure with Modified Distal Wedge Operation

According to ROBINSON (1966), the periodontal pockets adjacent to distal root surfaces of the second and third molars are aspects of the periodontal therapy of difficult solution and they have been denied frequently for many periodontists. The periodontal pocket on the distal surface of molars can be extremely deep due to the anatomy of this area. When the pocket becomes deeper, that depth is larger than in other areas and the inaccessibility of the area leads to the inability in the mechanical control of bacterial plaque executed by the patient. Regarding to these aspects, he developed the Distal Wedge procedure in order to treat periodontal pockets adjacent to the distal surfaces of the molars. This technique uses internal bevel incisions and it has as objectives: to obtain access to the bone tissue, to preserve attached gingiva, to eliminate periodontal pockets, to reduce the healing period and to minimize the postoperative pain (Robinson RE The distal wedge. Periodontics 1966; 4:256-264).

@Clinical Procedure for Mod. distal wedge:(Surgery by Dr. Perio)







@PostSx 1 wk....