MINIMALLY INVASIVE SINGLE FLAP APPROACH WITH CONNECTIVE TISSUE WALL FOR PERIODONTAL REGENERATION

INTRODUCTION: The destructive periodontal diseases are among the most prevalent in the human population. In some cases, bony defects are formed during the disease progression, thus sustaining deep periodontal pockets. The reconstruction of these defects is usually done with the classical techniques of bone substitutes placement and guided tissue regeneration. The clinical and histological data from the recent years, however, demonstrate the relatively low regenerative potential of these techniques. The contemporary approaches for periodontal regeneration rely on minimally invasive surgical protocols, aimed at complete tissue preservation in order to achieve and maintain primary closure and at stimulating the natural regenerative potential of the periodontal tissues. AIM: This presentation demonstrates the application of a new, minimally invasive, single flap surgical technique for periodontal regeneration in a clinical case with periodontitis and a residual deep intrabony defect. MATERIALS AND METHODS: A 37 years old patient presented with chronic generalised periodontitis. The initial therapy led to good control of the periodontal infection with a single residual deep periodontal pocket medially at 11 due to a deep intrabony defect. A single flap approach with an enamel matrix derivate application and a connective tissue wall technique were performed. The proper primary closure was obtained. RESULT: One month after surgery an initial mineralisation process in the defect was detected. At the third month, a complete clinical healing was observed. The radiographic control showed finished bone mineralisation and periodontal space recreation. CONCLUSION: In the limitation of the presented case, the minimally invasive surgical approach led to complete clinical healing and new bone formation, which could be proof for periodontal regeneration

EFFECTIVNESS OF TARGET ANTIMICROBIAL THERAPY OF SEVERE CHRONIC PERIODONTITIS PART I: REDUCTION OF GINGIVAL INFLAMATION AND ACTIVE PERIODONTAL DISEASE SITES

The correlation between recurrent bleeding on probing and the progression of periodontal destruction is suggested in many studies. One of the main goals of the periodontal treatment is the achievement of good control of the gingival inflammation and the reduction of the active periodontal sites.Aim: Evaluation of the effectiveness of treatment of severe chronic periodontitis with additional target antibiotic administration in comparison with the therapy with adjunctive antimicrobial combination amoxicillin + metronidazole and conventional mechanical periodontal treatment regarding the achieved control of the gingival inflammation and BoP.Results: Significant reduction of the gingival bleeding and the BoP is achieved in all groups. In the group with target antibiotic administration the final mean values of the GB (gingival bleeding) and BoP (bleeding on probing) are the lowest and could suggest a low risk for progression of the periodontal disease

MODIFIED SINGLE ROLL FLAP APPROACH FOR SIMULTANEOUS IMPLANT PLACEMENT AND GINGIVAL AUGMENTATION

INTRODUCTION: The frequent result of tooth extraction is the resorption of the buccal alveolar wall and formation of I class (Siebert) alveolar ridge defect. Another frequent problem in the implant surgery after the elevation of the standard full thickness flap is the choice of the exact vertical implant position to provide adequate biological width with 3mm keratinized soft tissue above a bone level implant. Nowadays the aim is to develop minimally invasive surgical approaches for other surgical applications. AIM: This presentation demonstrates the application of a newly modified, minimally invasive, single roll flap approach for simultaneous implant placement and gingival augmentation. MATERIALS AND METHODS: A 47 years old patient presented with fractured left central incisor. A new surgical technique for simultaneous implant placement and gingival augmentation was applied. Buccal partial thickness flap was prepared with de-epithelization and roll flap elevation of the crestal keratinized tissue, thus forming new papillae and ensuring implant placement in the exact vertical position. After one week of healing the final screw retained restoration was placed. RESULT: The application of this newly developed by the author modification of the surgical protocol allowed precise implant placement consistent with the biological width requirements and simultaneously achieving buccal gingival augmentation. CONCLUSION: The proposed new surgical approach provides an opportunity for minimally invasive implant placement without periosteal elevation. The modified roll flap preserves the keratinized tissues of the alveolar ridge using them to provide adequate buccal soft tissue volume. Furthermore, this approach ensures precise selection of the optimal implant depth, thus providing maximal functional and aesthetic result

COMPLEX TREATMENT IN A PATIENT WITH SEVERE CHRONIC PERIODONTITIS (Case Report).

INTRODUCTION: Periodontitis is characterized by progressive destruction of periodontium, caused by relatively small group of microorganisms. The treatment aims to create proper environment which hampers the colonization of pathogens. The mechanical cleaning of the root surfaces combined with meticulous oral hygiene is the consensus treatment. In advanced cases the progression of the disease could lead to different problems - gingival recessions, insufficiency of attached gingiva, mobility and tooth loss which require complex treatment. OBJECTIVE: This presentation demonstrates the multidisciplinary treatment approach in a patient with a severe chronic periodontitis. METHODS: S.S. (42) with severe chronic periodontitis, insufficient mandibular vestibule depth, lack of keratinized gingiva, class III recessions and central incisors with grade III mobility. The #12 is missing and a crossbite is present on #32. The anti-infective therapy led to stable periodontal status. The corrective phase included the creation of vestibule depth with an autogenous gingival graft, dental implant placement with immediate provisional loading for #12, extraction of #31 and #41 due to attachment loss to the apex and immediate placement of provisionals with crossbite correction. RESULT: The reevaluation demonstrated good control of the gingival inflammation and stable periodontal status. The subsequent implant and prosthetic treatment led to the restoration of a functional dentition. CONCLUSION: The long term success of the treatment of the complex cases with severe chronic periodontitis depends significantly upon the proper control of the periodontal infection and the achievement of a stable periodontal status. These are the major prerequisites for successful further implant and prosthetic rehabilitation

ALTERNATIVE APPROACH IN THE TREATMENT OF A GINGIVAL CLEFT ASSOCIATED WITH LABIAL FRENULUM. A 3-YEAR FOLLOW-UP. (Case Report)

INTRODUCTION: The term Gingival cleft refers to a fissure in the gingival tissues and is usually caused by traumatic oral hygiene, abnormal frenula, trauma from occlusion, orthodontic, or pierce related trauma. Gingival clefts are classified depending on the extent of the inclusion of the gingival thickness into red and white. The recommended treatment approach for the incomplete white clefts is the gingivectomy of the affected keratinized tissue followed by a coronally advanced flap for the root coveradge, while the complete white clefts are treated with a laterally moved, coronally advanced flap, or a free gingival graft procedure. OBJECTIVE: This report presents a case with a spontaneous healing of an incomplete gingival cleft associated with a maxillary labial frenulum after an alternative frenuloectomy approach. METHODS: M.G. (45) with a localized chronic periodontitis, an abnormal papillary maxillary frenulum and an incomplete white cleft on the marginal gingiva of the left central incisor. An alternative frenuloectomy approach combined with a free gingival graft was selected for the correction of the abnormal frenulum. RESULTS:On the sixth month after the surgical procedure an almost complete recovery of the gingival margin was observed.The result at the third year demonstrates a stable gingival margin with a complete tissue recovery. CONCLUSION: The applied combined surgical approach led to a complete gingival recovery of the incomplete white gingival cleft without the commonly used gingivectomy and CAF. Further research is recommended to clarify the adjunctive benefits of the FGG in patients with gingival clefts associated with abnormal frenula

EFFECTIVNESS OF TARGET ANTIMICROBIAL THERAPY OF SEVERE CHRONIC PERIODONTITIS PART II: PREVALENCE OF RESIDUAL POCKETS

Comprehensive treatment of periodontitis is very different from the treatment of most bacterial infections. While periodontitis is traditionally considered a bacterial infection, many variables influence treatment outcomes. The reduction of the probing depth of the periodontal pockets is one of the main criteria for the success of the periodontal treatment. The prevalence of the residual pockets with probing depth greater than 4 mm determines the risk of disease progression. The reduction of the periodontal sites with PD above 7mm with non-surgical periodontal treatment could limit the necessity of periodontal surgery. Aim: Evaluation of the effectiveness of treatment of severe chronic periodontitis with additional target antibiotic administration in comparison with the therapy with adjunctive antimicrobial combination amoxicillin+metronidazole and conventional mechanical periodontal treatment regarding the prevalence and the achieved mean reduction of PD of periodontal pockets with initial PPD below 3mm, from 3 to 5mm, from 5-7mm and above 7mm.Results: In all study groups a reduction of the mean PD has been achieved. The prevalence of periodontal sites with PD above 7mm after therapy is the lowest in the group with target antibiotic administration. These results advocate the effectiveness of the target adjunctive antimicrobial treatment in order to limit the extent of the surgical procedures in the therapy of the periodontal disease

REDUCTION OF MOBILITY OF PERIODONTALY AFFECTED TEETH AFTER GINGIVAL AUGMENTATION WITH AN AUTOGENOUS GINGIVAL GRAFT (Case Report).

INTRODUCTION: The most severe complication of advanced periodontal lesions is the loss of teeth due to terminal attachment loss and high grade mobility. The goals of the treatment are the improving the plaque control stabilizing of the mobile teeth and arresting of the progression of gingival recession achieving gingival augmentation with adequate vestibulum depth. The autogenous graft is considered to be the most efficient approach where a significant increase of the attached gingiva is needed. OBJECTIVE: This presentation demonstrates the capacity of the autogenous gingival graft approach to reduce the high grade tooth mobility and to augment keratinized gingiva. METHODS: V.T. (46) with moderate generalized periodontitis. The examination reveals thin periodontal biotype, Class IV recessions on 31,41 with III grade mobility and terminal attachment loss, narrow vestibulum and lack of attached gingiva. An autogenous graft technique was selected to achieve simultaneous gingival augmentation and correction of vestibulum depth. RESULTS: A significant and stable increase of the attached gingiva is observed which led to better access for oral hygiene thus creating better conditions for successful long-term outcome. The root coverage was more that 40% and the tooth mobility was decreased to grade I. CONCLUSION: In the limitations of the presented case the free autogenous graft technique seems an appropriate approach in cases with deep Class IV recessions and high grade toot mobility in mandibular frontal area creating proper conditions for effective oral hygiene and decreasing tooth mobility by creating a sufficient amount of attached gingiva needed for the long term maintenance

COMBINATION OF APICALLY POSITIONED AND CORONALLY ADVANCED FLAP IN THE TREATMENT OF A COMPLEX MUCOGINGIVAL AND RESTORATIVE PROBLEM. A 3-YEAR FOLLOW-UP. (Case Report)

INTRODUCTION: The modern Periodontology has various approaches to achieve a complete functional and aesthetic rehabilitation of the mucogingival complex. These techniques include application of flaps with apical or coronal advancement in order to achieve different treatment objectives. Complex cases with different pathology on adjacent teeth require several surgeries thereby increasing treatment time and patient discomfort. New combined approaches are needed to meet the challenges of such cases. OBJECTIVE: This report presents a case with a simultaneous application of a resective and a mucogingival technique in one dental sextant. METHODS: I.C. (36) with a localized chronic periodontitis, Miller Class I gingival recessions (13,14) and subgingival caries lesions (15,16). A combined approach with simultaneous crown lengthening with apically positioned flap for 16,15 and root coverage with enamel matrix derivate and a coronally advanced flap for 14,13 was applied in order to avoid multiple surgical procedures. RESULTS: On the third month after the surgical procedure a complete root coverage (13,14) was achieved. The crown lengthening procedure enabled the restoration of the caries lesions and the placement of new crowns (15,16). The result at the third year demonstrates a stable gingival margin with no recurrence of the gingival recessions. CONCLUSION: The applied combined procedure led to a complete resolution of the existing problems with a single surgery. The simultaneous application of different procedures seems a promising approach aimed to reduce the treatment time and to diminish patient discomfort

EFFECTIVNESS OF TARGET ANTIMICROBIAL THERAPY OF SEVERE CHRONIC PERIODONTITIS PART III: CLINICAL ATTACHMENT GAIN

The main goal of the periodontal therapy is the regeneration of the affected periodontal structures and achievement of stable periodontal attachment. The contemporary statement regarding the effectiveness of the periodontal therapy is that healing results with more coronal level of the connective tissue attachment are associated with better long term stability.Aim: Evaluation of the effectiveness of treatment of severe chronic periodontitis with additional target antibiotic administration in comparison with the therapy with adjunctive antimicrobial combination amoxicillin+ metronidazole and conventional mechanical periodontal treatment regarding the mean clinical attachment gain, reduction of the attachment loss extent and the variations of the attachment level in sites with initial CAL from 1-2mm, from 3-4mm and above 5mm.Results: In all study groups mean clinical attachment gain has been achieved after the non-surgical periodontal therapy. In the group with target antibiotic administration the highest reduction of periodontal sites with CAL above 5mm is reported