Microscope-enhanced periodontal therapy: a review and report of four cases

AIM

The aim of this report is to review the status of the use of surgical microscopes and microsurgery and their clinical application in the field of periodontics.

BACKGROUND

The use of magnification systems and periodontal microsurgery are part of a broad movement in dentistry toward the use of minimally invasive procedures to replace the need for more extensive surgical procedures. While magnification systems are widely used in endodontics, their application in periodontics is still in its nascent phase. However, clinicians have reported that use of magnification facilitates the use of minimal invasive periodontal surgery.

TECHNIQUE

The surgical microscope is an invaluable aid for periodontists in the diagnosis and treatment of periodontal disease. Magnified vision used in conjunction with microsurgical instruments and techniques can lead to a higher quality of care and an improved surgical outcome.

SUMMARY

Surgical operating microscopes have shown promising results in the hands of periodontists who are properly trained in their use. Despite the apparent advantages, there is still a lack of "high level of evidence" in the form of controlled clinical trials to estimate the magnitude of the real benefits of the microsurgical approach over the conventional approach.

CONCLUSION

The scientific community understands the need for more investigations to completely understand the conditions that would best favor the creation of a tooth substitute. Recent gains in the understanding of the molecular regulation of tooth morphogenesis, stem cell biology, and biotechnology offers the opportunity to realize this goal.

CLINICAL SIGNIFICANCE

Even though all the procedures shown in this review can be performed using normal vision, performing these procedures using a surgical microscope and microsurgical instruments offers definite advantages in terms of improved visual acuity, superior approximation of wounds, rapid wound healing, decreased post-operative morbidity, and increased acceptance by the patients.

Does Emdogain work?

Emdogain has been available commercially for just over a decade. It is used currently in clinical practice of periodontics and has been investigated in four clinical outcome studies of replanted teeth. This review covers the origin and concepts behind the use of this amelogenin derivative, the unique conditions associated with an avulsed tooth, and the laboratory and clinical characteristics of this material. Emdogain continues to be an experimental material for replantation applications.

Orthodontic treatment of periodontally involved teeth after tissue regeneration

In this consecutive series, 14 patients with severe intrabony defects and pathologic tooth migration were treated with guided tissue regeneration (GTR) and subsequent orthodontic therapy in an attempt to evaluate the validity of this multidisciplinary approach. Probing pocket depths (PPD), clinical attachment levels (CAL), and gingival recessions were assessed at baseline, 1 year after GTR, and at the end of orthodontic therapy. Radiographs were obtained at all time points. Esthetic parameters were recorded with the papilla presence index (PPI). Statistical analyses were carried out to compare the data at each time point. From baseline to 1 year after GTR, the mean PPD reduction was 5.57 mm, with a residual mean PPD of 2.71 mm; mean CAL gain was 5.86 mm. Both differences were statistically significant. There were no statistically significant differences between 1 year after GTR and the end of orthodontic therapy (mean PPD reduction 0.07 mm; mean CAL gain 0.43 mm). The reduction in PPI reflected the enhancement of papilla height that was observed in 9 of the 14 patients. Within the limits of this research, this study affirms the possibility of a combined orthodontic-periodontal approach that prevents damaging the regenerated periodontal apparatus and produces esthetic improvements as a result of realignments and enhancement of papilla height.

The use of lasers in periodontal therapy

In the same way that new, more advanced surgical procedures such as implant placement and sinus augmentation have allowed periodontal surgeons to restore the dental health of patients who, until now, have been destined for a lifetime of complete dentures, the laser has provided dentists with the instrument needed to produce an essentially bloodless and bacteria-free surgical field, allowing for deeper surgical procedures within the oro-nasal cavity. The article is meant to help dentists determine which lasers are suitable for various periodontal procedures.

Current status of clinical laser applications in periodontal therapy

Periodontal disease is a chronic inflammatory disorder caused by bacterial infection. Laser treatment demonstrates specific characteristics that may be valuable in managing periodontal disease. In addition, lasers reduce stress and uncomfortable conditions for patients during and after treatment compared to other conventional tools. This article reviews the literature to describe the current clinical applications of lasers for gingival tissue management-including esthetic treatment, non-surgical and surgical periodontal pocket therapy, osseous surgery, and implant therapy.

Computer-aided design/computer-aided manufacturing applications using CT and cone beam CT scanning technology

CT and cone-beam CT technology provides clinicians with new methods to view patient anatomy exceeding conventional two-dimensional radiology. Interactive software applications allow for improved interpretation of the CT scan data. Proper use of this new technology must be based on a solid foundation of fundamental surgical and prosthodontic protocols. Advances in software and associated hardware have empowered clinicians with the necessary tools to harness the technology, while remaining true to conventional standards. The enhanced capability of innovative software applications that allow clinicians to interpret and maneuver through various three-dimensional images has far-reaching implications when interactive treatment planning software is combined with computer-aided design and manufacturing. Using all available virtual tools, true restoratively driven implant dentistry can be accomplished, ultimately benefiting patients.

Contemporary periodontal surgery: 2. Surgical practice

Contemporary surgical techniques emphasize gentle tissue handling with a minimum of trauma. This in turn provides a predictable operative environment and promotes healing. A modern surgical armamentarium may be very different from that encountered a decade ago. This is clear from the greater availability of dental microsurgical instruments. Whilst the complexity of microsurgery may not be routinely necessary in general dental practice, many of the principles and equipment used may make standard surgical management easier and more predictable.

CLINICAL RELEVANCE

A greater understanding of the evidence base behind periodontal surgery will allow us to improve flap design, closure and operative management. Also, the use of microsurgical techniques and equipment will improve the quality and outcomes of periodontal surgery in practice.

Multidisciplinary care: periodontal aspects to treatment planning the anterior esthetic zone

The field of periodontology has changed dramatically during the past 30 years. The goal of periodontal therapy is not only to establish and maintain the dentition and the periodontium free of any oral infections, but also to provide an environment with optimal function and esthetics. Esthetics has become an integral portion of the overall treatment goal in periodontics. This article discusses the role of periodontal plastic and reconstructive surgery in treatment planning the anterior esthetic zone in interdisciplinary dental care.

Contemporary periodontal surgery: 1. Surgical principles

Periodontal surgery comprises surgical intervention of the supporting tissues of the teeth. This ranges in complexity from simple exodontia to technically demanding periodontal plastic surgery and includes the management of periodontal diseases, implant placement and preparatory treatment for fixed and removable prostheses. Modern surgical management reflects both a move towards evidence-based practice and the introduction of improved techniques and armamentarium. General principles of surgical management hold true regardless of what procedure is being carried out. These principles form a sound basis for any practitioner contemplating surgical interventions for their patients.

CLINICAL RELEVANCE

A sound understanding of first principles will simplify periodontal surgical management. Careful surgical preparation will render surgical procedures more predictable and reduce post-operative discomfort.

The esthetic management of a severe isolated periodontal defect in the maxillary anterior

A 30-plus year-old woman presented to the periodontist with a chief complaint concerning the esthetics of the black space between her maxillary right lateral and central incisors (Figure 1). The history of the problem dated back several years when her general dentist noted increased pocket depth in this area. The patient was referred to a periodontist who elected to attempt grafting in this site to improve both the bone and soft tissue. The patient reported that after the initial surgery the defect became significantly worse and a large quantity of gingival tissue was lost. The patient was then referred to a second periodontist who, after evaluation, also chose to attempt both a bone and soft tissue grafting procedure and again the defect became worse. At that point the second periOdontist referred the patient to the periodontist in our group for evaluation and treatment. At her initial consultation the patient indicated she had been managing the defect esthetically by placing pink wax into the large open space every day to minimize the appearance.

[Effect of cryopreservation of bone marrow stromal cells on periodontal tissue regeneration]

OBJECTIVE

To investigate the influence of cryopreservation on bone marrow stromal cells' (BMSC) capability of enhancing periodontal regeneration.

METHODS

Twenty-six artificial periodontal defects were established in 5 Beagle dogs and divided into 3 groups at random. Only collagen membrane, the complex of cryopreserved and un-cryopreserved BMSC and collagen scaffold were transplanted in the blank control group, cryopreserved and un-cryopreserved groups respectively. The periodontal regeneration was observed 8 weeks after transplantation.

RESULTS

The percentage of periodontal regeneration in cryopreserved and un-cryopreserved groups was significantly greater than that of the blank control group (P < 0.05), but no statistical difference was found between cryopreserved and un-cryopreserved groups.

CONCLUSIONS

Cryopreservation had no significant negative effects on BMSC capability of enhancing periodontal regeneration.

Nd:YAG and diode laser in the surgical management of soft tissues related to orthodontic treatment

OBJECTIVE

The aim of this clinical study was to observe and evaluate the surgical management efficiency of soft tissues during orthodontic treatment.

MATERIALS AND METHODS

Thirty-seven young patients were selected and treated by laser-assisted surgery before or during orthodontic treatment and were classified by sex, age, and type of surgical management. Three different wavelengths were used (diode 810 nm, diode 980 nm, and Nd:YAG 1064 nm) in different surgical situations: maxillary vestibular and lingual frenectomies, surgical exposure and alignment of ectopic or retained teeth, and re-contouring gingival overgrowth.

RESULTS

In all evaluated patients, the laser treatment was performed without local anesthesia or sutures. Only topical anesthetic was needed.

CONCLUSION

These use of these wavelengths of laser energy was a noticeable aid in the surgical management of soft tissues before or during orthodontic treatment. The benefits of laser treatment include reduced bleeding during surgery with consequent reduced operating time and rapid postoperative hemostasis, thus eliminating the need for sutures. The lack of need for anesthetics and sutures, as well as improved postoperative comfort and healing, make this technique particularly useful for very young patients.

Nd:YAG and diode laser in the surgical management of soft tissues related to orthodontic treatment

OBJECTIVE

The aim of this clinical study was to observe and evaluate the surgical management efficiency of soft tissues during orthodontic treatment.

MATERIALS AND METHODS

Thirty-seven young patients were selected and treated by laser-assisted surgery before or during orthodontic treatment and were classified by sex, age, and type of surgical management. Three different wavelengths were used (diode 810 nm, diode 980 nm, and Nd:YAG 1064 nm) in different surgical situations: maxillary vestibular and lingual frenectomies, surgical exposure and alignment of ectopic or retained teeth, and re-contouring gingival overgrowth.

RESULTS

In all evaluated patients, the laser treatment was performed without local anesthesia or sutures. Only topical anesthetic was needed.

CONCLUSION

These use of these wavelengths of laser energy was a noticeable aid in the surgical management of soft tissues before or during orthodontic treatment. The benefits of laser treatment include reduced bleeding during surgery with consequent reduced operating time and rapid postoperative hemostasis, thus eliminating the need for sutures. The lack of need for anesthetics and sutures, as well as improved postoperative comfort and healing, make this technique particularly useful for very young patients.

Clinical application of erbium:YAG laser in periodontology

Various lasers have been introduced for the treatment of oral diseases and their applications in dental clinics have become a topic of much interest among practitioners. Technological advances and improvements have increased the choices of the available laser systems for oral use. Among them, a recently developed erbium-doped:yttrium aluminum garnet (Er:YAG) laser system possesses suitable characteristics for oral soft and hard tissue ablation. Due to its high absorption in water, an effective ablation with a very thin surface interaction occurs on the irradiated tissues without any major thermal damage to the irradiated and surrounding tissues. In the field of periodontics, the application of Er:YAG laser for periodontal hard tissue has begun with studies from Japanese and German researchers. Several in vitro and clinical studies have already demonstrated an effective application of the Er:YAG laser for calculus removal and decontamination of the diseased root surface in periodontal non-surgical and surgical procedures. However, further studies are required to better understand the various effects of Er:YAG laser irradiation on biological tissues for its safe and effective application during periodontal and implant therapy. Randomized controlled clinical trials and more basic studies have to be encouraged and performed to confirm the status of Er:YAG laser treatment as an adjunct or alternative to conventional mechanical periodontal therapy. In this paper, the advantages and current clinical applications of this laser in periodontics and implant dentistry are summarized based on current scientific evidence.

Bone grafts in periodontal therapy

This article is limited to a review of bone replacement graft materials used in periodontal therapy. The source, mode of bone regeneration and the respective advantages and disadvantages of autogenous, allogenic, xenogenic and alloplastic materials are discussed.