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牙周病是指发生在牙周支持组织的疾病。牙周病发展到较严重的阶段后,仅靠基础治疗不能解决全部问题,需要通过手术的方法对牙周软、硬组织进行处理,才能获得良好的疗效。本文就牙周手术治疗的概念和发展做一概述。     

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牙周手术治疗主要是为了消除牙周袋,建立生理性的软、硬组织形态,促进牙周组织修复和再生,建立新的牙周附着关系,恢复美观和功能需要.现代牙周手术往往包含软、硬组织的再生手术,而手术的成功,必须依赖实施规范的牙周外科操作,才能提高手术成功率.随着各种新技术和新材料用于牙周手术治疗,牙周手术的结果才会实现组织再生.     

Regeneration of gingiva following surgical excision

Abstract The present clinical trial was carried out in order to analyze whether a zone of keratinized and attached gingiva may regenerate following surgical excision of the gingiva. In addition the alterations occurring in the position of the “soft tissue margin” and the clinical attachment level were assessed. 6 patients, scheduled for periodontal surgery in the canine-premolar regions of both quadrants of the lower jaw, participated in the trial. A Baseline examination performed prior to surgery comprised assessments at the buccal surface of the teeth of dental plaque, gingivitis, probing depth, clinical attachment level, position of the “soil tissue margin” and width of the zones of keratinized and attached gingiva. The entire zone of keratinized and attached gingiva was removed surgically using either a “gingivectomy” or a “flap-excision” procedure. In the “gingivectomy” procedure the wounded area was left to heal by second intention, while in the “flap-excision” procedure the alveolar mucosa was repositioned in a coronal position to achieve complete coverage of the surgically exposed alveolar bone, During healing the patients' oral hygiene status was carefully supervised. All parameters included in the Baseline examination were assessed at reexaminations performed 1, 3, 6 and 9 months following surgery. Already 1 month after surgery all “gingivectomy” units and 9 out of the 14 “flap-excision” units demonstrated presence of a zone of keratinized gingiva. At the final examination (9 months following surgery) all surgically treated buccal areas had regained a zone of keratinized gingiva. However, a zone of attached gingiva reformed less frequently. The examination performed 3 months after surgery revealed that the “soft tissue margin” and the clinical attachment level had become displaced in apical direction, 0.9 and 0.4 mm, respectively. Between the 3-month and the 9-month examinations, however, no further alterations were observed and the gingival units were healthy, independent of the presence or absence of attached gingiva or the width of the zone of keratinized gingiva.     

Periodontal dressing after surgical crown lengthening: A randomized clinical trial

Objective. The aim of the present study was to evaluate the effect of periodontal dressing on post-operative pain and swelling after surgical crown lengthening. Materials and methods. A blind, randomized, clinical trial was carried out with 36 patients. Following surgical crown lengthening, the individuals were randomly allocated to the periodontal dressing group (PDG) and control group (CG, non-placement of periodontal dressing). Pain and discomfort were analyzed using a visual analog scale (VAS), verbal scale (VS) and the number of analgesics consumed in 7 days post-operatively. Post-operative infection, stability of the gingival margin and type of healing were also evaluated. Results. The PDG had a significantly higher percentage of responses of ‘strong pain’ on the VS in the first day post-operatively (33.3% vs 5.3%, p = 0.03) and greater pain on the first and second days post-operatively based on the VAS. Moreover, a significant difference between groups was found regarding gingival swelling after 7 days. However, gingival recession was found in 57.8% of the sites in the CG and only 5.5% of sites in the PDG. No change in condition was found among individuals with conjunctive tissue/bone exposure in the CG in the immediate post-operative period and 80% of the patients in the PDG had healing by first intention after 7 days. Conclusion. The use of periodontal dressing seems to be preferable following surgical crown lengthening with connective tissue/bone exposure. However, adequate post-operative analgesic strategies should be employed due to the possibility of intense pain in the first 24 hours.     

半导体二极管激光及其在牙周手术治疗中的应用

近年来,激光在牙周治疗中的应用引起人们的关注。本文介绍了半导体二极管激光在牙周软、硬组织手术中的应用及其理论基础。随着激光材料和技术的不断发展,激光在牙周手术治疗中将会发挥越来越大的作用。     

Improved wound stability with a modified minimally invasive surgical technique in the regenerative treatment of isolated interdental intrabony defects

Aims: This paper describes a modified surgical approach of the minimally invasive surgical technique (modified minimally invasive surgical technique, M-MIST) and preliminarily evaluates its applicability and clinical performances in the treatment of isolated deep intrabony defects in combination with amelogenins.
Material and Methods: Twenty deep isolated intrabony defects in 20 patients were studied. Fifteen were surgically accessed with the M-MIST, while in five sites, which presented a lingual intrabony component, the conventional MIST had to be applied. The M-MIST consisted of a buccal incision of the defect-associated papilla, according to the principles of the papilla preservation techniques. Only a buccal flap was raised while the interdental papilla was left in situ. The granulation tissue filling the defect was dissected and removed, leaving the interdental and palatal tissues untouched. Root instrumentation and application of the regenerative material were performed before suturing. Primary closure of the flaps was attained with a single internal modified mattress suture. Surgery was performed with the aid of an operating microscope and microsurgical instruments.
Results: The surgical chair-time of the M-MIST-treated sites ( N =15) was 56±8.64 min. Early wound healing was uneventful: primary wound closure was attained and maintained in all sites. No oedema or haematoma was noted. Patients did not report pain or discomfort. The 1-year clinical attachment level (CAL) gain was 4.5±1.4 mm in defects 6±1.5 mm deep. Residual probing depths (PDs) were 3.1±0.6 mm. A minimal increase of 0.1±0.3 mm in gingival recession between baseline and 1 year was observed.
Conclusions: M-MIST was applicable on 15 isolated interproximal defects out of 20 selected ones. It resulted in very limited patient morbidity and excellent clinical improvements. These outcomes should be confirmed in a larger study.     

Minimally invasive surgical technique and enamel matrix derivative in intra-bony defects. I: Clinical outcomes and morbidity

AIMS: This case cohort study was designed to evaluate the clinical performance and the intra-operative and post-operative morbidity of the minimally invasive surgical technique (MIST) associated with the application of an enamel matrix derivative (EMD) in the treatment of isolated deep intra-bony defects. MATERIAL AND METHODS: Forty deep isolated intra-bony defects in 40 patients were surgically accessed with the MIST. This technique was designed to limit the mesio-distal flap extension and the corono-apical flap reflection in order to reduce the surgical trauma and increase flap stability. The incision of the defect-associated papilla was performed according to the principles of the papilla preservation techniques. EMD was applied on the debrided and dried root surfaces. Stable primary closure of the flaps was obtained with modified internal mattress sutures. Surgery was performed with the aid of an operating microscope and microsurgical instruments. Clinical outcomes were collected at baseline and at 1 year. Intra-operative and post-operative morbidity was evaluated with questionnaires. RESULTS: The 1-year clinical attachment gain was 4.9+/-1.7 mm (p<0.0001 compared with baseline). This corresponded to a 77.6+/-21.9% resolution of the defect. Residual probing pocket depths were 3+/-0.6 mm. A minimal increase of 0.4+/-0.7 mm in gingival recession between baseline and 1 year was recorded. No patients experienced intra-operative pain, while only 14 reported a very moderate perception of the hardship of the surgical procedure [7+/-12 visual-analogue scale (VAS) units, on average]. Primary closure was obtained in all treated sites. At the 1-week follow-up visit, 38 sites (95%) were still closed. Only 12 subjects reported moderate post-operative pain (VAS 19+/-10) that lasted for 26+/-17 h. CONCLUSIONS: These data indicate that the minimally invasive surgical technique, in combination with EMD, can be successfully applied in the treatment of isolated deep intra-bony defects, resulting in excellent clinical outcomes with very limited intra- and post-operative morbidity.     

A sheep cadaver model for demonstration and training periodontal surgical methods

There is lack of data on the suitability of animal cadaver models for teaching purposes in dentistry. Here, we describe a model suitable for training for several periodontal surgical methods. Mandibles of freshly slaughtered Australian adult sheep and lambs were examined. Periodontal probing depths (PPDs) were measured at six sites of every tooth present. The following surgical techniques were critically analyzed: access flap with interrupted, continuous sutures; apically repositioned flap with periosteal sutures; coronally advanced flap with sling suture; gingivectomy; and distal wedge procedure. Probing depths were highest in the buccal furcation area of 1st and 2nd molars, where deep intrabony lesions were present in certain samples from adult sheep. Another area of increased probing depth was lingual to canines and incisors. Here, a pronounced lower dental pad of fibrous tissue was present. In this area, gingivectomy could always be accomplished. Fibrous tissue was also found distal to the most posterior molar, where the distal wedge procedure could be exercised. Access flaps and apically repositioned flaps could be performed particularly at premolars. Here, interrupted or continuous sutures were possible. Because of tight interdental contact areas, needle insertion was difficult at molars. After periosteal dissection, labial flaps at anterior teeth could easily be advanced coronally and sutured with sling sutures. Because of the teeth's dimensions and tight contact areas, simulation of more advanced techniques such as papilla preservation flaps was not possible. The sheep mandible seems to be a feasible training model for the demonstration and exercise of various periodontal surgical techniques for the treatment of periodontitis.     

A comparative study of a surgical method and scaling and root planing using the Odontoson®

Abstract This investigation compared a traditional periodontal surgical method with a non-surgical treatment of scaling and root planing by an ultrasonic device (Odontoson M®) using irrigation with an iodised solution. 8 adult patients with periodontal disease were each treated at 2 randomly chosen quadrants by a Widman flap type surgical technique, and the remaining non-surgically. The patients then attended bi-monthly oral hygiene sessions over a period of 1 year. At that stage, clinical evaluation revealed that the Odontoson M® plus an ionised irrigant solution achieved a statistically comparable outcome to that of surgical treatment, even in the pockets initially up to 7 mm in depth.     

Single minimally invasive surgical technique with an enamel matrix derivative to treat multiple adjacent intra-bony defects: clinical outcomes and patient morbidity

Aims: This case cohort study was designed to evaluate the clinical performance and the intra‐operative and post‐operative morbidity of the “minimally invasive surgical technique” (MIST) associated with the application of an enamel matrix derivative (EMD) in the treatment of multiple deep intra‐bony defects in a single surgical procedure. Material and Methods: Forty‐four deep intra‐bony defects in 20 patients (2 defects/patient) were surgically accessed with the MIST. This technique was designed to limit the mesio‐distal flap extension and the apical flap reflection in order to reduce the surgical trauma and increase flap stability. The incision of the defect‐associated papilla was performed according to the principles of the papilla preservation techniques. EMD was applied on the debrided and dried root surfaces. Stable primary closure of the flaps was obtained with modified internal mattress sutures. Surgery was performed with the aid of an operating microscope and microsurgical instruments. Clinical outcomes were collected at baseline and at 1 year. Intra‐operative and post‐operative morbidity was evaluated with questionnaires. Results: The 1‐year clinical attachment level (CAL) gain was 4.4±1.4 mm (p<0.0001 compared with baseline). Seventy‐three per cent of defects showed CAL improvements 4 mm. This corresponded to an 83±20% resolution of the defect (15 defects were completely filled). Residual probing pocket depths (PDs) were 2.5±0.6 mm. A minimal increase of 0.2±0.6 mm in gingival recession between baseline and 1 year was recorded. Twelve patients reported a mild perception of the hardship of the surgical procedure. Primary closure was obtained and maintained in all treated sites over time. Only six subjects reported moderate post‐operative pain that lasted for 21±5 h. Conclusions: These data indicate that a MIST in combination with EMD can be applied successfully for the treatment of multiple deep intra‐bony defects in the same surgical procedure with excellent clinical outcomes and very limited patient morbidity.     

Use of chlorhexidine as a plaque control measure following surgical treatment of periodontal disease

Abstract Chlorhexidine mouth rinsing was compared with regularly performed professional tooth cleaning as a plaque control measure during healing following periodontal surgery. 14 patients were selected for the study. A Baseline examination included assessment of oral hygiene status, gingival condition, probing depth and attachment level. In each patient, scaling and root planing was earned out in conjunction with the modified Widman flap procedure including reacontouring of alveolar bone irregularities in 2 jaw quadrants. The same procedures without osseous surgery were performed in contralateral jaw quadrants. 7 patients rinsed their mouth with a solution of 0.2% chlorhexidine digluconate twice a day, 2 min each time, for the first 6 months after therapy (healing phase). During the same period the remaining 7 patients were recalled every 2 weeks for professional tooth cleaning ad modum Axelsson & Lindhe (1974). Following reexamination after 6 months, all 14 patients were placed on a maintenance care program which included mechanical prophylaxis once every 3 months for 18 months (maintenance phase). Reexaminations were performed 6, 12 and 24 months after completion of initial therapy. The results revealed that professional tooth cleaning was somewhat more effective as a plaque control measure during healing following surgery than chlorhexidine mouth rinsing. At the end of the healing phase (1) there was a higher frequency of sites with pockets deeper than 4 mm in the patients who rinsed with chlorhexidine, (2) less gain of attachment occurred following chlorhexidine rinsing in pockets with an initial probing depth of >4 mm, and (3) attachment Joss in initially shallow pockets was somewhat more pronounced in the patients who rinsed with chlorhexidine, The differences in the effect of the 2 methods of plaque control, however, were small and in most respects diminished in the course of the maintenance phase. It was concluded that mouth rinsing with chlorhexidine is a proper alternative to plaque control during healing following periodontal surgery.     

Microbiological and clinical effects of surgical treatment of localized juvenile periodontitis

Since Actinobacillus actinomycetemcomitans appears to be a key etiologic agent in localized juvenile periodontitis, this study determined the effectiveness of different treatment modalities in suppressing A. actinomycetemcomitans in localized juvenile periodontitis lesions. A total of 25 deep periodontal lesions from 7 patients with localized juvenile periodontitis were included in the study. The test periodontal lesions either received scaling and root planing alone, scaling and root planing together with soft tissue curettage, or modified Widman flap surgery. Subgingival A. actinomycetemcomitans were enumerated using selective culturing. Clinical measurements included changes in probing periodontal attachment level, probing periodontal pocket depth, gingival index, plaque index, and digital subtraction of standardized serial radiographs. The microbiological and clinical effects of treatment were monitored over a period of 16 weeks. All periodontal lesions studied demonstrated high numbers of A. actinomycetemcomitans prior to treatment. Scaling and root planing alone did not markedly change the subgingival A. actinomycetemcomitans counts, nor any of the clinical parameters studied. In contrast, soft tissue curettage as well as modified Widman flap surgery suppressed A. actinomycetemcomitans to undetectable levels immediately after therapy in more than 80% of the lesions studied. A total of 5 periodontal lesions exhibited gain of probing periodontal attachment after subgingival curettage or Widman flap treatment; 3 of these sites revealed no detectable A. actinomycetemcomitans, and the remaining 2 sites harbored only low levels of A. actinomycetemcomitans. 5 periodontal lesions which lost probing attachment after treatment all demonstrated high numbers of subgingival A. actinomycetemcomitans. Changes in alveolar bone, assessed by digital subtraction of serial radiographs, correlated with changes in probing periodontal attachment level, confirming the clinical results. The present study revealed a close relationship between post-treatment A. actinomycetemcomitans levels and the clinical response to treatment, which supports the concept that A. actinomycetemcomitans is an important organism in the etiology of localized juvenile periodontitis. This study also showed that a substantial suppression of subgingival A. actinomycetemcomitans cannot be achieved by periodontal scaling and root planing alone, but can be accomplished by surgical removal of periodontal tissues.(ABSTRACT TRUNCATED AT 400 WORDS)     

Effect of cigarette smoking on periodontal healing following surgical therapy

The influence of cigarette smoking on the outcome of surgical therapy was investigated in 54 patients, 24 of whom were smokers. The patients had moderate to severe periodontitis with persisting diseased pockets after non-surgical therapy. The surgical modality used was the modified Widman flap operation and the pockets under scrutiny were those with an initial probing depth of 4-6 mm. Re-examination was made 12 months following the completion of surgery. The probing depth reduction at the 12-month follow-up was 0.76 +/- 0.36 mm (mean +/- SD) in smokers as compared to 1.27 +/- 0.43 mm in non-smokers. The difference was statistically significant (P less than 0.001) and persisted after accounting for plaque. The results suggest that smoking may impair the outcome of surgical therapy.     

A comparative clinical study of three periodontal surgical techniques

Abstract A comparative 4-month trial was performed after initial preparation. The procedures used were curettage, replaced flap and apically repositioned flap procedures with osseous recontouring respectively in a split-mouth technique in 17 male and 23 female patients, 22 to 65 years old. Changes were assessed with plaque and gingival indices, and measurements of pocket depths, attachment levels and tissue contours. All procedures reduced pocket depths. Apically repositioned flaps were the most successful, reducing overall mean pockets from 3.5 to 1.9 mm. Changes in attachment levels post-operatively showed only a small degree of variation among the three surgical procedures, and would not affect the choice of the apically repositioned flap as the most effective method for pocket reduction. A marked improvement in tissue contour was obtained in those areas treated by apically repositioned flap procedures and osseous recontouring. Despite failure to improve tissue contour, replaced flap procedures showed an equal degree of success in maintaining plaque control when compared to apically repositioned flaps, as evidenced by static plaque indices. Replaced flap procedures were also the only group to show improved gingival health over the 4-month post-operative period with lower gingival indexes. It would seem that good healing, followed by a high standard of oral hygiene, may overcome the presence of gingival and marginal osseous deformities.     

New attachment following surgical treatment of human periodontal disease

Abstract The present experiment was undertaken to test the hypothesis that new connective tissue attachment may form on a previously periodontitis involved root surface provided cells originating from the periodontal ligament are enabled to repopulate the root surface during healing. A mandibular incisor with advanced periodontal disease of long standing (the distance between the cemento-enamel junction and the alveolar bone crest was 9 mm) was subjected to periodontal surgery using a technique which during healing prevented the dentogingival epithelium and the gingival connective tissue from reaching contact with the curetted root surface. Preference was hereby given to the periodontal ligament cells to repopulate the previously diseased root surface. After 3 months of healing a block biopsy containing the incisor and surrounding tissue was sampled. The histological analysis revealed that new cementum with inserting principal fibers had formed on the previously diseased root surface. This new attachment extended in coronal direction to a level 5 mm coronal to the alveolar bone crest. This finding suggests that new attachment can be achieved by cells originating from the periodontal ligament and demonstrates that the concept that the periodontitis affected root surface is a major preventive factor for new attachment is invalid.