Dr shabeel pn

• Introduction
• Classification of failure
• Pre Therapeutic
• Therapeutic
Surgical
Non surgical
• Post Therapeutic
• Summary & Conclusion

• Dentist related failures
• Patient related failures

• Gathering data
• Improper diagnosis
• Improper investigations
• Inadequate motivation
• Improper treatment sequencing
• Incomplete treatment
• Irregular follow-ups.

Maintenance
Smoking
Systemic Diseases.
Poor healing potential.
Psychological component – probably the least studied and the most critical aspect in periodontics.

Incorrect Patient Selection
• Age
• Socio-economic status and nutritional deficiencies

s
Systemic disease:
Diabetes Mellitus
Blood Dyscrasias : leukemia, Cyclic neutropenia
Immune deficiences : Neutrophil-monocytic chemotactic defects,
AIDS
Genetic disorders : Down’s syndrome, Papillion Lefevre syndrome, hypophosphatasia , Chediak Higashi Syndrome) ;
Vitamin deficiences

Pretherapeutic
Incomplete diagnostic procedure or misdiagnosis
• Improper Clinical diagnosis
• Radiological interpretations
• Microbiological interpretation
• Biochemical interpretation
• Immunological interpretation
Inappropriate or improper dental restorations or prosthesis
• Overhanging Class II , overextended crowns & bridges.
Failure to carry out assoc. Prosthetic-restorative procedure

Pretherapeutic
Morphology of tooth surfaces :
Lateral accessory canals, dev. Grooves, resorption lacunae – act as “Guide plan”for bacterial penetration…..
Habits
Occlusal corrections or teeth preparation: TFO…prevent proper adaptive remodelling of periodontium

Non-Surgical
Scaling
Root Planing
Splinting
Occlusal therapy
Local Drug Delivery
Surgical
Curettage
Gingivectomy
Abscess Drainage
Flap Surgery
Bone Grafts
GTR procedures
Root coverage procedures
Implant
Aesthetic surgeries

• Obviously recognized by remnants of calculus
• Causes:
1. Incorrect instrumentation & Poor condition of instruments.
2. “Burnishing Calculus”.
3. “Induced Bleeding”.
4. Prescription of Gum paints.
5.Assessment of “calculus ratio”.

Rough root surface and persistence of inflammation.
Inadequate RP……detection of caries.
Over instrumentation…..hypersensitivity
Presence of developmental grooves….Use of rotary instruments to smoothen as far as possible

Failures could be:
• Inflammation in the area
• Breaking of splint
• Increased plaque accumulation.

Diagnose whether a temporary or permanent splint is required.
Contouring the splint
Proximal cleaning aids to be prescribed.
Should be clear of occlusal interferences.
Margins of splint should be flush with tooth surface

• Diagnosis of occlusal abnormalities…. occlusal scheme of pt., plunger cusps, or other occlusal
Interference.
• Assessment of tooth wear and judgement whether it can be corrected by selective grinding or a full fledged occlusal rehabilitation procedure is needed.
• “Fremitus Test”.

• Correction of worn out teeth must be done prior to invasive periodontal surgery.
• Patients with other oral habits like tongue thrust, occupational habits must be either advised to quit or forced to quit before attempting any periodontal therapy.
• Gross malocclusion must be corrected following basic therapy .

:
• Role of interdisciplinary dentistry is today unquestionable and this helps in sequencing…
• Not only the removal of primary etiological factors is important … need to eliminate the secondary complicating and confounding factors.
• Malocclusion, occlusal interferences, mild mobility, faulty restorations, open contacts, etc and so on and so forth .

Improper selection of technique:
• Design of surgery or procedure, right from types of incisions to the required modification …
• Improper selection of technique could be a primary trigger that leads to a cascade of events precipitating in failure.
Incomplete treatment:
• Incomplete debridment…
Improper asepsis:
Improper primary closure:… delays healing

Persistence of inflammation after procedure
Causes: 1. Diagnosis per se
2. Procedural errors;
- instrumentation
- when to stop
3. failure to irrigate…tags of granulation tissue
4. Suture a curetted area.

Defined by recurrence of lesion either immediately within a few weeks or by destruction of the periodontal apparatus.

Wade (1954) outlined 15 reasons why gingivectomy fail:
1. Unsuitable case selection. Cases - underlying osseous or intrabony defects.
2. Incorrect pocket markings
3. Incomplete pocket elimination
4. Insufficient beveling of the incision
5. Failure to remove tissue tags, resulting in excessive tissue
6. Failure to remove etiologic factors-calculus and plaque
7. Beginning or terminating the incision in a papilla

8. Failure to eliminate or control the predisposing factors
9. Inaccessible interdental spaces
10. Loose dressings
11. Lost dressings
12. Insufficient use of dressings
13. Failure to prescribe stimulators or rubber tip for interproximal use
14. Failure to use stimulators or rubber tip
15. Failure to complete treatment

• Defined by the recurrence of abscess/ resultant increase in periodontal destruction.
1. Identification of source/ origin….tortousity of pocket & complexity of the tooth .
2. Removal of entire abscess wall….remenant tags act as a nidus….
3. Chronic abscesses tend to show more recurrence.
4. Systemic/ Local drug delivery is mandatory; if it’s a periodontal abscess.

• Failures could be recurrence of pockets, flabby tissue, abscess formation, gingival recession, cleft formation, loss of interdental papilla.
• In most situations, some amount of gingival tissue recession and loss of papilla occurs, accepted to such an extent that we do not consider it a failure anymore.

Elimination of inflammation … Removal of deposits…improves tissue tone & texture
Failure to remove the entire pocket lining…
Recurrence of the pocket epithelium.
Failure to correct bony ledges….improper maintenance, periodontal infections & attachment loss
Incomplete debridement of granulation tissue and deposits.
Excessive reflection can cause increased … postoperative surface resorption.

• Bone grafting Procedures
• GTR Procedures
• Growth Factor usage

i.
Pre-surgical considerations ….decision to place a bone graft….
ii.
Assessment of defect morphology: interproximal well supported 3 or 2 walled defects & Furcation Involment.
iii.
Technique of placement …increments, compacted not condensed. Pore size or distance between particles….significant.

iv.
Maintenance of vascular continuity …..
• Alloplasts & xenografts…osteoconductive….only act as a scaffold.
• Establishment of vascular continuity…
• Clot….should preferably arise from bone….penetrations of cortical plate is reqd to enhance blood flow from marrow…..
trephination …aid in neovascularization.
iv.
Overfilling the defect …
• lead to fibrous encapsulation of the graft

Bone grafting Procedures v.
“ Flap margin bleed” …..persistent bleeding on flap surface results in clot forming from the flap involving graft….fibrous encapsulation.
vi.
Postoperative infection control ….antibiotics & antibacterial mouthrinse…..
vii. Graft sterilization ……most commonly overlooked aspects viii. Primary closure with no intervening graft particles.

• Adaptation of membrane….to provide adequate space to the periodontal ligament cells to migrate…
• Prevention of collapse…..use in conjunction with bone graft.
• Trimmed membrane…..should cover at least 2mm of adjacent alveolar bone, no sharp edges…
• Membrane exposure…tension free flap, bacterial accumulation..hampers healing
• Membrane suture… sling suture

• Poor plaque control
• Smoking
• Occlusal trauma
• Sub optimal tissue health (i.e. Inflammation persists)
• Mechanical habits (e.g.. Aggressive tooth brushing)

•Overlying gingival tissue
– Inadequate zone of keratinized tissues.
– Inadequate tissue thickness
•Surgical technique
– improper incision
– Traumatic flap elevation and management
– Excessive surgical time
– Inadequate closure or suturing
Barrier-Independent Factors

Barrier-Independent Factors
• Post surgical factors
- premature tissue challenge
# Plaque recolonization
# Mechanical insult
- Loss of wound stability (loose sutures, loss of fibrin clot).

• Inadequate root adaptation (absence of barrier effect)
• Non sterile technique
• Instability (movement) of barrier against root.
• Premature exposure of barrier to oral environment and microbes.
• Premature loss or degradation of barrier.

• Method of draw… various techniques …blood bank draw technique..superior viable platelet conc.
• Shelf life….24 hours, chair side equipment.
• Use of thrombin; and its ratio…released during surgery is enough, ratio 1:7
• Aspiration technique…platelets fragile
• When used alone will invariably fail to show desired results.
• Prevent standing of PRP….premature bursting

Presurgical considerations…. depends on the position of the tooth, the extent of malocclusion if present, the thickness of the gingiva present in the adjacent area
The etiology of the recession must be corrected.
Depth of the vestibule , width of attached gingiva .

Graft handling could be one of the reasons for failure…. Squeezing of the graft leads to leakage of the plasmatic fluid …..
dessication
Size of the graft should be adequate…. ideal size should be 1.25-1.5 mm
The presence of clot between the graft and root surface…. Compression of graft against root surface
Root conditioning is a must; esp in soft tissue graft procedures

Intra-surgical considerations:
• Horizontal incision; mandatory to maintain viability of papilla.
• Cut-back incision; prevents tissue ledges.
• Partial thickness is desired as this may prevent donor site recession.

Rotated flaps
• Coronally displaced flaps fail most often because they are either secured in tension and are not stable; thus vertical incisions play a critical role in success of this procedure.
• These procedures show limited success if inter-proximal recession is also present.

• Common reasons for failure
– Tension…. Distal incision
– Pedicle too narrow
– Exposure of bone at radicular surface
– Poor stabilization

• Common reasons for failure
– Non union of component flaps
– Full tickness flap…..Dehiscence or fenestrations
– Inadequate attached gingiva in the papillary area
– Proper placement of the flap on periosteal bed
– Adequate fixation of the flap to prevent shifting

• Epithelialized grafts
• Sub-epithelial Connective Tissue Grafts

Epithelialized grafts
• The sutured graft should always be either at the level or higher than the level of adjacent recipient bed but never below; this leads to graft rejection (Chiranjeevi
1989).
• Recipient bed preparation should be beveled and broader at the base.

• 2 techniques of procurement; separation of full thickness yields more C.T. and easier.
• Grafts have to be trimmed and the lipid layer has to be removed.
• Tunnel technique gives only marginal recession coverage as opposed to pouch technique

• Reasons for failure…. Langer & Langer 1992
– Recipient bed too small
– Flap perforation
– Inadequate graft size
– Inadequate coronal positioning of flap
– Too thick a CT graft
– Poor root preparation
– Poor papillary bed preparation

• Inadequate union of bone and implant at the time of surgical insertion.
• Improper biomaterials a) Use of dissimilar materials b) Bio-incompatible materials
• Contamination of the implant surface & infection
• Surgical overheating of bone
• Structural design that does not transmit forces evenly to the bone
• Premature loading with occlusal forces prior to healing phase
• Increased periodontal pocket activity

Instruction & Motivation
• Preservation of the periodontal health … requires as positive programme
• If periodontist follows a very good therapeutic procedures…..pt does not maintain or not under proper recall visits….signs of failure- bone loss
• Motivation + reinforcement of OHI.
PD,tooth loss etc.
• Failure to continue with treatment…conscious or unconscious decision

Unsupervised healing: Absence of supervision…
• Professional cleaning of supragingival area periodically
• Failure to assess OH status…
• Inbility to monitor nutritional status…
Persistent or reintroduction of certain microorganisms
• Failure to eliminate certain microorganisms..A.a….persistence or recurrence.
• Some remain in the DEJ…resistant to antibiotics…recurrence.
• Reintroduction…..

New Disease:
Refractory Periodontitis: “a disease in multiple sites in patients which continue to demonstrate attachment loss after appropriate therapy”
Ability or skill of the operator:

• Dr.Ramaswamy. Causes of failure of periodontal treatment. JISP 1995; 19:23-24.
• Gerald Kramer. Dental failures associated with periodontal surgery. DCNA 1972;16:13-31.
• Leon Lefer. Failures in motivation of dental home care. DCNA 1972;16:1:pg3.
• Bradley RE. Periodontal Failures related to improper prognosis & treatment planning.DCNA 19726:1:pg33-43.
• Wang HL, MacNeil RL. GTR. DCNA1998; 42:509.

• AlloDerm is an acellular dermal matrix derived from donated human skin that undergoes a multi-step proprietary process that removes both the epidermis and the cells that can lead to tissue rejection.
• AlloDerm has been used in a wide variety of soft tissue grafting procedures such as root coverage, soft tissue augmentation and guided bone regeneration with a consistent record of excellent results.1-7

•
Eliminates the need for palatal surgery
• Removes palatal harvesting limitations from treatment planning considerations
• Reduces patient reluctance to follow through with surgical treatment
• Consistent quality
• Provided in multiple convenient sizes
• Available in two thickness ranges for use in different procedures:
• 0.9 to 1.6 mm - AlloDerm for root coverage, soft tissue ridge augmentation, etc.
• 0.5 to 0.8 mm - AlloDerm GBR for guided bone regeneration and barrier membrane function

• AlloDerm provides a matrix consisting of collagens, elastin, vascular channels, and proteins that support revascularization, cell repopulation and tissue remodeling.
• After placement, the patient’s blood infiltrates the AlloDerm graft through retained vascular channels, bringing host cells that adhere to proteins in the matrix.
• Significant revascularization can begin as early as one week after implantation.
• The host cells respond to the local environment and the matrix is remodeled into the patient’s own tissue, in a fashion similar to the body’s natural tissue attrition and replacement process.

• Multiple, randomized clinical trials (RCT) have shown root coverage results with
AlloDerm to be equivalent to autogenous connective tissue, and concluded that the procedure was predictable and practical.
• A meta-analysis of eight RCTs showed no statistically significant differences between the two groups for measured outcomes: recession coverage, keratinized tissue formation, probing depth and clinical attachment levels.
Acellular Dermal Matrix for Mucogingival
Surgery: A Meta-Analysis. Gapski R, Parks
CA and Wang HL. J Periodontol
2005;76(11):1814-1822.

• Management of Gingival Recession by the Use of a
Acellular Dermal Graft Material: A 12-Case Series.
Santos A, Goumenos G and Pascual A. J Periodontal
2005;76(11):1982-1990.
• Subpedicle Acellular Dermal Matrix Graft and
Autogenous Connective Tissue Graft in the Treatment of
Gingival Recessions: A Comparative 1-Year Clinical
Study. Paolantonio M, Dolci M, Esposito P, D’Archivio D,
Lisanti L, Di Luccio A and Perinetti G. J Periodontol
2002;73(11):1299-1307.
• Clinical Evaluation of Acellular Allograft Dermis for the
Treatment of Human Gingival Recession. Aichelmann-
Reidy ME, Yukna RA, Evans GH, Nasr HF and Mayer

• Predictable Multiple Site Root Coverage Using an
Acellular Dermal Matrix Allograft. Henderson RD,
Greenwell H, Drisko C, Regennitter FJ, Lamb JW,
Mehlbauer MJ, Goldsmith LJ and Rebitski G. J
Periodontol 2001;72(5):571-582.
• Surgical therapies for the treatment of gingival recession. A systematic review. Oates TW, Robinson M and Gunsolley JC. Ann Periodontol 2003;8:303-320.
• Root coverage of advanced gingival recession: A comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. Tal
H, Moses O, Zohar R, et al. J Periodontol 2002;73:1405-
1411.
• The clinical effect of acellular dermal matrix on gingival