explains how Restorative, Endodontic, Prosthodontic, Orthodontic, Exodontic & Periodontic procedures itself affecting the Periodontium

1. IATROGENIC FACTORS
AFFECTING
PERIODONTIUM
Sangeeta Roy

2. INTRODUCTION
• Careless therapeutic procedures ,Injudicious use of instruments
&chemicals, Improper treatment planning and negligence cause
traumatic injuries to periodontium
• Supporting tissues must be always maintained in a state of health for
proper function
• Injuries induced by the dentist can severly impair the periodontium and
other oral structures leading to morbidity of patient

3. •So the dentist should inculcate thorough
knowledge and expertise to “do no harm” to the
patient

4. Iatrogenic means
•Iatros-
•Gennan-
PHYSICIAN
TO PRODUCE

5. DEFINITION
• IATROGENIC DISEASE
• Disease that has been induced by the physicians' activity, manner, or
therapy, and this term is usually used for an infection or other
complications of treatment.
• IATROGENIC FACTORS IN DENTISTRY
• Inadequate dental procedures that contribute to the deterioration of the
periodontal tissues.

6. CAUSATIVE FACTORS
Restorative Endodontic Prosthodontic
Orthodontic Exodontia
Periodontal

7. RESTORATIVE FACTORS
Marginal periodontium Fields of Restorative Dentistry & Periodontics overlap

8. HEALTHY
PERIODONTIUM
CRITICALLY
MAINTAINED
RESTORATION
HARMONY

9. RESTORATIVE FACTORS
•Violation of Biologic Width
•Morphologic Features of Restorations
•Restorative materials
•Direct injury to the Periodontium

10. Biologic width and itsViolation
• The biologic width is
defined as the dimension of
the soft tissue, which is
attached to the portion of
the tooth coronal to the
crest of the alveolar bone.
• Tissue occupying the area
between the base of the
gingival sulcus and alveolar
crest

11. • Gargiulo et al. (1961)
• 287 individual teeth from 30 autopsy specimens
• Definite proportional relationship between the alveolar crest, the connective
tissue attachment, the epithelial attachment, and the sulcus depth
• Mean dimensions:
• sulcus depth - 0.69mm,
• epithelial attachment -
0.97mm,
• connective tissue attachment
-1.07mm.
• biologic width- 2.04mm

12. • Vacek et al. (1994)
• Reported similar biologic width
dimensions
• Observed mean measurements
• • 1.34mm for sulcus depth
• • 1.14 for epithelial attachment,
• • 0.77mm for connective tissue
attachment
• biological width of 0.75- 4.3 mm

13. • BIOLOGIC WIDTH EVALUATION
• Radiographic – not diagnostic- due to
superimposition
• Sounding to bone

14. •A minimum of 3mm was required from the restorative
margin to the alveolar crest to permit adequate healing
of periodontium following restoration of the tooth.
Ingber et al(1977)
•This allows for adequate biological width when
restoration is placed 0.5 mm within gingival sulcus.

15. VIOLATION OF
BIOLOGICWITH
INFLAMMATION
BONE LOSS
ATTACHMENT
LOSS
PERIODONTAL
POCKETS
GINGIVAL
RECESSION

16. Violation of BiologicalWidth
Unpredictable bone Loss
Persistence of gingivitis
BODY ATTEMPTSTO RECREATETHE BIOLOGICAL WIDTH

17. • CORRECTION OF BIOLOGIC WIDTHVIOLATIONS
• Surgical Crown Lengthening to remove bone away from the
restorative margin
• Orthodontic extrusion of tooth

18. Surgical crown lengthening
• Gingivectomy
• Adequate attached gingiva and more than 3mm of soft tissue coronal
to the bone crest

19. • Flap surgery +bone contouring
• Inadequate attached gingiva and less than 3mm of soft tissue.
• The bone removed by measuring distance of the biologic width + 0.5 mm as
safety zone

20. Orthodontic extrusion
• Low orthodontic extrusion
forces
• Tooth will erupt slowly
bringing the alveolar bone &
gingival tissue with it till ideal
level
• Surgical correction of the
bone and gingival level
• Rapid orthodontic extrusion
• Tooth is erupted to desired
amount in several weeks
• Supracrestal fibrotomy
performed weekly in an effort to
prevent the bone and tissue from
following the tooth
• The tooth is stabilized for 12
weeks

21. Margins of Restoration
• Unaesthetic
• Well tolerated
Supragingival margins
• Earlier thought to retain plaque
• Well polished restorations are welltolerated
Equigingival margins
• Not accessible for cleaning and polishing
• Placed far below can violate biologic width
Subgingival margins

22. •Guidelines for placement of margins using sulcus depth as a
guide
•Sulcus depth 1.5 mm or less – margins 0.5mm below the gingival
crest
•Sulcus depth more than 1.5mm-margins at half the depth of the
sulcus below tissue crest
•Sulcus depth greater than 2mm esp on facial aspect-
Gingivectomy performed to reduce the depth to 1.5mm

23. •Effect of subgingival margins
•Large amount of plaque
•More severe gingivitis
•Greater loss of attachment & recession, Deeper pockets
•Increase rate of GCF flow
•(Waerhaug 1978, Silness 1980, Orkin 1987)

24. •Subgingival zone is composed of-
•Margin of the restoration
•The luting material
•Prepared and unprepared tooth surface

25. Marginal roughness can contribute to plaque accumulation
Improper marginal fit
Sources of deposition
Separation of the
restoration margin and
luting material
Dissolution and
disintegration of the luting
material

26. • Subgingival margins typically have a gap of 20 to 40 μm between the
margins of the restoration and unprepared tooth
• Colonization of this gap by bacterial plaque contributes to the detrimental
effect of margins placed in a subgingival environment
• Orkin et al. (1987) demonstrated that subgingival restorations had a greater
chance of bleeding and exhibiting gingival recession than supragingival
restorations.
• Supragingival position of the crown margin was the most favorable, whereas
margins below the gingival margin significantly compromised gingival
health

27. • Waerhaug (1978) stated that subgingival restorations are
plaque-retentive areas that are inaccessible to scaling
instruments
• Stetler & Bissada (1987) -Teeth with subgingival restorations and
narrow zones of keratinized gingiva showed significantly higher
gingival index scores than teeth with submarginal restorations
with wide zones of keratinized gingiva

28. • Esthetics
• retentive factors
• susceptibility to root caries,
• degree of gingival recession.
• Esthetic
• Increased retention form
• Preexisting margins
• Root caries
• Cervical abrasion
• Root Sensitivity
• Not a concern
• Factors determining location of
restorative margins:
• Prudent to place restorative
margins supragingivally if :

29. MORPHOLOGICCHARACTERISTICS
• OVERHANGS
• An extension of restorative material beyond the
confines of a cavity preparation
• Overhanging dental restorations
• a contributing factor to gingivitis and possible periodontal attachment loss
• prevalence
• estimated at 25–76% for all restored surfaces (Brunsvold & Lane1990)
• overhanging restorations contribute to gingival inflammation due to their
retentive capacity for bacterial plaque

30. • Jeffcoat and Howell (1980) demonstrated a link to the severity of the
overhang and the amount of periodontal destruction
• With overhangs, the flora changed from gingival health to one of
chronic periodontitis with increase in black pigmented bacteriodes.
Lang et al. (1983)
• Highly significant association b/w bone loss and overhanging
restoration Hakkaranein & Ainamo 1997
• Removal of overhangs permits more effective control of plaque and
reduction of inflammation and small increase in bone height. Jeffcoat &
Howell ( 1980)

31. •Mechanism by which overhangs cause periodontal
destruction
•Promote the retention of plaque
•Complicate plaque control
•Increase in the specific periodontal pathogens
•Impinge on the interproximal embrasure space
•Displacement of gingiva & violation of biologic width

32. • Overhanging restorations can be recontoured without replacing the
restoration
• Should be considered a standard component of nonsurgical treatment

33. • Prevention
• Use of wedges and proper adaptation of matrix bands

34. • CONTOUR AND CONTACTS
• Undercontouring
• Overcontouring plaque retentive no self cleansing effect
in ginival third
• Overcontouring can occur in-
1. Interdental Areas
2. Buccolingual Aspect
3. Furcation Aspects

35. •Interproximal contact areas are commonly
overcontoured
•The proximal contacts determine-
•• Marginal ridge relationships
•• Occlusal embrasure form
•• Buccal and lingual embrasure form,

36. •Marginal ridges of unequal height or of improper contour-
Encourage food impaction and retention
Contribute to the breakdown of interdental tissues
Subsequently to interproximal bone loss

37. •Overcontouring leads to
Collection of debris
Inflammation
Hyperplasia
Engorgement of marginal gingiva
Decreased keratinization
Deterioration of gingival fibers
•Greater the amount of facial and lingual bulge of an artificial
crown, the more the plaque retained at the cervical margin.
Yuodelis et al. (1973)

38. •Buccal and lingual crown contours should be ‘‘flat’’, not
‘‘fat”
•furcation areas should be ‘‘fluted’’ or ‘‘barreled out’
Becker & Kaldahl (1981)

39. Overcontouring of exposed furcation region
Formation of a horizontal triangular region
by roots & cervical bulge
Plaque accumulation
Periodontal breakdown

40. • CONTACTS
• loose or open proximal
contacts –contributing
factors to periodontal pocket
formation
• Greater food impaction at
sites with open or loose
contacts

41. •Literature proposes conflicting views-
•No difference in periodontal breakdown at sites with
deficient proximal contacts compared to satisfactory
sites. Kepic & O’Leary (1978) Hancock et al (1980)
•Excessively wide contacts obliterates interdental
embrasure
•Hyperplastic bulging of interdental papilla

42. • Interdental contacts if placed too high occlusally
Eliminate the marginal ridge & reduce sufficient area of
contact
Food Impaction
• Buccal view of excessive occlusogingival extent of
interdental contact, which also obliterates essential
interdental embrasure

43. normal position and size
of proximal contact
creating a slight col
Interdental view of
abnormally widened proximal
contact
Resulting in exaggerated col
formation that is subject to
breakdown.

44. •Broadened proximal contacts constrict both occlusal and
interdental embrasures.
•Difficult to clean the interdental area
•Characteristic changes of interdental tissue-
Facial and lingual hyperplasia of interdental papilla
Exaggerated col formation
Microbial invasion
Inflammation and edema
Osseous involvement

45. Excessively narrow interdental & lack of contact
food impaction and retention tooth drifting
marginal ridge discrepancy and bone loss

46. Occlusal Morphology of Restoration
Increased Buccolingual Width of OcclusalTable
More axial stress transmitted to periodontium with wide occlusal table than
narrow
Greater incidence of cross- arch & cross tooth balancing interferences during
lateral excursive forces

47. • Obliteration of natural sluiceways
• Improper passage of food from the occlusal table
• Food being forced into the contact area

48. High points-
Tooth with high
filling , painful Patient forced to
acquire a diff.
relationship of
maxilla to
mandible
Puts many other
teeth into
traumatic
functional
relationship
TMJ
problems

49. Carving-
Overcarving of
occlusal anatomy to
remove centric
holding areas
erupt in new
occlusal
relationship
Traumatic to the
periodontium
During functional and
parafunctional excursive
movements

50. RESTORATIVE MATERIALS
•Restorative materials are not themselves injurious
•Exception - self-curing acrylics
•Surface of restorations should be as smooth as possible
to limit plaque accumulation
•Crown & bridge cements cause irritation

51. •Non- precious alloys Inflammatory gingival response
Pierce LH, GoodkinRJ, 1989
•Nickel – allergic reaction in 9% of people
•Case of alveolar bone loss after the placement of crowns with a
high nickel content has been reported( Bruce GJ, HallWB 1995)

52. Surface Roughness
•Tissue respond more to surface roughness than
composition of material
•Roughness of intra-oral surfaces increase in plaque
retention .They protect bacteria against shear forces
•All restorative materials placed in the gingival
environment should have the highest possible degree of
polish.

53. ROUGHNESS AND MICROBIAL COLONIZATION
Roughness
affects the
Initial
Adhesion &
Colonisation
Bacteria
protected from
natural
removal forces
& oral hygiene
measures
Survive longer
-Reversible to
irreversible
attachment
Rough
surfaces
↑area
for
adhesion
by 2-3
times

54. •Rough surfaces accumulate and retain more plaque,
•It is less obvious when optimal oral hygiene
Increased proportion of motile organisms and spirochetes
Inflamed periodontium,
↑ bleeding index, ↑GCF

55. Procedures that Increase Roughness
•Polishing paste on restorative material
•Application of fluoride gel on porcelain
•Application of fluoride gel (pH<5) or gels containing
hydrofluoric acid on titanium implants
•Air powder abrasive systems on all materials

56. Subgingival Debris
•Subgingival debris can be left during-
Use of retraction cord
Impression material
Provisional material
Cement
•Examining the sulcus with explorer, remove the foreign
bodies

57. INJURYTO PERIODONTIUM
Application of Rubber Dam and Matrix
•Placed too subgingivally
•Placed for too long
Stripping of junctional
epithelium and gingival
connective tissue attachment
Ischemia to the degree that
sloughing of tissue and
subsequent gingival recession

58. Cavity and crown preparation
GINGIVAL
RECESSION
Inflammatory
gingival
margins
Laceration
of gingival
margin
Injury in the
region of
inadequate
attached
gingiva

59. Placing the Matrix/ Wedges
•Placement of matrix and wedges without care may
injure the PDL.
•A matrix which is not rigid and properly contoured may
not prevent intracrevicular overhangs.
•Injudicious separation beyond the width of the
periodontal ligament may injure the periodontium

60. •Improper placement of matrix band and wedge result in
poor contour
•Food lodgment and plaque accumulation

61. Impressions
•retraction cords are used to displace the free gingival
tissues
•May cause damage to subgingival tissue. (Usually
reversible)
•injudicious use of gingival-retraction techniques can
injure the soft tissues and cause permanent alterations,
such as recession.

62. •Dry retraction cords cause stripping of junctional &
sulcular epithelium while removal
•Retraction cords impregnated with chemicals- chemical
burns

63. •Electrosurgical retraction recession & loss of attachment
•Not indicated in regions of inflammation or of extremely thin
gingival tissue

64. •misuse can cause extensive damage
Gingival recession and sequestration of
bone after electrosurgery
Electrosurgical burn on the palatal
aspect of maxillary left canine

65. •Retained elastic impression materials, within
periodontal tissues after removing impression can lead
to massive loss of attachments

66. Provisional Restorations
•If made in haste or without consideration – permanent
damage to periodontium
•Critical areas include-
The marginal fit
The contour
The surface finish

67. Overextende
Temporary Crowns
• Gingiva alterations
I interdental, facial
& lingua marginal
region
• Hyperplasia or
recession if
attachment is
injured severely
Underextended
Temporary Crowns
• Not as serious as
overextension
• Hypersensitivity
interfering with
adequate oral
hygiene measures
Poor proximal
contact relationships
• Food impaction &
retention
• Drifting of the
approximating
teeth
Rough or Porous
Surface Finish
• Difficult t maintain
good oral hygiene
• Plaque
accumulation
• Inflammation
• Recession

68. ENDODONTIC
PROCEDURE

69. ROOT PERFORATIONS
•Frequency - 3 to 10%
•Artificial communication b/w root canal system and
supporting periodontium

70. •Root perforations occur
during-
Access cavity preparation
Root canal preparation
Post space preparation
•Location-
Cervical
Midroot
Apical

71. •Prognosis
•Location of perforation- most imp
•Time lapse b/w occurrence & treatment
•Size of the perforation

72. •Crestal root perforations -
most susceptible to epithelial
migrations & rapid pocket
formation
•Perforations in furcation
areas - because of proximity
to epithelial attachment
secondary periodontal
involvement

73. If the perforation is
located
close to the gingival
sulcus- periodontal
pocket
Bacterial infection
following perforation
Obturation of defects
with
gutta-percha- poor seal
and subsequent bacterial
inflammation of
periodontal tissues
Down growth of
epithelium,
inflammation ,
bone resorption and
necrosis can result
Exacerbation of a
preexisting periodontal
lesion -development of
clinical symptoms similar
to those of a periodontal
abscess

74. VERTICAL ROOT FRACTURES
•Causes
•preparation of canal for post
•Increased compaction pressure during obturation of root
canal
•Improper selection of post
•Expansion of posts and pins due to corrosion

75. • DIAGNOSIS
• Radiographs show typical ‘J
shaped’ radiolucency
• Wide space adjacent to the
obturated canal
• Deep narrow isloated pocket
depth
• COMPLICATIONS
• Inflammation due to plaque
accumulation
• abscess
• Fistulas
• Osseous defects

76. PROSTHETIC FACTORS

77. •Prosthesis are susceptible for plaque formation
•Inflammatory tissue reactions of mucosa covering
alveolar ridge can occur in response to bridge pontics

78. PONTIC DESIGNS
•Pontic should have a occlusal surface that Stabilizes the
opposing teeth
•Allows for normal mastication
•Doesn't overload the abutment teeth
•Occlusal table need not be buccolingually narrower than
those of the abutment teeth

79. •Manner in which pontic is designed & adapted to edentulous ridge
determines health of the surrounding tissues
•Concavities on tissue surfaces
plaque trap
bacterial accumulation
inflammation of adjacent tissues

80. Sanitary
Tissue surface
3 mm away
from ridge
Ridge lap
Tissue surface
straddles the
ridge like a
saddle
Modified
ridgelap
Tissue surface
on facial side
Concave lingually
Ovate
Tissue surface is
convex- fits into
receptor site

81. RIDGE-LAP
-Least desirable periodontally
- Difficult plaque control
SANITARY
-Easiest access for
hygeine procedure
-Unesthetic form
MODIFIED RIDGE- LAP
-More open lingual form
- Better access for hygiene
OVATE
-Ideal pontic design
- Easy to clean
- Esthetically satisfactory
Pontic design

82. Excessive contact of pontic with ridge
Causes initial blanching
Bone resorption

83. Scraping of
edentulous
cast for
positive
contact
Atrophy of
underlying
bone
Periodontal
involvement of
abutment teeth

84. Severely tilted
abutments
Deep
psuedopocket
on mesial
aspect of such
teeth
periodontal
breakdown

85. REMOVABLE PARTIAL DENTURE
• RPD increased gingivitis, periodontitis & abutment motility
• FACTORS ATTRIBUTED TO PDL BREAKDOWN
• Plaque Formation & poor oral hygiene
• Coverage of marginal gingiva by parts of RPD
• Occlusal forces transmitted to the remaining teeth & their periodontal
tissues by the prosthesis

86. Gingival responses to various types of removable partial
dentures (Bissad et al, 1974 )
•Gingival health was adversely affected by RPD
•Degree varied based on denture gingival relationship
•Severe pathologic changes occurred in areas without
relief
•Metallic bases elicited less response

87. Plaque formation and oral hygiene
• Increase plaque accumulation on tooth surface in direct contact
with dentures & teeth in opposing arch.
• El ghamrawy , 1976 showed
• the microbial composition of dental plaque developing on fifteen
abutment teeth
• removable partial dentures favored a proliferation of spiral
organisms.

88. • McHenry et al 1992-
• evaluated the effect of a removable partial denture
mandibularmajor connector design on the surrounding gingival
tissues
• Framework designs like Lingual plate contribute to ↑ plaque and
altered bacterial flora

89. Occlusal ForcesTransmittedTo Remaining
Teeth &Their PeriodontalTissues
• Occlusal forces transmitted to abutment teeth by RPDs -
• Jiggling as well as orthodontic component esp. in distal
extension RPD
• Magnitude, direction & frequency of force vary among patients
and sites

90. • Increased mobility of the abutment teeth ( Rissin et al 1979)
• Bergman et al 1982-
• Good alveolar bone support
• Good plaque control
• Periodic recall visits
• Carlsson et al 1965-
• poor patient co-operation
• Long recall interval
No PDL breakdown
Gingivitis
Pocket deepening
Mobility

91. • Rissin et al. (1985)
• Compared abutment teeth of patients with RPDs, FPDs and no
prosthesis
• RPD wearers - greatest plaque and calculus deposition, probing
depth & alveolar bone loss

92. • Zlataric et al. (2002)
• In an evaluation of 205 patients with RPDs, abutment teeth
• showed more disease than non abutment with
• ↑Plaque index,
• ↑Gingival index,
• ↑ Probing depth
• ↑Tooth mobility
• ↑ Gingival recession

93. • Improperly designed clasps lead to excessive stresses & occlusal
traumatism and damage abutment teeth
• During settling of posterior RPD ,clasp arm may impinge on
marginal tissue- if not supported by rests

94. Acrylic Partial Denture
• Acrylic non-rigid material whose strength is improved by
↑ the thickness
• Bulky dentures more potential to damage soft tissues

95. • Cause periodontal damage by-
• Physical stripping of gingiva
• Damaging lateral forces
• Increased plaque accumulation

96. ORTHODONTIC
PROCEDURE

97. • The periodontal reaction toward orthodontic appliances
depends on multiple factors-
• host resistance
• the presence of systemic conditions and
• the amount and composition of dental plaque

98. •Orthodontic fixed appliances induce an increase in the
volume of dental plaque
•cause a shift in the type of bacteria (Petti et al 1997).
•Direct trauma to supporting tissue

99. INTERFERENCE WITH PLAQUE
CONTROL
•Plaque - inflammation –gingivitis
•Appliance per se causes plaque accumulation
•Inability of the patient to adequately clean teeth

100. Effect of orthodontic band
• Main short term effects
gingivitis & gingival enlargement
Improved within 48 hrs of removal of band (Baer and Coccaro 1964)
• Gingival enlargement ↑ probing depth
• May be due toTrapped plaque
• Mechanical irritation caused by band or cement

101. • Mechanical irritation can be caused by bands by contact with gingival
margins .
• Chemical irritation by exposed cement at margin
• Greater likelihood of food impaction in posterior between arch wire &
soft tissue

102. Microbiology &Orthodontic Band
• ↑ed salivary
bacterial
count esp
Lactobacillus
• (Bloom &
Brown)
• 2-3 fold ↑se
in mortile
bacteria
• Legott et
al,1984
• ↑ese in
Anerobes &
P. Intermedia
• Diamanti,
1987

103. • Petti S et al 1997
• Evaluated Microbiological and clinical changes occurring during
the first six months of orthodontic therapy with fixed and
removable appliances
• 15 with fixed and 15 with removable appliances
• Patients with fixed appliances : ↑counts of motile rods,
subgingival spirochetes and a ↓ of Gram positive cocci.
• Patient with removable appliances: ↑ supragingival motile rods
and subgingival spirochetes

104. • Van Gastel et al., 2007
• fixed orthodontic treatment may result in localized gingivitis,
which rarely progresses to periodontitis

105. • Adolescents -fixed therapy
• cause Loss of attachment of
• 1- 2mm
Alstad &
Zachrisson 1979
• Higher prevalence of root
• resorption
Trossello &
Gianelly 1979
• Failed to show any
• significant changes in adult
Polson et al.
1988

106. Orthodontic Elastics & Separators
• Injudicious use rapid and severe periodontal destruction
• Elastic below height of contour has aTendency to slip apically
• Danger of elastics slipping beneath the marginal gingiva & detaching PDL
– mentioned as early as 1870 by McQuillen

107. • Stripping of junctionaln
epithelium. Extrusion of
cement into soft tissue -
acute gingival or periodontal
abscess
Band
Placement
• Use of banded attachments
• & removal of excessive
• bone negative impact .
• It compromise pdl
• attachment of adj teeth
Forced
Eruption of
Impacted
Teeth

108. Occlusal Consideration
• Orthodontic movement - Unavoidable occlusal traumatism -
Affect health of periodontium
• Disturbance of occlusion produces, although temporarily-
Jiggling type of forces

110. Root resorption
• Ottolengui (1914), related root resorption directly to orthodontic
treatment
• In 1927 root resorption was a subject of major concern to the
orthodontic field.
• Katcham, demonstrated, with radiographic evidence, the differences
between root shape before and after orthodontic treatment
• The etiology of root resorption still remains unclear and is complex,
including genetic predisposition and environmental factors
Abass and Hartsfield, 2007

111. Types
• Cementum or surface resorption with remodeling.
• Dentinal resorption with repair (deep resorption)-
The final shape of the root may or may not be
identical to original form.
• Circumferential apical root resorption-root
shortening is evident
• Movements of roots outside the confines of alveolar
process
- development of mucogingival problems especially in
areas of thin bone & gingiva

112. Forces during
frontal & lateral
expansion of teeth
• Development of
• tension in
• marginal tissues
Stretching
• thinning of the
• soft tissues
If expansion
• bone dehiscence
• • Development of
• soft tissue recessions in
• presence of bacterial
plaque &/or mechanical
• trauma like improper
brushing

113. EXODONTIC
PROCEDURES

114. • Injudicious tooth removal initiate periodontal disease or
aggravate existing pathosis in the vicinity

115. Procedures affecting periodontium
• Manner in which facial and lingual flaps are raised
• Manner in which the teeth are luxated and elevated
• Degree of post-extraction debridement
• Way in which the wound is closed

116. • Practice of tightly suturing flaps for hemostasis without regard
for flap position -position that is too far occlusal.
• Since connective tissue does not attach to the enamel surface –
pseudopockets
• Also the incorrectly positioned band of gingiva becomes
nonfunctional leading to exaggerated free gingival margin
• Situation is esp serious if the original zone of attached gingiva in
the vicinity is minimal

117. Impacted 3rd Molar extraction
• Creation of vertical defects distal to 2nd molar

118. • Kugelberg et al. (1985)-
• Retrospective study -215 patients 2yr after surgery
• 43.3%- probing depth > 7mm
• 32.1%- probing depth > 4mm
• Kugelberg (1990)
• evaluated Periodontal healing after 2 & 4 yrs in 51 cases
• 2yrs post operatively
• 16.7% ≤ 25 yrs – intrabony defect more than 4mm
• 40. 7%≥ 25 yrs- intrabony defects more than 4mm
• 4yrs post operatively
• 4.2 % ≤ 25 yrs – intrabony defect more than 4mm
• 44.4 %≥ 25 yrs- intrabony defects more than 4mm

119. • Javier Montero et al 2011
• The periodontal health of the second molar was found to
improve gradually after third molar surgery
• Probing depth was gradually reduced by about 0.6 mm
quarterly, until a final depth of 2.6 was attained.

120. PERIODONTAL
PROCEDURES

121. • Calculus maybe dislodged and pushed into the soft tissue during scaling
• Inadequate scaling calculus to remain in the deepest pocket
area
• Resolution of the inflammation at the coronal pocket area
Occlude the normal drainage

122. • Trauma to the marginal
gingiva
Polishing
Brush
• Generated heat may cause
thermal damage leading to
pulpitis
Polishing
Cup

123. Post flap surgery , common sequelae
• Gingival recession
• Inevitable sequence of periodontal surgery
• Sensitivity
• Exposed root surfaces become sensitive to heat,
cold, mechanical and chemical stimuli
• Reduces over few weeks or months but
occasionally may persist for long period of time

124. Burns due to electrocautery unit

125. Burn injury caused by heated ultrasonic scaler

126. • Treatment of food
impaction with a cold
cure acrylic appliance
resulting in chemical
burn and pathologic
changes in
periodontium

127. MISSING STRATEGICTEETH ANDTHEIR
NON REPLACEMENT
• Replacement of strategic teeth is often overlooked in dental
practice
• Unreplaced missing teeth Drifting of adjacent teeth
&create conditions that lead to periodontal disease
• Initial tooth movement can be aggravated by loss of periodontal
support

128. Flaring of anterior teeth due to usage of anterior for
chewing
When no back teeth are touching the stress is
now placed on the front teeth, this ‘overloads’
them and forces them to move forward and
outward.
When back molars are
missing the damage is
even more serious.
When teeth are missing,
the opposite teeth have no
“counter acting force” and
will erupt upward into the
mouth

129. The back chewing
teeth begin to erupt
down into the empty
spaces where the
lower molar teeth are
missing.
The back chewing teeth
drop even further down into
the lower missing teeth
spaces
The chewing forces have shifted to
the front teeth and due to
overloaded stress the front teeth
begin to flare and fan apart creating
spaces.

130. The fanning and spaces get worse
over time. This fanning eventually
leads to looseness and gum disease
and the loss of the front teeth.

131. Gum disease due to the movement and
misalignment of the teeth can cause more tooth
loss and decay.

132. Sinus Expansion Destroying Bone -MissingUpper
Teeth
One the teeth are missing, the sinus begins to expand and
destroy bone from the “inside out.” Teeth in the bottom
jaw erupt and traumatize the upper gum tissue. If a partial
denture is being worn it causes bone damage from the
other side of the sinus doubling the deterioration
When the upper
teeth are present
the sinus stays
in its proper
position.

133. Without the support of back chewing teeth, as the teeth randomly
drift, unusual dental bites develop that cause excessive stress and
damage to the joints (TMJ) that connect the two jaw bones with pain
and headaches being a common side effect.
Headache from missing teeth

134. Failure to Replace First Molars
• Tilting of 2nd & 3rd molar causing decreased vertical dimension
• Mandibular incisors tilt or drift lingually
• Premolars move distally, lose their intercuspating relationship with
maxillary teeth and may tilt distally
• Increased anterior overbite. Mandibular incisors strike maxillary
incisors & may traumatize the gingiva
• Maxillary incisors - pushed labially & laterally
• Anterior teeth extrude due to loss of incisal apposition
• Formation of midline diastema

135. Sequale of non replacement of first molar

136. CONCLUSION
• Iatrogenic factors play a considerable role in periododontal
diseases.
• When treating the patients objectives of dentists must be clear
,to avoid any undesirable outcomes of treatment.
• There is a need to increase awareness among dental
practitioners about the role of iatrogenic factors in order to get
successful outcome of any dental therapy, which unfortunately
is ignored for a long time.