Aap part 2

1
DEPARTMENT OF PERIODONTICS AND
IMPLANTOLOGY
RAJAS DENTAL COLLEGE AND HOSPITAL
SEMINAR TOPIC : THE CLASSIFICATION OF PERIODONTAL
AND PERI-IMPLANT DISEASES AND CONDITIONS
PART 2.
PRESENTER
Dr. BABU SALAM C
2nd Year Postgraduate
Guide Name: Dr. Jacob Raja MDS
(Professor & H.O.D)
UNLEARN, LEARN

OUTLINE
 PERIODONTAL DISEASES & CONDITIONS
 PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS.
 Periodontal health and gingival health.
 Gingivitis: Dental Biofilm Induced.
 Gingivitis: Non Dental Biofilm Induced.
 PERIODONTITIS.
 Necrotizing Periodontal Diseases.
 Periodontitis.
 Periodontal manifestation of systemic diseases and conditions.
 OTHER CONDITIONS AFFECTING PERIODONTIUM
 Systemic diseases or conditions affecting periodontal supporting tissues.
 Periodontal abscess and endodontic periodontal lesions
 Mucogingival deformities and conditions.
 Traumatic occlusal forces.
 Tooth and prosthesis related factors.
 PERI-IMPLANT DISEASES AND CONDITIONS.
 Peri implant health
 Peri implant Mucositis
 Peri implantitis
 Peri implant soft and hard tissue deficiencies.
3

OUTLINE
 PERIODONTITIS.
 Periodontitis.
4

1. Systemic disorders that have major impact on the loss of
periodontal tissues by influencing periodontal inflammation.
– Genetic disorders
– Acquired immunodeficiency diseases
– Inflammatory diseases.
2. Other systemic disorders that influence the pathogenesis of
periodontal disease.
3. Systemic disorders that can result in loss of periodontal tissues
independent of periodontitis.
– Neoplasms.
– Other disorders that may affect the periodontal tissues.

1. SYSTEMIC DISORDERS THAT HAVE MAJOR IMPACT ON THE
LOSS OF PERIODONTAL TISSUES BY INFLUENCING PERIODONTAL
INFLAMMATION.
Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the
periodontal attachment apparatus: case definitions and diagnostic considerations.
J Clin Periodontol. 2018;45

GENETIC DISORDERS
• GENETIC DISORDERS
• Disease associated with immunological disorders.
– Down syndrome.
– LAD syndrome.
– Papillon Lefevre syndrome.
– Chediak Higashi syndrome.
– Severe neutropenia.
– Primary immunodeficiency diseases.
– Cohen syndrome.
• Diseases affecting the oral mucosa and gingival tissues.
– Epidermolysis bullosa.
– Plasminogen deficiency.
• Diseases affecting the connective tissues.
– Ehler Danlos syndromes.
– Angioedema
– SLE
• Metabolic and endocrine disorders.
– Glycogen storage disease
– Gaucher disease.
– Hypophosphatasia.
– Hypophosphatemic rickets.

• ACQUIRED IMMUNODEFICIENCY DISEASES
– Acquired neutropenia
– HIV infection
• INFLAMMATORY DISEASES
– Epidermolysis bullosa acquisita
– Inflammatory bowel diseases.

2. OTHER SYSTEMIC DISORDERS THAT INFLUENCE THE
PATHOGENESIS OF PERIODONTAL DISEASES

– Diabetes mellitus
– Obesity
– Osteoporosis
– Arthritis
– Emotional stress and depression
– Smoking (nicotine dependance)
– Medications

3. SYSTEMIC DISORDERS THAT CAN RESULT IN LOSS OF
PERIODONTAL TISSUES INDEPENDENT OF PERIODONTITIS.

• Neoplasms
– Primary neoplastic disease of periodontal tissues
• Oral squamous cell carcinoma
• Odontogenic tumors
• Others
– Secondary metastatic neoplasm of periodontal tissues
• Other diseases that may affect the periodontal tissues.
– Granulomatosis with polyangitis
– Langerhans cell histiocytosis
– Giant cell granulomas
– Hyperparathyroidism
– Systemic sclerosis
– Vanishing bone diseases.

OUTLINE
 PERIODONTITIS.
 Periodontitis.
15

• Periodontal biotype
– Thin scalloped
– Thick scalloped
– Thick flat
• Gingival soft tissue recession
– Facial/lingual surfaces
– Interproximal (papillary)
– Severity
– Gingival thickness
– Gingival width
– Presence of NCCL/ Cervical caries
– Patient esthetic concern
– Presence of hypersensitivity
• Lack of keratinized gingiva
• Decreased vestibular depth
• Aberrant frenum/ muscle position
• Gingival excess
– Pseudopocket
– Inconsistent gingival margin
– Excess gingival display
– Gingival enlargement
• Abnormal color
Cortellini P, Bissada NF. Mucogingival conditions in the natural
dentition: Narrative review, case definitions, and diagnostic
considerations. J Clin Periodontol. 2018;45(Suppl 20):S199–S206.

PERIODONTAL BIOTYPE
• Thin scalloped: slender triangular crown, subtle cervical
convexity, interproximal contacts close to the incisal edges and a narrow
zone of KT, clear thin delicate gingiva, thin alveolar bone.
• Thick flat biotype: square shaped tooth crown, pronounced
cervical convexity, large interproximal contact located more apically, a
broad zone of KT, thick, fibrotic gingiva, thick alveolar bone.
• Thick scalloped biotype: thick fibrotic gingiva, slender
teeth, narrow zone of KT, pronounced gingival scalloping.

• Periodontal phenotype = gingival phenotype + bone
morphotype.
• Biotype= group of organ having same specific phenotype.
• Phenotype = appearance of an organ based o a multifactorial
combination of genetic traits and environmental factors
• Change through time

GINGIVAL RECESSION
PREDISPOSING FACTORS
• Periodontal biotype and attached gingiva:
• Thin biotype, absence of AG, reduced thickness of alveolar bone. (abnormal tooth
position)
• 2mm of KT, 1 mm of AG – desirable/ not needed to prevent.

• Impact of tooth brushing
• Mechanical factor.
• Data – inconclusive.
• Potential risk factors:
– Duration of tooth brushing,
– Brushing force,
– Frequency of changing tooth brush
– Bristle hardness,
– Tooth brushing technique.

• Impact of cervical restorative margins
• Minimal/ no gingiva – prone to recession.

• Impact of orthodontics
• Direction of orthodontic tooth
movement.
• Facial to lingual – increase in width.
• Higher probability of recession
<2mm, augmentation indicated.

• Other conditions
• Persistent gingival inflammation.
• Shallow vestibular depth.
• Frenum position.
• Tissue deformities – clefts/ fissures.

CLASSIFICATION SYSTEM OF FOUR DIFFERENT CLASSES OF ROOT
SURFACE CONCAVITIES
CEJ step Descriptors
Class A - CEJ detectable without
step
Class A + CEJ detectable with step
Class B - CEJ undetectable without
step
Class B + CEJ undetectable with step

Recession classification based on interdental
CAL – treatment oriented Cairo 2011
• Recession type 1(RT 1) – 100 %
No loss of interproximal attachment, CEJ not detectable.
• Recession type 2(RT 2) – 100%
Loss of interproximal attachment < Buccal
• Recession type 3(RT 3) - full coverage not achievable
Loss of interproximal attachment > Buccal

Gingival site Tooth site
REC
Depth
GT KTW CEJ
(A/B)
Step
(+/-)
No
recessi
on
RT 1
RT 2
RT 3
CLASSIFICATION OF GINGIVAL BIOTYPE AND GINGIVAL RECESSION

OUTLINE
 PERIODONTITIS.
 Periodontitis.
39

Occlusal trauma
Primary occlusal trauma – adaptive
Secondary occlusal trauma - progressive
Orthodontic forces
Excessive --------- traumatic occlusal force.
Fan J, Caton JG. Occlusal trauma and excessive occlusal forces: Narrative
review, case definitions, and diagnostic considerations. J Clin Periodontol.
2018;45(Suppl 20):S207–S218

• Defined and diagnosed on the basis of histologic
changes.
• Proposed clinical and radiographic indicators of
occlusal trauma:
1. Fremitus.
2. Mobility.
3. Occlusal discrepancies.
4. Wear facets.
5. Tooth migration.
6. Fractured tooth.
7. Thermal sensitivity.
8. Discomfort/ pain on chewing.
9. Widening PDL space.
10. Root resorption.
11. Cemental tear.

OUTLINE
 PERIODONTITIS.
 Periodontitis.
42

 Localized tooth related factors
 Tooth anatomic factors
 Root fractures
 Cervical root resorptions, cemental tears
 Root proximity
 Altered passive eruption
 Localized dental prosthesis related factors
 Restoration margins placed within supracrestal attached tissues
 Clinical procedures related to facbrication of indirect prosthesis.
 Hypersensitivity, toxicity reaction to dental materials.
Ercoli C, Caton JG. Dental prostheses and tooth‐related factors. J Clin Periodontol. 2018;45(Suppl
20):S207–S218.

BIOLOGIC WIDTHSUPRACRESTAL TISSSUE ATTACHMENT

BIOLOGIC WIDTH
• INTERPROXIMAL MARGINS placed within varying distance from the
alveolar bone:
– GROUP 1 <1mm between crown margin and alveolar crest.
– GROUP 2 1 to 2mm
– GROUP 3 >2mm
• PBI greater in group 1, PD
• Caused by bacterial plaque or trauma / combination.

FIXED DENTAL RESTORATIONS AND PROSTHESIS
• Overhangs 0.2mm –
• 0.5 mm and 1 mm - gingival inflammation, crestal bone loss.
• Direct restoration – subgingival margins – localized gingivitis, increased PD.
• Direct/ indirect restoration – overhanging margins - + interproximal bone loss.
• Plaque retentive

DENTAL MATERIALS
• Minimum roughness threshold (Ra < 0.2µm) – plaque
retention.
• Ni and Pd – hypersensitvity – clinically appears as gingivitis.

RPD
• Plaque control, prosthesis designed – no attachment loss.
• Distal extension RPDs – not relined, great force, torque on
abutment – mobility.

CERVICAL ENAMEL PROJECTION 82.5%
• CEP I – distinct change in CEJ attitude with enamel projecting towards the
furcation.
• CEP II – Approaching the furcation, not contact.
• CEP III – extending into furcation proper. 4.3 to 6.3%

ENAMEL PEARL
• Spheroidal shape, furcation.
• Plaque retentive factor.
– Developmental grooves
• Maxillary lateral incisors.
• 43% - 5mm apical to CEJ.
• 10% - 10 mm apical to CEJ.

TOOTH AND ROOT FRACTURE
• TOOTH FRACTURES:
– Coronal to gingival margin – do not initiate gingivitis or periodontitis.
– Surface characteristics – plaque retention.
• ROOT FRACTURES:
– Trajectory of the fracture - Vertical, transverse, oblique
– Extent - complete/incomplete
– Location - apical, midroot, cervical regions – plaque retentive.

ROOT PROXIMITY
• IRD (interproximal root distance): < 0.6mm
loose 0.5 to 1 mm of bone.
– Type 1 >0.5 to < 0.8mm
– Type 2 > 0.3 to <0.5mm
– Type 3 < 0.3mm

OUTLINE
 PERIODONTITIS.
 Periodontitis.
54

A NEW CLASSIFICATION FOR PERI-IMPLANT
DISEASES AND CONDITIONS
55

• Fibrin clot, neutrophils
• Fibroblasts
• 2nd to 3rd week – collagen, epithelial cells
• 4th week – fiber bundles
• 6 to 8 weeks – mucosa matures
• 1st month – no change.
• 200 µm wide zone – connective tissue
• 40 µm – inner, fibroblasts
• 160 µm – outer, collagen fibers

• Coagulum
• 4th day – granulation tissue – inflammatory, mesenchymal, vessels.
• 1 week – woven bone projects.
• 2 weeks – woven bone fill
• 6 to 12 weeks – lamellar bone, BIC.

• Cementum, pdl, bundle bone.
• Dentoalveolar, dentogingival
• GM follows CEJ
• Multiple implants – crestal bone.
• Single – con.tissue adhesion adjacent teeth.
• Tooth – mobile in socket, ankylosed.
• Longer ep, orthokeratinized, no fiber.
• Coronal – sulcular epithelium, thin JE, apical – connective tissue…direct.
• Less vascularized.

• Absence of erythema, BOP, swelling, suppuration.
• Probing depth greater at implant site.
• Shorter papilla.
• Mucosa 3-4mm in height – keratinized/non
• Lateral – small inflammatory infiltrate.
Berglundh T, Armitage G, et al. Peri‐implant diseases and conditions: Consensus report of workgroup 4 of the 2017
World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions.J Clin Periodontol.
2018;45(Suppl 20):S286–S291.

OUTLINE
 PERIODONTITIS.
 Periodontitis.
62

• BOP. Bleeding dots.
• Increase PD.
• Resolution > 3 weeks.
• Lateral – well defined inflammatory infiltrate.
• Doesn’t extend apical.
• Absence of crestal bone loss beyond initial remodeling.

OUTLINE
 PERIODONTITIS.
 Periodontitis.
64

• BOP.
• Increase PD.
• Apical – well defined inflammatory infiltrate.
• Larger.
• Crestal bone loss beyond initial remodeling.
• PD >6mm
• Bone level >3mm apical.
• Non linear, accelerating pattern.
Heitz‐Mayfield LJA, Salvi GE. Peri‐implant
mucositis. J Clin Periodontol. 2018;45(Suppl
20):S237–S245.

• Strong evidence
– History of chronic periodontitis
– Poor plaque control skills
• Smoking and diabetes – potential – inconclusive
• Limited evidence
– Submucosal cement
– Genetic factors
– Systemic conditions
– Iatrogenic factors
– Occlusal overload
– Titanium particles
– Lack of KM
– Positioning of implant ------------ to be determined
• Rare
– Progressive crestal bone loss in absence of soft tissue inflammation.
Schwarz F, Derks J, Monje A, Wang H‐L. Peri‐implantitis. J Clin Periodontol. 2018;45(Suppl 20):S246–
S266.

OUTLINE
 PERIODONTITIS.
 Periodontitis.
68

 Hard tissue deficiencies prior to implant placement
 Hard tissue deficiencies after implant placement
 Soft tissue deficiencies prior to implant placement
 Soft tissue deficiencies after implant placement

Factors affecting hard and soft tissue deficiencies at
dental implants
• Hard tissue deficiencies prior to
implant placement
– Tooth loss
– Trauma from tooth extraction
– Periodontitis
– Endodontic infections
– Longitudinal root fractures
– General trauma
– Bone height in posterior maxilla
– Systemic diseases
Hämmerle CHF, Tarnow D. The etiology of hard and soft‐tissue deficiencies at dental implants: A narrative
review. J Clin Periodontol. 2018;45(Suppl 20):S267–S277.

• Hard tissue
deficiencies after
implant placement
– Defects in healthy
situations
– Malpositioning of
implants
– Periimplantitis
– Mechanical overload
– Soft tissue thickness
– Systemic diseases

• soft tissue deficiencies prior to implant placement
– Tooth loss
– Periodontal disease
– Systemic disease
• soft tissue deficiencies after implant placement
– Lack of buccal bone
– Papilla height
– Keratinized tissue
– Migration of teeth and lifelong skeletal changes.

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