Failures in Periodontal Therapy: Review Article
Failures in Periodontal Therapy: Review Article
4 Jul’10
Review article
Failures in periodontal therapy
KD Jithendra1, Bansali A2, Ramachandra SS3
Abstract
Studies have shown that modern periodontal therapies are effective in maintaining a
healthy natural dentition as well as controlling periodontal disease. Numerous treatment
strategies and various techniques have been designed & described to treat periodontal
disease. Most of these procedures had drawbacks which were identified, leading to the
modifications of the original techniques which lead to better treatment options, but still
very less emphasis has been laid on failures. Without a regular program of clinical
reevaluation, plaque control, oral hygiene instructions, and reassessment of biomechanical
factors the benefits of treatment are often lost and inflammatory disease in the form of
recurrent periodontitis may result. So, this review describes the most common failures
noticed in periodontal therapies and also discusses the possible solutions to reduce the
incidence of failures in periodontal therapy.
1. *Jithendra K D M.D.S, Professor and Head, Department of Periodontics, Kanti Devi Dental College and
Hospital.
2. Ashok Bansali M.D.S, Senior lecturer, Department of Periodontics, CSMSS Dental College and Hospital,
Aurangabad, Maharastra.
3. Srinivas Sulugodu Ramachandra M.D.S, Senior lecturer, Kanti Devi Dental College and Hospital.
*Corresponds to: Dr Jithendra K D, Professor and Head, Department of Periodontics, Kanti Devi Dental
College and Hospital, Delhi-Agra National Highway # 2, Mathura, P.O. Chhatikhara, Pin-281006,
Uttarpradesh, India. Email: [email protected].
Jithendra KD, A Bansali, SS Ramachandra
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Jithendra KD, A Bansali, SS Ramachandra
bone removal should be planned to sutures will lead to gaping of the wound
maintain the biologic width as well as bone and hence recurrence of the disease.12
support of the tooth.11
Failures associated with papilla
Failures associated with depigmentation preservation flap4
Failures associated with this procedure are Papilla preservation flap surgical procedure
mainly due to lack of patient co-operation was devised by Takie et al.,13 in 1985, to
in smokers. An increase in melanin prevent the partial or complete exfoliation
pigmentation is associated with increase in of bone graft material by providing
smoking. If the procedure of primary coverage of the entire
depigmentation is carried out with interproximal defect.13 It is commonly used
electrocautery, care should be exercised to in regenerative techniques. Failures
prevent necrosis of bone. So, contact of the associated with this procedure are i)
cautery instruments with underlying bone presence of too narrow interdental space.
should be avoided. If chemicals are used to This procedure should be performed only if
produce depigmentation, there may be the interdental space is adequate to permit
damage to the bone and underlying tissue the reflection of the papilla. If there is too
because the depth of action of these narrow interdental space then it should not
chemicals is not controlled.12 be attempted as it will lead to failure of this
procedure. ii) Incisions should be placed
Failures associated with periodontal flap without compromising the blood supply,
surgery otherwise it will lead to necrosis of the
Failures of periodontal flap surgery can be papilla, iii) While suturing, flap should be
due to i) Improper incision: the rationale of adapted properly, if not, there will be
any periodontal flap surgery is to gain gaping of the flap & failure of
access to underlying root and bone regeneration.10
surfaces. If incisions are not made upto the
bone/root surface a mucosal flap is Failures associated with soft tissue
elevated which, hinders in gaining proper augmentation surgery2,14
access to the underlying root surfaces. It It is most widely used and predictable
can also cause increased amount of bone technique for increasing the width of the
resorption. Therefore while giving incision attached gingiva. Common failures
the blade should hit the bone in order to associated with soft tissue autografts are i)
elevate a full thickness flap. ii) Reflection Mismatch between graft size and defect: if
of the flap: elevation of the periodontal the denuded root defect is small enough,
flap should be such that only around 1 mm the collateral circulation will be adequate
of marginal bone is exposed. Over to support bridging. On the other hand,
reflection will result in bone resorption, when prominent roots, with relatively wide
whereas under reflection will result in areas of root exposure are grafted, two –
limited access to the underlying root/bone point collateral circulation is insufficient
surface. iii) Debridement of the root for the graft support. As a result, the center
surfaces and the bone: complete of the graft thins and becomes necrotic; the
debridement with removal of plaque and graft splits and ultimately fails. ii)
calculus from the root surface is essential Improper graft adaptation to the underlying
for success of any periodontal flap surgery. periosteum. After suturing, slight pressure
iv) Suturing of the separated flaps should is applied to the soft tissue graft with gauze
be done to closely adapt the flap to the moistened in saline for 5 minutes to permit
tooth margins. Failure to properly place the fibrin clot formation and prevent bleeding.
Bleeding will result in hematoma under the
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Failures in periodontal therapy
graft with subsequent necrosis.14 iii) To palatal artery. Cutting the palatal artery can
permit adequate transfusion of the graft, it be dangerous near its exit point from the
has been recommended that all fat and greater palatine foramen. iv) Extension
glandular tissue be removed prior to beveling or thinning of tissue on a low,
suturing to prevent possible necrosis and/or broad palate invites damage to the palatal
inadequate take. Even though the need for artery. v) Tissue placement to high onto the
this has been questioned, it is still generally teeth results in poor flap adaptation &
accepted procedure. iv) Graft movement as recurrent pocket formation. This can be
a result of inadequate or insufficient corrected by proper trimming at the time of
suturing will surely result in failure flap placement prior to suturing which is
because no plasmatic diffusion will occur. usually accomplished with scissors or
v) The final failure is often seen only after scalpel blade. It often results in a thick,
the graft has healed. The clinical heavy margin.4
appearance is acceptable, but the graft is
totally movable when probed. This is a Failures associated with root coverage
failure of technique and results from not procedures1,15
removing all loose connective tissue and Gingival reconstruction is today not only
muscle fibres from the periosteal bed prior possible but a routine part of periodontal
to the placement and not making sure that practice. The ability to cover unsightly
the bed is firmly attached to the underlying exposed roots, sensitive roots, and crown
bone.14 margins, to reconstruct lost ridges & to
enhance prosthetic reconstruction has made
Failures associated with palatal flaps4 root coverage procedures popular both
The palate, unlike other areas, is composed among patients and clinicians. According
mainly of dense collagenous connective to Langer and Langer15 in 1992 common
tissue. This fact precludes the palatal tissue failures associated with root coverage
from being positioned apically, laterally or procedures are i) Recipient bed is too small
coronally. Therefore, surgical techniques to provide adequate blood supply, ii)
are required that allow the tissue to be Perforation of the mucosal flap, iii)
thinned & apically positioned at the same Inadequate (small) size of the graft, iv)
time. Common failures associated: i) The Inadequate coronal positioning of the flap,
flap may be too short. Generally the result v) Poor root preparation and/or root
of deep primary incision, or use of a conditioning.15
beveled gingivectomy incision. This results
in delayed healing & increased patient Conclusion
discomfort. ii) Poor marginal flap Therapeutic failure appears to be more
adaptation caused by incomplete thinning frequent in periodontology than in other
of the tissue. The margins of the flap stand fields of dentistry.16 Such failure may be
away from the tooth when the flap is caused by errors in patient selection,
replaced. This can be corrected either by incomplete diagnostic procedures,
additional thinning of inner flap surface diagnostic or prognostic errors, treatment
close to the base of the original incision or difficulties and obstacles, non-controlled
by more osteoplasty. Careful examination healing, or the absence of maintenance
will reveal the problem. iii) Incision therapy. Most failures can be avoided by
beyond the vertical height of the alveolus, instituting a regular recall system.16
bringing the scalpel blade close to the
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Jithendra KD, A Bansali, SS Ramachandra
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