Complex periodontal treatments and peri-implant surgery

Prevention and treatment of gum and periodontal diseases - with modern methods.

What is periodontology?

Periodontology is the branch of dentistry that deals with the health and pathology of the periodontal tissues, i.e. the tissues that support the teeth. These structures include the gums (gingiva), the alveolar bone, the periodontal ligament, and the cementum covering the tooth root. In our practice, periodontal diagnostics and therapy play a prominent role, as the condition of the periodontal tissues fundamentally determines the long-term stability of both the natural teeth and the implants.

Why is periodontology important?

A healthy periodontal pocket is one of the most important pillars of permanent dental restorations. At our clinic, all prosthetic interventions are performed only after thorough dental hygiene preparation and achieving perfect oral hygiene. We do not make permanent dentures until the long-term prognosis of all affected teeth or implants is clear – thus preventing the later development of periodontal disease (periodontitis) or inflammation around the implant (peri-implantitis).

Untreated periodontal disease is the most common cause of tooth loss in adults, and chronic oral inflammation has been linked to an increased risk of cardiovascular disease and diabetes. That's why periodontal screening and treatment not only protects your smile, but also your overall health.

Symptoms and diagnosis of periodontal disease

When should you contact us?

Establishing an accurate diagnosis is the basis for successful periodontal treatment. In our office, the examination is performed by a dental hygienist, who takes a detailed periodontal status. During this, the following parameters are recorded:

Measuring pocket depth – we use a periodontal probe to examine the depth of the pocket between the gum and the tooth, which may be of soft tissue or bony origin (bone crater).
Tooth mobility assessment – we assess the mobility of teeth on a three-grade scale: grade 1 means 1 mm of unidirectional movement, grade 2 means more than 1 mm of multidirectional movement, while grade 3 indicates vertical mobility, which without treatment leads to tooth loss.
Gingival bleeding index – the bleeding of the gums upon probing is recorded on a three-grade scale, which indicates the degree of inflammation.
Periodontal X-ray diagnostics – we assess the level and condition of the alveolar bone surrounding the teeth using X-rays taken using a parallel technique (periodontal status scan).

Periodontal treatment options

Treating periodontal disease – from diagnosis to therapy

Periodontal treatment is always planned based on detailed diagnostics. Periodontal disease typically develops gradually: initially it appears as gingivitis, which is a consequence of bacterial biofilm (plaque) deposited on the surface of the teeth. If the plaque is not removed, it spreads to the areas below the gums, then mineralizes and turns into subgingival tartar. If left untreated, the inflammation also spreads to the deeper tooth-bearing tissues – the alveolar bone – which can lead to irreversible damage and ultimately tooth loss.

Conservative and tooth-preserving periodontal treatments

Tooth-preserving periodontal surgeries are divided into closed and open curettage. In the case of closed curettage, a more conservative surgical approach is used: the intervention does not affect the aesthetic gingival course, does not require flap exposure, and is therefore considered a less invasive procedure. Open curettage is performed when direct visualization is required due to pocket formation – in this case, vertical auxiliary incisions are made that touch the mucogingival border. In complex cases involving horizontal bone loss, an apically displaced flap is used, only in cases of significant deviation, taking into account its aesthetic consequences.

Regenerative periodontal solutions

In advanced horizontal bone loss, the interdental spaces open up, which poses a significant aesthetic and functional challenge. In such cases, periodontal treatment options are limited: complete regeneration of the bone is often not possible. In such cases, prosthetic solutions – such as the creation of a cleanable, washable bridge – ensure proper hygiene and long-term sustainability of the area, striving for the best aesthetic result.

Treatment of vertical bone defects and bone craters

Vertical bone defects affecting the periodontal ligament – single-walled, double-walled and triple-walled bone pockets – can be visualized and diagnosed most accurately during periodontal status assessment. In our practice, according to the rules of the profession, we only undertake the regeneration of vertical bone defects with a favorable prognosis: in the case of triple-walled defects, if the vertical depth measured with a probe is no more than 7 mm and their angle of inclination is between 20-25 degrees.

During our periodontal surgeries, we use collagen matrix, PRF (platelet-rich fibrin), and free connective tissue flap (CTG) for soft tissue regeneration, in the latter case the palate serves as the donor area. The essence of guided tissue regeneration (GTR) is that we use the regenerative material that we use, which ensures the greatest success in the case of our own teeth, Emdogain (porcine enamel matrix derivative), which contains enamel matrix proteins (amelogenins) and is called "pluripotent" because it is able to promote the simultaneous regeneration of multiple tissue types - cementum, periodontal fiber and bone - in periodontal (gum) surgery. This can be enhanced in the case of larger defects by using Emdogain and bone substitute materials together.

For bone replacement, we use animal-derived, absolutely prion-free, lyophilized and gamma-irradiated xenografts, which serve as an inorganic framework for the ingrowth and vascularization of bone tissue. If necessary, we also perform block augmentation with autogenous bone taken from the jawbone to repair more extensive defects. If the patient is not a suitable solution for using their own bone (in terms of fear), we have pre-fabricated, human-origin bone blocks (bonealbumin) available in various shapes, which represent a safe alternative to block augmentation.

After tooth extraction, it happens that the primary stability required for immediate implantation cannot be achieved – whether it is a foreseeable situation or a rare failure that occurs during surgery. In such cases, we perform alveolar preservation: guided tissue regeneration (GBR) with cortical lamina with or without the use of bone substitute material – depending on the situation.

In addition, depending on the extent of the bone defects, we use a collagen membrane fixed with Master Pin® rivets or, in the case of more extensive bone defects, titanium-reinforced non-absorbable Teflon membranes (cytoplast) which are fixed with the membrane screws of the Profix® system. Whether the bone block is autogenous or bone albumin, they are fixed with the bone screws of the Profix® system. Depending on the case, a smooth cytoplast Teflon membrane is removed with a Profix® tent nail and replaced with a xenograft. These must be removed after bone regeneration (on average 4-6 months, in the case of a single-walled bone pocket or 8-9 months in the case of vertical augmentation).

Successful regeneration of bone tissue allows for the optimization of soft tissue aesthetics, where digital smile design is used to precisely define the gingival zenith to create the ideal smile for the patient.

The patient's smile is greatly influenced by the course, shape and extent of the hard tissues (i.e. the bone structures of the dental bed surrounding the tooth), the atrophy and resorption of which is always followed by the contour of the soft tissue. The contour of the soft tissue itself is the course of the interdental papillae (the tight keratinized gum tissue located in the space between the teeth) following the emergence of the teeth.

If we want to achieve papillae in periodontology or implantology, the presence of interproximal bone is essential and these two together determine the gingival zenith.

What is the gingival zenith?

The gingival zenith refers to the most apical (root-facing) point of the gingival margin when the tooth is viewed from the vestibular (cheek) side. In the maxillary central incisors, this point is usually located slightly distally (further from the vertical midline of the tooth). This subtle asymmetry contributes to a more natural and harmonious curve of the gingival line. In the natural dentition, the position of the zenith determines the contour and structure of the gingiva. In implant restorations, reproducing or preserving this point is a surgical and prosthetic challenge.

Why is it crucial in implantology?

In implant therapy, especially in the aesthetic zone, the gingival zenith is determined by:

✓ Visual harmony between implant crowns and adjacent natural teeth.

✓ The symmetry and natural appearance of the smile.

✓ Long-term health and stability of peri-implant soft tissues.

Key clinical decisions influencing the final position of the gingival zenith:

✓ 3D implant positioning: Buccolingual and apicocoronal placement are crucial for soft tissue outcomes.

✓ Soft tissue treatment: Connective tissue grafts, alveolus preservation, and flap formation are essential for recreating the gingival contour.

✓ Custom healing abutments and prosthetic emergence profiles: These allow for targeted shaping of the soft tissue during temporary restoration.

✓ Load timing: Immediate loading protocols can help preserve the gingival zenith if properly indicated and managed.

Peri-implant surgery – the key to the long-term success of implants

Peri-implant surgery deals with the preservation and restoration of the bone and soft tissue around implants. In our practice, we use prosthetically guided planning and implantation, which ensures that the implant is placed in an ideal position, both functionally and aesthetically.

Before or after implantation, we often encounter bone and soft tissue deficiencies, which can be horizontal or vertical bone defects or insufficient firm, keratinized gingiva. These deficiencies can significantly affect the long-term stability and aesthetic outcome of the implant.

The greatest professional challenge is the complete absence of keratinized tight gingiva, when soft tissue is present only at the mucosal level. This condition is associated with an increased risk of peri-implantitis and can lead to serious aesthetic and functional compromise. In such cases, soft tissue augmentation techniques – using a free connective tissue flap (CTG), collagen matrix – are used to create the appropriate biological environment around the implant.

In which cases is bone augmentation possible?

We undertake horizontal or vertical bone augmentation only when the intervention provides aesthetically and functionally predictable results. For the design, we use digital smile design, Exocad and DTX software, which help us determine whether FP1 (fixed restoration 1, hereinafter referred to as FP1) – consisting exclusively of a dental crown –, FP2 (fixed restoration 2, hereinafter referred to as FP2) or FP3 (fixed restoration 3, hereinafter referred to as FP3) is the most appropriate solution in the given case. When bone grafting does not lead to acceptable results, regardless of trends in the profession, we do not recommend the procedure and we do not convince the patient of a treatment that does not serve their true interests.

The combination of prosthetically guided digital planning and guided surgery allows us to tailor the treatment plan to the patient's individual anatomy and aesthetic needs. With this, with appropriate bone and soft tissue management, in some cases, following the rules of the profession, we can create an FP-3 to FP-2 (containing multiple dentures) or an FP-2 to FP-1 (replacement containing only a dental crown), which is more aesthetically favorable.

FP2 – pink ceramic solution

If FP1-level dental restoration is not feasible and horizontal or vertical bone loss cannot be augmented, alternative methods are used. In the case of moderate bone loss and massive soft tissue loss – or if the patient does not undertake bone and soft tissue augmentation due to time, financial reasons, or fear – the ideal solution is the FP2-type restoration. The essence of this is the use of pink ceramic, which aesthetically replaces the missing soft tissue while ensuring a stable and long-lasting result.

FP3 – fixed bridge prosthesis

In the case of a greater bone and soft tissue deficiency, during fixed replacement 3, we replace both the bone and the gum with the dental prosthesis (either zirconium or plastic dentures - with individualized teeth selected from a high-quality, premium set and a gum imitation, for example made of Gradia material).

In case of multiple or older tooth loss, FP3 – fixed restoration – may not be a feasible solution either. In such cases, the DTX Implant software double scan method (CT made with temporary denture and separate CT made of the denture) can be the perfect solution: an overdenture: a covering denture, which can be placed on a mesostructure: a bar or retention elements (ball head or locator). In case of extensive bone and soft tissue loss, this is the optimal choice.

In the case of larger bone and significant soft tissue deficiencies, depending on the clinical case, we use bone fracturing and bone compaction to increase the quantity and quality of bone supply, or in rare, extreme cases, we also use Megagen mini implants with good results (these are 3 - 3.3mm in diameter).