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108 Cards in this Set
- Front
- Back
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What is gingival recession?
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-Gingival margin apical to the CEJ
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What does gingival recession implies?
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-Loss of PDL, root cementum. and alveolar bone
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What are the predisposing factors?
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-Inadequate attached gingiva
-High frenum -Tooth malposition -Osseous dehiscence |
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What are the Precipitation factors?
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-Vigorous tooth brushing
-Laceration -Recurrent inflammation -Iatrogenic factors |
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What the clinical variables in assessing the Probability of Successful Treatment?
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-GM
-CEJ or surrogate (restorative margin) -MGJ (Mucogingival junction) -CBL (interproximal crestal bone levels) |
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Indications for Root Coverage?
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-Root sensitivity
-Shallow root caries lesions -Esthetic demands -Young age -Gingival augmentation prior to orthodontic tooth movement |
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Contraindications for Root coverage?
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-Low chance of obtaining root coverage (Class III or Class IV)
-Anatomical restrictions -Perceptible mismatch -Lack of donor tissue |
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What is the problem with anatomical restrictions?
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-XS MD root surface width + narrow interproximal tissue = problem with adequate blood supply
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What is the recommended thickness of donor tissue?
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-1.5 mm (Allograft available)
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What are the Classification of Marginal Tissue Recession?
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-Class I
-Class II -Class III -Class IV |
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What are the % of sucessful procedure depending on recession depths?
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-96% root coverage < 3mm
-81% root coverage 4-5 mm -77% root coverage >5mm -Inverse relationship b/t the vertical extend of gingival recession amt of root coverage |
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For horizontal dimension, the degree of root coverage is better for ___ recessions (95%) than for ____ recessions (71%).
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-Narrow (95%)
-Recessions (71%) |
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What is the relationship b/t width (Vertical dimension) of Keratinized Gingival & Gingival health
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-80% of sites w/ >2mm keratinized gingiva had no inflammation
-All sites with <2 mm exhibited clinical inflammation and gingival exudate |
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Insufficient width of keratinized tissue determined by?
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-Eruption pattern of permanent incisors
-Labiolingual width of alveolar process |
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-Labially displaced teeth, more likely to exhibit more keratinized tissue (T/F)
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False: Less
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Lingual movement of a labially prominent incisor does increase the labial keratinized tissue (T/F)
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False: No increase in labial keratinized tissue
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TX of mucogingival problems should be accompolished after completion of ortho, to ensure adequate attachment of keratinized tissue (T/F)
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-False: Prior to ortho to reduce reduce of loss of keratnized tissue
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What are the 5 surgical Methods to Correct Gingival Recession?
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1. Epithelial Free gingical Autografts
2. Connective Tissue Autografts 3. Pedicle Grafts 4.Guided Tissue Regeneration w/ Membranes 5. Acellular Dermal Matrix Allograft (alloderm) |
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Describe the Recipient Bed Preparation?
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-Incision at or above the mucogingival junction
-Butt joint margin -Partial thickness flap -Periosteal bed -Excellent revascularization potential |
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Descrbe how to harvest in palatal Donor site?
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-Away fro Greater Palatine foramen
-1.5-2.0 mm mm thick -Surgicel & Stent necessary |
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How is the Graft Site treated?
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-Immobilized with extra sutures
-Dressing optional |
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Describe the Wound healing cycle?
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-2 days after: grat survival by diffusion: plasmatic circulation
-Day 3: capillary budding starts -Day 4-6: Anastomosis of vessels |
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What is the fx of flap base in wound site?
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-Provides nourishment to wound site
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Describe the incision for a laterally Positioned graft?
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-Externally beveled recipient incision
-Internal bevel edge |
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Describe the Coronally Positioned Graft?
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-Partial thickness flap beyond MGJ
-Coronally advance -Passive fit, suturing |
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Subepithelial Connective Tissue Graft used for what tx?
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-Recession
-Cervical abrasion -Sensitivity -Esthetic concerns |
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Describe the incision of Subepithelial Connective Tissue Graft?
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-Partial thickness flap
-Sharp dissection beyond MGJ |
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Describe the CT harvest?
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-sharp, new blade w or w/o vertical incisions
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Intial Changes in Tissue after injury (1st 3 mins)
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-Injury --> Vasoconstriction
--> Blood spill --> Mast cell degranulation --> Vasodialation --> Platelet adhesion --> Platelet aggregation --> Platelet plug |
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What are the phase of wound healing?
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-Adapation phase: injury-Inflammation-Clotting
-Proliferation phase: Proliferation/mobilization of cells --Formation of granulation tissue -Attachment phase: Repair -Maturation phase: Remodeling |
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Benefits of Acellular Dermal Allograft-Alloderm?
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-Unlimited supply
-Second surgical site unnecessary |
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Limiting factors of Acellular Dermal Allograft-Alloderm
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-Existing sone of keratinized tissue
-Relatively thick "tissue" -Potential problems if unable to completely cover graft with flap -infection, inflammation. |
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Objective of Guided Tissue Regeneration (GTR) in the TX of Facial Recession
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-Formation of new CT attachment to a thoroughly debirded, previously diseased or denuded root surface, preferably with regrowth of alveolar bone
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Which surgical method to correct gingival recession involve usage of resorbable or non-resorbable barrier membranes
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-GTR in TX of Facial Recession
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What is the indication of GTR in TX of Facial Recession
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-Single tooth w/ wide deep, localized recession, 5 mm in width or depth or wider or deeper
-Repair of recessions ass. w/ failing Class V restorations/ |
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What is the contraindication for GTR in TX of Facial Recession
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-Multiple defects
-Limited by Height of interproximal bone -Non-resorbable membrane needs 2nd surgery after 4-6 wks |
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When does a non-resorbable membrane needs a 2nd surgery after 4-6 wks.
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-Newly formed tissue over root surface is very thin and increases adhesion and maturity over time; membrane removal disrupts and decreases regeneration
-Attachment of regenerated tissue to root surface is weak; regeneration tissue is damaged/ detached w/ removal of membrane |
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Advantages of GTR vs Mucogingival Surgery for Root Coverage Procedures
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-Better coverage in cases of deep (>5mm) recessions
-Greater probing attachment gain -Possibility of obtaining new CT attachment instead of long epithelium -Can provide highly esthetic results -No donor site surgery required |
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Disadvantages of GTR vs Mucogingival Surgery for Root Coverage Procedures
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-Demanding surgical technique
-Additional costs -Less predictable results in cases of pulling frena and shallow vestibule. |
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Guidelines for Successful Root Coverage
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-No root sensitivity
-Gingival margin should be at the CEJ after TX of Class I or II defects -Suclus depth of 2 mm or less -No bleeding on probing -Good color match -Adequate dimension of gingiva |
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Factors Ass. w/ Incomplete Root Coverage
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-Improper classification
-Inadequate root planning -Failure to use root conditioning -Improper preparation of the recipient site -Inadequate size of the interdental papilla at the recipient site -Improper preparation of donor tissue -Dehydration of donor tissue -Inadequate graft thickness -Failure to stabilize the graft -Inadequate adapation or suturing of graft -XS or prolonged pressure -Failure to reduce prior inflammation -Trauma during healing -Smoking of 10 or more cigarettes/day |
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Root coverage is a predictable outcome of mucogingival surgical in Miller Class __ and __
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-Class I and II recessions
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Shallow probing depths should be the results of ALL procedures (T/F)
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True
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END OF PERIODONTAL PLASTIC SURGERY
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END OF PERIODONTAL PLASTIC SURGERY
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What are some consideration for Pre and Post surgical?
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-Med HX update
-Anxiety control -Pre-op medication -Post-op care/instructions -Post-op medication |
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When an anxiety control occur?
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-Bedtime prior to surgery
-Prior to the surgery -During the surgery -Post-surgical care |
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Example of Anxiety Control-Oral
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-Ativan (Lorazepam): 2mg: 2h prior
-Valium (Diazepam): 5-10 mg: 1 h prior -Vistaril (Hydroxyzine): 10-20 mg: 1 hr prior |
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Example of Anxiety Control-IV Sedation
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-Versed (Midazolam)
-Demoral (Meperidine) |
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Example of Analgesics Pre-Surgical Medications?
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-Ibuprofen 800 mg
-Acetaminophen 500-1000mg |
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Example of antibiotics
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-Amoxicillin: 1000 mg
-Clindamycin: 300 mg -Doxycycline: 100 mg |
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Post-Op instructions?
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-Blood tinged saliva normal
-No rinsing or swishing (24 hrs) -No drinking w/ a straw (48 hrs) -Minimal physical activity (48hrs) -Avoid hard, crunchy, sticky foods (~5d) -Brush teeth normally except on affected area -Take medication as directed -Some swelling expected. Invasive procedures may require Medrol Dose Pack (Rx steroids) |
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Oral hygiene following surgery
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-CHX rinse: startind day after surgery
-Usual oral hygiene in areas not treated surgically |
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One Week Post-Op Appt
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-Evaulate pt comfort
-Evaulate healing -Remove sutures (regenerative procedure remove at 2 weeks, Prerinse using CHX if pt usually given antibiotic cover -OH instruction: CHX usage optimal for up to 6 weeks |
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What is the present of liver clot mean in Hemorrhage
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-Gelatinous mass of fibrin
-Liver clots represents an unstable mass of fibrin -Pt must be seen to remove it so clot can stablize |
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What is the meaning no liver clot in Hemorrhage?
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-Try some-at-home treatments first
-Place moist tea bag in area of bleeding. Keep gentle but firm pressure for 5 mins and check the area and give care provider a call -Place moist clean cloth with firm but gentle pressure for 5-10 minutes. |
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When is swelling normal
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-Some swelling is normal in first 48 hrs
-After that think possible infection |
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What are the options if infection does happen after periodontal surgery?
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-Rare with Aseptic Surgical Technique
-Establish Drainage -Evaluate Etiology -Change Antibiotic Coverage |
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Post-Surgical Problems: Pain steps
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-Reassess previously prescribed medication
-Assess etiology of pain -Aggressively deal with it |
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Options for After-Hours Bleedings?
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-Aspirate Completely -ID source
-Firm pressure with a moist gauze -Surgicel -Collagen Hemostat -Blind Mattress Suture -Observe about 15 min after control |
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Step on Controling Hemorrhage?
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-Moist gauze pressure for 5 min
-Apply Monsel's soln (ferric subsulfate), light pressure, place gauze pack -Apply surgicel, if under flap -Apply avitene or other topical collagen hemostat (Hematex) -Anesthetize the area and place a blind mattress suture (compromises blood supply) -After control of bleeding, monitor the pt for at least 10-15 minutes. |
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What are some othe complications beside infection and hemorrhage?
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-Bone Sequestration
-Herpetiform Lesions |
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What is bone sequestration?
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-Most common at the lingual aspect of mandible
-Sequestrum= dead bone buff/ivory color and hard -Follow closely (weekly) unit mobile -Remove with cotton pliers -Don't try to remove until mobile |
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Describe Flap Surgery- 48 hours later
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-Epithelial cells begin apical migration over the borders of flap
-Regenerating epithelium migrates b/t necrotic and living CT under the surgical surface of flap -Large # of active endothelial cells and fibroblasts at the surgical opening of PDL -Some loss of osteocytes -Cementoblasts deranged for about 1mm from wound surface |
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Flap Surgery-5 days later
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-Epithelial cells proliferating and migrating in apical direction
-Granulation tissue from PDL and bone -Some crestal bone resorption (osteoclastic activity seen) -Cementoblasts apical to the bone crest missing for about 1mm. |
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Flap Surgery-14 days later
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-New JE seen
-Young/Immature CT in apical parts -New periosteum -Few gingival groups of fiber seen |
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Flap Surgery-21 days later
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-Fully epithelialized gingival crevice with well defined JE (No probing)
-Beginning functional arrangement -Evidence of osteoblastic activity at the alveolar crest and on the periodontal surface of alveolar bone. -Cementum line reestablished |
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Flap Surgery-72 days later
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-JE and gingival sulcus well established
-Probing ONLY if necessary, better to wait another 10-12 weeks w/ good oral hygiene -Some chronic inflammation at the base of the gingival crevice (sub-clinical inflammation) -Gingival margin may be more stable at this point |
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What at point is it ok to prep tooth after crown lengthening
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-72 days later
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Factors Affecting Healing of Flaps
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-Extend of Root Preparation
-Flap Adapation (space for granulation tissue) -Extent of Surgical Trauma -Plaque control |
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While healing may be complete by 21 days with good adapation, healing may be not be complete even after 72 days when flap adapation is POOR. (T/F)
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True
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What is the best management in dealing with emergencies?
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-Take the necessary steps to prevent them.
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END POST-SURGICAL MANAGEMENT
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END POST-SURGICAL MANAGEMENT
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What are the gingival biotype?
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-Thick and thin
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What does the presence of inflammation affect?
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-crest bone levels
-periodontal disease -furcation involvement |
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What affect does rough surfaces or overahngs have on oral tissue?
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-Bacteria colonize and cause periodontal destruction
-Sub-gingival microfloa changes to more pathologic form -Results: Deeper probing depth (inflammation, attachment loss, bone loss) |
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Deep sub-gingival restorative margins can cause
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-Result in poor esthetics
-Chronic gingivitis -Amalgam tattoo -Tissue recession/attachment loss |
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ScRP and OH are not affected if overhangs and roughness is removed (T/F)
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False: More effective
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What are the steps in Decision Making process?
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-Can tooth/teeth be restored
-Treatment planning (ant vs. post, surgery, restoration) -Costs -Esthetic concerns |
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What are the indications for Surgical Flaps?
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-Eliminate or reduce pockets
-To gain access to bony structures -To correct mucogingival defects -To lengthen clinical crowns |
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What are the Biological Principles for Surgical flaps?
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-Maintain adequate blood supply
-Vertical incisions at line angles -Flap extension for access -Maintain adequate band of attached gingiva -Placement of incision on sound bony base -Good surgical handling |
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What blade is used for harvesting connective tissue?
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-#10A
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What is the most commonly used surgical blade?
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-#15BP
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What blade is described as sharp pointed used to incise around the teeth or abscess drainage?
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-#11
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Special gingivectomy knives, sharpened on 3 sides?(KIRK like THIRD)
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-Kirkland knives
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Gingivectomy knives sharpended on two sides and have long blades? (2 Long O)
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-Orban knives
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Has a pointy end and a small paddle on the other end. (Be small)
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Buser Elevator
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Large rectangular end useful for retracting larger flaps (Pitch Pritchard)
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-Pritchard Elevator
-Look like a flat bat |
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What is the most common retractor
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-Minnesota retractor
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Flap Management
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-Minimize trauma
-Handle w/ tissue forceps -Maintain moisture -Passive suturing |
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Describe Straight Line incisions?
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-A horizontal incision made on the same level as the base of the periodontal pocket
-Used along edentulous ridges, mucosa, palate or gingiva. |
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Describe Inverse bevel incisions?
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-A scalloped incision made outside the sulcus in a beveled manner along the gingival line also called internal bevel incision.
-Imagine going into the sulcus. |
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External Bevel Incision?
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-An incision made from apical to coronal aspect
-Typically used for gingivectomy |
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What is another name for Inverse Bevel incisions?
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-Internal Bevel incision
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What is the usage for the external bevel incisions?
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-Gingivectomy
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What is a Scalloped incision?
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-Follows the contours of the teeth
-May/maybe preserve the interdental papilla. |
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Incision into the gingival sulcus to the alveolar crest
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-Sulcular Incision
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Indications for crown lengthening (CL)
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-Extensive caries
-Fractures -Perforations -Insufficient crown length -Excessive gingival display |
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Considerations for crown lengthening
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-After gross preparation and temporization
-Crestal bone levels -Furcations/root trunk length -Keratinized tissue -Tooth sensitivity |
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After gross preparation and temporization, what should you evaluate?
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-Evaluate margin/attachment
-Evaluate unsupported tooth structure -Improve surgical access/evaluate anatomy |
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Orthodontic extrusion can sometimes be used as a tx alternative/adjunct to increase clinical crown length (T/F)
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True
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Problems of an edentulous space adjacent to an abutment tooth
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-Plaque hard to control
-Effects of initial therapy may be suboptimal b/c of limited accessibility of instruments during scaling and root planing. -Maxillary tuberosity and retromolar triangle tent to form deep perio. pocket due to thick gingiva. -Abutment adj. to edentulous space at high risk for bone loss |
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Objectives for distal wedge?
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-Eliminate periodontal pocket
-Maintain and preserve attached gingiva -Make area accessible to instruments -Lengthen clinical crown -Lengthen clinical crown -Create easily cleansable gingiva-alveolar form |
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Flap design: Triangular incision?
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-Small wedge, deep periodontal pocket in edentulous side, easy access to osseous defect
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Square incision?
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-Large wedge, thick soft tissue, deep periodontal pocket in edentulous side
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Linear incision?
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-Narrow band of attached gingiva, thick soft tissue, easy access to osseous defect reliable wound closure, can be used for a regenerative procedure.
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Objectives Gingivectomy?
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-Complete eradication of pockets, establishment of a physiological gingival sulcus
-Access to treat root surface |
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Contraindications for Gingivectomy
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-Lack of keratinized tissue
-Intraosseous defects (infrabony pockets) -Inadequate attached gingiva -Acute inflammation -Etiologic factors not removed/ controlled |
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Indications for Gingivectomy?
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-Adequate attached gingiva
-Suprabony pockets -Gingival enlargement -Gingival deformities |
