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130 Cards in this Set
- Front
- Back
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Objectives in Perio Surgery
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1.address perio disease
-access for SCRP -elminate PD by removal and/or recontouring of soft or osseous tisues -regnerate lost perio structures -establishment of tissue contours that facilitate oral hygiene maintainance 2. Restore/create a biologically and restoratively favorable tooth-bone-gingival interface in light of caries, trauma genetic etc -functional and esthetic crown lengthening 3. adress mucogingival defects or soft tissue redundancy 4. pre-implant tissue augmentation 5. exploratory surgery when DX uncertain 6. establishment of drainage (perio abcess) 7. biopsy |
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Augmentation
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adress gingival recession and associated esthetic and cold/heat sensitivity
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Reduction
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address deficient bony/soft tissue anatomy prior to implant placement
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Periodontal and Bone Augmentation Surgery (Indications)
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1. treatment of mod-severe perio disease
2. treatment of mucogingival dfects: gingival recession 3. Increase clinical crown length 4. Bone augmentation prior to implant placement 5. Exploratory surgery when DX uncertain |
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Pre-surgical assessment
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1. control of systemic health
2. Acceptable patient compliance and motivation -Plaque accumulation </= 20% -smoking >/= 1 pack surgery typically not indicated 3. soft tissue response positive (SRP) after initial therapy |
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Central theme in Perio and Bone Augmentation procedrues
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1. Control of etiological factors
2. good patient compliance prior to surgery |
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Pseudo Pocket
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formed by gingival enlargement without destruction of the underlying periodontal tissues
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Suprabony defect
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bottom of the pocket is coronal to the underlying alveolar bone (bone loss is HORIZONTAL)
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Infrabony defect
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bottom of the pocket is apical to the level of the adjacent alveolar bone (bone loss is VERTICAL)
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Types of infrabony defects
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4 wall defect: circumferential "moat-like". Most extraction sockets will have 4 remaining bony walls.
3 wall defect trough 2 wall defect crater 1 wall defect hemiseptal Combinations: example is a 2 wall defect with 3 wall component |
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Flap design
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-incision and reflection (push away) of a segment of soft tissue such that its wide base remains attached for preservation of blood supply (trapezoidal)
-FTF -PTF |
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FTF(full thickness flap)
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- incision and refection of tissue such that the periostium is attached to the flap
- indications: procedures that address perio disease, implant placement, bone grafting |
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PTF (partial thickeness flap)
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-incision and reflection of tissue such that periostium remains attached to bone
-indications: correction of gingival recession defects |
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Surgical Flaps
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-maintain adequat blood supply
- sharp and clean incisions -placement of incisions on sound bony base -vertical incisions at line angles -flap extension for access -maintain adequate band of attached gingiva -gentle manipulation of flaps |
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Straight line incsion
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-horizontal incision made on the same level as the base of the perio pocket.
-used primarily along ed ridges, mucosa or palate |
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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)
-points towards the root -bleeds towards the tooth |
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External Bevel Incisions
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- an incision made from apical to coronal aspect. typically used for gingivectomy procedures
-point towards the incisal edge -bleeds towards you |
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Scalloped incision
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- an incision that follows the contours of the teeth
- may/may not preserve the interdental pailla |
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Sulcular incision
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- incision into the gingival sulcus o the alveolar crest
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Physiologic contours of bone in health
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pronounced bony scalloping anteriorily and flattening topography posteriorily
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Physiologic contours in disease
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irregular bony topography with areas of peaks and valleys (non-discriminantly)
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Periodontal Bone Sounding
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-probing to osseous crest under local anesthesia
-provides information of bony topography without flap reflection |
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Osseous recontouring to address perio disease
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1. restore contour of alveolar bone conducive to heatlh (decrease probing depths)
2. regenerate lost perio tissues if possible |
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Ostectomy
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Removal (excision) of supporting alveolar bone (directly contacting tooth)
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When do i refer to patient to a periodontist?
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1. when therapy required to address/correct periodontal condition is beyond the scope of practitioner training
-pt desires ivsedation 2. when the practitioner does not have proper equipment on hand to perform indicated procedures 3. complex and/or multiple surgical proccedures required 4. complex med history |
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Endondontic Pain
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-acute
-severe, spontaneous -pain intensifies and localizes when inflammation spreads -can awaken patient at night |
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Periodontal Pain
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--chronic, mild to moderate pain
-periodontal abscess can cause severe pain, regressing after drainage -does not awaken patient at night |
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Combined pulpal perio lesion pain
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-usually minimal pain
-avenue of dranage through gingival sulcus |
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Swelling Endo
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often occurs in mucobuccal fold or spreads into fascial planes
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Periodontal Swelling
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usually found in attached gingiva and rarely spreads beyond the mucogingival junction
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Mobility
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on one isolated tooth: source could be perio, endo or occlusal
generalized: suggests lesion of periodontal or occlusal origin; crestal bone loss evident |
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Cold response
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immediate response and disappears when removed if no response or linguer pulp is necrotic or irreversily inflamed
one time test tetraflourethane |
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Heat response
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normal response is pain that intensifies until stimulus is removed lingering pain indicates irreversibly inflamed pulp: hot gutta percha
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Pulpal Periodontal lesions
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-toot is pulpless or has a necrotic pulp
-destruction of perio attachment apparatus -from the apex of the toth into gingavl sulcus -from an involved lateral canal into the gingival sulcus -both endo and perio treatment is required to resolve the lesion |
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Differential diagnosis for pulpal periodontal lesions
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-root fracture
-developmental groove -cervical enamel projections |
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Primary periodontal lesion
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-tooth vital
-crestal bone loss present -plaque calculus -soft tissue inflamed/lost -deep pocket formation broadly noted around tooth -possible occlusal trauma |
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Primary pulpal lesion
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-sinus tract formation through the periodontium
-some degree of tooth mobility -varying degree of bone loss -narrow pocket formation -soreness to percussion -tooth may exhibit a large restoration |
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Primary periodontal lesion with secondary pulp involvement
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-ddep pockets
-history of extensive perio procedures -evidence of irreversible pulpal disease -evidence of pain accentuation -tooth may or may not be restored |
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Primary pulpal with secondary perio involvement
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-long standing pulpal disease
-superimposition of plaque/calculus -evidence of perio disease present |
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True combined lesion
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merging of a lesions of pulpal origin with a proressive periodontal lesion (pockets)
-may mimic a lesion of pulpal origin -may be acute or chronic |
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Treatment of combined lesion
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1. endodontics FIRST
2. Corrective perio therapy SECOND |
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Indications for Perio Surgery
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1. areas with irregular bony contours, deep craters and other defects
2. pockets on teeth in which a complete removal of root irritants is not considered clinically possible may call for surgery (this occurs freuently in molar and premolar areas) 3. in cases of furcation involvement of grade II or III, a surgical approach ensures the removal of irritants 4. intrabony pockets on distal areas of last molars are usually unresponsive to nonsurgical methods 5. persistent inflammation in areas with moderate to deep pockets |
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Methods of Pocket Therapy
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1. new attachment technique- 2. removal of the pocket wall (Most common method)
3. removal of the tooth side of the pocket |
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New attachment techniqe
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ruinite the gingiva to the tooth at a position coronal to the bottom of the preexisting pocket
-involves new bone and pdl regeneration |
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Removal of pocket wall
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-wall of the pocket consists of soft tissue and may also include bone in the case of intrabony pockets
-retraction or shrinkage, in which SCRP resolve the inflammatory process gingiva therefore shrinks reducing the pocket depth -surgical removal -apical repositioning of the flap |
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Removal of the tooth side of pocket
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accomplished by ttoth extraction or partial tooth extraction
-hemisection (split molar into two premolar sized teeth) -roort resection (remove a root) |
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gingival pocket wall
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-can be edematous or fibrotic
-edematous shrinks after the elimination of local factors thereby reducing or totally elminating PD SCRP treatment of choice here -Fibrotic walls ar enot reduced in depth after SCRP surgical elimination is indicated |
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Therapy for slight perio
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-small amt of bone loss
-pockets shallow to moderate - conservative approach with good oral hygiene is indicated to control the disease (SRP 3,4 month perio intervals) -incipient perio that recurs in previously treated site may require analysis for cause -a surgical approach may be required (uncommon) |
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Therapy Moderate to Severe perio in anterior sector
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-technique that causes the least amount of visual root exposre considered
-two advantages -they are all single rooted and easily accessible -patient compliance is easier to attain -SCRP are treatment of choice -sometimes surgery for improved accessiblity for Root planing or for osseous defects -infrequently do bone contouring tecnique of choice is the apically displaced flap with bone contouring |
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therapy Moderato Severe in posterior
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-most patinet have developed osseous defects that require some degree of osseous remodeling
-surgery frequently indicated -no esthetic problems but difficult accessibility -enhanced acessibility or the need for definitive pocket reduction -when osseous defects with no possibilty of reconstruction (bone grafting) are present such as interdental craters, treatment of choice is flap with osseous contouring |
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Osseous Resective Surgery
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-to reshape marginal bone to resemble the alveolar process undamaged by perio
-osteoplasty or ostectomy |
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Postive vs. Negative Architecture
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-refer to the relative position of interdental bone to radicular bone
-Positive architecture when the radicular bone is apical to the interdental bone -Negative architecture when interdental bone is apical to radicular bone -osseous bone is "ideal" when it is positive architecture |
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Incision Design
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-if regenrative (bone grafting) potential exists perform sulcular incisions only (sounding indicated here to confirm)
-Otherwise, 3 incisions are necessary for flap surgery First- internal bevel incision Second- sulcular incision Third-interproximal straight line incision |
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Elevation of flaps
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1. internal bevel incision, splitting the papilla, and vertical incisions are drawn at line angles
2. the flap has been elevated, and the wedge of tissue next to the tooth is stil in place 3. all marginal tissue has been removed, exposing the underlying bone 4. tissue returned to its original position. Proximal areas are not totally covered. healing proceeds by secondary intent. - When full thickness flap is desired, reflection of the flap is accomplished by blunt dissection -periosteal elevator used to separate the mucoperiosteum from the bone by moving it mesially, distally and apically until the desired reflection is accomplished |
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FTF incision based on:
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1. width of keratinized tissue: if </= 2mm present no gingival collar excised
2. as the discussed above, if defect has regenerative potential (i.e. 3-walled) -sulcular incisions only, no removal of gingiva: need to achieve primary closure to protect graft materials |
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Subtractive osseous surgery
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-designed to restore the form of preexisting alveolar bone to level present at the time of surgery or slightly mre apical to this level
-brings about ideal rsult of perio therapy |
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Additive osseous surgery
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includes procedures directed at restoring the alveolar bone to its original level
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Osseous resective surgery technique
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1. after complete flap reflection debridement of granulation tissues
2. SCRP 3. Ostectomy (flatten interproximal bone) 4. Osteoplasty(vertical grooving, radicular blending) 5. suture: apically positioned flap |
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Initial bone removal: interproximal
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-2 walled defect often seen interproximally
-perform ostectomy in shallow (</= 3mm) defects -excessive removal of buccal and lingual bone may result in significant loss of supporting bone -solution: "bone ramping" ostectomy of palatal/lingual bone to create a sloping effect and reduce probing depths |
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Nondisplaced flaps (NDF)
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when the flap is returned and sutured in its original position
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Displaced Flaps
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which are placed apically, coronally, or laterally to their original position
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What can be displaced?
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-both full thickness and partial thickness flaps
to do so the attached gingiva must be totally separated from the underlying bone, thereby enabling the unattached portion of the gingival to be movable -palatal flaps cannot be displaced because of the absence of unattached gingiva |
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Distal Molar Surgery
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-tx of perio pockets on distal surface of terminal molars complicated by presence of bulbous fibrous tissue over the max tuberosity or prominent retromolar pads in the mandible
-deep vertical defects present in conjunction with the redundant fibrous tissue -some of these osseous lesions may result from incomplete repair after the extractionof impacted thirds |
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Distal Molar surgery: Maxillary Molars
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-tx on the maxillary arch is usually simpler than the tx of a similar lesion on the mandibular arch because the tuberosity presents a greater amt of fibrous attached gingiva than does the area of the retromolar pad
-anatomy of tuberosity extending distally is more adaptable to pocket elmination than is that of the mandibular molar arch where the tissue extends coronally -lack of a broad area of attached gingiva and the abruptly ascending tuberosity sometimes complicate therapy |
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Distal Molar Surgery: Mandibular Molars
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-retromolar pad does not have as much fibrous attached gingiva. The keratinized gingiva if present may not be found directly distal to the molar
-greatest amt may be distolingual or distofacial and may not be over the bony crest. The ascending ramus of mandible may also creat a short, horizontal area distal to the terminal molar |
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Sutures
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-purpose is to maitain flap in desired position until helaing has progressed to point in which sutures ar eno longer needed
-after procedures complete, the area is reexamined, cleanesed, flap placed in desired position -flap should remain in position without tension -Nonresorbable or resorbable and can be braided or monofilament |
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Resorbable
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Surgical: gut
Plain gut: monofiliament (up to 30 days) Chromic gut: monofilament (up to 45-60 days) |
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Nonabsorbable
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Silk braided
Nylon: monofilament (ethilon) ePTFE: monofilamen( Gore-Tex) Polyester: braided (Ethibond) |
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When to refer a pt
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-isolated or generalized deep probing depths (>/= 6mm)
-radiographic evidence of significant bony defects -medically compromised individuals -pts requiring sedation |
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Furcation areas
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-may be dificult or impossible to debride by routine perio instrumentation
-routine home care methods may not keep furcation area free of plaque -presence of furcation involvement is a clinical finding that can lead to a diagnosis of advanced perio -presents both diagnostic and therapeutic dilemmas -primary etiology factor of furcation defects is bacterial plaque - |
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Perio progression into furcation
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-studies indicate that prevalence and severity of furcation involvement increase with age
-dental caries and pulpal death may also affect a tooth with furcation involvement or even the area of the furcation |
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Anatomical features relavant to prognosis and tx of furcation involvement
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-root trunk length
-root length -root form -interradicular dimension -anatomy of furcation -cervical enamel projections/pearls -distance from CEJ to entrance of furcation can vary -theeth may have very short root trunks, moderate root trunk, or roots that may be fused to a point near the apex -combination of root trunk length with the number and configuration of the roots affects the ease and success of therapy -shorter root trunk, the less attachment needs to be lost before the furcation is involved -once exposed, teeth with short trunks may be more accessible to maintenance procedures and may facilitate surgical procedures -teeth with unusually long root trunks or fused roots may not be appropriate candidates for treatment once the furcation has been affected. That is, too much bone has been lost. |
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Root length and furcations
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-longer root lengths increase prognosis of teeth and vise-versa
-more anchorage available with longer roots |
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Root form and furcation
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-the mesial root of most mandibular first and second molars and the mesiofacial root of the maxillary first molar are typically curved to the distal side in the apical third
-the distal aspect of the maxillary first molar root is usually heavily fluted |
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Interradicular Dimension
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- dimensino of furcation entrance is variable but usually small
-81% of furcations have an orifice of 1mm or less -58% are .75mm or less -the furcal aspect of roots of max 1st molars is concave in: -94% of mesiobuccal roots -31% of distobuccal roots -17% of palatal roots -results in challenge to oral hygiene, periodontal maintenance and surgical therapy |
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Cervical Enamel Projections
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-Frequency: Buccal surfaces of mandibular molars: 28.6%, maxillary molars 17%
-treatment: enameloplasty -removal improves prognosis |
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Enamel Pearls
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-Frequncy: 1.1-9.7% with predilection for 2nd, 3rd max molars
-treatment: limited due to nerovascular presence in pearl -presence decreases prognosis |
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Probe mesial furcation
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from the palatal aspect
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Furcation Involvement Classification
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-amount of periodontal tissue destruction in the interradicular area-horizontal root exposure/attachment loss
-Degree I -Degree II -Degree III |
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Degree I
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horizontal loss of perio support not exceeding 1/3 of the width of the tooth
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Degree II
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Horizontal loss of perio support exceeding 1/3 of the width of the tooth, but not encompassing the total width of the furcation area
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Degree III
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horizontal "through and through" destruction of the perio tissues in the furcation area
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Furcation therapy objectives
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-elmination of microbial plaque and calculus from the surfaces of the root complex
-establishment of an anatomy of the affected surfaces that facilitates proper self-performed plaque control |
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Degree I therapy
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-SCRP
-surgical option: furcation plasty |
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Furcation therapy: surgical
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-osseous resection
-regeneration -root resection -hemisection -extraction -dental implant |
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Degree II Therapy
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-furcation plasty
-guided tissue regeneration -extraction & implant placement -root resection/separation -tunnel preparation |
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Site a good placement for immediate implant placement?
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1. furcal bone present
2. bone present apical to root apex 3. bone present coronal to mandibular canal |
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Degree III therapy
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-extraction-implant
-root resection -tunnel preparation |
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tooth loss after root resection
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-35% of root resected teeth lost after 10 years
-Most lost after 5 years by root fracture |
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Prognosis
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-furcation involvement significantly decreases long term prognosis
Grade 1>2>3 Grade 1 fair to poor Grade 2 and 3 poor to questionable |
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when to refer
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Grade 2 or 3 furcation
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Guided Tissue Regeneration (GTR)
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-regeneration (grow back) of periodontal tissues (bone, cementum, PDL)
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Guided Bone Regernation (GBR)
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involves regeneration of bone only--> produces bone for dental implant placement
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Guided
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placement of a physical barrier to exclude epithelium from repopulating the root surfaces during early healing
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Regeneration
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reproduction or reconstitution of a lost or injured part to restore the architecture and function of the lost or injured tissues
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Repair
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healing of a wound by tissues that do not fully restore the architecture or function of the part
-in perio therapy most conventional therapeutic procedures result in healing by repair |
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New attachment
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-formation of new cementum with inserting PDL fibers on root surface previously exposed to disease (e.g. regeneratin of root which was part of pocket wall)
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Reattachment
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-the formation of new cementum ith inserting PDL fiers on root surface that is healthy (e.g. repair of healthy areas exposed surgically during periodontal flap surgery
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Wound healing in the oral cavity
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Cellular proliferation rates can negatively impact regenerative procedures
-epithelial cells= fast --> results in long junctional epithelium & a repair process (not as good) -bone, cementoblasts, PDL cells = slow --> needed for regeneration (replaces lost supporting tissues of the tooth) -we need to create environment conducive for bone, pdl cementum growth and not for epithelial |
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Solution to epithelial growth problem
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-place a barrier between defect and epithelium to provide space for tissue regernation and exclude epithelial cells form invading into defect
-barrier blocks epithelium to allow progenitor cells from PDL & bone to populate defect and form new cementum/bone/PDL |
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What to repair with GTR?
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Yes:
-deep, narrow (3 walled) defects (v-shaped) -grade II furction defects without horizontal bone loss No: -shallow, wide defects -furcations defects with horizontal bone loss -any horizontal bone loss |
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Pre requisites for successful grafting
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-presence of amenable defect
-removal of etiology/root preparation -stabilization of teeth -appropriate flap design -removal fo inflamed connective tissue -pakcing of graft material into defect -tissue coverage -maintenance care |
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Patient factors impacting outcome
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-plaque control must be good
-systemic health -risk for infection present -uncontrolled diabetes = contraindication -smoking (none!) |
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Steps in GTR surgical procedure
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-open FTF reflection
-Clean it granulation tissue removed and roots thorougly planed -Pack it -graft defect with particulate bone -Cover it: shape barrier covers the defect and about 2-3 mm of healthy bone -Close it membrane barrier placed and suture flaps replaced and sutured |
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What to expect
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-50% radiographic bone fill
-decreased PD -increased prognosis -may need 2nd procedure to remove membrane if you use nonresorbable or to eliminate residual pocket |
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osteoinductive
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-induction of bone forming cells (BMP)
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osteoconductive
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-scaffolding properties
-space maintaining function (helps keep gingiva from collapsing into defect) |
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Autogenous grafts
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-grafts transfered from one position to another within the same individual
-can be cortical bone or cancellous bone and marrow -can be harvested either form intraoral (chin, tuberosity, ramus, tori) or extraoral (hip, tibia) donor sites -may retain cellular viability and are considered to promote bone healing mainly though osteogenesis and/or osteoconduction -gradually resorbed and replaced by new viable bone -problems of histocompatibility and disease transmission eliminated in autogenous grafts |
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Allogeneic Grafts
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-grafts transferrred between genetically dissimilar members of the same species
-can be frozen cancellous or cortical bone -mineralized or demineralized -freeze-dried |
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Freeze-dried decalcified bone allograft
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-contains BMP to simtulate osteogenesis
-may be mixed with llogenous bone |
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Xenogeneic Grafts
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-tissue from another species (bovine)
bio-oss osteGraft-N PepGen P-15 |
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Alloplastic Materials
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-synthetic inorganic biocompatible and or bioactive bone graft substitutes to promote osteoconduction
-Four kinds: 1. hydroxyapetite (HA) 2. beta tricalcium phophate (B-TCP) 3. polymers 4. bio-active glasses (bio-glasses) |
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Bioactive molecules
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-Emdogain: enamel matrix derived proteins (amelogenins) from porcine tooth buds
Procedure: -SRP affected teeth -roots are etched with etching gel -emdogain gel applied over etched root surface with syringe -non membrane, bone graft required -flaps replaced & sutured GEM21S: highly purified recombinant human platelet-derived growth factor with an osteoconductive matrix (B-TCP) |
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Nonresorbable membranes
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-polytetraflouroethylene (PTFE)
-expanded (ePTFE) -solid non proours -expanded: subjected to tensile stres and is more durable and porous, has a prous microstructure of solid nodes and fibrils which allows tissue ingrowth -titanium reinforced (gore-tex) ePTFE : titanium embedded between 2 layers, similar surface properties, improved mechanical properties |
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Bioabsorbable Membranes
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-collagen (natural)
-synthetic (polyactic acid, copolymers of polyactic and polyglycolic acid) -do not require additional surgery for removal -difficulty predicting extent and nature of disintegration process -risk of disease transmision (negligible) |
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Natural products: Collagen
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-Type I collagen: predominant component of perio tissues
-Collagen possess additioanl advantages: hemostasis, chemotaxis for PDL fibroblasts and gingival Fibroblasts -promotes increase synthesis of additional ECM components -primarily degraded by the enzymatic action (collagenase) of infiltrating macrophages and PMN leukocytes |
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Synthetic Membranes
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-degradation by hydrolysis to CO2 and H20
-polyactic acid or polyglycolic acid |
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Block Graft
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-majority of reports
-most common form in which bone is obtained- primarily autogenous bone used -access is manageable: symphysis> ramus -armamentarium: fissure burs, rephines and chisels required for graft delineation and removal |
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Particulate graft
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-minority of reports
-allograft bone primarily used -for autografts, access is manageable symphysis > ramus -for atugenous grafts armamentarium consists of burs, trephines, bone traps, bone scrappers, and chisels required for graft delineation and removal |
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Autogenous Donor sites
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-mandibular symphysis
-mandibular ramus -retromolar/edentulous sites -tori -external oblique ridge |
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POI (post operative instructions)
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-systemic antibiotics
-0.12% chlorhexidine (CHX) rinse -non-resorbable membranes are removed 4-6 weeks after placement -resorbable membranes, require tight infection control protocol for 6-8 weeks -NO probing or deep scaling are avoided for at least 6months-1year -ask periodontist when it is OK to probe/clean/restore!! |
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Block grafting complications
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-donor stie incision dehiscence (0-12.9%)
-recipeint site/block exposure (0-37%) -block dislodgement (0-12%) -membrane exposure (0-2%) |
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Particulate grafting complications
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-membrane exposure (0-13.6%)
-donor site incision dehisence (0-12.9%) |
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Block grafting
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-horizontal and vertical (more difficult) ridge augmentation achievable as early as 4 months
-histo evidence of new bone formation -complications manageable with infrequent limintation on final ability to place implants -more morbidity noted due to 2nd surgical site- -allows for successful placement of implants in sites otherwise not allowed |
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Particulate grafting
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-horizontal and vertical (more difficult) ridge achieavable as early as 4 months
-histo evidence of new bone formation -complications manageable however may affect final ability to place implants -potentially greater cost of materials -allows for successful plcement of implants in sites otherwise not allowed |
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GTR
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-wound coverage = open
-sterility durin healing = no -membrane stable = difficult -adaptation= difficult -spacemaking = difficult -predictability = low |
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GBR
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-wound coverage = closed
-sterility durin healing -= yes -membrane stable = yes -adaptation = easy -spacemaking = easy -predictability = high |
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Complications of bone grafts
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-post operative infection
-sequestration of graft material (large cortical pieces) -potential for root resorption & ankylosis (fresh marrow) |
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when to refer
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-GTR/GBR procedure complicated
-GTR indicated for systemically healthy patients with graftable defects -GBR indicated for patients who request dental implant placement but lack adequate bony dimensions for proper restorative placement of implants |
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Conclusions
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-membranes are effective in facilitating GTR
-bioabsorble preferable over non resorbable (less chance of infection, no second surgery required, more biocompatible) -block and particulate grafts are both successful in GBR -acuisition potentially more challengin with blocks -critical compications: blocks: dislodgement particulate: membrane exposure/graft infection -both procedures are essential components of modern implant therapy |
