Perio-Yr3(Second Semester)

Front 1

List some forms of Non-surgical therapy

Back 1

Plaque Control

Supra and subgingival and root planing

Adjunctive use of chemotherapeutic agents

Occlusal Adjustment

Front 2

List some forms of surgical therapy

Back 2

Pocket reduction surgery (MWF, ORS, Ging)

Mucogingival

Regenerative

Pre-prosthetic

Implant

Front 3

What are the main objectives of periodontal surgery?

Back 3

-Create accessibility for proper professional SRP

-Establishing a gingival morphology conducive to plaque control

- Pocket depth reduction

May Aim at regeneration of periodontal attachment

Front 4

Indications for Surgical Approach

Back 4

1) Mucogingival deformities

2) Areas with irregular bony contours, intrabony pockets or deep craters

3 )Pockets on teeth in which complete removal of local irritants not possible non-surgically

4) Deep pockets on grade II or III furcations for complete removal of irritants or root removal

5) Pre-prosthetic surgeries-for creation of favourable restorative environment (e.g. biologic width)

6) Establishment of tissue contours that facilitate oral hygiene measures (ex. Overgrown/fibrotic tissues)

7) Placement of endosseous implants

Front 5

What are three things that need to be completely removed in order for therapy to be effective regardless of Non-Sx vs. Surgical tx?

Back 5

1. Calculus

2. Plaque

3. Diseased Cementum

Front 6

Why is it not a good reason to jump into surgical tx?

Back 6

1) Removal of calculus + Bacterial plaque will decrease local inflammation. Therefore edema, hyperemia, tissue excess-->improved assessment of gingival contours+pocket depths

2) There is a threshold below which surgical therapy is actually more destructive.

3) Decrease in gingival inflammation in deep pockets makes soft tissues more fibrous+ firmer, makes surgical handling of tissue easier

4) Phase 1 can be used to assess home care efficiency. No home care= no point

Front 7

What is the definition of critical probing depths?

Back 7

Initial Probing depths (for a theurapeutic modality) below which loss of clinical attachment is likely to occur and above which attachment gain often results.

Front 8

What is the Critical probing depth for the MWF technique?

Back 8

4.2mm (less than that and you'll cause CAL, above that you're more likely to get attachment gain)

Front 9

What is the Critical probing depth for SRP technique?

Back 9

2.9mm

Front 10

In the Kaldahl study that compared surgical methods and pocket depth reduction, which surgical technique sustained the most pocket reduction after phase II therapy?

Back 10

Osseous Resective surgery

1) Mean change in pocket depth for probing depths >7mm was around -3.7mm in the first year after surgery, followed by stability at -3.3mm

2) Mean change in pocket depth for probing depths 5-6mm was around -2.3mm in the first year after surgery, followed by stability at -2.0mm

Front 11

When comparing mean changes in attachment levels, which surgical techniques generated a loss of Clinical attachment when performed on probing depths at 1-4mm?

Back 11

Both Osseous resective surgery and Modified Widman saw loss of clinical attachment when performed on probing depths of 1-4mm. Hence the trend towards destructive effect of surgery in shallow pockets

Front 12

When comparing mean changes in attachment levels, which technique was least effective in terms of gaining attachment in pockets with probing depths that are greater than 7mm?

Back 12

Coronal Scaling alone. Generally ineffective for treating sites with deep probing depths! (Subgingival plaque is not removed). Many deep probing depths ended up with periodontal abscesses with just coronal scaling.

Front 13

Which surgical technique has been demonstrated to have the best reduction in probing depths and maintenance of clinical attachment gain over time?

Back 13

Osseous resective surgery. Everything else had 7mm pockets or got worse over time.

Front 14

For probing depths ranging from 1-6mm, which surgical technique showed the best maintenance of clinical attachment levels?

Back 14

Osseous resective surgery

Front 15

Rank the tx in terms of effectiveness at Pocket reduction from most effective to least effective

Back 15

ORS>MWF>RP>CS

Front 16

Rank the tx in terms of how much gingival recession they generate, from most recession to least recession

Back 16

ORS>MWF>RP>CS

Front 17

Rank the tx in terms of which ones are more likely to have periodontal abscess from least likely to most likely

Back 17

ORS>MWF>SC/RP>CS

(NB: Perio abscesses occurred in initially deep pockets)

Front 18

Which tx had the most attachment gain?

Back 18

In >7mm: Equivalent, In <7mm MWF+RP>ORS

Front 19

Which Tx had the best PD reduction and maintenance of AL for PD over 7years for PDs>5mm?

Back 19

ORS

Front 20

Which Tx had the best PD reduction and maintenance of AL for PD over 7years for PDs< 5mm?

Back 20

RP

Front 21

Rank the tx in terms of which ones are more likely to have site breakdown in PD>5mm

Back 21

CS>RP>MWF>ORS

Front 22

Which patients had a majority of sites with breakdown?

Back 22

Smokers!

Front 23

T/F Furcation sites have loss of attachment over time regardless of tx

Back 23

True. Which is why furcated molars are not good abutments!

Front 24

Which tx were most effective at reducing PD in furcated molars?

Back 24

ORS>MWF>RP>CS

Front 25

Based on the Metal-analysis on surgical vs. Non-surgical therapy, which tx results in less attachment in shallow pockets?

Back 25

Non-Sx tx.

Front 26

Based on the Metal-analysis on surgical vs. Non-surgical therapy, which tx results in more gain in attachment but less pocket depth reduction in moderate pockets?

Back 26

Non-surgical tx

Front 27

Based on the Metal-analysis on surgical vs. Non-surgical therapy, which tx results in more gain in attachment AND more pocket reduction in deep pockets?

Back 27

Surgical tx

Front 28

What is typical sequela following most periodontal procedures?

Back 28

Appearance of Gingival recession but remember that recession is NOT caused by Periodontal tx! Perio Tx uncovers recession previously induced by the disease

Front 29

What are three potential problems that gingival recession brings?

Back 29

1. Esthetics

2. Sensitivity

3. Root caries

Front 30

What are the Basic necessities of surgery?

Back 30

1) Adequate visibility

2) Adequate knowledge and training

3) Appropriate instrumentation

4) Aseptic Technique

Front 31

What is the problem with overthinning flaps?

Back 31

results in compromise of blood supply and sloughing

Front 32

Two general factors that help decrease post op pain?

Back 32

Decreased Surgical time

Decreased trauma during surgery

Front 33

Why should you avoid heating bone? What is the temperature threshold?

Back 33

You risk inducing osteonecrosis. Keep temperature under 47 degrees Celsius. Keeping it above this temperature for more than 1 minute will induce osteonecrosis

Front 34

Why do you want to avoid unnecessary exposure of bone?

Back 34

You will have increase resorption!

Front 35

What are three main ways peridontal flaps can be classified?

Back 35

1) Bone exposure after flap reflection

-Full thickness (mucoperiosteal)

-split thickness (mucosal)

2) Placement of flap after surgery

-Nondisplaced flaps(returned to original position)

-Displaced flaps (placed apically, laterally or coronally)

3) management of papilla

-Conventional (removal of interdental

tissue)

-Papilla preservation

Front 36

What is a full thickness flap?

Back 36

All soft tissue +periosteum is reflected to expose underlying bone

Front 37

What is a Split thickness flap?

Back 37

Reflection of epithelium and a layer of connective tissue leaving some connective tissue and periosteum on the bone

Front 38

What are some indications for Full thickness of flap?

Back 38

-Osseous resective surgery

• Regeneration
• Implant surgery
• Osseous harvesting

• Crown lengthening

Front 39

What are some indications for soft thickness flaps?

Back 39

Mucogingival surgery

• Apically displaced flap

Front 40

T/F Whether or not you lose bone after the periosteum is raised depends on the surgical procedure

Back 40

False. You always lose bone when periosteum is raised. There Full thickness results in more surgically induced bone loss than split thickness

Front 41

How much bone loss is lost on average when mucoperiosteal flaps are used?

Back 41

0.8mm

Front 42

When are some situations where a conventional flap can be used?

Back 42

Used when esthetics is not an issue – posterior quadrants
• Used when interproximal tissue too thin for papilla preservation

Front 43

When are some situations where a papilla preservation flap should be used?

Back 43

Used in anterior sextants when possible

• Need fairly large width of tissue
• May also use for regeneration surgery

Front 44

What is negative (reverse architecture)?

Back 44

abnormal gingival and/or osseous marginal contours; commonly not parabolic in form with the inter proximal tissue located in an abnormally apical position

Front 45

What is positive architecture?

Back 45

normal gingival and osseous marginal contour; commonly parabolic in form with the apex of the parabola located at mid buccal/lingual surfaces and interproximal tissue in the most coronal.

Front 46

What is one of the most important aspects of ORS?

Back 46

Correcting negative architecture

Front 47

Why is negative architecture so bad?

Back 47

The interproximal sites get deeper and deeper, making it impossible to clean.

Front 48

How what is the minimum amount of teeth that should be included in a flap?

Back 48

always extend at least one tooth mesial and distal to the area that you are working

Front 49

What is the benefit of increasing the amount of teeth involved in a flap?

Back 49

↑ visualization of site
↓ amount of tension on flap
Not related to ↑ post op discomfort (Can include 3,5 or 7 teeth and post op pain will be the same!)

Front 50

Benefits of vertical releasing incisions?

Back 50

↑ visualization of site

Front 51

Which locations can vertical releasing incisions be used?

Back 51

Can be used on one or both ends of the horizontal incision

(As long as the area permits it)

Front 52

Areas where vertical releasing incisions shouldn't be used?

Back 52

Mental Foramen, lingual of the mandible (Lingual nerve), distal of 7/8 in the maxillary (Greater palatine nerve), Canine Prominence

Front 53

How does vertical releasing incisions affect post op discomfort?

Back 53

↑ significantly post of discomfort (cuts off lateral blood supply)

Front 54

What is wrong with A?

Back 54

Danger of losing papilla

Front 55

What is wrong with B?

Back 55

Danger of increased recession

Front 56

What is the incision in C called?

Back 56

Paramedian incision. Much better compromise than A or B

Front 57

What is the problem with the black hashed lines in D?

Back 57

Far too close!

Front 58

Should vertical incisions be convergent or divergent from eachother?

Back 58

Divergent from eachother (Hashed black lines). (red is bad design). This helps to maximize blood supply

Front 59

What are some types of monofilament/ pseudomonofilament?

Back 59

steel, nylon, polyglycolic, Vicryl, Gore-tex

Front 60

What are some Advantages and disadvantages of monofilament/pseudomonofilament?

Back 60

• Advs: Ease of use, strength, minimal tissue rxn Disadvs: Poor knot strength

Front 61

What are some types of complex fibers?

Back 61

Silk

Front 62

What are some Advantages and Disadvantages of complex fiber?

Back 62

• Advs: Excellent knot security, ease of use, strength
• Disadvs: Severe tissue reaction, wicks bacteria

Front 63

What is a type of twisted fiber?

Back 63

Catgut

Front 64

What are the advantages and disadvantages of Twisted fibers?

Back 64

• Advs: Soft, resorbable
• Disadvs: Poor strength, Poor knot security, Moderate tissue reaction

Not suitable if you want suture to last greater than 4-5 days time.

Front 65

What are the most common suture size used for periodontal surgery?

Back 65

Size 4 and 5

Front 66

What are the three components of a surgical needle?

Back 66

-Press fitted end (swage)

-Body (Circle size)

-Needlepoint

Front 67

What are the most common needle sizes used?

Back 67

3/8 and 1/2

Front 68

Why should only Reverse needles be used in dentistry?

Back 68

prevents suturing material from tearing through surgical flaps.

Front 69

Difference between conventional and reverse cutting needles?

Back 69

Conventional: Needle is square in cross section

Reverse cutting: triangular cross section.

Front 70

What chemical can be used for suturing?

Back 70

Cyanoacrylate/Histoacryl. Specificially butyl and isobutyl.

Do NOT used ETHTYL ('Super glue'). Toxic!!!

Front 71

How long does Cyanoacrylate last?

Back 71

exfoliated 4-7 days following use

Front 72

What is rationale for using Periodontal dressing?

Back 72

Rationale for use:

Protect site from trauma

↑ Patient comfort if exposed bone present

Keep debris out of wound

Stabilize + protect grafts

Help control post-op bleeding

Front 73

What is a contraindication for using Coe-Pack periodontal dressing?

Back 73

Patients with peanut allergies (Contains peanuts!)

Front 74

What does the scientific evidence say about periodontal dressing?

Back 74

No evidence to show improved healing and actually most patients prefer no pack (They hate the taste)

Front 75

What are the two kinds of healing that can occur?

Back 75

Primary and Secondary healing.

Front 76

Some features of healing by primary intention

Back 76

-Wound edges are replaced essentially in same position before the incision (No Gap)

-Allows for wound repair with minimal scar formation

-Decrease re-epithelization, collagen deposition, contraction+remodeling

-Faster healing with decreased risk of infection+ scar formation

Typical of: Periodontal flap surgeries, CTGraft harvest sites, GTR, most implant surgeries

Front 77

Some features of healing by secondary intention

Back 77

A gap is left between the edges of the incision

Requires large amount of epithelial migration, collagen deposition, contraction and remodeling

Slower healing

More scar tissue

Typical of: extraction sockets, FGG harvest sites

Front 78

Does administration of antibiotics (pre or post op) increase or decrease the prevelance of infections?

Back 78

tends to increase. Two possible reasons:

1) disturbs oral flora

2) Surgeons think they can be sloppier because patient is on Anti-Biotics

Front 79

What are other factors that may help decrease risk of infection

Back 79

Chlorhexidine

Periodontal dressing

(Not statistically significant in the study that looked at infection factors however)

Front 80

How much blood is lost on average during periodontal surgery?

Back 80

134mL

Front 81

Why is more blood lost in mandibular surgery versus maxillary surgery?

Back 81

Local infiltration used for maxillary which is better for hemostasis than blocks

Front 82

At what point should you consider IV fluid replacement for the patient?

Back 82

If greater than 500mL of blood lost during surgery

Front 83

Why should 1:50,000 epi not be used for LA?

Back 83

Rebound bleeding: 1:50,000 is really powerful. When you use
that it really constricts the blood supply significantly. When the
epi wears off, the arteriole expands and tension from the expansion
causes bleeding again. In general, we should always use Epi for surgery

Front 84

What is the cause of the initial hemorrhaging during surgery?

Back 84

presence of granulation tissue

Front 85

What are some reasons for excessive hemorrhaging?

Back 85

• Lacerated capillaries and arterioles

• Damage to larger vessels (palatine, incisal, inferior alveolar, lingual

• Patients taking non-selective anti-inflammatory, blood thinners

• High Blood pressure

• Recent alcohol consumption

• Bleeding disorders

Front 86

What are some methods that can be used to obtain hemostasis?

Back 86

-Pressure with Gauze

-Sutures (deep with strong suture, vicryl, goretex, silk)

-Surgical dressings (all stimulate coagulation physically rather than physiologically stimulating clotting cascades)

-Epinephrine

-Electrosurgery

Front 87

What are some methods for post-op pain control?

Back 87

Advil 600 mg q6h (2-3 days, continuously)

Tylenol #3 1-2 tablets q6h (for break through pain only)

Toradol 10 mg q6h (most effective if started IV...but GP won't use this generally)

Front 88

When is the only time that you would prescribe percocet or percodan?

Back 88

Extensive surgeries

Front 89

What are some things to help control swelling?

Back 89

Ice pack on for 10 minutes and off for 10 minutes for 1-2 hours

May give tapering dose of dexamethasone depending on body dose for sinus grafts or osseous harvesting surgeries

Front 90

What should be used to help control Oral hygiene after surgery?

Back 90

-Peridex (chlorohexidine 0.12%) as a mouthrinse 10 ml BID for 7-14 days following surgery.

• Grafts: Q-tip area

Front 91

List the post operative expectations of surgery

Back 91

discomfort – peak intensity in 2-3 days

Bruising + Swelling – peaks in 2-3 days

Swelling and bruising not common following flap surgery but possible following grafting

Sensitivity to percussion not likely

↑ in tooth mobility

Dentin sensitivity

Front 92

Main Objectives of Periodontal surgery?

Back 92

Creating accessibility for proper professional SRP

Establishing a gingival morphology conducive to plaque control

Pocket depth reduction

May aim at regeneration of periodontal attachment

Front 93

Definition of Gingivectomy

Back 93

The excision of the soft tissue wall of a pathologic periodontal pocket without exposure of underlying bone. (NOT TO CROWN LENGTHEN!)

Front 94

Definition of Modified Widman Flap

Back 94

The excision of periodontal pocket with minimal alveolar bone exposure.

Front 95

Definition of ORS?

Back 95

The excision of periodontal pocket with osseous recontouring and the possibility of apical displacement on the flap

Front 96

What techniques can not be used to treat infrabony pockets?

Back 96

Gingivectomy or MWF. Only ORS can be used to treat Infrabony pockets

Front 97

What techniques can be used to treat gingival or suprabony pockets?

Back 97

Gingivectomy or MWF.

Front 98

Indications for Gingivectomy:

Back 98

Elimination of soft tissue pocket wall in suprabony pockets where a sufficient width of attached gingiva exists

Elimination of soft tissue interdental craters and reverse architecture (ie. in necrotizing disease)

Elimination of gingival tissue which is distorted because of a fibrous hyperplastic response to chronic irritiation

Front 99

Contraindications for Gingivectomy:

Back 99

Base of pocket approaches or extends beyond the MGJ (i.e. inadequate AG)

When infrabony pocket or osseous craters exist

Cannot be used for cosmetic crown lengthening (altered passive eruption) if osseous reduction necessary

When regeneration of tissues is of interest

Front 100

What is the exception where Gingivectomy may be used for Crown lengthening?

Back 100

When it is to crown lengthen areas with gingival hypertrophy

Front 101

List the Healing timeline for Gingivectomies:

Back 101

• 0-5 hours: Clot formation, acute inflammation → clearance of necrotic cells
• 5 hrs – 3 days: Proliferation of epithelium, migration over wound (0.5mm/day)
• 4 – 10 days: Epithelial cells cover wound, ↓ in inflammation
• 10 days - : JE formed = 12 days, Epithelium matured = 21 days, CT maturation 4-6 weeks

Front 102

When should Gingivectomy be probed again?

Back 102

4-6 weeks after surgery

Front 103

Indications for Modified Widman Flap?

Back 103

Elimination of soft tissue pocket wall in suprabony pockets while maximally maintaining attached/keratinized tissues

Elimination of soft tissue interdental craters and reverse architecture

Allows complete removal of subgingival calculus as well as smoothing and planing of root surface with direct vision

Used in areas where minimal gingival recession is desired (ie. Maxillary anteriors)

Front 104

Contraindications for Modified Widman Flaps?

Back 104

When infrabony pocket or osseous craters exist

Cannot be used for cosmetic crown lengthening (altered passive eruption) if osseous reduction necessary

When regeneration of tissues is of interest

Front 105

What type of surgery uses a external bevel incision?

Back 105

Gingivectomy ( solid black line)

Front 106

What type of surgery uses a internal bevel incision?

Back 106

MWF (------)

Front 107

T/F: In MWF there is a incison made around the base of the pocket

Back 107

False: in MWF the base of pocket undisturbed

Front 108

What sutures knots are generally used to close Modified WIdman Flaps?

Back 108

Single interrupted or Continuous sling

Front 109

Indications for Osseous Resective Surgery

Back 109

• Elimination of soft tissue pocket wall in suprabony and infrabony pockets while maximally maintaining attached/keratinized tissues

• Elimination of soft and hard tissue interdental craters and reverse architecture

• Allows complete removal of subgingival calculus as well as smoothing and planing of root surface with direct vision

• Allows for elimination of infrabony osseous defects and all negative architecture

Front 110

Contrindications for Osseous Resective Surgery

Back 110

• When regeneration of tissues is of interest

• When working in a region/patient where cosmetics is of utmost importance

Front 111

ORS initial incision: Why is incision location on buccal more forgiving than on palate?

Back 111

Buccal tissue is more
mobile. Palatal tissues are non
mobile. All Attached ginigva.
Have to be precise about where
we cut. Can’t expose too much
bone and we get resorption.
but if we are too conservative
we don’t get enough access
for cleaning

Front 112

What are the four steps to Osseous resection?

Back 112

1. Vertical Grooving

2. Radicular Blending

3. Flattening interproximal bone

4. Gradualizing Marginal bone

Front 113

Definition of Ostectomy?

Back 113

the removal of supporting bone designed to minimize post-operative sulcus depth, and attain positive architecture

Front 114

Definition of Osteoplasty?

Back 114

the removal of non- supporting bone designed to minimize post-operative sulcus depth and maximize gingival contour

Front 115

What is the most common intrabony defect?

Back 115

Interdental craters

Front 116

Reasons why interdental craters in Mx Molars are ramped palatally?

Back 116

Existence of abundant keratinized tissue

Greater surgical access to wider palatal embrasures

Cleansing effect of tongue

Less post-surgical bone resorption → Palate contains ↑ cancellous bone

Front 117

What is a class I interdental crater and how is it treated?

Back 117

2-3 mm deep osseous cavity with thick buccal + lingual walls. Tx: Complete palatal ramping (black part is removed)

Front 118

What is a class II interdental crater and how is it treated?

Back 118

4-5 mm deep osseous cavity. Wider cavity = thinner walls + more

abrupt slope into cavity. Most common defect.

Tx: Removal of buccal bone

to level of furcation and gross reduction of palatal bone.

Front 119

What is a class III interdental crater and how is it treated?

Back 119

Class 3: 6-7 mm deep osseous cavity. Even more severe than class 2.

Tx: Removal of buccal bone to level of furcation and gross reduction of palatal L bone as much as possible. May not be able to completely erradicate

Front 120

What is a class IV interdental crater and how is it treated?

Back 120

Crater of varying depth but with very thin B/L walls. Least common. Tx: As above, buy more conservative removal on buccal due to possible post-op resorption

Front 121

Give the healing time points for post ORS

Back 121

0-4 days: Clot formation b/w flap + bone.
4-10 days: Clot replaced by provisional matrix, osteoclastic phase peaks at 4-6 days,

epithelial attachment initiated.
10 - 28 days: Osteoblastic phase, connective tissue maturation
28 - 185 days: Functional repair: Continued osseous remodeling and maturation

Front 122

What are the 2 main methods to eliminate pockets distal to the last maxillary molar

Back 122

Distal Wedge and Modification

Front 123

Describe the distal wedge technique on the last maxillary molar

Back 123

Distal Wedge: 1st incision delineates wedge. 2nd incision undermines it. N.B. Very important to conduct osseous resection, otherwise will not get significant pocket resolution.

Front 124

Describe the modification technique on the last maxillary molar

Back 124

Modification: 1st incisions are two parallel lines straight back. 2nd is perpendicular and 3rd incision undermines flap. Osseous resection just as important.

Front 125

What anatomical structure(s) complicates Distal pocket elimination in the mandible?

Back 125

Lingual nerve

Front 126

Which of these distal wedge incisions in the mandible is the preferred method?

Back 126

The bottom one! Incision remains in attached gingiva(N.B.!) and in a buccal direction which reduces the chances of severing the lingual nerve!

Front 127

What is the most common location of the lingual nerve relative to the last mandibular molar?

Back 127

86% of cases present with lingual n. 2 mm and 3 mm away in a horizontal + vertical distance from the lingual plate and crest in 3rd molar region.

Front 128

Does doing a distal wedge incision straight back or buccal completely eliminate the risk of severing the lingual nerve?

Back 128

NO! Reason:

14% of cases lingual n. is above osseous crest

In 1/669 cases the lingual n. was in the retromolar pad

Front 129

What sensory information does the lingual nerve supply?

Back 129

– Anterior 2/3 of the tongue

– Lingual mucosa and gingiva of the mandible

Front 130

What special sensory information does the lingual nerve supply?

Back 130

Taste to the anterior 2/3 of the tongue

Front 131

What procedures does not generally lead to an increase of tooth mobility?

Back 131

SRP, currettage, modified widman surgery

Front 132

What procedures will generate a significant decrease in mobility?

Back 132

SRP/curretage. ie. Non-surgical tx

Front 133

Which procedures will usually cause a temporary increase in mobility?

Back 133

Pocket reduction/Osseous resective surgery

Front 134

What is the typical progression of mobility post ORS/pocket reduction surgery?

Back 134

Peak at 2 weeks
• Return to pre-op levels by 4 months – 1 year

• Continue to ↓ for up to 2 years post op

Front 135

In which situations are there more likely to have residual deep PDs even after pocket reduction surgery?

Back 135

-Deep pockets greater than 9mm (DO NOT LET IT PROGRESS TO THIS STAGE IN THE FIRST PLACE. SUPERVISED NEGLECT!!!!)

-If surgical access is poor

-Post operative infection

-poor oral hygiene (contraindicates surgery!)

-Endodontic component to the lesion

Front 136

Histology of Keratinized Gingiva?

Back 136

Thick stratified squamous Keratinized epithelium

Front 137

Histology of Non-Keratinized Gingiva?

Back 137

Thin Non-keratinized squamous epithelium

Front 138

Which locations in the mouth have keratinized gingiva?

Back 138

Attached and free gingiva, hard palate

Front 139

Which locations in the mouth have non-keratinized gingiva?

Back 139

lining mucosa of lips, vestibule, cheeks, floor of mouth

Front 140

What is the prevailing but contentious concept on the role of keratinized gingiva?

Back 140

To protect the periodontium from injury caused by wear and tear (mastication)

To dissipate the pull on the gingival margin created by muscles of mastication on adjacent alveolar mucosa

To protect against attachment loss + soft tissue recession b/c of ↑ tissue resistance to plaque associated gingival lesions

Front 141

How do we measure attached gingiva? How do we confirm?

Back 141

Measuring AG

Step 1: Measure Pocket Depth

Step 2: Measure distance from gingival margin to Mucogingival line/junction

Step 3: Subtract step 1 measurement from step 2

Confirmation of lack of AG

Coronal traction on probe

Front 142

Which has more attached gingiva? the Maxilla or mandible?

Back 142

Maxilla

Front 143

Which areas in the mouth have the smallest width of attached gingiva?

Back 143

Cuspid and 1st bicuspids on both arches

Front 144

Which areas in the mouth have the largest width of attached gingiva?

Back 144

Centrals and laterals

Front 145

Definition of Recession

Back 145

Location of marginal gingiva apical to the cemento-enamel junction

Front 146

Mucogingival defects are generally the result of _____________?

Back 146

recession of attached gingiva

Front 147

What are the etiology of recession?

Back 147

Periodontal disease

Traumatic oral hygiene

Tooth position and angulation

Cortical bone dehisences/ fenestrations of overlying roots

Iatrogenic treatment

Frenum pull

Front 148

What are some iatrogenic causes for dehiscences?

Back 148

Ortho: buccal version of teeth can cause dehisences

Front 149

What are some options for treating the cause of recessions?

Back 149

Txing periodontal disease

Changing oral hygiene routine

Tooth repositioning

repositioning frenum

Front 150

Why are frenum pulls considered disadvantageous to OH?

Back 150

Thought to act as a trap door

1. Opens up during muscular movements = potential plaque trap

2. Closes and locks plaque in = facilitates subgingival plaque formation

Front 151

How does frenum pulls affect orthodontics?

Back 151

Orthodontically may lead to relapse of tx. or inability to close diastema

Front 152

Why are shallow vestibular depths considered disadvantageous to OH?

Back 152

1. Accumulation of food particles during mastication

2. Impedes proper oral hygiene measures (with recession you have shallow vestibular depth and it's hard for the patient to angle the toothbrush to allow the bristles to get into the sulcus)

Front 153

What are some indications for Mucogingival surgery?

Back 153

To increase the width of attached gingiva

To attain root coverage

To increase vestibular depth

To manage high frenum pull

Pre-orthodontics (if buccal tooth movement is planned + thin attached gingiva)

To develop better soft tissue contours around teeth, pontics or dental implants.

Front 154

Is there a difference between grafted sites and un- grafted sites in progression of recession?

Back 154

YES!

Maintained: both treated (FGgraft) and recession sites remained stable

Unmaintained: FGgraft sites remained stable but sites with recession had inflammation and increased recession over time.

Front 155

What is the current consensus on what is considered inadequate keratinized tissue.

Back 155

Inadequate keratinized tissue(gingiva) is defined as < 2mm in width of which less than

1 mm is attached gingiva.

Front 156

Is there a minimal amount of attached tissues required around subgingival restorations?

Back 156

YES!

If subgingival restorations placed, teeth with MAG had ↑ marginal inflammation than teeth with adequate attached gingiva (more plaque accumulation)

Front 157

Is there a minimal amount of attached tissues required around supragingival restorations?

Back 157

no differences in marginal inflammation noted between regular sites and sites with MAG

Front 158

if a tooth is moved orthodontically from a prominent buccal position to lingual, how does it affect bone/tissue height?

Back 158

You will increased bone height and tissue height. (Reverse is also true!!)

Front 159

under what conditions should a patient be treated with a graft as a part of pre-orthodontic care?

Back 159

Marginal tissue comprised of alveolar mucosa with a frenum pull

Exposed root surface with minimal keratinized tissue and no attached

Labial incisor eruption with minimal keratinized tissue and no attached and no lingual movement planned

Thin periodontium and labial movement is planned

Root exposure during tooth movement

All of the above may progress with age

Front 160

When to consider grafting?

Back 160

Evidence of progression (noted longitudinally)

In areas where oral hygiene is limited (lack of vestibule / frenum pull)

Pre-prosthetic – in areas of subgingival restorations or where a denture flange may cause irritation (controversial)

Pre-orthodontic

Patient demands: Esthetics, root sensitivity

Combination of: Minimally attached/keratinized tissues with presence of inflammation (BOP) and inadequate home care ± strategically important teeth

Restorative: In areas with recession and shallow class V restorations – consider excavation of decay and root coverage

Front 161

Why can tissue grafting only be used to restore shallow class V restorations?

Back 161

deep it wont work because soft tissue wont flow into defects greater than 1mm.

Front 162

What are the tx options for recession in kids?

Back 162

In children – observe recession defects longitudinally – will most likely improve. No general need for therapy

Front 163

What is class I recession?

Back 163

Marginal tissue recession that does not extend to the MGJ.

There is no periodontal loss (bone or soft tissue in the interdental area

Front 164

What is Class II recession?

Back 164

Marginal tissue recession that extends to or beyond the MGJ.

There is no periodontal loss (bone or soft tissue in the interdental

area.

Front 165

What is class III recession?

Back 165

Marginal tissue recession that extends to or beyond the MGJ.

– Bone or soft tissue loss in interdental area or there is malpositioning

of teeth.

Front 166

What is class IV recession?

Back 166

Marginal tissue recession that extends to or beyond the MGJ.

Bone or soft tissue loss in interdental area is so severe that root

coverage cannot be anticipated.

Front 167

In which classe(s) of recession can we expect to have 100% root coverage after grafting?

Back 167

Class I +2 can anticipate 100% root coverage

Class 3 cannot predictably gain 100% root coverage

Class 4 cannot predictably gain any root coverage

Front 168

indications for free gingival grafting?

Back 168

-To increase width of attached gingiva

-Root Coverage

-Frenectomy

-Vestibular extension.

Front 169

Why are the first 48 hours in the healing of a Free gingival graft most critical?

Back 169

First 48 hours are most critical period since no vascularization

Front 170

What the sources of nutrition and hydration for the graft in a free gingival graft?

Back 170

Nutrition and hydration to graft provided by fluid diffusion from vessels of periosteal bed (called plasmotic circulation)

Front 171

What occurs during phase 1 (0-48 hours) of healing in a free ginigval graft?

Back 171

Blood clot forms between graft and underlying periosteal bed

CT in graft is disorganized and undergoes some remodeling

Front 172

What occurs during phase 2 (3-5) days of healing of free ginigval grafts?

Back 172

Get sloughing of the epithelium +

survival of underlying CT which contains genetic information for keratinized tissue

Re-vascularization starts in 2-3 days. Get anastomosis between vessels in graft and underlying tissue bed

Front 173

What occurs in the 11-21 days after free gingival grafts?

Back 173

Graft and wound bed have joined + decrease in inflammatory response in underlying host CT

Front 174

What occurs 28 days after a free gingival graft?

Back 174

Epithelium appears normal , with surface keratinization, increased thickness and rete peg formation

Front 175

how long does it take for a free gingival graft to be fully repaired?

Back 175

4-6 weeks

Front 176

How does free gingival graft compare to connective tissue graft for root coverage?

Back 176

May not get full root coverage and not as aesthetic because it's thick

Front 177

What are some safe donor sites to get a connective tissue graft from?

Back 177

-Safe zone=canine-2nd premolar (GP nerve+ vessel)

-Typically want 2mm thickness (will contain more glandular tissue thanFGG)

-Heal by primary intention

Front 178

What are some safe donor sites to get a free gingival graft from?

Back 178

-Larger grafts can be acquired (not near vital structures)

-Variable thickness (thicker grafts needed for root coverage, generally better CT)

-Heal by secondary intention (Takes longer to heal)

Front 179

How does the depth of incision compare for FGG vs. CTG?

Back 179

Front 180

Cross section of a connective tissue graft?

Back 180

Front 181

Cross section of a free gingival graft?

Back 181

Front 182

Which procedures is technically easier to do? FGG or CTG?

Back 182

FGG

Front 183

Which is more esthetic, FCG or CTG?

Back 183

CTG

Front 184

Blood supply for FGG?

Back 184

Periosteum

Front 185

What are two sources of blood supply for CTG?

Back 185

From Periosteum (split thickness flap)

From overlying flap

Front 186

Which has better root coverage? CTG or FGG?

Back 186

CTG (Over avascular root, flap provides blood supply)

Front 187

Indications for Guided Tissue regeneration?

Back 187

-Increase width of Attached Gingiva

-Root coverage

-Root sensitivity.

Front 188

How is a Guided tissue regeneration performed?

Back 188

A flap is raised, a membrane is placed is around the necks of the teeth, sutures are placed and the idea is to let CT migrate.

Front 189

Indications for Coronally Advanced flap?

Back 189

– Class I recessions (Very minor cases)
– Minimum of 3 mm of keratinized gingiva apcial to the exposed root – Recession not greater than 4 mm
– Adequate thickness of keratinized gingiva in surgical site

Front 190

Rank the order of mean root coverage from least root coverage to most root coverage for the different surgical techniques

Back 190

Coronally advanced flap (61%)

Lateral pedicle flap (67%)

Free gingival graft (69%)

Guided tissue generation (73%)

Connective tissue graft (84%)

Front 191

What is alloderm?

Back 191

acellular dermal graft processed from cadaver skin

Only the dermis layer(CT) present including the basement membrane

Cellular components removed (therefore just a scaffold)

Integrity of ECM maintained to avoid induction of inflammatory response

Front 192

What are the indications for Alloderm?

Back 192

Root coverage

-Augment Width of attached gingiva (very poor because it's a different tissue!)

Front 193

Which had more PD reductions? Alloderm vs. CTG?

Back 193

CTG

Front 194

What had better root coverage between Alloderm vs. CTG in the short term?

Back 194

Comparable (Alloderm=93.4%, CTG=96.6%)

Front 195

What had better root coverage between Alloderm vs. CTG in the long term?

Back 195

CTG (97.0%)!

(Alloderm (65.8%) only)

Front 196

Does Alloderm have more or less root coverage when multiple roots are covered?

Back 196

More root coverage!

(Multiple=70.8 vs. One root 50.0%)

Front 197

Only in what type of pockets can you perform regeneration sx?

Back 197

Infrabony pockets!

Front 198

Definition of Repair and a clinical example?

Back 198

Healing of a wound by tissue that does not fully restore the:

• Architecture

• Function

Ex: Long junctional epithelium (after OFD)

Front 199

Definition of Regeneration and a clinical example?

Back 199

Reproduction or reconstitution of a lost or injured part in such a way that the architecture and function of the lost or injured tissues are completely restored.

Clinically → New Cementum, PDL, Alveolar bone

Front 200

What are the 4 types of cells that involved in the "race" after Sx or Non-sx tx? Which of these are the fastest?

Back 200

Oral Epithelium cells (FASTEST!)

Gingival connective tissues

PDL cells

Osseous cells

Front 201

what is the result if oral epithelium cells win the race and are the first to bind to the root surface?

Back 201

Formation of Long junctional epithelium

Front 202

what is the result if gingival connective tissues win the race and are the first to bind to the root surface?

Back 202

possible root resorption

Front 203

what is the result if Periodontal ligament cells win the race and are the first to bind to the root surface?

Back 203

Potential for new CT attachment

Front 204

what is the result if Osseous cells win the race and are the first to bind to the root surface?

Back 204

potential for ankylosis

Front 205

What are the 4 different possible manifestations of repair post perio tx?

Back 205

A LJE

CT adhesion/Root

resorption

Ankylosis/Root

resorption

Unpredictable

amount of osseous healing in repair

Front 206

List the 4 tissues that make up the periodontium

Back 206

• Epithelium

• Gingival Connective Tissues

• Periodontal Ligament Cells

• Alveolar Bone

Front 207

what is the requirement needs to be met for the 4 tissues in order for healing to be classified as regeneration?

Back 207

All tissues must be involved and compartmentalized to allow for reconstitution of lost tissues

Front 208

What cells need to be excluded in order for regeneration to occur?

Back 208

Epithelial and Gingival connective tissue cells. This allows re-population of the site by PDL and osseous cells

Front 209

What is used in GTR that helps create space for cells to repopulate and regenerate tissues?

Back 209

Membrane (resorbable or non-resorbable)

Front 210

draw diagram that shows how repair occurs post conventional surgery

Back 210

B: race of tissues

C: repair

Front 211

draw diagram that shows how repair occurs post GTR

Back 211

T: exclusion of epithelial and GCT by membrane to create space for PDL +osseous healing

R=regeneration

Front 212

Potential benefits of regeneration vs. conventional surgery

Back 212

Improvement in both clinical attachment and bone levels

Reduction in amount of recession → improved esthetics

(mx. anterior)

Less post-op sensitivity

Reduced furcation involvement

No compromise of osseous structure on adjacent teeth

Both however lead to decreased probing depths and more maintainable sites

Front 213

List the requisite parameters for regeneration

Back 213

Pocket type: Infrabony pocket

• Character of bone loss: Vertical bone loss

• Defect type
• Defect depth (>4mm!)

• Proximal bone levels
• Primary closure
• Tension free
• Removal of all granulation tissue

Front 214

What are the two main reasons why regeneration can only be achieved in infrabony pockets?

Back 214

-Improved vascularization (Surrounded by blood) vs suprabony where blood has to move vertically which is hard

-Containment of materials

Front 215

What do bony walls provide in regeneration?

Back 215

increased protection/compartimentalization

increased vascularity

increased sources for pluripotential cells

Front 216

In the study where infrabony defects were treated with GTR, how many of the sites gained at least 2mm of bone?

Back 216

90%

Front 217

In the study where infrabony defects were treated with GTR, 3 wall defects gained how much % of the original depth?

Back 217

95% fill of original depth

Front 218

In the study where infrabony defects were treated with GTR, 2 wall defects gained how much % of the original depth?

Back 218

82%

Front 219

In the study where infrabony defects were treated with GTR, 1 wall defects gained how much % of the original depth?

Back 219

39%

Front 220

How deep must a intrabony defect be in order for the site to benefit from GTR?

Back 220

greater or equal to 4mm deep. This is the depth from the crest of the bone down to base of the infrabony pocket. NOT PD!

Front 221

Extent of regeneration is critically dependent on __________________ levels

Back 221

Proximal bone

Front 222

What type of flaps should be used for GTR and why?

Back 222

Papilla preservation flaps (preserves interproximal tissue!)

Front 223

Why is primary closure critical for regeneration?

Back 223

protection of biomaterials and exclusion of epithelium

Front 224

What is a autogenous graft?

Back 224

Graft obtained from the same patient

Front 225

What is a allogenic graft?

Back 225

graft obtained from other human, stored and processed in tissue banks

Front 226

What is a xenogenic graft?

Back 226

graft obtained from other species eg. Bovine, porcine

Front 227

What is a alloplast

Back 227

graft obtained from synthetic and inert material eg. Tricalcium phosphate and hydroxyapatite.

Front 228

Definition of Osteogenic

Back 228

Contain bone forming cells (marrow cells, undifferentiated cells)

Front 229

Definition of Osteoinductive

Back 229

Contains bone-inducing substances, ex. BMPs.

Front 230

Definition of Osteoconductive

Back 230

Serves as a scaffold for bone formation

Front 231

What type of properties does Autogenous graft have?

Back 231

Osteogenic, Osteoinductive, Osteoconductive

Front 232

What type of properties does Allogenous graft have?

Back 232

Osteoinductive, Osteoconductive

Front 233

What type of properties does Xenogenic graft have?

Back 233

Osteoconductive

Front 234

What type of properties does alloplast graft have?

Back 234

osteoconductive

Front 235

What are post-op complications unique to autografts?

Back 235

-Sequestration

• Root resorption(when natural teeth present):

Undifferentiated marrow cells – stimulated to

generate odontoclasts
• Excessive root preparation with dentin exposure

Front 236

What are the two types of allograft:

Back 236

Freeze dried bone allograft (FDBA)

Demineralized freeze dried bone graft (DFDBA)

Front 237

List two ways demineralized freeze dried bone allograft(DFDBA) is different from Freeze dried bone allograft (FDBA)

Back 237

DFDBA: Oinductive and Oconductive + radiolucent( no minerals!)

FDBA: Oconductive only and radiopaque

Front 238

What allows Demineralized freeze dried bone allograft to be Osteoinductive?

Back 238

Demineralization exposes protein necessary for osteoinduction

Front 239

Are allografts safe?

Back 239

Very very safe. Materials used for >20 years and not a single case of dx transmission

Front 240

What are some uses/benefits for Xenograft?

Back 240

High degree of osteoconductivity

Stabilizes blood coagulation

Space maintenance function for membranes

Front 241

How predictable is GTR in furcations?

Back 241

•Substantial bone fill in mandibular and maxillary buccal class II furcations

• Limited clinical improvements in maxillary interproximal class II furcations

• Unpredictable for class III furcations

Front 242

What is emdogain?

Back 242

Porcine derived enamel matrix derivative containing a protein complex belonging to Amelogenin family.

Attempt to mimic events during development of the dental root.

By applying to denuded root surface, possible to regenerate acellular cementum → necessary for

PDL and bone re-formation

Front 243

How does Emdogain work?

Back 243

Allows for attachment of PDL and proliferation of cells to exclusion of epithelial cells

Front 244

What are some patient factors affecting clinical outcomes of regeneration in intrabony defects

Back 244

Oral hygiene

Smoking status (esp > 10 cigs/day)

Level of residual periodontal infection

Front 245

What are some defect factors affecting clinical outcomes of regeneration in intrabony defects

Back 245

Morphology, i.e. depth/width

# of residual bony walls

Hypermobility

Endodontic status of tooth

Front 246

What are some technique/healing related factors affecting clinical outcomes of regeneration in intrabony defects

Back 246

Careful flap design

Correct placement of the material

Optimal wound closure

Optimal post-operative plaque control

Front 247

In general, rank GTR, GTR+bone substitute and OFD from most to least effective in terms of AL change, PD reduction and Hard tissue probing at re-entry?

Back 247

GTR+bone substitute> GTR alone >OFD

Front 248

In general which is more effective, Emdogain or OFD in terms of positive AL change and PD reduction?

Back 248

EMD>OFD

Front 249

What are the three way the pulp and the periodontium communicate?

Back 249

1. Apical Foramen

2. Lateral (aka accessory) Canals

3. Patent dentinal tubules

Front 250

What is marginal periodontitis?

Back 250

An inflammatory response to an infection in dentogingival region

Front 251

What is apical periodontitis?

Back 251

An inflammatory response to an infection of the root canal space

Front 252

What are two ways apical and marginal periodontitis communicate?

Back 252

Deep periodontal pockets

lateral/accessory canals

Front 253

What are the most common routes of communication between PDL and the pulp?

Back 253

Apical third of root

Furcation area

Front 254

What is a primary endo lesion?

Back 254

It is a chronic apical lesion due to a necrotic pulp that is exacerbated, leading to a endodontic abscess. Periodontal support may be lost in the process

Front 255

What are the 2 possible routes by which a primary endo lesion can drain?

Back 255

can drain either through sulcus or pocket

Front 256

What is the typical tx for primary endo lesions?

Back 256

RCT alone. Can even resolve perio damage done by the primary endo lesion

Front 257

Generally, what are the statuses of the pulp involved in periodontal lesions?

Back 257

Generally Vital

Front 258

What is a primary perio lesion?

Back 258

Begins as marginal periodontitis that progresses to involve the apical foramen. Plaque and calculus on root surface

Front 259

What is usually the pulpal status of primary perio lesions?

Back 259

Start off as vital, but subsequently necrose

Front 260

What is the typical treatment for primary perio lesions?

Back 260

RCT, followed by Perio Tx.

Front 261

What is a primary perio and 2ndary endo lesion?

Back 261

Marginal periodontitis progresses apically, which exposes lateral canals. This leads to pulp pathosis -->pulp necrosis (Contentious pathogenesis)

Front 262

Are primary perio and 2ndary endo lesions common?

Back 262

No. they're controversial and unlikely to occur

Front 263

Does Marginal periodontitis cause pulp pathosis?

Back 263

Several studies have failed to find a correlation between periodontal disease and tissue changes in pulp. Perio lesions almost never affect pulp unless apical foramen is involved!

Front 264

What needs to be present in order for a pulp to withstand marginal periodontitis?

Back 264

a intact blood supply via apical foramen

Front 265

What is a true combined lesion?

Back 265

Tooth has marginal periodontitis but then subsequently develops apical periodontitis.

Front 266

In teeth with true combined lesions, what should be the order of tx?

Back 266

RCT first, then perio.

Front 267

What occurs in the PDL during ortho tx despite our best efforts to prevent it?

Back 267

Necrosis and Undermining resorption

Front 268

In dentition that is periodontally susceptible, how often should the maintenance period be?

Back 268

3 months

Front 269

how does aligning crowded anterior teeth help a periodontal patient?

Back 269

Allows adult patient better access for adequately cleaning all surfaces of their teeth

Front 270

Vertical orthodontic tooth repositioning can improve ____________ in periodontal patients

Back 270

Osseous defects. (note. moving teeth towards teeth can also increase lesions)

Front 271

How can ortho tx be beneficial in severe fracture cases?

Back 271

Forced eruption allows crown prep to have sufficient form and retention for final restoration

Front 272

True/false? ortho can help regain lost papilla

Back 272

True

Front 273

Patient has a gummy smile. What is a perio tx you can do to fix this? What parameter must be checked before you do this tx?

Back 273

Gingivectomy. Must ensure that they have enough attached gingiva and sulcular depth!

Front 274

What are some common perio surgical procedures done in preparation for ortho tx(5)?

Back 274

Frenectomy

Supracrestal fibrotomy

Free gingival graft

Apically positioned flap

Closed Eruption technique

Front 275

When is a apically positioned flap required as part of orthodontic tx?

Back 275

used to uncover labially impacted maxillary anterior teeth.

Front 276

When is closed eruption technique used?

Back 276

Used to uncover labially impacted maxillary anterior while maximally preserving attached gingiva

Front 277

What are 5 things that Ortho perio procedures can be used to correct (5)?

Back 277

1) Bony defects

2) Molar uprighting

3) Forced Eruption

4) Intrusion

5) Preimplant ortho

Front 278

What are the two main ways with which forced eruption can occur?

Back 278

With bone or through bone

Front 279

What is the speed at which you want to do forced eruption? What is the problem with this?

Back 279

Eruption needs to be done slowly. The problem is that doing this is that the bone surrounding the tooth will be brought down as well. Solution to this: remove excess bone with file or bur.

Front 280

If you intend to do forced eruption through the bone what fibers need to be removed in order for the tooth to erupt while not bringing bone down with it?

Back 280

supracrestal fibers

Front 281

During forced eruption the tooth needs to be continually grinded down as it's erupting. What needs to be added to the newly erupted tooth as a result of poor C:R?

Back 281

Fixed retention

Front 282

Patient has ankylosed molars that need to be extracted and later replaced with a implant. What is the sequence of the tx?

Back 282

Extract ankylosed primary molar. Move the 4 posteriorly, converting it into 5. The process of moving the 4 distally will improve the bone deficiency caused by the ankylosis. The space where the 4 previously occupied now because the space for the implant. Place implant

Front 283

What are some aesthetic evaluation criteria for teeth that are evaluated?

Back 283

1) Midline (ON?)

2) Tooth axis

3) Incisal edge location

4) Interincisal angle

5) Shape and Outline of teeth

Front 284

What are some aesthetic evaluation criteria for gingiva that are evaluated?

Back 284

Gingival Margin

Gingival Zenith

Papillary triangle

Interproximal Contact

Front 285

What are some aesthetic evaluation criteria for lips that are evaluated?

Back 285

Smile line (high or low)?

Front 286

What is the the magic number for Golden proportion?

Back 286

When the ratio between B and A is in golden proportion, then B is 1.618 times larger than A

Front 287

What is the significance of the golden proportion?

Back 287

human proportions that follow the golden proportion are aesthetically pleasing to the eye.

Front 288

What aspect of anterior teeth should ideally be in golden proportion?

Back 288

Their widths. (Central is 1.618 times wider than the lateral. Lateral is 1.618 times wider than the canine).

The anterior sextant also should be 1.618 times wider than posterior sextant

Front 289

How much longer should the canines and central incisors be than the lateral incisors?

Back 289

20%

Canine and Canine incisor avg length:

(10.5-12mm)

Lateral incisors average length (9-10.5mm)

Front 290

How much wider is the centrals compared to laterals and canines?

Back 290

*

Centrals are 25% wider than laterals

and 10% wider than canines (Centrals are the widest teeth!)

Front 291

What is the length to width ratio of the anterior teeth?

Back 291

L to W ratio:

Central-1.1:1

Lateral- 1.2:1

Canines-1.2:1

Front 292

What line should the line drawn across the canines be parallel to?

Back 292

interpupillary line

Front 293

How much gingiva should be exposed during a smile?

Back 293

*

Smile should expose interproximal papilla or (~1 mm) of gingiva apical to centrals and canines.

Front 294

how much further apical should the gingival margin of the central be compared to the lateral and canines?

Back 294

*

Gingival margins of centrals should be 1-1.5 mm apical to laterals and in line with or slightly coronal to canines.

Front 295

What is the Gingival zenith and position should they ideally be relative to the center of the margin?

Back 295

Zenith: highest point of the crest. Should be slightly distal relative to the center of the margin

Front 296

What the treatment plan flow for esthetic cases requiring Crown lengthening?

Back 296

1. Consultation with patient regarding treatment outcomes
2. Wax-up of case and further discussion with patient
3. Surgical stent fabrication (acetate) or send wax up to surgeon

4. Surgery
5. Healing time

Front 297

What is the significance of the 3mm measurement shown here?

Back 297

3mm distance away from the margin to re-establish new biological width

Front 298

How long should you wait for healing to ensure stability of gingival margins after crown lengthening?

Back 298

Should be O.K. after 3 months – if wanted to be extra cautious wait 6 months.

Front 299

What's the problem with placing a restoration too early after crownlengthening?

Back 299

Recession. Patient won't be happy!

Front 300

For cosmetic cases requiring post and core + endo. What should be performed first? CL or RCT? Under what circumstance would the choice be reversed?

Back 300

1) RCT FIrst! Want to see if there are any endo complications (no point doing CL if endo is going to cause case to fail)

EXCEPTION: CL first if you know you can't get seal after endo.

Front 301

What is the definition of Passive eruption?

Back 301

Is the exposure of the teeth by apical migration of the gingiva.

Front 302

Stages of Passive eruption?

Back 302

1.

Base of sulcus (BOS) and JE are on enamel

2.

BOS on enamel and part of JE is on the root

3.

BOS is at CEJ and entire JE on cementum

4.

Both BOS and JE on root

Front 303

Of the stages of passive eruption, which stage is pathological?

Back 303

4 (Recession)

Front 304

Of the stages of passive eruption, which is normal in an adult?

Back 304

2 and 3

Front 305

*

Is there an age beyond which a diagnosis of

altered passive eruption can be made?

Back 305

*

24 ± 6.2 years

Front 306

Tx for delayed altered passive eruption?

Back 306

Raise flaps, remove bone covering crown and suture

Front 307

for patients that had 4mm or less distance between contact point and gingiva, how many of them had papilla present?

what about 5mm, 6mm and 7mm?

Back 307

4mm-100% of patients had papilla

5mm-98% of patients

6mm-56% of patients

7mm-27% of patients

Front 308

You placed implants to replace 21 and 11. The distance between the contact point and gingiva is 6.5mm. Patient has a black triangle...what is the most predictable way of eliminating it?

Back 308

Place more square shape restorations. Papilla regeneration surgery is unpredictable!

Front 309

What is the definition of Biological width?

Back 309

The dimension of space that the healthy gingival tissues occupy above the alveolar bone.

Front 310

What are the two components of biologic width and what are their average dimensions?

Back 310

1) Junctional Epithelium (JE)=0.97mm

2) Connective tissue Attachment = 1.07mm

Sulcus is NOT part of it!

Front 311

Of the components of biologic width, which is most variable?

Back 311

JE

Front 312

How is biological width assessed clinically?

Back 312

Bone sounding with LA sulcus depth on a number of teeth with gingival health.

Front 313

What is violation of biologic width?

Back 313

Violation of BW will occur if the margins of a restoration impinge on the minimum distance required for the respective tissues (CT, JE)

Front 314

What is the body's response to violation of biologic width?

Back 314

Body doesn’t like violation and you’ll get a zone of chronic inflammation and the inflammation will cause BL and try to create new BW. Bone Loss will generate soft tissue loss, leading to recession and black triangles.

Front 315

On average, how much distance is needed from margin of restoration to alveolar crest to prevent violation of Biologic width?

Back 315

3mm (BUT on we should still do bone sounding)

Front 316

What is the typical response seen in people with thin biotype after biological width violation?

Back 316

Unpredictable amount of bone loss accompanied by soft tissue recession (unphysiologic re-establishment of biologic width)

Front 317

What is the typical response seen in people with thick biotype after biological width violation?

Back 317

Bone level appears unchanged but gingival inflammation develops and persists.

Front 318

What is expected if you place a restoration and the margin is at the bone crest?

Back 318

Expect to see significant loss of attacment and increase in recession due to violation of BW

From study: 3.16mm recession and 1.17mm bone loss

Front 319

What are two methods of correcting violated biologic width?

Back 319

1) Removing bone away from proximity of the restorative margin (To allow for ~ 3 mm of space b/w margin and bone). If anterior crowns= may have to replace! Since we are creating recession

2) Ortho extrusion of tooth

Front 320

What are the soft tissue requirements needed in order to use a ovate pontic?

Back 320

Front 321

How long is the scultping period for an ovate pontic?

Back 321

3-4 months

Front 322

What are 2 methods to ensure pontic height is preserved?

Back 322

1) Ovate pontic site development OR

2) Ridge preservation procedure (ie. Place a graft at time of extraction)

Front 323

Pictured here is a patient who got extraction of 11 and had a FPD placed. Patient isn't happy with the results. What could have been done differently to avoid this result? What can you do to fix this?

Back 323

Avoid it: Wait at least 8 weeks after extraction prior to taking final impression!

Alternatively we can crown lengthen the abutments

Front 324

What is it a good idea to do a free gingival graft as a ridge augmentation procedure?

Back 324

FGG=good for vertical and horizontal ridge augmentation

Front 325

What is it a good idea to do a Connective tissue pedicle as a ridge augmentation procedure?

Back 325

Good for horizontal ridge augmentation

Front 326

What is it a good idea to do a Pouch graft procedure as a ridge augmentation procedure?

Back 326

Good for both horizontal and vertical ridge augmentation

Front 327

What are the Goals of Periodontal Maintenance

Back 327

*

Prevent or minimize recurrence of disease

*

Prevent or reduce incidence of tooth or implant loss

*

To ↑ probability of locating and treating disease in a timely fashion

*

Monitor peri-implant status

*

Assess condition of implant-supported

prostheses

*

Evaluate plaque control

Front 328

T/F: Maintenance phase can be performed on a periodontium with active disease

Back 328

F: Can only maintain a stable periodontium!

if periodontium is unstable then this patient is NO LONGER A MAINTENANCE PATIENT!!!

Front 329

What are the criteria for a stable periodontium?

Back 329

1. Stable (preferably shallow) PDs + ALs

2. No inflammation

3. No abscesses

Front 330

List the 7 components of Periodontal maintenance

Back 330

A) Update Med/Dent Hx

B) CLinical exam and compared to baseline

C) Radiographic Exam

D) Assessment of Oral Hygiene

E) Tx

F) Communication

G) Planning

Front 331

List the things that are done during "Treatment" in periodontal maintenance

Back 331

*

Removal of bacterial plaque – supra/subgingival

*

Behavioral modification: OHI, Counseling, adherence to PM intervals

*

Selective Root planning + Implant debridement

*

Occlusal adjustment

*

Use of systemic antibiotics, local antimicrobial agents

*

Surgical therapy (discontinuation of PM + treatment of recurrent disease).

Front 332

In private practice, how often should a patient have their periodontium evaluated?

Back 332

every 6 months

Front 333

What are biological basis behind Periodontal maintenance?

Back 333

*

PM can limit recurrent periodontitis

*

Patients on PM have ↓ PDs, ↓ CAL, ↓ tooth loss, compared to those who are not

*

Patients rarely effective in completely removing plaque

*

Pocket debridement suppresses subginginval microflora, but pathogens return to pretx. levels in 9-11 weeks

*

It is not possible to predict progression of perio disease ∴PM provides periodic monitoring

Front 334

Is there a set time for how long a Periodontal maintenance should be? (ie. All maintenance appointments should be 1 hour)

Back 334

NO! Time required should be individualized!

based on:

– # of teeth/implants
– Oral hygiene levels + compliance

– Systemic health

– Hx. Of disease

Front 335

T/F: Periodontal maintenance is not necessary if the surgery was successful

Back 335

F: Any surgical procedure no matter how proficiently done will fail without PM

Front 336

How much faster do patients who aren't treated and maintained lose teeth compared to patients that ARE treated and maintained?

Back 336

Patients who aren't treated or maintained lose teeth approx 3.5X faster

Tx and maintained =(lose tooth every 9.1 years)

No Tx and maintenance = lose tooth every 2.8 years

Front 337

How much faster do patients who are treated but not maintained lose teeth compared to patients that are both treated and maintained?

Back 337

approx 2x faster

Tx and maintained =(lose tooth every 9.1 years)

Tx and but no maintenance = lose tooth every 4.5 years

Front 338

What are some proposed reasons for why compliance is so poor with Periodontal maintenance?

Back 338

Possibly because Perio dz is chronic and non-threatening

-Economics

-Fear

-Others (Lack of compassion or re-enforcement from dental team)

Front 339

What factors tend to decrease patient compliance with periodontal maintenance?

Back 339

young age, smokers, non-surgically treated patients

(Sx: patient don't want have to do surgery again)

Front 340

The study that came up with the 3 month recall...what is a problem in the patient selection for that study?

Back 340

Patients with Non-Sx and Sx Tx were placed in the same recall pool.

therefore: study doesnt' suggest Non-Sx therapy is only kind of therapy needed!

Front 341

What was the conclusion from the study about 3 month recalls?

Back 341

Personal OH/plaque scores not critical for maintenance of periodontal support if pt. received PM every 3 months

Front 342

What is effect of gingival

inflammation if have 3 month

recall?

Back 342

*

OH which impacts on levels of GI has no effect on PD and ALs if 3 month maintenance

*

Provides further evidence that gingivitis doesn't lead to periodontitis

Front 343

What does the data suggest about the periodontal maintenance of patients who have a history of perio dz?

Back 343

4x/year

Front 344

What are the 4 parameters that must exist before you can make the dx of recurrent gingivitis?

Back 344

*

No deep probing depths

*

BOP / Suppuration / Redness or other signs of inflammation

*

No progressive attachment loss or marginal recession

*

Persistent damage from previous periodontitis and associated treatment in the form of gingival recession and some radiographic evidence of bone loss

Front 345

Patient comes to you during a new patient exam and you make the dx of recurrent periodontitis. Is this possible?

Back 345

NO! At a single visit it is not possible to determine if previously treated periodontitis is recurring

Front 346

What are some clinical indicators of recurrent periodontitis?

Back 346

-Bleeding on probing at multiple PM visits (these sites are more likely to develop attachment loss)

-↑ in Probing Depths
-↑ in Clinical Attachment Loss

Front 347

Patient probing depths of 2s and 3s, no signs of BOP or edema, but there are clear signs of attachment loss(Exposure of root surface). What is the Dx?

Back 347

Marginal recession.

Front 348

What is definition of Recurrent/Refractory periodontitis?

Back 348

Disease that is not readily yielding to treatment

Front 349

What is refractory periodontitis characterized by?

Back 349

Progression of :

– Clinical attachment loss
– Bone loss
– Tooth loss

Despite seemingly adequate therapy

Front 350

List the 7 etiologies of Recurrent/Refractory Periodontitis?

Back 350

1) Inadequate or inappropriate treatment

• Ex. Non-surgical treatment only

2)Inadequate maintenance

• Non-compliance or too long of an interval

3) Inadequate plaque control

• Recall effect of poor supragingival plaque control (Lecture #3) 4) Undetected systemic disease

• Diabetes, neutrophil abnormalities, blood dyscrasias, etc.

5) Poor immune/host response

6) Persistent pathogens

7) Smoking

Front 351

What's a type of host modification therapy?

Back 351

low dose doxycyclin

Front 352

If a patient has been diagnosed with recurrent periodontitis and doesn't require sx, what is the staple treatment they require?

Back 352

Non-Sx treatment with antibiotics!

Followed by OHI and a tight 3 month recall schedule

Front 353

What is the typical regimen for clindamycin when it is used as tx for recurrent periodontitis?

Back 353

150 mg qid X 7 days

Front 354

What is the typical regimen for Amox + Metronidazole when it is used as tx for recurrent periodontitis?

Back 354

Amoxicillin 375 mg tid + Metronidazole

250 mg tid X 7 days

Front 355

What is the typical regimen for Amox + Clavulin when it is used as tx for recurrent periodontitis?

Back 355

Amoxicillin/Clavulin 250 mg tid X 2 weeks

Front 356

What is the rationale behind using plastic currettes to maintain implants?

Back 356

Metal and ultrasonic instruments were found to scar implant surfaces. Plastic currettes are thought to be cause minimal or no significant changes to implant surface. However there is No clinical data to support hypothesized relationship between implant maintenance technique and implant failure.

Front 357

Pt has recurrent gingivitis or mild chronic periodontitis...who should do the Periodontal maintenance?

Back 357

GP

Front 358

Pt has hx of chronic periodontitis and moderate attachment loss...who should do the Periodontal maintenance?

Back 358

Alternate between GP and Periodontist

Front 359

Pt has hx of severe periodontal Attachment loss or aggressive periodontitis...who should do the Periodontal maintenance?

Back 359

Periodontist

Front 360

Pt with dental implants + extensive periodontal prostheses+ concurrent ortho therapy who should do the periodontal maintenance?

Back 360

Periodontist

Front 361

Describe the process responsible for dentin hypersensitivity after SRP?

Back 361

Initiation: smear layer that develops over root dentin follow SRP, but dissolves over 1 week= exposed dentin tubules.

Remission: Natural occlusion of tubules by mineral deposits

Front 362

How long does dentin sensitivity last?

Back 362

Peaks within 1 week of therapy and then disappears

Front 363

2 proposed mechanisms behind dentin hypersensitvity?

Back 363

1) Open tubules = ingress of bacteria --> increase pulpal inflammation --> sensitization of pulpal nerves

2) Hydrodynamic theory (fluid shift in dentinal tubules)

Front 364

What are the factors which impact degree of dentinal hypersensitivity?

Back 364

1) Open tubules

2) Tubular Sclerosis

3) Tertiary Dentin

Front 365

What are the four main treatments for Dentin hypersensitvity?

Back 365

*

K+ containing agents (nerve desensitiziation)

*

F- containing agents (promotion of tubular

occlusion, sclerosis)

*

Bonding/filling materials (tubular occlusion)

*

Root coverage (tubular occlusion)

Front 366

What is the last resort to tx dentin hypersensitivity?

Back 366

Endo

Front 367

Definition of Osseointegration

Back 367

Direct structural connectionat the light microscopiclevel between bone + thesurface of a load carryingimplant

Front 368

What is the typical % of osseointegration observed between bone and implant?

Back 368

50-60%

Front 369

What are the requirements for osseintegration? (6)

Back 369

1. Biocompatible (Titanium)

2. Implant design (Cylindrical + threaded)

3. Healthy and vital bone

4. Atraumatic and low Temp sx technique

5. Surface finish: rougher>smoother

6. Loading conditions: No movement during healing

Front 370

What the 2 types osteogenesis that occur during the process of osteointegration?

Back 370

Distance Osteogenesis

Contact Osteogenesis

Front 371

What is distance osteogenesis?

Back 371

New bone is formed on the surfaces of the '􏰁old bone'􏰀 in the peri-implant site (Bone is grown from outside in towards implant surface)

Front 372

What is contact osteogenesis?

Back 372

New bone forms 1st on the implant surface and thenprogresses outwards (towards edge of osteotomy)

Front 373

what process recruits osteogenic cells onto the implant surface prior to contact osteogenesis?

Back 373

Osteoconduction

Front 374

Briefly list the 5 steps of implant healing immediately following surgery (5)

Back 374

1. Bleeding

2. Blood clot, platelets--> growth factors induce contact osteogenesis

3. blood clot forms fibrin network

4.Mechanical stability

5. Coagulum fills chamber b/w threads

Front 375

Criteria for implant success (5)?

Back 375

1 An individual, unattached implant should be immobile whentested clinically

2. No per-implant radiolucency

3. Vertical bone loss around implant should not exceed 0.2mm per year following the implant's first year of service

4. Need to be absence of persistant S&S or sensation

5. At the end of 10 years, 80% of individually placed implants should be successful in the context of these criteria

Front 376

List the 4 classifications of bone quality for implants

Back 376

Type 1 bone: Almost the entire jaw is composed of homogenouscompact bone (found predominantly in Md. anterior)

Type 2 bone: A thick layer of compact bone surrounds a core ofdense trabecular bone (Mx. anterior, md. posterior)

Type 3 bone: A thin layer of cortical bone surrounds a core of densetrabecular bone (mx. anterior, md. posterior, mx. posterior) – Type 4 bone: A thin layer of cortical bone surrounds a core of low-density trabecular bone (mx. posterior)

Front 377

Of the different types of bone quality, which types are the best for implant success?

Back 377

Types 1-3

Front 378

How do the supracrest fibers differ between tooth and implant?

Back 378

Tooth: oriented at different angles and fan out but some perpendicular to the tooth

Implant: Supracrestal fibers: Oriented predominantly parallel to the tooth

Front 379

How does the orientation of the supracrestal fibers in implants affect perio probing?

Back 379

-There will be ↓ resistance towards perio probing onimplant vs. tooth sites

-The tip of the probe will consistently be positioned deeper in the connective tissues on implants than on teeth.

Front 380

What is the distance between probe tip and bone in teeth? in implants?

Back 380

Teeth: 1.2mm

Implants: 0.2mm

Front 381

What is the type of proprioception used in real teeth? What about implants? Which one is better?

Back 381

Teeth: Periodontal Mechanoreceptors

Implants: Osseoperception

-Teeth have better proprioception.

Front 382

What does most of the stress concentrate when an implant is being loaded?

Back 382

Stress concentrates at the crestal bone

Front 383

What is the axial mobility of an implant? what about a tooth?

Back 383

Implant: 3-5um

Tooth: 25-100um

Front 384

What are some signs of implant overloading?

Back 384

Screw loosening or fracture, abutment or prosthesis fracture, bone loss, implant fracture

Front 385

What is the mean bone loss for implants during the 1st year of function?

Back 385

1mm

Front 386

What is the mean bone loss for implants between 1 and 20 years post op?

Back 386

1-2mm

Front 387

When looking at success rates for initial endo treatment, which conditions/factors negatively affected the success rate?

Back 387

presence of Peri-apical lesions, >2 roots, complications present (aberrant anatomy, crack in pulp chamber, perforation, file breakage, calcified canals)

Front 388

with regards to initial Endo treatment, which of the following has the highest odds ratio for failure? Peroperative radiolucency, # of roots or Complications?

Back 388

Radiolucuency! (3.55) followed bt number of roots (2.17) and complications (2.23)

Front 389

When looking at success rates for endo Non-surgical retreatment, which conditions/factors negatively affected the success rate?

Back 389

Periapical lesions pre-op, perforations pre-op, temporary restoration at follow-up

Front 390

with regards to Endo treatment, which of the following has the highest odds ratio for failure? Peroperative filling quality, Preop perf or restoration at follow up?

Back 390

Perf (26.52) followed by restoration (14) and last is pre-op filling quality (6.61)

Front 391

When is surgical re-treatment conducted for previously endo treated teeth?

Back 391

When large periapical lesion (>5mm)

Front 392

How many more times likely is a surgical re-treatment likely to fail if you have a >5mm lesion vs. <5mm lesion?

Back 392

2x more likely

Front 393

Is the overall success rate higher for NSRCT re-treatment or surgical retreatment?

Back 393

NSRCT re-treatment

Front 394

What factors are associated with only a 75-85% success rate for endo treatment

Back 394

-Teeth with periapical pathology (≤ 5mm)

-Teeth requiring initial, non-surgical or surgical re-treatment

-Multi-rooted teeth

Front 395

What factors are associated with only a >90 % success rate for endo treatment?

Back 395

-Teeth without any periapical pathology

-Teeth requiring initial or non-surgical re-treatment

-Teeth without any complications

-Single rooted teeth

Front 396

What factors are associated with only a 40-65% success rate for endo treatment?

Back 396

-Teeth with large (> 5mm) periapical pathology --Teeth for surgical re-treatment

-Teeth with complications

-Teeth with Multiple roots

Front 397

In the meta-analysis that looked at 92 papers that evaluated success of implants vs. fixed partial dentures, what was the overall success rate for single implant restoration?

Back 397

95.1%

Front 398

In the meta-analysis that looked at 92 papers that evaluated success of implants vs. fixed partial dentures, what was the overall success rate for fixed partials of all designs?

Back 398

84.0% (include maryland bridges)

Front 399

What is the typical failure pattern with conventional fixed partial dentures?

Back 399

Small early failure rate, followed by increasing failure with time

Front 400

What is the typical failure pattern with Implant supoorted restorations?

Back 400

Small but rapid early failurerate followed generally stable long-term service

Front 401

List 3 complications that can cause implant failure (most common to least common)

Back 401

1) Screw loosening or fracture

2) Material wear/Cement failure

3) Implant fracture (rare)

Front 402

List 4 complications that can cause fixed partial dentures (most common to least common)

Back 402

1) Caries

2)Endodontic pathology

3) Material wear/Cement failure

4) Loss of abutment teeth

Front 403

What are some factors that may make us sway for implants over fixed partial dentures for tooth replacement?

Back 403

• Young patient (18+)

• Unrestored dentition

• Patient with high caries risk

• ↑ Endodontic complications

• ↑ Loss of abutment teeth

Front 404

What are some factors that may make us sway for fixed partial dentures over implants for tooth replacement?

Back 404

-Older patient

-Heavily restored dentition

-Teeth already RCT

Front 405

What are the 3 broad categories of implant placement?

Back 405

1) Immediate (right after exo)

2) Early (after soft tissue healing 4-8 weeks)

3) Late (beyond 8 weeks)

2&3 are delayed implant placement

Front 406

2 main driving forces behind immediate implant placement?

Back 406

1) Reduce tx time

2) improve esthetic outcomes

Front 407

Which types of implant placement (early, late etc.) may need bone subtitute and membrane?

Back 407

Immediate and Early

Front 408

Of the different timings of implant placement, which one is the easiest to achieve ideal implant positioning?

Back 408

Late

Front 409

How is primary stability achieved in immediate and early implant placement?

Back 409

Apical + lateral stabilization

Front 410

Are immediate implants successful?

Back 410

They are predictable with only 5-8% lower than delayed implants

Front 411

T/F: Immediate implants are more esthetic because they preserve bone and prevent remodeling of the socket

Back 411

False. Remodelling ocurs no matter what and occurs more on the buccal than lingual

Front 412

Are immediate implants more esthetic?

Back 412

No definitive evidence to prove this. Many studies find no difference in esthetics of immediate implants versus delayed implants

Front 413

How many mm reduction in buccal-lingual width is observed in a socket post extraction within the first year?

Back 413

2.7-5.2mm

Front 414

Which socket sites in the mouth have increased bone loss post exo?

Back 414

Molar sites have more loss than non-molar sites

Front 415

How much bone height is lost on average during socket remodeling?

Back 415

0.8-0.9mm

Front 416

How much of the remodeling occurs within the first 6 months?

Back 416

85%

Front 417

What is a potential consequence of immediate placement of implant without doing any ridge augmentation?

Back 417

dehiscence

Front 418

How do we minimize bony remodeling following extraction?

Back 418

Use of a bone graft within the socket and an overlying membrane to ensure lack of epithelial or connective tissue downgrowth. In general, it's always good idea to place bone at time of exo. It's easier to preserve bone rather than trying to regain it

Front 419

How much more bone loss is observed in sockets without ridge augmentation procedures compared to those that received it?

Back 419

1.6 mm and 2.2 mm greater loss of ridge width and height(respectively) without ridge preservation

Front 420

What is the prognosis of placing an implant in an infected site (due to previous PA pathology)?

Back 420

Some evidence says it's possible but make sure you debride the site effectively and rebuild the buccal bone with grafting to achieve primary stability.

Front 421

What are the different loading protocols for Implants?

Back 421

Immediate (within 1 week) post implant placement

Early (1-8 weeks)

Conventional (>8 weeks)

Front 422

Can you immediately load full arch implant cases?

Back 422

Yes but usually it requires multiple long splinted units with x-arch stabilization

Front 423

How are multi-unit cases or single fixture implants typically loaded?

Back 423

first immediately restored and then immediately loaded

Front 424

Can you achieve success with immediately loading?

Back 424

Yes but there is a high failure rate for inexperienced providers!

Front 425

What are the 3 factors that help with success of immediate loading?

Back 425

-Achieving high primary stability >30 Ncm2

- Multiple long splinted units with x-arch stabilization(typically full arch cases)

– If single fixtures used (no occlusal loading, ie. non-functional provisional)

Front 426

When is the bone-Implant interface the weakest?

Back 426

Most implant failures occurrs within 3-5 weeks following loading

Front 427

Does immediate restoration = improved esthetics throughsculpting/support of tissues during healing?

Back 427

Studies Found no differences in interproximal papilla or bone levels inimmediate vs delayed restoration

-most important factor was distance from contact point to pre-op bone level on adjacent teeth

Front 428

What is a benefit of immediate restoration?

Back 428

Provides a fixed provisional

Front 429

What is the minimum distance between the edges of 2 implants placed side by side? Why?

Back 429

3mm. Less than this and the two remodeling sites will overlap, leading to increased crestal resorption and interproximal bone loss.

Front 430

What is the minimum distance required between a tooth and implant? What is the problem of placing an implant too close to the tooth?

Back 430

1.5mm-2mm. Less than this and this is a high risk of losing the interproximal papilla

Front 431

If you were to place a standard platform (4mm in width) implant in a site with neighbouring teeth, what is the minimum mesial distal width required?

Back 431

7 mm (1.5+4+1.5)

Front 432

If you were to two standard platform (4mm in width) implants in a site with teeth on either side of the edentulous site what is minimum mesial distal width required?

Back 432

14 mm (1.5+4+3+4+1.5)

Front 433

If you were to place a narrow platform (3.3mm in width) implant in a site with neighbouring teeth, what is the minimum mesial distal width required?

Back 433

~6.5mm (1.5+3.3+1.5)

Front 434

How far below the buccal gingival is the platform on a single piece fixture implant typically placed?

Back 434

1-2mm

Front 435

How far below the buccal gingival is the platform on a 2 piece fixture implant typically placed?

Back 435

3-4mm

Front 436

for a patient with excessive loss of hard/soft tissue loss such as the one shown here, what are some procedures they need before they can receive implants?

Back 436

– Vertical ridge augmentation (unpredictable)

– Soft tissue grafting (may be multiple)

Front 437

For the compromised anterior implant case such as the one shown here, what are some keys to success for managing this case?

Back 437

– Provision of a wax – up and honest discussion with patient about realistic expectations

– Assessment of smile line

– Consideration for provision of bridge work instead of single fixtures

Front 438

Why might be a good idea to consider an implant supported bridge versus single fixture implants in this case?

Back 438

Papilla fill is much easier obtain in pontic-pontic situations compared to implant to implant

Front 439

Definition of Implant survival?

Back 439

Applies to those implants which are still in function butwhich do not meet (in 1 or more ways) the definedcriteria of implant success

Front 440

Definition of Implant failure?

Back 440

When the performance of an implant measured in somequantitative way falls below a specified, acceptable level.(great deal of arbitrariness). In general, mobility is considered failure

Front 441

What are typical rates of implant success from long term studies?

Back 441

Machine surfaced implants (oldest type):

70% Maxillary and 76% success rate

TiUnite (Nobel), Osseotite and SLA (straumann) have overall success rates of greater than 95%

Front 442

What are the 4 general categories of implant failure?

Back 442

1. Biological

2. Mechanical (fractures of the different components)

3. Iatrogenic

4. Inadequate patient adaptation (psychologica

Front 443

What are the two subcategories within Biological implant failure?

Back 443

Early: Failure to establish Osseointegration

Late: Failure to maintain osseointegration

Front 444

What are 4 reasons for early failures of implants?

Back 444

improper preparation of site (surgical)

Bacterial Contamination (sterilization)

Lack of primary stability

Premature loading

Front 445

What are 2 reasons for late failures of implants?

Back 445

Excessive load (prosthetics)

Infection (perimplantitis)

Front 446

What are the factors that can cause excessive load type failures?

Back 446

1) Insufficient bone volume (width + height)

2) Deficient bone quality (density)

3) Occlusal Overload

Front 447

What is the failure rate of implants in the maxilla versus the mandible?

Back 447

3X more failures in the maxilla than mandible

Front 448

What are some clinical signs of an early infection after implant placement?

Back 448

Swelling

Fistulas

Suppuration

Mucosal Dehiscences

None of these are a good sign.

Front 449

What are the four diagnostic criteria for implant failures?

Back 449

1) Clinical sign of early infection

2) Pain or sensitivity

3) Mobility (always a clear sign of failure)

4) Radiographic signs (peri-implant radiolucency)

Front 450

What are the 3 diagnostic criteria for a failing implant

Back 450

1. Progressive X-ray bone loss (If bone loss is >1.5 mm in 1st year or >0.2 mm everysubsequent year)

2. Clinical signs of late infection (Hyperplastic soft tissues, suppuration, swelling)

3. Probing depth (progressive increase)

Front 451

What are some endogenous factors that impair bone healing or interfere with maintenance of bone healing in implants?

Back 451

Age, Systemic Health (diabetes, smoking), Periodontal disease, Bone quality (Grafted/non-grafted, radiation)

Front 452

What are some exogenous factors that contribute to implant failures?

Back 452

Operator experience

Operator technique + policy

Front 453

How old should a patient be to undergo implant

placement?

Back 453

-Most important criteria is make sure skeletal and dental growth is completed. (study found eruption occurred even at 19)

-Also make sure there is no delayed passive eruption

Front 454

What is the leading causes of implant failure?

Back 454

Smoking, but seems to be have less of a negative impact on rough surface implants

Front 455

How does smoking cessation affect chances of implant failure?

Back 455

If smokers are able to stop for 1 week prior to implantplacement and continue for 8 weeks afterwards theirimplant failure rate ~ non-smokers

Front 456

Are there higher failure rates in patients with Type II diabetes?

Back 456

Maybe, but there are no definitive conclusions from studies yet

Front 457

How do the SURVIVAL rates and SUCCESS rates of patients with treated periodontitis disease differ?

Back 457

Survival rates are the same but success rates ARE lower

Front 458

Can you predict success failure in patients who have active periodontitis?

Back 458

No predictions can be made to patients withuntreated periodontitis but inferences arestrongly implicated

(History of Chronic PDz success rate is 71% but No previous PDz success rate is 95%. Secondly, if you have history of PDz, your chance of Peri-implantitis is 29% but only 6% if you don't have a history of periodontal disease)

Front 459

List the clinical features of Peri-implantitis

Back 459

Presence of plaque

• Bleeding on probing

• Changes in contour and color

• Presence of deep probing depths (Progression more important than absolute!)

• Radiographic evidence of bone loss

Front 460

What cells are significantly affected by Radiation therapy?

Back 460

Bone cells and Blood vessels. The tissues become hypocellular, hypoxic and hypovascular

Front 461

Rank the following in terms of their implant survival rates: irridiated residual bone,non-irradiated residual bone, grafted bone (irradiated residual)

Back 461

1. Non-irradiated residual bone = 95% survival

2. Irradiated residual bone = 72% survival

3. Grafted bone (irradiated residual) = 54% survival

Front 462

How many times higher are failure rates of implants performed by inexperienced surgeons compared to those with experience?

Back 462

2X

Front 463

Do angulated abutments increase implant failure rates?

Back 463

No

Front 464

should you prescribe antibiotics prophylaxis before implant placement?

Back 464

no good scientific evidence to recommend or discourage antibiotic prophylaxsis for implant surgery

Front 465

what impact does Chx have on implant failure rates?

Back 465

Chx rinse bid for 2 weeks reduces infections by 2.5x. This decreases implant failure rates because early infections increases implant failure rates by 6x.

Front 466

What are the effects of leaving behind cement?

Back 466

increased tissue inflammation, abscess and bone loss

Front 467

List some things that can cause overloading of an implant

Back 467

Overextended cantilever

-Parafunction

-excessive premature contacts

-Large occlusal table

-steep cusp inclination

-poor bone density/quality

-Inadequate number of implants

Front 468

Does splinting implants improve success rate?

Back 468

No human clinical trials demonstrating thatsplinting implant restorations has + long-term effect.

Front 469

Does length of an implant affect implant failure rates?

Back 469

-<10mm fail more than >10mm implants

-If there is adequate bone: consider putting in >10mm fixtures

Front 470

What is a failing implant?

Back 470

An implant that exhibits progressive bone loss, but is still immobile

Front 471

What is Peri-mucositits?

Back 471

Reversible inflammatoryreaction to mucosa adjacent to implant

Front 472

What is Peri-implantitis

Back 472

IrreversibleInflammatory process additionallycharacterized by loss of peri-implant bone

Front 473

How common is Peri-mucositis?

Back 473

50%

Front 474

How common is Peri-implantitis?

Back 474

12-25%

Front 475

what is the Peri-mucositis analogous to and what are its clinical features?

Back 475

Gingivitis

-Presence of plaque

- Bleeding on probing

-Changes in contour and color

-Shallow probing depths

- No radiographic evidence of bone loss

Front 476

What is the evidence that peri-mucositits is equivalent to gingivitis?

Back 476

Study asked implant patients to stop OH for 3 weeks. Results:

1) Similar amounts of plaque formed on both implants+teeth

2) Composition of plaque formed was similar on both implants+ teeth

3) Resultant inflammatory in filtrate was equal in size on bothimplants + teeth

Front 477

what is the Peri-implantitis analogous to?

Back 477

Periodontitis

Front 478

What strain of bacteria are found around implants with per-implantitis?

Back 478

Same as those found within periodontitis!

-P. ginigvalis

-P. intermedia

-P.Actinobacillus

Aa

Front 479

how do the inflammatory infiltrate differ between peri-implantitis and

Back 479

Similar but peri-implantitis the infiltrate is deeper

Front 480

Average value for the biological width for an implant?

Back 480

3.8mm

GM-JE=2.14mm

CT=1.6mm

Front 481

How much How much force should be used when probing implants?

Back 481

0.2-0.3N (if you apply the same force on your fingernail, the fingernail should just start to blanch)

Front 482

How much more sensitive are implants compared to teeth when it comes to probing?

Back 482

2X

Front 483

How many days does it take for the JE to reattach to the surface of the implant after probing?

Back 483

5 days

Front 484

What clinical sign observed around an implant is an indication for systemic antibiotic tx?

Back 484

Suppuration

Front 485

What sign found during your clinical exam of an implant is a cardinal sign of inflammation?

Back 485

Bleeding on probing (0.25N). Presence of BOP is a good indicator of disease progression around implants.

Front 486

What clinical sign is a good indicator of clinical stability of an implant?

Back 486

Absence of BOP

Front 487

What is suppuration at an implant site an indication of?

Back 487

active disease destruction. You have a inflammatory mediate destruction of collagen+tissue necrosis that leads to pus formation

Front 488

List the intervals that radiographs should be taken post implant placement

Back 488

1) Abutment connection

2) Following crown/bridge installation

3) Within 6-12 months of prosthetic function

4) In intervals of every 2-3 years in asymptomatic patients

Front 489

What are 3 reasons radiographs are a important component of your evaluation of a implant?

Back 489

Ensuring maintenance of crestal bone

• Evaluation of continued osseointegration

• Evaluation for prosthetic complications

Front 490

Although mobility is the definitive test for implant failure, why can it not be used as a stand alone measurement?

Back 490

NOT sensitive. You can lose 90% of bone around the implant and it can still be rock solid

Front 491

What are some features of Clinically stable implants?

Back 491

-Presence of clinically healthy peri-implant tissues

- Absence of Plaque

- Absence of BOP

- Absence of suppuration

- Probing depth ≤ 3mm

Front 492

Why is a deeper PD value (ie. 4-5mm) alone not really indicative of disease in a implant?

Back 492

A deep PD might be deliberate because the surgeon placed the platform deeper to achieve a better emergence profile for the restoration. However, really deep probing depths (ie. 10mm) is not good because it's hard to clean.

Front 493

What is the name of the tx protocol that was developed to treat peri-implantitis?

Back 493

CIST: Cumulative Interceptive Supportive Therapy

Front 494

What is the hierarchy of CIST tx for implants?

Back 494

1) Mechanical Debridement

2) Antiseptic Therapy

3) Antibiotic Therapy

4) Regenerative or resective therapy

Front 495

An Implant has:

Plaque and calculus

BOP

No suppuration

PD<3mm and stable.

What CIST protocol should you employ?

Back 495

CIST Protocol A: Mechanical Debridement

Front 496

What is material is recommended to mechanically debride implants?

Back 496

Titanium

Front 497

Implant has Plaque and calculus,

BOP positive, Suppuration negative and Probing depths of 5mm. What CIST protocol should be employed?

Back 497

CIST Protocol A+B:

Mechanical Debridement (A) +

Antiseptic cleaning (B).

Antiseptic cleaning involves 0.1% CHX gel BID for 3-4 weeks

Front 498

Implant has Plaque and calculus, BOP positive, Suppuration positive and Probing depths of 5mm. What CIST protocol should be employed?

Back 498

CIST Protocol A+B: Mechanical Debridement (A) + Antiseptic cleaning (B). Antiseptic cleaning involves 0.1% CHX gel BID for 3-4 weeks

Front 499

Implant has Plaque and calculus, BOP positive, Suppuration positive and Probing depths of >6mm and Radiographic signs of bone loss. What CIST protocol should be employed?

Back 499

CIST Protocol A+B+C.

C is systemic antibiotic therapy.

OR CIST Protocol A+B+C+D

D is regenerative or resective therapy.

(if CIST protocol ABCD is chosen, infection should be resolved first before doing resection/regeneration)

Front 500

Is re-osseointegration possible with regenerative surgery in failing implants?

Back 500

No histological evidence currently demonstrates that this occurs

Front 501

Why is it so hard to detox a implant?

Back 501

implants are much more rough and rugged than cementum. The scalers and cavitron will only clean the peaks but not the valleys of the implants. (air embrasure can potentially hit those valleys0

Front 502

When is CIST protocol E (Extraction) employed for an implant?

Back 502

- If implant becomes clinically mobile during active phase of treatment

-If peri-implant infection cannot be controlled(Suppuration, BOP, PD ≥ 8 mm, ± pain)

Front 503

How successful is the CIST protocol in treating implants with peri-implantitis?

Back 503

ranges from 87-58%.

In a study with 26 Perimplantitis cases,

7 ended being extracted

4 lost more bone

9 were unchanged

6 gained bone

Front 504

If a patient lost teeth due to chronic periodontitis and replaced them with implants, how much more likely are they going to get peri-implantitis compared to healthy patients?

Back 504

5x more likely

Front 505

Do Patients who have lost teeth due to chronic periodontitis and replaced them with implants have a lower success rate compared to healthy patients?

Back 505

Yes. there is a 11% difference in success rates in patients with a hx of Chronic periodontitis versus healthy patients

Front 506

How do we avoid peri-implantitis in a patient with a history of chronic Pdz?

Back 506

1) Complete Perio exam prior to implant

2) Treat the Pdz before the implant!

3) Patients with history of treated periodontal disease that nowhave a stable peridontium should be maintained closely

Front 507

In a 10 year study that looked at implants in chronic PDz versus healthy patients, was there a difference in cumulative bone loss?

Back 507

Yes. Periodontitis patients lost an average of 1.7mm while only 0.7mm in healthy patients.

Front 508

In a 10 year study that looked at implants in Generalized aggressive periodontitis versus healthy patients, was there a difference in cumulative bone loss and success rate?

Back 508

Yes.

-Aggressive perio lost 3.37mm of bone while healthy patients lost 1.24mm

-Implant survival rates were only 83% for aggressive PDz compared to 100% for healthy patients

Front 509

Which implant patients should be placed on a 3 month recall frequency?

Back 509

-Patients with some risk factors and/or a history ofperiodontal disease

-Patients with a history of peri-implant diseases

Front 510

Which implant patients should be placed on a 6 month recall frequency?

Back 510

No hx of PDz, single or multiple fixtures

Front 511

What cells do Osteoblasts become once they are trapped in their newly formed bone matrix? What is the name of the connection between a Osteophyte and Osteoblast?

Back 511

Osteocytes. They connect to Osteoblast by canaliculus

Front 512

What happens to the osteoblasts after distant osteogenesis occurs?

Back 512

They die a horrible death. The process of making bone cuts off their own blood supply.

Front 513

What is the cement line in osteogenesis and where do you see it?

Back 513

Cement line is a calcium collagen free matrix that seperates old bone from new bone. It is seen on the surface of the implant

Front 514

what are the first things that bind to the surface of an implant. What do they release?

Back 514

Platelets. They release cytokines and growth factors such as :

1) platelet derived growth factor

2) transforming growth factor beta

3) Neutrophil activating peptide.

Front 515

what on the implant activates the platelets to release cytokines?

Back 515

The Implant surface topography. The smaller the topography, the more activation of platelets there is

Front 516

What is activated as a result of the release of the cytokines from the platelets on the implant surface?

Back 516

White blood blood cells and other platelets in the periphery of the implant are activated.

Front 517

What directs the Osteogenic progenitor cells to find its way to the surface of the implant?

Back 517

The density gradient of cytokines generated by platelets. The concentration of cytokines gets larger as you get closer and closer to the surface of the implant. They travel to the site via a fibrin network created by the blood clot

Front 518

What is critical for osteoblasts in order for them to maintain their metabolism?

Back 518

Angiogenesis and blood supply

Front 519

What is generated within the fibrin network as the Osteoprogenitor cells migrate along it to the implant surface? Why is this important?

Back 519

Tension and stress. Therefore, it is important the fibrin be firmly attached to the implant surface. If not, then Osteogenic cells movement can cause detachment of the connection between the implant and the fibrin.

Front 520

What happens to the Osteogenic cells reach the implant surface after migration from the periphery?

Back 520

They differentiate into osteoblasts

Front 521

What is the most important factor dictating how strong the adhesion is between the fibrin network and the implant?

Back 521

The Implant topography.. likely why SLA (rough) implant has earlier implant stability than Turned implants because you have higher degrees of contact osteogenesis.

Front 522

Is there a difference in the final bone pattern on the surface of SLA and Turned implants?

Back 522

No. They are indistinguishable once healing is complete

Front 523

Why might Single piece implant designs not get as much crestal remodeling compared to 2 piece fixtures?

Back 523

Single piece implants have a microgap placedmuch higher up than two piece fixtures.

-This is because the transmucosal component ofimplant attached to fixture.

Front 524

When placing an single piece implant, what is the expected distance between the marginal of the restoration and the crest of the alveolar bone post resorption?

Back 524

Around 3mm (ie. 3.2mm in the maxilla and 3.4mm in the mandible)

Front 525

Why is understanding the biological width of implants important?

Back 525

-You need to be able to predict where your bone levels post implant restorations is going to be!

-You always need to anticipate osseous resorption and soft tissue recession especially interproximally in the anterior region.

Front 526

What is the mean papilla height between Tooth to implant?

Back 526

4.2mm

Front 527

What is the mean papilla height between implant to implant?

Back 527

3.4mm

Front 528

What is mean papilla height between implant and pontic?

Back 528

5.5mm

Front 529

What is the mean papilla height between pontic and pontic?

Back 529

6mm

Front 530

Patient missing 11 and 21 and wishes to have implants to replace them. Patient is a thin biotype with triangular shaped teeth. What should you be concerned about and what is the only option you can do to prevent it?

Back 530

You're worried about formation of a black triangle because of the poor papilla fill between implants and implants. Your only choice is to have a long contact connector.

Front 531

2 piece implants have higher osseous remodeling. What are some ways to decrease amount or remodeling?

Back 531

1) Concept of Platform switching

2) Scalloped Implant design (mimics morphologyof CEJ)