1. Rationale of Periodontal Surgery Flashcards
[reads slide] \_\_\_\_ is not diagnostic for perio disease ◦ Gives general overview ◦ But it doesn't show exactly what interdental bone levels are
____ is better tool to diagnose perio disease
Pan
FMX
BOP
• Until new classification published in 2018, gingivitis was simply recognized by ____ and CAL = ____
BOP
0
CAL
CAL = 0
OR
CAL > 0 with no evidence of progressive ____
attachment loss
Identifying a Gingivitis Case
BOP score ≥ ____% of sites
- ____ (BOP ≥ 10% and ≤30%)
- ____ (BOP > 30%).
It can occur on either ____ peridontium or ____ peridontium
10 localized generalized intact reduced
Periodontitis
◦ Periodontitis classified as deep ____, ____ and ____
PDs
CAL
BOP
Periodontitis (OLD CLASSIFICATION)
Extent:
Generalized: CAL in >____% of teeth
Localized: CAL in ≤ ____% of teeth
Severity:
Slight: CAL= ____mm or radiographic BL ≤____% and PD < ____mm
Moderate: CAL= ____mm or radiographie BL ____% & PD = ____ mm
Severe: CAL ≥____mm or radiographic BL >____% and PD ≥ ____ mm.
30
30
1-2
15
5
3-4
16-30
5-6
5
30
7
Identifying a Periodontitis case
____ CAL at ≥2 non-adjacent teeth,
OR
Buccal or oral CAL ≥____ mm with pocketing >____ mm at ≥2 teeth
the observed CAL is not due to non-periodontal causes:-
- gingival ____ of traumatic origin
- caries extending in the ____ area of the tooth
- Not on the distal aspect of a ____ molar and associated with malposition or extraction of a ____ molar
- an endodontic lesion draining through the ____
- ____ root fracture
interdental
3
3
recession cervical second third marginal vertical
• Identify first the intact vs reduced periodontium
◦ New classification
◦ If still confused about these terms, refer to classification lecture
• Pt classified as Clinical Health, Gingivitis Case, or Periodontitis Case
• [reads through Gingivitis Case]
• Periodontitis Case
◦ ____ (scored from 1-4) reflects the severity of disease and complexity of treatment
◦ ____: localized, generalized, or incisor-molar
◦ ____
‣ Risk factors: smoking, diabetes
stage
extent
grade
What’s the primary etiology of gingivitis
____
plaque
What is the goal of treatment in periodontal disease?
- Elimination of the etiologic factor
• ____
2. Elimination of the local contributing factors • \_\_\_\_ • Pockets • \_\_\_\_ - Crown margins • Cervical enamel projections • \_\_\_\_ groove
- Control of the systemic contributing factors
• ____
• Diabetes
• ____
microbial plaque
calculus
overhangs
distopalatal
smoking
medications
What is the Sequence of Treatment in Periodontal Disease?
I. Phase I Therapy (non-surg)
Step 1: Plaque or Biofilm Control ____
Step 2: Removal of ____ or Biofilm and Calculus
Use of antimicrobial agents if needed,
Treatment of occlusal trauma
Extraction of hopeless teeth
Step 3: ____ and/or replacing Defective
Restorations and Crowns “contributing to the pockets”)
Step 4: Management of ____ Lesions
instruction
supragingival and subgingival plaque
recontouring
carious
What is after phase I therapy?
- Re-evaluation
• “Assess improvements following initial therapy”
• Ideal time ____ weeks
• Check ____, ____, ____
• Assess compliance to ____
• Assess the need for retreatment or referral
• Assess the tissue condition prior to surgical
tx
It is very important to note BOP (she sees this missing a lot on charts)
You are assessing oral hygiene of pt and their compliance to your instructions
◦ If you see no improvement, you must ____ yourself and give OHI again
◦ Bring pt mirror, brush, and floss, make them engaged and make them practice in front of
you
4-6 PD BOP mobility OHI repeat
Additional Treatment Following Re-evaluation
Active therapy should continue until all areas of ____ disease have been eliminated
• Patients who have 5mm or deeper pockets with BOP cannot go into ____
• Non-surgical
◦ [reads list]
◦ You see some factors like overhang margins that you can detect
‣ Maybe there was a lot of inflammation in the first round of SRP, but now you can see it better and correct it
• [reads surgical list]
unresolved
maintenance
What is the Sequence of Treatment in Periodontal Disease?
3 possible options after phase I re-eval
Phase I Therapy (non-surg)
- ____
- ____
- ____
re-evaluation
phase II therapy
periodontal maintenance
• Let’s say after Phase 1 Re-eval, you decide to send pt to periodontist for surgical treatment ◦ They will do necessary surgery and follow up with pt
◦ depending on type of surgery, you cannot probe
‣ If an osseous surgery was done by periodontist, cannot probe for at least ____ months
‣ If a regeneration treatment was done (Ex: GTR), no probing for ____ months
◦ You may see patients like this in clinic for recalls, encourages communication between student dentist and periodontist
3
6
• Comprehensive charting must be updated every 12 months
◦ If you don’t need comprehensive charting, you still must do ____
◦ Still checking probing depths, BOP, mobility, furcation,….just coding differently on recall 2 form
• This is important because if you see any sites breaking down after treatment,
patient must go through phase 1 therapy again
PSI (perio screening index)
Critical Probing Depth
- Study compared the effect of SRP alone vs. modified Widman flap (MWF) with the resultant level of attachment and in relation to initial pocket depth.
- SRP: caused CAL in pockets < ____ mm while gain of attachment in ____ pockets.
- MWF: induced CAL if performed in pockets < ____ mm but resulted in a ____ gain of attachment than SRP in pockets deeper than 4.2 mm.
2.9
deeper
4.2
greater
Limitation of phase I (non-surgical SRP)
____ teeth planned for extraction with 42 pockets with PD= 2-10mm
____ performed with ultrasonic and hand instruments
Root surface assessed for ____, calculus, and signs of instrumentation under magnification
7
SRP
residual plaque
Limitation of phase I (non-surgical SRP)
Instrument limit
The maximum pocket depth the instrument tip can variably reach is
• ____ mm (____mm)
Curette efficiency
The maximum depth where a plaque and calculus-free surface can be established
• ____ mm (____mm)
5.52
2-10
3.73
1-6
Limitation of phase I non-surgical SRP
• No difference in shallow pockets - notice it is still not ____%, but it is considered a successful treatment
% of tooth surfaces that are calculus-free following different modalities (SRP alone vs SRP + flap) classified according to PD
Probing Depth (1-3)
SRP: ____
SRP + FLAP: ____
Probing Depth (4-6)
SRP: ____
SRP + FLAP: ____
Probing Depth (>6)
SRP: ____
SRP + FLAP: ____
100
86
86
43
76
32
50
Limitation of phase I non-surgical SRP
82 Periodontal patients from Nebraska
7-year randomized controlled clinical trial Split-mouth design: prophy, SRP, MWF, APF
Unstable sites: ≥ ____mm CAL loss from baseline Data stratified according to PD at baseline
3
Limitation of phase I non-surgical SRP
1. Periodontal breakdown in sites that had initial PD ≥ ____ mm, was more in ____ > MWF > APF
- Breakdown rate infurcation areas following different treatment modalities:
- SRP ____%
MWF 5.9%
APF 2.6%
5
SRP
8.4
- Longitudinal studies found that all patients should be treated initially with ____, root planing, and plaque or biofilm control and that a final decision on the need for periodontal surgery should be made only after a thorough ____ of the effects of phase I therapy .
- Don’t move on to phase 2 until you have done a thorough ____
scaling
evaluation
evaluation
Which of the following describes the main goal of surgery as part of a patient’s overall periodontal therapy?
- ____ the depth of the periodontal pocket
decreases
Types of Periodontal surgical therapy
- ____ disease
- ____ plastic
- ____
periodontal
periodontal
pre-prosthetic
Phase II Therapy
Objectives:
1. Controlling or eliminating ____ disease
2. Correcting ____ conditions that favor
periodontal disease, impair aesthetics, or
impede placement of prosthetic appliances
3. Placing ____ to replace lost teeth and
improving the environment for their placement and function
periodontal
anatomic
implants
Phase II Therapy
Objectives:
- Controlling or eliminating periodontal disease
a) To access the ____
b) To reduce or eliminate ____
c) To ____ soft and hard tissues to attain a harmonious topography.
root surface
pocket depth
reshape
Resective Surgery
Gingivectomy
Indications:
1. Elimination of suprabony pockets if the pocket wall is ____ and firm
2. Elimination of gingival ____
• Contraindications:-
- Access to ____ required
- ____ zone of keratinized tissue
fibrous
enlargements
bone
narrow
Resective Surgery
Flap surgery • Indications Access for root \_\_\_\_ Gingival \_\_\_\_ Osseous \_\_\_\_ Periodontal \_\_\_\_
Five different flap techniques are mostly used: \_\_\_\_ flap Undisplaced flap, \_\_\_\_flap, Papilla preservation flap \_\_\_\_ flap (distal wedge)
instrumentation
resection
resection
regeneration
modified widman
apically displaced
distal terminal
Apically positioned flap(APF)
• Positioning flap in more ____ position to eliminate pocket
• ____ structures recontoured
Modified Widman Flap (MWF)
• MWF is similar to APF, except ____ aggressive because removing less tissue
◦ Bone is ____ and flap is sutured back on
apical
osseous
less
recontoured
Papilla Preservation flap
• ____ is included in the buccal flap for preservation
papilla
Distal Wedge technique
- Very ____ procedure
- ____ of terminal tooth
- Done to eliminate ____
common
distal
pocket
Regenerative Surgery
Regeneration of ____, CT, PDL, and cementum: Guided tissue regeneration
Using ____ and membranes
We will have separate lecture for this Vertical defect on messiah of #24 [bottom right] re-entry surgery to show that bone filled in defect
bone
bone grafts
Common conditions we face were tried to be corrected in new classfication, one of which is tissue biotype
If you can see probe, 1mm or less (thin)
In cases when pt goes through ortho and teeth need to be moved bucally, they are at risk for recession if they have thin biotype
Aberrant ____
◦ Can cause recession if positioned ____
◦ Frenum between 8 and 9 can cause diastema
‣ Frenectomy must be done for ortho treatment of diastema to be successful
Lack of ____
◦ A minimum amount of KT is not required to prevent attachment loss ONLY when the pt has ____ plaque control
Decreased ____ depth
◦ Can be more difficult for pt to brush
◦ Removable prosthesis, not enough retention
____
◦ Pt complaints
‣ Sensitivity, aesthetic
◦ Want to do some kind of root coverage procedure
frenum
high
KT
good
vestibular
recession
Inconsistent ____
◦ Usually lateral is positioned more occlusally than centrals
◦ Aesthetic - want gingival margin to be consistent
Gingival ____
◦ Aesthetics and plaque retention are problems
◦ Perform gingivectomy
excessive gingival display is an aesthetic concern
gingival margin
enlargement
Phase II (surgical therapy)
- Correcting anatomic conditions that favor periodontal disease, impair aesthetics, or impede placement of prosthetic appliances
a) To create or widen ____; “Plastic surgery techniques”
c) To cover ____ root surfaces, and to recreate lost papillae; “Esthetic surgery techniques” (____)
e) To modify the ____ and neighboring tissues to receive prosthetic replacements; “Pre-prosthetic techniques”
KT
denuded
gold standard
periodontal
Tx: coronally positioned flap with acellular dermal matrix
• Notice that the tissue is ____ after procedure
100% ____ coverage
100% ____ coverage
thicker
root
recession
Tx: free gingival graft
- Incision made at ____
- Graft taken from ____ of pt
• Much more ____ after procedure
MGJ
palate
KT
Crown lengthening
Esthetic: mainly for ____ reasons
Treatment for gingival ____
Functional: mainly for restorative reasons
To expose sub gingival ____, fracture or restorative margins
To increase ____
To avoid violation of ____ by the restoration
esthetic
excess
caries
retention
biologic width
Biologic width concept
30 human autopsy specimens with a total of 325 surfaces
Average sulcus depth was ____ mm
Average epithelial attachment was ____ mm Average connective tissue attachment was ____ mm Average biologic width was ____ mm
- 69
- 97
- 07
- 04
What is the importance of biologic width?
In esthetic crown lengthening:
The biologic width needs to be re-established either with ____ removal, osseous/ bone removal or combination.
In functional crown lengthening:
Adequate space needs to be allowed from the margin of the (future) ____ for the development of the ____
soft tissue
restoration
biologic width
What’s the etiology of the gingival display?
____
• ____ eruption and ____ induced are also correct
answers
• very common in african american population to require ____ after ortho treatment
Plaque
passive
medically
gingivectomy
Phase II (surgical therapy)
- Placing implants to replace lost teeth and improving the environment for their placement and function
- including techniques for site developments for implants (i.e.: ridge ____, sinus ____)
augmentation
lifting
- Vertical and horizontal bone loss
* Building the ____ ridge back is more unpredictable than horizontal
vertical
Freeze-dried bone graft and membrane on top
◦ Purpose of membrane: ____ and ____ (want osteoblasts to regenerate area)
space maintenance
cell exclusion
What surgical technique should we use?
Selection is based on the following considerations:
- characteristics of the ____, relation to bone, and configuration
- accessibility to ____, including furcation involvement
- existence of ____ problems
- response to ____ therapy
- patient ____, including the ability to perform effective oral hygiene and stop smoking
- ____ and general health of the patient
- ____ considerations
- previous ____ treatments
pocket depth instrumentation mucogingival phase I cooperation age esthetic periodontal
