2.13.23 Zimmer_Periodontal surgeries

Question 1

Who first mixed bone grafts with antibiotics?
Is it a good idea to do this?

Answer 1

Yukna - first mixed them (acc. to Dr. Wang)
Somerman - suggested that Minocycline can be toxic to cells if the concentration is too high. This will slow down the bone resorption & the graft will stay longer

This is why Dr. Wang - mixes tetracycline (or doxycycline) antibiotic with bone grafts for the top sinus layer. This is also why speakers mix it with bone graft for peri-implantitis grafting cases.

Slot - early studies focused on A.A. bacteria, so the early generation liked to mix bone graft with tetracycline (later on, was doxycycline)

Question 2

Describe the Baab study and Zigdon study

Answer 2

Baab - 134 mL of blood is lost during periodontal surgery (gingivectomy). THis was measured from the suction

Orthostatic hypotension - happens when 500 mL (half a liter) of blood is lost. It is treated with IV saline (or blood transfusion)

Zigdon - patients do not need to stop baby aspirin (80 mg) before the surgery.

Question 3

What are the Tylenol #1, 2, 3, 4?
What is Vicodin R and Vicodin ES?

Answer 3

Acetaminophen 300 mg, plus:
1. 7.5 mg codeine
2. 15 mg codeine
3. 30 mg codeine
4. 60 mg codeine

Vicodin ES: 7.5 mg hydrocodone
Vicodin R : 5mg hydrocodone

Question 4

Is a Coe-Pak necessary after periodontal surgery?

Answer 4

Dr. Wang study - Coe-Pak can help apically position the flap and slightly reduce patient sensitivity; however, the patient has to keep it clean.

It also reduces the dead space and, therefore, prevents infection; reduces mobility (minimally)

However: Cons of coe-pak include: Plaque retention; pressure; must be removed within 1-2 weeks; Patient discomfort due to the bulk; Takes surgical time;

Coe-Pak types: Eugenol vs. light-cure. Eugenol has a “soothing” effect on the wound surface. Some people historically mixed Coe-Pak with antibiotics and then it was refrigerated

Question 5

Describe the Caffesse study on flap access & residual calculus

Answer 5

Caffesse ‘86 - Studied 21 patients with SRP only or SRP + Access Flap. Extraction of teeth and miocroscopic evaluation of residual calculus

PD 1-3mm: 86% (SRP+ flap) vs. 86% (SRP) residual calculus
PD 4-6mm: 43% (SRP+ flap) vs. 76% (SRP) residual calculus
PD >6mm: 32% (SRP+ flap) vs. 50% (SRP) residual calculus

Waerhaug ‘78: The chance of calculus removal decreases as PD increases:
5+: 11%

Question 6

What study examines the prevalence & location of the maxillary tubercle?

Answer 6

Nery - 2.2mm thick tissues at 8mm below the CEJ
The primary location of the palatal tubercle? It is the 1st molar (at 40%) - so, never drop a vertical at the 1st molar since the tissue is the thinnest at this area

Question 7

Describe the Tavelli study and the greater palatine foramen location, and the location of the Greater Palatine artery.

Answer 7

Tavelli et al., 2018 - Systematic review, Based on: 26 cadaveric, CT, or CBCT papers

The most common location of of the GPF was in the mid-palatal aspect of the third molar (57.08%)

Distance to the posterior border of hard palate: 3.8 mm
Distance to midsagittal suture: 15.2 mm
Distance from the GPA to the CEJ gradually decreased as the artery traversed anteriorly, except in the 2nd PM area.
Least distance: C 9.9mm
Greatest distance: 2nd PM 13.9mm

Remember: 14, 13, 14, 12, 10mm (distance of GPA starting from the 2nd molar & moving anteriorly

Question 8

Describe the palatal vault heights by Reiser

Answer 8

Reiser et al., 1996: Cadaver study – Distances btwn CEJ of Max. M and PM to GP canal

Shallow Palate 7mm
Average palate 12mm
High Palate 17 mm.

Question 9

Describe the Cho study on maxillary sinus anatomy & perforation risk.

Answer 9

Cho et al., 2001
34 patients, 49 sinus elevation procedures

Narrow (< 30°): 62.5% perforation
Wide (30-60%): 28.6% perforation
Widest (> 60%): 0% perforation

Remember “30% and 60%” and perforation risk “2/3, 1/3, zero”

Question 10

Where is the mental foramen located, according to Neiva ‘04?

Answer 10

Neiva et al., 2004 - Used 22 Caucasian skulls and preformed a FTMPF reflection.

Mental foramen:
* Mean height: 3.47 (range: 2.5 to 5.5 mm)
* Mean Width: 3.59 (range: 2 to 5.5 mm)
* Most common location: between the 1st and 2nd mandibular PM 58% of the time.
Anterior Loop:
* Has a high percentage of incidence: 88%, frequently presented bilaterally 76.2%

Question 11

Summarize the most important points from the study by Juodzbaly & Wang on the mental foramen, incisive canal, and neurovascular bundles

Answer 11

Depending on the method that was utilized to identify the mandibular foramen and canal, the occurrence of the MIC variates from 11% (Panorex) to 92% (Cadaver study), CBCT was 83% according to Pires 2009
The position in the vertical plane in relation to premolars apex can be situated coronal to the apex, at the apex, or apical to the apex.

A safe guideline of 4 mm from the most anterior point of the MF is recommended for implant treatment planning.
Mental canal and mental foramen opening can have different emergence patters, factors like race, age and gender can influence this difference
1 = MF to midline aprox 28 mm
2 = MF to the inferior border of the mandible (14 to 15 mm)
3 = possible MF location zone in the horizontal plane in relation to the roots of teeth
4 = the shape of MF can be round or oval, the diameter is 1.68 to 3.5 mm
5 = prevalence location of MF in the horizontal plane for Caucasian population;
6 = prevalence location of MF in the horizontal plane for Mongoloids and African people

Question 12

What’s the prevalence of the anterior loop acc. to Apostolakis & Brown, 2012

Answer 12

Apostolakis & Brown, 2012 - 93 patients that had CBCT taken to assess anterior loops.

Prevalence of anterior loop in dentate patients: 48% Prevalence of anterior loop in edentulous patients: 95%

Question 13

How far is the lingual nerve to the CEJ? (acc. to Chan et al., 2010)

Answer 13

Chan et al., 2010
Studied 18 cadavers and measured:
Vertical distances between the lingual nerve to the CEJ of M and PM.
Location of the lingual nerve turning towards the tongue

Vertical Distance:
2nd PM: 14.8 mm
1st M: 13 mm
2nd M: 9.6 mm
Remember: 10, 13, 15 starting from 2nd molar & moving forward - this is why you usually never drop a vertical incision on the lingual of these teeth

Turning of the Lingual nerve:
2nd PM: 25%
1st M: 41.7%
2nd M: 33.3%

Question 14

Describe the Takei papilla preservation, the modified Papilla preservation, the simplified papilla preservation, MIST, M-MIST, Entire papilla preservation (EPT)

Answer 14

The Takei & modified Papilla flaps required an interdental space of ≥ 2mm. They often had membrane exposure (of 75 - 80%). - Takei et al. 1985, Cortellini et al., 1995

Simplified papilla preservation - oblique incision in the papilla. It is for interdental space ≤ 2mm - Cortellini et al., 1999

MIST and M-MIST - Use EMD and high magnification via a microscope. - Cortellini & Tonetti 2007, Cortellini & Tonetti, 2009.
* MIST - both sides of papilla are elevated
* M-MIST - only one side of the papilla is elevated

Entire papilla preservation (EPT) - Flap is lifted laterally (using a vertical incision) to access the defect. - Aslan et al, 2017

Question 15

What is the wound healing process of a lateral pedicle flap?

Answer 15

Wilderman & Wentz 1965 -
Dog histology study using 11 mongrel dogs.
STages of flap healing: Adaptation, proliferation, attachment, maturation

0-4 days: Adaption stage
4-21days: Proliferation stage
21-28 days: Attachment stage (definite collage finer formation)
28 days – 6 months Maturation stage (periodontal finers, cementum formation)

Question 16

How fast does a fibroblast migrate?

Answer 16

Engler ‘66: fibroblasts migrate for 0.5 to 1 mm per day.
This was based on the gingivectomy histology study using thymidine dye on monkeys

Question 17

When should sutures be removed? And according to whom?

Answer 17

Hiatt et al. 1968
Measuring the tensile strength of attachment of full thickness flaps in 16 mongrel dogs using silk sutures

2-3 days: 225 g
7 days: 340 g
14 days: 1700 g
Funtional stability achieved after 14 days - this is when sutures can be removed

Question 18

What are the classifications for infrabony defects?

Answer 18

Goldman & Cohen, 1958 - Suprabony defect: Defect in which has the base of the pocket is located coronal to the alveolar crest
Infrabony defect:Defect in which the base of the pocket is located apical to the alveolar crest. Infrabony defects can be further classifies into

Papapanou & Tonetti, 2000
Craters: Primarily affect two adjacent teeth/roots
Intrabony defects: Primarily affects one tooth/root
1-walled defect: a defect limited by only 1 osseous wall & the tooth surface
2-walled defect: a defect limited by 2 osseous walls & the tooth surface
3-walled defect: a defect which has 3 osseous walls surrounding it, & the tooth surface
Combination defect: where a combination of the above defects can occur; when there is a 3-walled defect in the apical portion and a 2- or 1- walled defect in the coronal portion of the defect

Question 19

Describe the vertical classifications of the furcation defects

Answer 19

(Tarnow and Fletcher 1984)
Class I: ≤ 3 mm (vertical)
Class 2: 4-6 mm (vertical)
Class 3: ≥ 7 mm (vertical)

(Tonetti et al. 2017)
Class A = Attachment loss/bone loss extending to the coronal third of the root (Vert)
Class B = Attachment loss/bone loss extending to the middle
third of the root (Vert)
Class C = Attachment loss/bone loss extending to the apical third of the root. (Vert)