2.6.23_Hoda Resective surgery & reattachment Flashcards
Who first described the purpose of gingivectomy?
It was Goldman who described the modern concept of gingivectomy, and the overall goal of reestablishing a “physiological gingival sulcus” by eliminating the pocket and festooning the gingiva to provide a proper form and contour (Goldman 1951).
What are the indications / contraindications of gingivectomy?
Indications:
* 1- Deep supra-alveolar pockets (Orban 1941)
* 2- Recontouring the gingiva (Goldman 1950)
* 3- Altered passive eruption (Coslet 1977)
Contraindications
* 1- Shallow periodontal pockets (Waerhaug 1978)
* 2- Pockets extending beyond MGJ (Waerhaug 1955)
* 3- Inadequate keratinized and attached gingiva (Miyasoto 1977)
* 4- Infrabony pockets (Prichard 1961)
What are the surgical steps of a gingivectomy?
Lindhe 2003
1- Marking of pockets. Fig 4
2- Primary incision. (Straight line vs. scalloped) Fig 5
3- Interdental incision.
4- Removal of tissue, the goal is to achieve physiological contours that allow the patient to clean the area.
5- Hemostasis.
What are the indications / contraindications of the distal wedge?
Robinson 1966
Indications:
1- Deep periodontal pockets on the terminal tooth.
2- Proximal periodontal pockets requiring the elimination of the underlying bone.
Contraindications:
1- Limited distal space.
2- Flat palate which would result in gingival deformity upon repair.
Describe the surgical steps of the distal wedge.
Lindhe 2003
1- Buccal and lingual vertical incisions through the retromolar pad
* Original distal wedge: triangle distal to the molar
* Modified: 2 Parallel incisions
* There is also a “straight line” variant for limited KTW
2- Removal of the tissue.
3- Undermining the buccal and lingual flaps to reduce their thickness.
4- Re-approximation of the flaps, trimming whenever necessary to prevent the overlap of wound margins, suturing.
What are the indications / contraindications of resective surgery?
Barrington ‘81, Wilson ‘92
1. Thick bony ridges, tori or exostoses.
2. Furcation defects requiring hemisection or amputation.
3. Shallow crater and minor angular defects.
Contraindications
1. Anatomic limitations.
2. Esthetic zone.
Siebert ‘76
Advantages:
* Allows visualization of bony defects.
* Simplicity.
* Decreases treatment time.
* Eliminates the need for more surgical sites.
Disadvantages:
* Dimensions and location of defects.
* Shape and length of the roots.
* Prominence of the roots.
* Width of the bone.
* Relationship between surrounding teeth and anatomical structures to the infrabony defects.
Describe the Ochsenbein ‘86 classification for root trunks and craters. Compare to the Ochsenbein & Bohannon classification
Ochsenbein ‘86
Root trunks:
* Maxillary: A=3mm, B=4mm, C=5mm
* Mandibular: A =2mm, B=3mm, C=4mm
Craters:
* A=1-2mm, B=3-4mm, C=5+mm
The ultimate goal is to eliminate the bony crater defect. However, compromised approach should be used if
ostectomy would result in the furcation exposure.
Approach from the lingual or palatal sides to avoid gingival recession on buccal sides.
Ochsenbein & Bohannon ‘64
Class I Crater: 2-3mm deep, thick
B&L walls, gradual slope to the base
Class II Crater: 4-5mm deep, wider
orifice, thinner walls, more abrupt
slope. Most commonly found.
Class III Crater: 6-7mm deep, sharp
drop from walls to wide flat base
Class IV Crater: variable depth,
extremely thin B&L walls, possibly
even single walled. Least common.
What are the definitions and indications of ostectomy & osteoplasty?
Carnivale 2000, Friedman ‘55
Osteoplasty: Reshaping of the alveolar process to achieve a more physiological form without removal of supporting bone.
Ostectomy: The excision of bone or a portion of it, it is done to correct or reduce deformities caused by periodontitis in the marginal and intra-alveolar bone and includes the removal of supporting bone.
Indications of osteoplasty:
1- Buccal and lingual bony ledges or tori, shallow lingual or buccal infrabony defects.
2- Thick interproximal areas and incipient furcation involvement that do not require removing supporting bone.
Indications of ostectomy:
1- Shallow (1-2mm deep, medium (3-4mm deep) infrabony and hemiseptal osseous defects.
2- Correct reversals in the osseous topography (negative architecture).
3- Deep interproximal pocket with V-shaped archeticture (Fig 7 up)
4- Infrabony pockets where reattachment procedures failed.
What is the rationale for the palatal / lingual approach in osseous surgery?
Palatal approach was suggested by Ochsenbein and Bohannan 1964, due to the limitations of the buccal approach such as buccal recession, denudation of buccal root surfaces, inadequate embrasure space buccally and reverse gingival architecture of the interradicular papilla. So the goal is to maintain the buccal bone height.
Lingual approach was discussed by Tibbetts 1976, and the rationale behind it is that the anatomical features of the mandible support such approach as we have the inclination of the molars putting their furcation more apically. In addition, the location of the interdental craters are more lingually under the contact point, and to avoid the thick facial bone. However, care must be taken to avoid injuring the lingual artery and nerve.
What is the rationale for the APF?
APF was originally described by Nabers 1954, where he justified its use explaining that when the periodontal pocket base is apical to MGJ, and excising the gingiva (gingivectomy) will result in the removal of the keratinized tissue leaving only non-keratinized type of tissue (More discomfort during OH, less resistant to masticatory injury)
Describe the surgical technique for the APF.
Dahlberg 1969:
1- Scalloped reversed bevel incision.
2- Vertical releasing incisions beyond MGJ, to reposition the flap apically.
3- Full thickness flap elevation.
4- Degranulation of soft tissue and debridement of root surfaces.
5- Repositioning the flap apically.
6- Suturing with vertical mattress or continuous (+ Periodontal dressing)
Describe the “FiReORS” (Fiber retention osseous resective surgery)
Carnevale et. al 2007
It combines the traditional osseous surgery with fiber retention technique for the treatment of deep periodontal pockets, it is a hard and soft tissue management method that aims to have minimal probing depths, create positive bone architecture and optimal gingival tissue contours with adequate amount of keratinized tissues.
It is superior to the traditional method in the fact that it preserves more bone. The main reference point in this technique is the level of connective tissue fibers inserted in the cementum, which determines the amount of bone removed.
Aimetti and colleagues conducted an RCT where they compared the “fiber retention osseous resective surgery” to the traditional osseous surgery and they found that the FiReORS resulted in more preservation of the supporting bone, and that the traditional osseous surgery removed X3 more bone during ostectomy compared to FiReORS. (Aimetti et. al. 2018 and Aimetti et. al. 2015)
–> Dr. Stuhr says: Microscope is indicated for this technique; it is very difficult
Technique:
Intrasulcular/Internal bevel incision (depending of PD and amount of KT
Split/Full thickness flap
Identify healthy connective tissue fibers
Retention of healthy fibers
APF with periosteal sutures.
Describe the success rates of root resection.
Goal of root resection: to eliminate deep pocket depths, furcations and subsequent inflammation around molars.
Root resected molars survival:
Fugazzotto ‘01: 96.8% (15yrs)
Basten ‘96: 92% (12 yr)
Most failed due to fracture & caries, and depends on the anatomy of the tooth and the technique that is used.
Root resected molars failure:
Langer ‘81: 38% (10 yrs)
Green ‘86: 73% (10 yrs)
Why is gingival curettage no longer used?
Echeverria and Caffesse et. al 1983
Historically, this technique was widely used. In the early 80s, the authors investigated the clinical efficacy of curettage where they did a clinical study of a split mouth design, scaling and root planning was done to all quadrants, 4 weeks later, curettage was done to only 2 quadrants. 5 weeks following the treatment, clinical parameters were compared, and they found that both groups had similar clinical results, concluding that **curettage did not have clinically significant improvement. **
Ramfjord 1987
Ramfjord and colleagues challenged this technique by comparing it with a regular scaling and root planing. They found that curettage does not give any clinical advantage when SRP was done with or without it (Ramfjord 1987)
Describe the ENAP (Excisional New Attachment Procedure)
Yukna ‘76
described ENAP technique for the management of suprabony pockets. It basically involves the excision of the inflamed pocket epithelium with a surgical knife. It has indications and contraindications as follows:
Indications:
1- Suprabony pockets.
2- Accessibility for root debridement.
3- Adequate KT.
4- Esthetic concerns.
Contraindications:
1- Osseous defects.
2- Mucogingival defects.
3- Pseudo pockets.
4- Inadequate KT.
[Can add photo here]
Surgical procedure:
1- Local anesthesia followed by pocket markings to determine the incision depth. (A)
2- Scalloped, Internal bevel partial thickness incision from the free gingival margin crest to the base of the pocket. (C)
3- Excision of tissues and degranulation using curettes.
4- SRP (root surface debridement) (E)
5- Irrigation of the site with saline, removal of tissue tags and root surface irregularities and blood clots.
6- Repositioning the gingival around the teeth using interproximal vertical mattress or interrupted sutures. (G)
7- Application of pressure with a gauze for 3 minutes to minimize the blood clot.
8- Placement of periodontal dressing (optional)
9- Suture removal in 1 week.
