CAD PERIODONTOLOGY Flashcards
What is gingival recession?
The displacement of the marginal tissue where it becomes apical to the CEJ
name the two anatomical structures involved in recession
- Underlying buccal bone
- Marginal gingivae
Recession is a result of…
- Anatomical Abnormalities
- Periodontitis: the primary aetiology
- Tooth position
- Orthodontics: causing tooth movement, arch expanding, pushing the teeth outside the alveolar envelope
Name the Soft tissue anatomy (gingivae) in order from top to bottom
Free gingivae
Attached gingivae (Keratinised mucosa)
Mucogingival junction
Oral Mucosa
compare and contrast the Keratinised mucosa with the oral mucosa
- Keratinised mucosa:
1. Densely organised collagen fibres
2. Attached to the root surface/ periosteum
3. Resist movement by the action of lips/ cheeks - Oral mucosa:
1. Non-keratinised epithelial
2. Mobile tissue
3. Not designed to function like the gingivae
What is the role of keratinised gingivae?
- It is important for Aesthetic
- At least 2mm is required for gingival health
What is gingival biotype?
- Gingival biotype relates to shape, position and thickness of gingivae.
- It can be detected by looking at teeth as welll/ e.g. long crown usually have a thin biotype.
- Thin biotype are more likely to develop recession
Compare and contrast the Thick Flat bio type with the Thin Scalloped bio type
Thick Flat
Flat soft tissue and bony architecture
Thick, dense and fibrotic tissue
Wide band of keratinized tissue
Rectangular/ square crowns
Pronounced emergence profile
Long interproximal contacts to cervical 1/3
Thin Scalloped
Thin and fragile
Narrow band of keratinised
mucosa
Frequent osseous dehiscence
Triangular crowns
Short IP contacts within incisal third
Flat emergence profile
Name the aetiologies of recession
Poor oral hygiene*
Trauma*:
- Toothbrushing
- Iatrogenic: invasion of biological width
- Foreign bodies
- Frenal pull
- Traumatic overbite
- Self induced
Tooth position: when a tooth is outside gingival or buccal bone, it’s more susceptible to recession
Orthodontics
- Loss of buccal plate
- Buccal tooth movement always causes slight recession as a result of stretching of buccal mucosa
- No correlation between amount of keratinised gingivae and amount of recession observed
[PS1] What are the goals of perio tx? Include both clinical and patient-related factors.
1) Reduce BoP (no more than 20-30% BoP) (Clinical)
2) Reduce PPD to less than or equal to 5mm (Clinical)
3) Absence of pain (patient-related)
4) Satisfactory aesthetics + function (patient-related)
[PS1] What is the aim and objective of initial therapy?
Aim: To motivate pt to perform optimal plaque control
Objective: to achieve clean + infection free conditions
[PS1] What is aim of corrective therapy?
Addresses consequences of infection that was treated in initial therapy.
[PS1] What is aim and objective of supportive therapy?
Aim is to prevent re-infection and disease recurrence
Objective: to preserve gingival/periodontal health obtained via regular reviews and appropriate tx.
[PS1] What checks/treatments are involved in Supportive therapy?
-Assess deeper sites with BOP
-Re-instrumentation
-Fluoride application
-Check for integrity of restorations
-Assess vitality
-Take radiographs
[PS1] What is the aim of non-surgical periodontal tx (NSPT)?
To eliminate living microorganisms in the biofilm and calcified microorganism from the tooth surface and adjacent soft tissues
[PS1] What will NSPT achieve?
-Reduced inflammation
-Reduced pocketing and BOP
-Improve plaque control
[PS1] What are surrogate measures and name three.
Surrogate measures are predictors of further attachment loss or stability so we can determine if further tx is required and inform us of the prognosis of the teeth to inform the pt.
They are: PPD, BOP, PFS.
[PS1] What are three factors that may lead to further breakdown of teeth?
1) Patient
2) Tooth
3) Site
[PS1] Describe how further breakdown of teeth may occur at patient level.
-Increased no. of >6mm sites
-Perio tx without LA (less likely to succeed as less thorough debridement provided)
-% of BOP, extent of baseline attachment loss, PPD
[PS1] Describe how further breakdown of teeth may occur at tooth level.
-Furcation
-Mobility
-Limited residual periodontal support due to severe attachment loss
-PRFs
[PS1] Describe how further breakdown of teeth may occur at site level.
-We aim for BOP of no more than 20-30% = periodontal stability. If BOP present, there is 30% likelihood of disease progression.
-PPD >5mm present means risk of further attachment loss (esp. if with BOP).
[PS1] Name 6 factors that you could explain to a pt will make disease progression and tooth loss more likely.
1) Poorer OH
2) Irredular supportive therapy
3) Interleukin polymorphism (genetic factor)
4) Smoking
5) Age
6) Initial diagnosis of severe disease
[PS1] Why do we carry out surgical perio tx?
1) improve prognosis of tooth
2) Eliminate pockets >5mm and BOP
3) Facilitate plaque control
4) Regenerate lost periodontium
5) Resolution of mucogingival problems (overgrowth/recession)
[PS1] Name 4 surgical strategies.
1) Pocket reduction
2) Regeneration
3) Gingivectomy
4) Surgery for recession
[PS1] On a patient level, what describes an appropriate case for surgery?
1) Highly motivated pt, excellent OH
2) Compliance with OHI and appointments (Plaque free scores of > 70% on more than 1 occasion)
3) No medical contraindications
4) Non-smoker
5) Thorough non-surgical periodontal therapy completed
6) Localised residual pocketing
7)Surgery is part of comprehensive treatment plan (Including ongoing SPT)
[PS1] Why is it beneficial to carry out NSPT before perio surgery?
-Reduction in depth and number of pockets
-Reduce inflammation in tissue by removal of plaque/calc.
-Allow assessment of ‘true’ gingival contour
-Tissues firmer -> facilitating surgery (easier to raise flap) and reduce intraoperative bleeding and facilitate post-op healing
-Get better idea of prognosis and pts response to tx and their compliance with OH and form relationship with pt
[PS1] On a site level, what describes an appropriate case for surgery?
•No plaque in area to be treated
•Non-mobile teeth
•Strategic teeth - that provide functional occlusal contact or aesthetic importance
•Pocketing >5mm
[PS1] What pocket depth can we carry out perio surgery on and why?
6mm+
There is better access for debridement in pockets >6mm.
Worse outcomes in pockets less than 6mm.
[PS1] Describe the steps for regenerative surgical technique.
1) Elevate papilla with small incision between the two teeth to retract soft tissue enough to visualise defect and residual bone crest.
2) Use hand instruments to curette out granulation tissue from down inside defect until healthy bone at base of defect can be seen.
3) Can see small flaps buccally and lingually. Retracted only enough so that we can visualise defect and root surface, for thorough cleaning, to curette out granulation tissue from base of defect and thorough debridement of root surface -> hand + ultrasonic instruments.
4) Regeneration of lost attachment -> Emdogain and Bio-Oss are used. Animal based products.
5) Sutures following completion.
[PS1] What 2 animal based products are used in regeneration surgery?
Emdogain (stem cell of porcine origin) and Bio-Oss (bovine derived bone).
[PS1] Describe the different classifications of furcation defects.
-Class I: Horizontal loss of periodontal support <3mm
-Class II: Horizontal loss of periodontal support >3mm
-Class III: Horizontal ‘through and through’ destruction of the periodontal tissues in the furcation.
[PS1] What tx options are there for each furcation class? (Refer to ‘Furcation decision-making’ flowchart in lecture)
Class I: NSPT
Class II:
1) Extraction
2) GTR (lower molars)
3) Resective surgery (Root resection or tunnel prep)
Class III:
1) Extraction
2) Resective surgery (Root resection/hemisection or tunnel prep)
[PS1] What are favorable conditions for regenerative surgery to furcations?
•Class II lesions
•Shallower lesion
•Narrower lesion
•Mandible more predictable than maxilla
•Buccal/lingual sites (better access)
•Thicker biotype → less post-op recession
[PS1] What anatomical considerations are there to determine feasibility of surgical options?
-Depth of root trunk (short root trunks may have early furcation involvement but have larger remaining bone support compared to furcation involved teeth with longer root trunks)
-Root divergence (less divergence= harder to manage with resective surgery)
-Length and shape of root cones
-Amount of remaining support around individual roots
-Stability of individual roots
-Access for surgery and for oral hygiene post surgery
[PS1] What is the aim of furcationplasty?
To improve cleansibility of class 2 defect and reduce plaque accumulation via alteration of morphology of defect
[PS1] Describe the steps involved in furcationplasty.
1) Raise flap to access defect for curettage of granulation tissue + debridement of root surfaces
2) Removal of tooth tissue to eliminate/ reduce the horizontal component of defect and widen the furcation entrance
3) Recontour alveolar bone
4) Flap repositioned to cover furcation (papilla like soft tissue closure)
5) Used on buccal/lingual sites…easiest sites to access
6) Risk of sensitivity…caution on vital teeth.
[PS1] What is tunnel preparation?
It is a resective technique used for class 2 and 3 furcation defects to create a broad class 3 furcation defect supragingivally to enable OH and plaque control under roof of furcation.
[PS1] True or False: Tunnel preparation can be done on upper molars.
False- Tunnel preparation is only possible in lower molars due to the nature of the furcation and root morphology.
[PS1] Describe the steps of tunnel preparation.
-Raise buccal and lingual flaps
-Curettage of granulation tissue and debridement of root surfaces
-Alveolar crest in furcation reduced to increase space between roots (short root trunks and divergent roots = suitable)
-Apically repositioned flap sutured
-Post-op instructions on how to introduce OH aids between roots of teeth
*High risk of sensitivity and caries in furcation! -> topical fluoride during SPT
[PS1] What is root seperation and how does it aid plaque control?
Sectioning of root complex and maintenance of all roots to provide extra coronal restorations to restore the coronal morphology.
OH aids can be introduced in the furcation areas improving plaque control and cleansibility (furcation areas are crown material= reduce risk of caries).
[PS1] Define root resection and hemisection.
Root resection: removal of only root, leaving entire coronal portion of tooth in situ
Hemisection; sectioning of root and coronal portion
[PS1] In terms of root trunks depth, root divergence and length of root cones, what is more favourable for stability?
Shorter root trunks, divergent roots, larger root cones.
(Shorter/smaller roots more mobile post-op and form poor abutments for and subsequent ECR)
[PS1] When is surgery not feasible? (10 things)
Terminal dentition (teeth are at end of lifespan, are in v bad state and need to be removed, can’t be saved)
Generalised pocketing
Tooth mobility
Non-motivated patient
?advanced age
Poor OH
Poor compliance with Tx
Large furcation defects, especially in maxilla
Extensive/hopeless bone loss
Horizontal bone loss: regeneration not possible
[PS1] What are the options if surgery isn’t feasible?
-Extraction
-Palliative ongoing SPT
[PS1] When would you choose extraction over ongoing SPT?
-symptoms present
-mobility causing discomfort
-infection or suppuration from pocket
-detrimental to remaining dentition- (increase bacterial load or preventing access for OH/debridement of adj teeth)
[PS1] What is gingivectomy used for?
-Gingival overgrowth (idiopathic or drug-induced)
-Crown lengthening procedures (restorative/aesthetic indications; eg late failure of eruption, short clinical crown height, facilitate restoration of teeth)
[PS1] Describe the steps involved in gingivectomy.
•Scalpel/laser/electrosurgical (or combination)
•External bevel (to leave raw bed of tissue that will heal by secondary intention)
•Internal bevel with flap (raise flap and remove tissue from underneath)
•Coe-pak dressing 1/52 (for a week) following scalpel/laser/electrosurgical techniques or external bevel. (Dressing not needed if internal bevel done as primary closure and sutures in place)
•Biopsy the excised tissue in all cases (evidence of malignancy in gingival overgrowths)
[PS1] Describe the different classes of Millers classification for recession.
Class 1: Within attached gingiva. No loss of interdental bone. Papillae intact.
Class 2: Extends to or beyond the MGJ. No loss of interdental bone. Papillae intact.
Class 3: Extends to or beyond the MGJ. Loss of interdental bone but bone height coronal to apical extent of recession defect. Some loss of papilla height.
Class 4: Extends to or beyond the MGJ. Loss of interdental bone apical to recession defect. Loss of papilla height to level of recession.
what aspects of orthodontics make it a risk factor for a recession?
A) Extent of tooth movement ( whether they move out or in towards the alveolar socket)
B) strength of forces (how quickly the teeth move)
C) Gingival biotype
D) plaque control
What are the rationals for recession treatment
- Aesthetic
- prevent progression
- patient concerns
sensitivity
difficulty clearing
discomfort from the gingivae
loss of tooth
what are the goals of surgical treatments?
- enhance periodontal regeneration
- prevent scarring
- optimum tissue blend and colour
- 100% root coverage
- improve access for oral hygine
what techniques would you use for periodontal wound healing?
- Regenerative technique:EMD: this is enamel matrix proteins, secreted by HERS during tooth
development are responsible for formation of acellular
extrinsic fibre cementum (AEFC)
AEFC directly anchors tooth to bone
How does EMD causes regeneration?
It restricts:
- epithelial growth
- connective tissue
- Bacterial growth
It promotes:
- bone growth
- cementum growth
- PDL growth
- wound healing and defence
In what conditions should the EMD be placed on the tooth in order to promote regeneration? (how do we prepare the tooth)?
- There should be no inflammation
- The exposed root surface should be clean (polish+ debrided if calculus present)
- EMD placed on dry root surface
- post-operative wound healing (optimum flap design, suturing technique, post-op pressure)
what factors can interfere with the goal of 100% root coverage after the periodontal surgery?
Patient factors
Oral health pre and post surgery
Smoking
Defect: teeth/ bone/ soft tissue
Extension (depth, number of surfaces, papillae height)
Wear defects
Surgical Technique
Microsurgery
How does poor oral hygiene affect the wound healing negatively
by:
Increased risk of infection
Reduced collagen fibres affects wound closure
Increased intra-operative bleeding
How do we classify recession and explain each classification
- we classify it using Miller classification:
Miller Class 1
Does not cross mucogingival line (MG)
No loss of interdental hard,
papillae intact
complete root coverage can be anticipated
Miller Class 2
Extends to or beyond MG
line
No loss of interdental hard,
papillae intact
complete root coverage can be anticipated
Miller Class 3
Slight loss of interdental
hard and soft tissues
partial root coverage can be anticipated
Miller Class 4
Significant loss of
interdental hard and
soft tissue.
Recession level with
interproximal bone
no root coverage can be anticipated
why is it preferred to use optical magnification with microsurgery?
Reduces surgical trauma
More precise approximation of wound margins
Improved outcomes
Name 3 examples of surgical techniques used to treat recession
Frenectomy
Free grafts
Pedicled flaps
- or we can have Combination of the two
Describe the free graft procedure
Harvesting soft tissue from a distant site in the mouth and
grafting it over a localised recession defect
Does the graft (in free graft procedure) have its own blood supply and blood vessels?
No, it relies on the recipient site
What are the advantages and disadvantages of free gingival graft?
Disadvantages
Low potential for root coverage
Poor colour blend
Palate difficult to dress postoperatively
Advantages
Faster
Very predictable
what is the difference between free gingival graft and the connective tissue graft?
CT harvested from the palate
A three-sided/two-sided/single incision is made on the
palatal tissue to create a trap door
Epithelial layer is dissected away to harvest connective
tissue
Graft placed between a split thickness flap at the
recipient site
Gold standard for mucogingival procedures
what are the aftercare advices for patient undergone graft surgery?
Suture removal
-1 week palate
- 2 weeks graft site
Chlorhexidine 2% BDS for two weeks
No toothbrushing for 2 weeks
Soft toothbrush for 4 weeks
- Assessment after 6-12 months
What are the complications of graft surgery?
- Intra-operative
Failure of LA
Injury to greater palatine artery - Post-operative
Graft necrosis
Pain, bleeding
Swelling
Bruising
