Perio 2 Test 2 Flashcards
What happens if we don’t do any tx to perio?
Tooth loss in susceptible individuals
What happens if we don’t do surgery?
Less reduction in probe depths
What happens if we do surgery?
Why?
Greater and sustained probe depth reduction
Flap approach reduces calculus, less calculus less inflammation
Advantages and disadvantages of surgical therapy (cutting open gums to work on perio)
A: direct vision
Easier manipulation and removal of tissues
D: moribidity
Esthetics
Cost
What are the short term vs long term benefits of surgery?
Surgery has better short term and long term pocket reduction
Benefit of regenerative surgery?
Favorable outcomes on even hopeless teeth (92% retention)
Stable 5 years after tx
Gingivectomy vs gingivoplasty
Ectomy: excision of the soft tissue wall of a perio pocket
Plasty: reshaping the gingiva to recreate physiological contours
Plasty is a step in a gingivectomy procedure
2 indications for gingivectomy
3 contraindications
Hyperplastic tissue
Suprabony pockets
Osseus involvement
Minimal attached gingiva/mucogingival involvement
Furcation involvement
Steps in gingivectomy
- LA
- Pocket depth marks (Bleeding Pts)
- External bevel
- Tissue removal
- Excision of tissue tags
- Gingivoplasty
- Application of surgical dressing
Complete healing after gingivectomy takes _ weeks
7
Gingivectomy vs. flap
Gingivectomy:
Cuts at 135˚ to tooth
External bevel
Exposed tissue during healing
Flap: Leaves gap b/t leftover tissue and tooth Internally beveled Provides access to bone Tissues not exposed during healing
Purpose of perio flaps
3 contexts for use
Provide access to bone and furcations
- Resection (removal of tissue)
- Conservative (access only)
- Regeneration (new perio support)
Flaps preserve _
Keratinized gingiva
Surgical access facilitates what 3 things
Calculus removal
Elimination of perio pockets
Perio regeneration
Other than calculus removal, 5 other applications for perio flaps
Surgical extractions Biopsies Exploratory surgery Clinical crown lengthening Pre-prosthetic surgery
Blade used for primary incision
15
Steps of full thickness flap
- LA
- Incisions
- Flap elevation
- Removal of soft tissue
- Osseus surgery
- Flap placement
- Sutures
- Dressing
3 pre-flap-surgery essential considerations
Pocket depth
Amount of keratinized gingiva
Intended position of flap
3 problems that can occur with flap elevation
- Difficult if 1st incision doesn’t extend to bone
- tearing of flap with excessive force or improper direction of elevation
- Exostoses require special attention
Why place a wedge
Access to bone and Furcations
Internal thinning of bulky tissue
Closure and primary healing after reduction
2 conservative flap designs
Modified wild man
Flap curettage
A widman flap is 3 things
Scalloped
Replaced mucoperiosteal
With internal bevel incision
6 goals of suturing
- Tension that’s adequate enough for wound closure, but loose enough to prevent ischemia and necrosis
- Hemostasis maintained
- Primary intention healing permitted
- Post-op pain reduced
- Bone exposure prevented (faster healing)
- Proper flap position
4 points of a suture needle
Swage
Radius
Body
Point
2 types and subtypes of NON-resorbable sutures
- Silk
- Polyester
A. Nylon
B. PTFE
2 types and subtypes of resorbable sutures
- Natural
A. Plain gut
B. Chronic gut - Synthetic
A. Coated vinyl
Chromic gut
Pros/cons
Heals fast
BUT
Relatively weak
Moderate tiss. Rxn
Coated vicryl pros/cons
Strong
Minimal tissue rxn
BUT
56-70 day hydrolysis resorption
Surgical silk pros/cons
2+ strength
BUT
Moderate tissue rxn
Non-resorbable
ePTFE pros/cons
Strong
Extremely low tissue rxn
BUT
Non-resorbable
2 types of interrupted sutures
2 types of sling sutures
I: simple loop
Figure 8
S: single sling
Continuous sling
Sutures inserted through _ first
More mobile flap
Distance from sutures to the edge of the flap
2-3 mm
3 phases of postsurgical healing
Inflammation
Fibroblasts granulation
Matrix formation/remodeling
Primary Intention healing at: 24 hrs (2) 1-3 days (2) 3-7 days (3) 1 week (1) 2 Weeks (2) 1 month (6) 2 months (2)
24 hrs
- Neutrophils infiltrate
- Epithelium starts to migrate from wound margins
1-3 days
- Space b/t flap and tooth narrows
- Ep cells migrate over border of flap
3-7 days
- Neutrophils replaced by macrophages
- Blood clot replaced by granulation tissue
- revascularization
1 Week
-Ep attaches to root
2 Weeks
- Collagen fibers oriented parallel to tooth (non-functional, immature)
- Union of flap to tooth is weak
1 Month
- Inflammatory cells gone
- Fibroblasts multiplying, making collagen
- Less revascularization
- Ging. Crevice is epithelialized
- Ep attachment is well defined
- Functional arrangement of supracrestal fibers
2 Months
- Collagen remodeled and cross-linked
- Wound regained tensile strength
How does exposed bone heal
Superficial bone necrosis (1-3 d)
Osteoclastic resorption (4-6 days)
How much bone is lost if exposed to oral environment
1mm
4 things to do for best surgical outcome
Minimize tissue trauma
Minimize wound desiccation (irrigate)
Suture meticulously
Address systemic health issues b4 surgery
Healing by secondary intention:
3 things that are worse than primary
More inflammation
More granulation tissue
More wound contraction during healing
Where do growth factors and cytokines come from
Blood clot
3 growth factors released from the blood clot
PDGF- induces fibroblast and macrophage migration, proliferation and activation
EGF-induces epithelial proliferation
TGF-Beta - induces migration of inflammatory cells and proliferation of fibroblasts
What do TNF and IL-1B do and from where are they released
They activate endothelium and induce neutrophil migration
Fibroblasts and macrophages
Epithelial healing requires _ days
Healing is complete in _
7-14 days
Complete in 6-7 weeks
What 3 things happen to cause alveolar bone loss
Gingival inflammation is extended
Trauma from occlusion
Systemic disorders
How does gingival inflammation extend? 4 ways
Extends along collagen fiber bundles
Follows course of blood vessels
Enters alveolar bone
Enters max sinus
Angular defects happen if interdental septum is _ wide. If less than that, horizontal bone loss will occur.
> 2.5mm
5 types of osseus defects
Horizontal bone loss Angular bone loss Ledges Reverse architecture Furcation involvement
Tx options for horizontal bone loss
SRP
Gingivectomy
Open Flap Debridement
Osseus Surgery
Angular defect tx options
OS
GTR
Osseus surgery flap vs regenerative surgery flap
Both are full thickness
FLAP:
Osseus is apically positioned
Regen is coronally positioned
Incision:
Osseus is usually scalloped but if keratinized tissue is limited, sulcular incision
Regen is sulcular
Ostectomy
Removal of bone ATTACHED TO TOOTH
How to correct reverse architecture
Bring interdental bone up
Lower facial bone
4 requirements for ostectomy
- Horizontal bone loss with irregular marginal bone height
- Intrabony defects that we can’t regenerate
- No esthetic or anatomic limitations
- Sufficient remaining bone for establishing physiologic contours w/o attachment compromise
Contraindications for ostectomy
Insufficient remaining attachment Unfavorably affect adjacent teeth Anatomic limitations Esthetic limitations Effective alternative
Ostectomy vs osteoplasty
Ectomy: removal of bone attached to tooth
Plasty: removal of bone not attached to tooth
Indications for osteoplasty
Tori Intrabony defects adjacent to edentulous ridges Incipient furcations Reduction of buttress bone or exostoses Shallow osseus craters
Guided tissue regen:
Procedures that allow a perio defect to get cells that can form new connective tissue attachment and alveolar bone
3 principles of GTR
Exclude unwanted
Protect wanted
Hold the space
6 qualities of an ideal oral membrane
Absorbable Biocompatible Cell Occlusive Space Maintenance Tissue Integration Clinically Manageable
3 types of materials used for GTR
Non-resorbable
Resorbable
Stem cells, functionally graded membranes
Gore-Tex is otherwise known as _ which stands for _
e-PTFE
Expanded Poly Tetra Fluoro Ethylene
Two types of resorbable membranes
Polylactic acid
Collagen (bovine/porcine, need consent)
Graded membrane components
HA surface layer
Two core (protein) layers
Metronidazole epithelial layer
How is space maintained after extraction
Reinforcing the membrane
Creating a scaffold (screws and fillers)
Cells in:
Osteogenesis vs osteoinduction vs osteoconduction
Which are Conductive, inductive, genic?
OG: viable bone cells
OI: uncommitted CT cells induced
OC: non-viable scaffold
Autograft is all 3
Allograft is 1.5
Alloplast/xenograph is conductive only
3 things you use when doing a graft
Membrane
Graft
Mediator
What are 2 types of biological mediators
Enamel matrix proteins
rhBMP - recombinant human bone morphogenetic protein
What does an enamel matrix derivative (Emdogain) do
Helps grow bone, PDL, cementum and matrix
What does PDGF do?
Aids in formation of bone, PDL and cementum by stimulating osteoblasts, fibroblasts, and cementoblasts
3 reasons for GTR
Space maintainer
Exclude epithelium
Protect and promote bone and PDL growth
The Furcation transitional part?
The crotch?
Entrance
Fornix
Width of a blade of a new gracey curette
0.75mm
Order of Furcation sizes in max molar from biggest to smallest
Mesial
Distal
Buccal
Most often root concavities can be found where (which sides of which molars)
Almost always (94-100)
- M/D of mandibular
- MB of max
Rare
- DB (31)
- Palatal max (17)
CEPs:
What
Frequency
Main type
Cervical enamel projections
13% of molars
Enamel pearl
Glickman vs Hamp, Nyman and Lindhe’s Classifications
G: 1-4 1-catch, not visible on r-graph 2-visible on r-graph, can be shallow or deep 3-through and through 4-clinically visible
HNL: 0-3
Basically same thing, but 3 is through and through, no 4
3 things a Furcation radiolucency could be:
How to tell?
- Perio
- Drainage of infection from accessory canal from chamber (non-vital tooth)
- Trauma from occlusion (won’t have deep probe depths)
Most effective way to treat grade 2 furcations
Osseus surgery (plasty and ostectomy)
Root resection is indicated when?
Contraindications
Grade 2 severe, or grade 3 Furcation
CI: inadequate bone support, fused roots, inoperable endo, patient considerations
Window to do root canal after root resection
2 weeks
If doing root resectioning, what is the sequence
Endo Provisional RSR Perio surgery Final prosthetic
When is hemisection indicated
Mandibular molar
Grade III Furcation
Widely separated roots
Soft tissue below level of pulp chamber
Regen of Furcation defects works best on _ and is done by _
Type II furcations
GTR
Treatment of furcations:
Class I
Class II
Class III
I- SRP
II- open flap, SRP, osseus surgery, GTR, tunneling, root resection
III-tunnel, hemisection, resection, extraction
Survival of treated furcated molars
70%
6 pre-prosthetic perio surgical procedures
Tooth prep to gingival margin Restorative in perio surgery Crown-lengthening Gingival grafting Ridge plumping Ridge reduction
T/F gingival retraction works on inflammed tissue
FALSE
Crown lengthening to treat excessive gingival display is indicated and contraindicated when
I: not enough of anatomic crown is exposed (altered passive eruption)
CI: hypermobile lip
Skeletal problem
Dentinogingival complex vs. biologic width
DGC: sulcus, JE, connective tissue
BW: JE, Connective
Optimal distance from GM to alveolar crest
From alveolar crest to tooth structure?
At least 3
2 for attachment, 1 for sulcus
At least 4
How long do you need to wait after crown lengthening to do a restoration
6 weeks
2 indications to do mucogingival alteration not on a tooth
3 methods to alter it
Lack of keratinized/attached gingiva
-For abutment teeth or edentulous site
Shallow vestibular depth
- for RPD
- for complete denture
- Subepithelial connective tissue graft
- Free gingival graft
- Vestibular extension
