Perio Final Flashcards
4 mechanic causes of gingival recession
Traumatic brushing, flossing
Ortho Tx
Trauma
Parafunctional habit
Generalized vs. localized causes of biological gingival recession (2 of each)
G: tissue biotype
Oral hygiene
L: anatomy
Defective restoration
Brushing abrasion commonly affects _ in young adults
Premolars
Miller classification of recession
1- no interprox bone loss Recession doesn’t extend to MGJ 100% Root coverage 2- No interprox bone loss Recession to or past MGJ 100% root coverage 3-Interprox bone loss May pass MGJ Partial root coverage 4-Interprox bone loss PAST level of recession No root coverage
Perio-ortho interrelationships
S
Who has a higher increase in plaque after ortho?
Adults. Adolescents have higher baseline and it doesn’t increase that much
After ortho, subgingival pathogens __. Several months later they _
Temporarily increase
Return to pretreatment levels
_ % of people have gingival enlargement that remains after ortho tx
30%. 50 start, 100 end tx, 80% after 3-12 mo.
What do normally erupting teeth look like at time of eruption
Developing root and 3/4 final root length complete
Unerupted teeth have a more _ than erupting teeth
More completely developed root
Order of frequency of impacted teeth
3rd molars Maxillary canine Man 1st PM Man 2nd PM Man Canine Max premolars
Most impacted max canines are _ impacted
Palatal
Buccally impacted canines are associated with _ deficiency
Arch length
Local causes of tooth impaction
Failure of deciduous roots to resorb Abnormal position Supernumerary tooth Tooth crowding Dentigerous cyst Thickened soft tissues Soft/hard tiss. Pathology Premature extraction of primary tooth
3 Systemic factors that can cause impaction
Childhood diseases
Hereditary factors
Genetic syndromes
Problems that can follow canine impaction
Malpositioning of impacted tooth Migration of neighboring teeth Internal/external resorption Dentigerous cyst formation Referred pain
Surgical aims for impacted teeth (not extraction)
Provide conditions for normal, unimpeded eruption
Provide access for ortho appliances
Open eruption vs closed eruption
Open: cut a window, let it erupt
Closed: cut flap, ortho appliance, close flap
Advantage/disadvantage of closed and open eruption
Open: more pain, hard to eat, if ortho breaks, don’t need surgery
Closed: more comfortable, but if ortho breaks, need surgery again
ANUG starts where
Papilla then moves to gingiva
Characteristics of advanced ANUG
Lack of deep pockets
Papillary and marginal involvement
STINKS
Necrosis causing craters
4 microbes that cause ANUG
Treponema
Selenomonas
Fusobacterium
Prevotella
Treatment of ANUG
1st
2nd
3rd
- History
Removal of necrotic tissue
Emergency tx
1/2 rinse with H2O2
- Evaluation
Scaling
Emergency
Confirm home hygiene - No more rinses
Plaque control
Counsel on hygiene
SRP repeated if needed
4 types of abscesses, causes of each
Gingival - Trauma
Pericoronal - Trauma
Periodontal - Infection
Periapical - Infection
Antibiotics are contraindicated for which abscess
Gingival
Perio abscesses most often happen on which teeth and under what condition
Molars
PD ≥ 5mm
Causes of perio abscesses
Periodontitis
Non-perio, acute infection from another source
Treatment of perio abscesses
Drainage through pocket retraction or incision SRP Perio surgery Extraction Antibiotics if systemic complications
Types of mucogingival defects
Gingival recession Lack of gingival keratinization Lack of attached gingiva -high frenum attachment -shallow vestibule Recession with abrasion
Etiology of gingival recession can be divided into two categories _
The first has 4 types
The second has 2 types
Mechanic/biological M: Traumatic brushing/flossing Ortho Trauma Parafunctional habit B: Generalized (tissue type, oral hygiene) Localized (anatomy, defective restoration)
Miller classifications for recession
I: no interprox bone loss, recession does NOT extend to MGJ
II: no interprox bone loss, recession extends to MGJ. Full root coverage
III: interprox bone loss, recession may reach MGJ. Partial root coverage (to level of interprox bone)
IV: interprox bone loss beyond level of recession. No root coverage
5 flap options for treating recession
Coronally advanced flap Tunnel Lateral sliding flap Double papilla Semilunar
Mucograft:
Xenograft porcine collagen I and III
Indications and disadvantages of free gingival graft
I: increase KG/attached gingiva
Increase vestibular depth
Achieve root coverage
D: not predictable for root coverage
Color doesn’t match
Complications at donor site
3 phases of healing of free gingival graft
Initial phase 0-3d
Revascularization 2-11d
Tissue maturation 11-42d
4 classifications of labial frena, definitions
Mucosal - frenum ends in mucosa or at MGJ
Gingival - frenum ends in gingiva
Papillary - frenum ends at papilla
Papillary penetrating - frenum ends at papilla and penetrates to palate
Main syndrome associated with prominent max frenum
Ellis van Creveld syndrome
Genetic syndromes (2) associated with absence of max labial frenum
Ehlers-Danlos
Holoprosencephaly
3 types of tissues make up frena
Ortho and parakeratinized ep.
Collagen fibers
Chronic inflammatory infiltrate
4 indications for frenectomy
Recession
Interference with oral hygiene procedures
Diastema
Denture fabrication
Frenotomy vs frenectomy
Otomy: cutting of frenum, esp release of ankyloglossia
Ectomy: total removal of a frenum
4 surgery options for a frenectomy
V shaped
Z-plasty
Lasers
Electrosurgery
Do ortho before or after frenectomy
Before unless really wide and thick
1st
1st
6 factors determining LASER interactions with tissues
Wavelength Energy level Waveform How focused the beam is Duration of exposure Tissue characteristics
Disadvantages of laser use
Technical difficulties
Less precise
Hazardous
Can disperse viral particles in plume
LANAP:
How does it work
Laser assisted new attachment procedure
Remove sulcular epithelium
Modify root surface
New attachment will occur
How does photodynamic therapy work
Sensitizer is injected, absorbed by tissues. Light targets only sensitized tissue, kills whatever is absorbed
4 indications for perio surgery
Failure to resolve inflammation by SRP (hard to reach areas)
Regeneration of periodontium
Cosmetic improvements to periodontium
Resorative needs
Two purposes of perio surgery
Access and regeneration
T/F open flap debridement is statistically significant in its effect
TRUE
3 types of healing
Repair - doesn’t restore function
New attachment - CT + root surface, deprived of original attachment
Regeneration - new cementum, PDL and bone to reconstitute lost part
T/F surgical tx is necessary to arrest inflammatory progress of disease
TRUE
T/F surgical access to root surface is least common surgical treatment to arrest periodontal disease
FALSE - it is the most common
T/F Regenerative surgery is rapidly changing the way perio disease is managed
TRUE
Biologics are generally comparable to _ and _ and superior to _ in improving clinical parameters in treatment of intrabony defects
Demineralized freeze-dried bone allograft AND GTR
OFD
In the infrabony defects meta-analysis, clinical outcomes appear most influenced by _ rather than by tooth and defect characteristics
Patient behaviors and surgical approach
T/F periodontal regeneration in intrabony defects is impossible on previously diseased root surfaces
FALSE
T/F surgical treatment is necessary to arrest inflammatory progress of disease
TRUE
_ is the most common surgical treatment to arrest periodontal disease
Surgical access to root surfaces
The two most frequent causative factors for gingival recessions
Toothbrushing trauma
Bacterial plaque
What is the bilaminar technique, why use it
Coronally advanced flap covering a connective tissue graft
Use of graft increases the likelihood of achieving complete root coverage (especially long term)
Tooth loss is _ proportional to perio maintenance therapy
Inversely
3 therapeutic goals of PMT
Prevent recurrence and progression of perio disease in patients treated ja
Prevent tooth loss by monitoring teeth
Increase probability of treating other diseases in mouth
Ideal frequency of PMT
3 months
What requires retreatment during maintenance
Continued inflammation (surgery) Aloss (SRP + antibiotics or surgery)
2 species of bacteria around teeth/implants with inflamed tissues
Prevotella intermedia
Pophyromonas gingivalis
In maintenance of implants, what 3 things are we looking at
Tissue health
Crevicular fluid
Mobility and occlusion
Soft tissue healing: First day 1-3 days 3-4 days Week 1 Week 2 Week 4-6
Day 1: blood clot/coagulin
1-3d: fibrinolysis
3-4: mesenchymal cells, replacement of coagulum by gran tiss.
1w: vascular networks formed
2w: socket covered w/ new conn. Tiss with blood vessels and inflammatory cells
4-6w: soft tissue keratinization
Hard tissue healing:
4-6 weeks
4-6 months
6mo+
4-6w: woven bone in alveolus
4-6m: lamellar bone on woven
6mo+: bone deposition continues, won’t reach coronal bone level of neighboring teeth
More resorption occurs in the _ of the max and mand
Buccal aspect of alveolus
Resorption occurs more on _ (type) alveoli and in the presence of _ or _ or after the formation of a _ following healing
Thin, cortical, knife edged facial alveoli
Dehiscence or fenestration
Buccal concavity
Bone loss in the first 6 months-1 yr occurs more in _ direction
Horizontal
Following extraction, what 3 things can affect the amount of residual bone
Surgical trauma
Elevation of a flap
Age of the patient
Class I-V bone defects
I: extraction sockets
II/III: dehiscence defects
IV: horizontal defects
V: vertical defects
ARP:
Definition
Purpose
Diff b/t GBR
Alveolar ridge preservation at time of extraction.
Control resorption
GBR targets regeneration of already resorbed/lost bone
When to do ARP
When immediate implant placement isn’t possible
3 contraindications for ARP
Infection
Indication for immediate implant placement
Soft tissue limitation
Bone grafting materials can be either _ (scaffold) or _ (stimulates resident cells)
Osteoconductive
Osteoinductive
Which materials are osteogenic, osteoinductive, osteoconductive
Autogenous grafts: all 3
Allografts: OI/OC
Xenografts: OC
Synthetics: none. Just fillers
Synthetic grafts can be absorbable or non-absorbable. Examples of each
A: plaster of paris, calcium carbonate
NA: bioglass, HA, PMMA
Where is autogenous bone graft material taken from
Iliac
Max tuberosity, extraction site, osseus coagulum
3 types of allogenic bone grafts
Frozen iliac cancellous bone
Freeze-dried bone allograft (mineralized/demineralized)
(D)FDBA w/ autogenous bone
What is the role of the barrier in the ARP
Type of tissue in a space is determined by what cells have access. Block off unwanted cells
6 types of membranes
Millipore filter ePTFE (w/ or w/o titanium) Cross-linked bovine collagen barrier Bioabsorbable polymer: polylactic acid base Autogenous conn. Tiss membranes
4 things affecting outcome of ARP
Blood supply
Space maintenance
Membrane stability
Tension in flap closure (want none)
In mature bone, implants should have _ mm on all sides
At least _ mm of interocclusal distance is needed from top shoulder of implant to occlusal of opposing tooth
At least _ mm space b/t two adjacent implants and _ mm b/t implant and adjacent tooth
1
7
3, 2-3
3 types of mandible shapes, best one for implants
C P U
C is best, U is worst (concave)
4 implant placement types based on timing
Immediate
Early
Late
Conventional
Immediate implant placement
Advantages
Disadvantages
A: less surgeries, less treatment time, optimal use of bone
D: site morphology needs to be good Tissue biotype needs to be good Need keratinized mucosa for flap Adjunctive surgeries may be necessary Technique sensitive
Immediate implant placement may not prevent _ that follows tooth extraction
Physiologic modeling/remodeling
Early implant placement has two advantages
Easier flap adaptation
Allows resolution of local pathology
Disadvantages of early implant placement
Bad site morphology Longer treatment time Bone resorption at socket walls May need adjunctive surgery Technique sensitive
At least _ mm of bone height is needed apically to the socket for immediate and early implant placement
3
_ biotype is indicated for early implant placement
Soft
Early/immediate implants need _ walls and no _)
3/4 walls and no dehiscence or fenestration of buccal
Advantages for late implant placement
Clinically healed ridge
Mature soft tissues, easy flap management
Disadvantages of late implant placement
Treatment time
Adjunctive procedures
Large variation in available bone (more bone loss with longer wait time)
New bone formation is decreased after
3-4 months
Indications for early implant placement of a single-rooted tooth
Good extraction (preserve bone) Thick biotype soft tissue Manageable gap following placement Root length (mand ant., max lat)
Contraindications for immediate/early placement of implant of single rooted tooth
Oval shaped socket Rotated tooth Malocclusion Esthetic zone Anatomical landmarks Long root length (canines)
Indications/contraindications of early implant placement for a multi-rooted tooth
I: large intact septum b/t divergent roots
Non-esthetic area
CI: multiple sockets
Lack of soft tissue
Heavy occlusal forces
Anatomy
T/F Immediate implant placement is best
T
Why wouldn’t immediate implant placement be done (2 reasons)
Infection
Soft tissue issues
_ implant placement is done unless _ or _,
in which case _ is done until _ can be done, unless _
In which case _ will be done and delayed implant placement will be done.
Immediate, infection, soft tissue issues
Socket preservation until early placement
Not enough bone, guided bone regeneration
5 steps in drilling sequence for implant
Round bur Pilot hole Parallel pin (radiographs) Widen hole Final diameter
Advantages/disadvantages of ONE STAGE implant placement (3/2)
A: no 2nd surgery to uncover implant
Better evaluation of wound healing
Early temporization
D: Exposure to oral cavity during osseointegration
Difficult to control loading
Contraindications for one stage implant placement
Torque value less than 35 Ncm
Smokers
Thin tissue (soft and hard) biotype
All _ problems should be solved prior to any types of implant placement surgery
Periodontal health related
The implant shoulder should be placed _ to CEJ of adjacent teeth in patients without gingival recession
2 mm apical to CEJ
Implant pre-op procedures to control bacteria and prep for surgery
Antibiotic prophy
Chlorhexidine rinse
NSAIDS
Prep for sedation
The incision for an implant is where
Mid-crestal or slightly lingual
What happens in post op visits
7-10d post op
1 mo post op
7-10:
- chlorhexidine rinse
- review OHI
- remove sutures if necessary
1 mo:
-check that implant is covered still
BOTH:
Check for signs of infection
At least _ mm bone thickness b/t two implants
3mm
It is harder to create alveolar bone _ than _
Height than width
T/F inter-implant papillae can be predictable re-established
FALSE
3 ways dentures can be supported by implants
Ball attachments
Bar and clips
Hybrid (fixed implant supported denture)
Lateral vs vertical bone augmentation
Lateral is predicable and achievable
Vertical is difficult
Multiple anterior implants should be aligned _ with _ between each other
Parallel
3mm
Three components of an implant
Implant fixture (first part in) Abutment (screws into fixture) Restoration
Infection indicator that is more common on implants than teeth
Suppurations
Peri-implantitis vs peri-implant mucositis
PI- Inflammation and loss of supporting bone around implant in function
PIM- gingivitis around implant
Ailing vs. failing vs. failed implant
A: PI mucositis
Failing: P-implantitis
Failed: P-implantitis, hopeless, non-functional, pain
Peri-implantitis is almost always _ shaped
Cup
3 goals in treating failing implants
Resolve inflammation
- plaque debridement
- improve oral hygiene
- adjunctive antibiotics
Correct pseudo pockets by flap surgery/gingivectomy
Re-osseointegration (decontaminate implant, GBR)
How to treat peri-implantitis
Class I
II
III/IV
I: repositioning of flaps
Cleaning implant surface
Implantoplasty if needed
II: same as one
GTR if vertical with 3+ walls
1/2 walls = osteoplasty/bone leveling
III/IV: GBR
Active ingredient in infuse
What does it do, when do you use it
Recombinant human bone morphogenic protein-2
Stimulates bone formation
Regeneration after peri-implant bone defect
Why perio before restorative? (4)
No inflammation means ideal tooth access and prep ability
More stable, less Aloss
Better esthetics
6 steps in treatment sequence
- Etiologic phase (faulty rest.s)
- Pre-prosthetic surgery (preservation, augmentation)
- Restoration design
- Pre-implant surgery
- sinus lift - Post-prosthetic surgery
- tissue deformities/gummy smile - Maintenance
When is perio necessary before ortho
When there is inflammation/perio problems
When can you do ortho in perio patients
Reduced but healthy and stable periodontium
Active perio with ortho will have problems
Pre-ortho, what perio procedures can help with ortho (5)
Tooth exposure Root coverage Frenectomy Perio accelerated ortho Implants for anchorage
Post/during ortho, what perio procedures can help with ortho
Fiberotomy
Frenectomy
Gingivectomy
Root coverage
Adjunctive ortho can help what perio problems (4)
Diastemas
Gingival margin discrepancies
Intrabony defects
Implant site development (space/ridge development)
Clinical data doubles ever _
18 months
3 types of gingival grafting
Free gingival graft
Pedicure (lateral)
Sup-epithelial connective tissue graft
