Perio Midterm Flashcards
Primary Etiology of Chronic Periodontitis
Primary Etiology
- Bacterial plaque and its byproducts in a susceptible host
Secondary Etiology
- Calculus, poor oral hygiene, smoking history, lack of dental care, furcation involvement, open contacts, ill-fitting restoration margins, root proximity, secondary trauma from occlusion
Difference between chronic and aggressive periodontitis
Chronic-P. GInigivalis
- Disease control phase
- Needs-related oral hygiene instructions
- Surgical corrective phase
- Maintenance phase
- Supportive care (3-6 months)
Aggressive Periodontitis
- Disease control phase
- Consider pre-treatment bacterial assessment
- Periodontal debridement - systemic antibiotic at last debridement visit
- Surgical corrective phase
- Maintenance phase
- Supportive care (2-3 months)
Sequence of treatment we follow for perio evaluation and treatment
Sequence of treatment we follow for perio evaluation and treatment
- Emergency treatment (endo, restorative, non-surgical, surgical)
- SRP (OHI, initial phase of periodontal tx)
- Re-eval
- Perio surgery (surgical tx, resective, regenerative)
- Maintenance
Goals, indications, and contraindications of “periodontal surgery” in general
Goals of Therapeutic surgery
- Alter or eliminate the microbial etiology and contributing local risk factors
- Arresting the progression of the disease
- Preserving the dentition in a state of health, comfort, and function
- Maintenance of esthetics if possible
- Regeneration of periodontal tissue when indicated
Indications for Periodontal surgery
- To gain access for root debridement
- To correct osseous architecture
- To correct soft tissue contours
- Osseous grafting
- Root resection
- Pocket reduction
- Guided tissue regeneration
- Dental implants
- Patients with active periodontal disease with signs of: probing depth (>/= 5), attachment loss, bone loss, BOP despite good oral hygiene
- PI < 30%
- Patients with minimal attached gingiva (less than 1 mm)
- Patients with gingival recession
- “periodontally healthy” patients with needs crown lengthening
- “periodontally healthy” patient who needs implant placement
Contraindications of Periodontal surgery
- Patients with poor oral hygiene/plaque control (PI > 30%)
- Poor patient compliance
- Uncontrolled systemic diseases (ie. poorly controlled diabetics, smokers)
- Acute oral infections
What is “periodontal surgery”
“when I use the term ‘Periodontal surgery’ in a question, I mean perio surgery in general with all of the sub-classification”
When he specifies “osseous surgery or crown lengthening” what does he imply?
“when I specify Osseous surgery or crown lengthening that implies only that sub-classification of surgery, for example, osseous surgery is indicated in chronic periodontitis after SRP and re-eval when we have 10-20% horizontal bone loss with attachment loss and PD 5-7 mm (that would have been an indication for osseous surgery)”
THe use of sutures after surgery indication and benefits
The use of absorbable or non-absorbable sutures after periodontal surgery will:
- Provide wound closure
- Position tissue
- Control bleeding
- Helps reduce postoperative pain
Definition of periodontal flap
Periodontal flap
- The part of the gingiva or oral mucosa that is separated from the teeth and alveolar bone by vertical and/or horizontal incisions, yet remains attached to the rest of the alveolar mucosa in at least one area
Flap Design and Classifications
Flap Design and Classification
Classification of Flap
- Type (anatomy-based definition)
- Gingival
- Mucogingival
- Mucosal
- Design
- Enveloped
- Relaxed
- Placement
- Replaced = repositioned (R.F) - envelope, full thickness, replaced, mucogingival flap
- Apically Positioned (APF)
- Coronally positioned (CPF) - relaxed, split-thickness, coronally positioned, mucogingival flap
- Laterally positioned (LPF)
- Distal or proximal wedge (D/PW)
- Width (histologic Definition)
- Full-thickness = mucoperiosteal
- Partial (split) thickness
- Combinations
Periodontal Flap Design Summary
- Repositioned flap: full thickness or partial thickness and relaxed flap or enveloped flap
- Apically positioned flap: full thickness or partial thickness and relaxed flap or enveloped flap
- Coronally positioned flap: full thickness or partial thickness and relaxed flap
- Laterally positioned flap: full thickness or partial thickness and only relaxed flap
- Distal or proximal flap: Full thickness
Advantage/disadvantage of envelop and relaxed flaps
Envelope Flap
- Advantages
- Faster healing, less post-op pain, esthetic areas, conserve tissue, easier closure
- Disadvantages
- Limited access to bone, limited flap mobility
Relaxed flap: includes vertical releasing incisions
- Advantages
- ACCESS!
- Tissue position (APF, CPF)
- Allows for smaller surgical field
- Disadvantages
- Delayed healing (decreased blood supply)
- More post-op pain
Full-thickness vs. partial thickness flap and its anatomy
Full thickness flap
- Include reflection of the periosteum connective tissue and epithelium to expose the alveolar crest
- Used for osseous resective or regenerative surgery
- Look at the bone
Partial Thickness Flap
- Periodontal plastic surgery
- Incising within connective tissue
- Blood supply comes from remaining periosteum
Indication/contraindication of “osseous surgery”
Indication/contraindication of “osseous surgery”
- resective = reduce pocket depth surgery
Indications for Osseous Surgery
- Mild horizontal bone loss
- Shallow 1,2,3 wall vertical bone defects
- 1-3 mm
- Mild to moderate
- Pocket depth 4-6 mm
- CAL 1-3 mm
Contraindications for Osseous Surgery
- Advanced horizontal bone loss
- Deep 1,2,3 wall vertical bone defects
- >/= 4 mm
- Advanced
- Pocket depths >/= 7 mm
- CAL >/= 4 mm
- Mobility
- High caries rate
- Heavy smoker
- Dentinal hypersensitivity
- Esthetic zone
- Anatomical Consideration - sinus proximity
Defect size/shape and prognosis 1,2,3 wall defects meaning best defect to graft and treat)
Defect size/shape and prognosis 1,2,3 wall defects meaning best defect to graft and treat)
-
Osseous Resection Best Defect Treatment
- Shallow, wide, 1 wall defect
- Less protected (non-confined)
- Osseous resection most predictable
-
Osseous Regeneration (graft) best to treat
- 3 wall defect deep
Ostectomy vs. osteoplasty
Ostectomy = removal of alveolar bone proper/PDL
Osteoplasty = removal of non-supporting bone
Indication/contraindication with definition of crown lengthening (CPT code D4249)
Indication/contraindication with definition of crown lengthening (CPT code D4249)
-
Definition of Crown lengthening
- This procedure is employed to allow restorative procedure or crown with little or no tooth structure
- Crown lengthening requires reflection of a flap and is performed in a healthy periodontal environment as opposed to osseous surgery, which is performed in the presence of periodontal disease
- Where there are adjacent teeth the flap may involve a larger surgical area
-
Indication
- To maintain biological width (JE + CT)
- To increase the retention of crowns
- To improve esthetics (hard and soft tissue removal)
- To access carious lesions, fracture lines restoration margins
- Combinations
-
Contraindication
- Non-strategic (endo+post/core + crown + CL vs. implant or bridge)
- Non- restorable
- Esthetics
- Compromised periodontal condition
What is the definition of “Ferrule effect”
Ferrule Effect
- A 360 collar of the crown surround the parallel walls of the dentine extending coronal to the shoulder of the preparation
- A 2 mm height of tooth structure should be available for a ferrule effect
The ferrule effect helps reduce the risk of the tooth fracturing, though it doesn’t guarantee it. A solid tooth foundation is necessary so that a crown has its finish margin on natural tooth structure.
