PERIO - perio surgery Flashcards
what is another name for periodontal surgery?
mucogingival surgery
what BSP guideline step does perio surgery fall under?
step 3 - managing non responding sites
what does the first step of the BSP guidelines include?
implementation of pt motivation strategies
implementation of behaviour changes
control of local risk factors
control of systemic risk factors
PMPR supragingival plaque and calculus
at the end of step 1 of the BSP guidelines, when evaluating, describe an engaging pt?
OH improvement >50%
plaque levels <20%
bleeding <30%
meeting targets in self care plan
at the end of step 1 of the BSP guidelines, when evaluating, describe a non engaging pt?
insufficient improvement in OH <50%
plaque levels >20%
bleeding >30%
states preference to palliative approach
at the end of step 1, the patient is not engaging, what do you do?
repeat step 1
what is step 2 in the bsp guidelines?
subgingival instrumentation
US or hand instruments
quadrant wise or full mouth
describe a stable patient at the end of step 2?
no perio pockets >4mm with BOP
no remaining deep sites >6mm
describe an unstable patient at the end of step 2?
deep sites remain >6mm
BOP in pockets >3mm
when is non surgical periodontal therapy predictable successful?
good patient compliance/ buy-in
appropriate professional management
what is the aim of non-surgical periodontal therapy?
control microbial load/ composition
reduce inflammatory cell infiltrate
how is step 3 in the bsp guidelines carried out?
holistic approach
- focus on residual sites: access, eliminate or regenerate lesions
interventions
- repeated subgingival instrumentation +/- adjunctive antimicrobials
- periodontal surgery (resective, repair, or regenerative) for pockets >6mm
what is periodontal surgery?
a collection of surgical interventions involving the supporting tissues of the teeth
what are the 3 types of periodontal surgery?
resective
reparative
regenerative
what are the indications for periodontal surgery?
pocket reduction
improvement of gingival contour
improvement of access for OH measures
access to inaccessible, non responding sites for diagnosis and management
regain lost clinical attachment
in step 3, when would periodontal surgery as an intervention be appropriate?
residual deep sites (>6mm)
infrabony defects > 3mm
furcation involvement (class II)
when should periodontal surgery not be performed? and why
if self-performed OH insufficient
plaque score <20-25% consistently associated with better surgical outcomes
who can perform periodontal surgery?
dentists with additional specific training
what are the absolute contraindications for perio surgery?
bleeding conditions (INR >3-3.5, low platelets)
recent MI or stroke (<6 months)
recent vascular prosthesis placement or transplant (<6-12 months)
significant immunosuppression
active cancer therapy
IV bisphosphonate treatment?
what are the relative contraindications for perio surgery?
patient wound healing potential (genetic)
social history - smoking
what is the most important environmental risk factor in periodontitis?
smoking
why is smoking a risk factor for periodontitis?
impairs wound healing - less attachment gain and PD reduction after surgery in smokers
what are the soft tissue considerations that must be made before perio surgery?
phenotype
interdental papilla
volume of keratinised, attached gingival tissue
pocket depth
what are the hard tissue considerations that must be made before perio surgery?
defect angulation (<25 degree better than >37 degrees)
number of bony walls of infrabony defect
depth of defect (>3mm)
what is the case selection criteria at DDH for perio surgery?
- NSPT and RSD under LA at max potential carried out
- minimal supra/ subgingival calculus deposits present
- compliance with smoking cessation
- good plaque control demonstrated by PFS >80%
- presence of PPD >6mm + BOP +/- suppuration
- no/minimal mobility, or able to splint grade I/II mobility teeth
- pre-operative radiograph clearly showing bony morphology
what do you consent the patient for pre perio surgery?
pain, swelling, bleeding, bruising, post-op infection, recession, scarring
transient mobility of teeth, dentinal sensitivity, failure of procedure, use of biomaterials
what pre-operative advice is given to the patient for perio surgery?
wear loose clothing, especially layers
unless having GA or sedation, have a good breakfast/ lunch
take all regular medication unless told otherwise
if concerned about getting home, have someone with you
long procedure - put enough money in parking meter
can change mind about going ahead if they wish - even if signed consent forms
what are the main principles of flap design for perio surgery?
keep flaps as minimal as possible
every design is unique to the clinical situation
careful handling of tissues at all times
measure interdental papilla to determine handling
what type of relieving incisions do perio surgeries tend to avoid?
vertical relieving incisions
they use horizontal relieving incisions instead
if a relieving incision is required for perio surgery, what are the principles?
start at 90 degree to gingival margin
vertical direction
extend just past mucogingival junction
avoid cutting over bulbosity such as canine eminence
describe the haemostasis involved in perio surgery?
minimal blood loss during surgery
most have primary closure - suturing applies small amount of pressure and wound stability
what materials have been used for perio surgery sutures?
traditionally - black silk
present day - synthetic mono-filament suture
what are the properties of the synthetic mono-filament sutures used for perio surgery?
resorbable or non-resorbable
non-wicking
low bacterial colonisation
can be difficult to tie as ‘springy’
what advice do you tell the pt whilst sutures are present after perio surgery?
no brushing in the region
use chlorhexidine mouthwash to reduce plaque formation
what are the post op instructions for perio surgery?
take regular analgesia - paracetamol and ibuprofen
use ice pack for first 12 hours to reduce swelling
avoid surgical site when brushing until sutures removed - use CHX mouthwash
suture removal at 5-7 days - longer grafting surgery to ensure stability
no probing or instrumentation of site for 3 months (9-12 months if biomaterials used)
what are the available types of resective perio surgery options?
gingivectomy
root resection
what are the available types of repair/ reattachment perio surgery available?
OFD (open flap debridement)
MWF (modified windman flap)
describe resective perio surgery?
pocket elimination procedures which establish a morphologically normal attachment but with apical displacement of the dento-gingival complex; recession (oldest technique)
what are examples of resective perio surgery?
gingivectomy
apically repositioned flaps
root resection
osseous reduction
distal wedge incision
what is gingival overgrowth and what are its causes?
abnormal overgrowth of gingival tissues
multiple causes:
- inflammatory (plaque)
- drug-induced
- related to systemic conditions
can be localised or generalised
what is a gingivectomy?
management of gingival overgrowth by resection/ recontouring the gingivae
describe the healing process following a gingivectomy?
a raw wound is left
- healing by secondary intention (0.5mm re-epithelialisation per day)
- periodontal dressing pack (coe-pack) is used to cover for 7-14days
*very painful for some patients
indications for gingivectomy?
gingival enlargement/ overgrowth persists despite non-surgical care
supra-bony periodontal pocketing
trauma caused by gingival overgrowth
interference with speech or aesthetics
excellent at home care
wide zone of attached gingivae
contraindications for gingivectomy?
narrow attached gingivae
planned osseous recontouring
infra-bony periodontal pockets
medical contraindications (especially bleeding disorders)
what would be your non surgical management of gingival overgrowth?
OHI - single tufted brush angulated into gingival margin
eliminate drug
when would scrubbing the gums be fine to do?
with a thick gingival phenotype
advantages of a gingivectomy?
simple
good vision
can achieve ideal soft tissue morphology
disadvantages of a gingivectomy?
limited indications
heal by secondary intention (painful)
risk bone exposure
wastes attached gingivae
excessive recession in pd disease
when could you use electrosurgery for gingival recontouring?
for smaller areas of recontouring
what are the advantages of electrosurgery for gingival recontouring?
cauterises as you go - less bleeding risk
what is a contraindication of electrosurgery for gingival recontouring?
contraindication - pacemakers
describe surgical crown lengthening?
a surgical procedure which apically repositions the soft tissue and alveolar bone to expose more tooth structure, and increase the length of the clinical crown
- normally a resective procedure depending on amount of attached gingiva available
what is the aim of SCL?
surgically maintain biologic width whilst apically repositioning the gingival level
indications for SCL?
toothwear
poor gingival aesthetics
restoration of subgingival lesions
replacement of crowns with deep margins
management of coronal third fractures
management of infringement of biologic width
develop ferrule for pulpless teeth restored with posts
contraindications for SCL?
poor plaque control
poor compliance
non-functional teeth or teeth or poor strategic value
periodontal destruction
endodontic compromise
medical history considerations
what are the complications for SCL?
poor aesthetics due to black triangles
transient mobility of the teeth
root sensitivity
rebound of marginal tissues
root resorption
after SCL, how long do you wait for the gingival margin to re-establish?
2 months
describe repair/ reattachment surgery?
pocket reduction surgery, but without replication of the normal attachment - healing is by formation of a long junctional epithelium
normally managed with partially reflected flap
referred to as open flap debridement
describe a partially reflected flap for repair/ reattachment (OFD) surgery?
crevicular incision without relieving incisions
what are the aims of OFD?
access for root surface debridement under direct vision
assessment of root surface (grooves, fractures, enamel pearls, iatrogenic damage)
indications for OFD?
excellent maintenance
site >6mm with BOP or suppuration
horizontal bone loss pattern
vertical defect <3mm
isolated periodontal pockets remain
contraindications for OFD?
aesthetic region
need for graft/ membrane
complex furcation/ bone defects
advantages of OFD?
healing by primary intention
minimal crestal bone resorption
effective in pockets 6-7mm
disadvantages of OFD?
can be unpredictable - dependant on healing potential
no new true attachment - healing by long junctional epithelium
risk of recession
interdental craters
describe regenerative surgery?
recreation of the complete attachment apparatus of bone / cementum / functionally orientated periodontal ligament against exposed root surface
what is repair vs regeneration?
repair
- long junctional epithelium
- crestal remodelling
regeneration
- new cementum
- new PDL
- new alveolar bone
what are the aims of regenerative surgery?
- enhance access for plaque control and 2. maintenance
- regenerate defect
- remove factors associated with disease progression
how does regenerative surgery regenerate defect?
gain clinical attachment
minimise soft tissue recession
increase bone volume
in regenerative surgery, what factors are removed which are associated with disease progression?
- residual deep sites
- infrabony defects
- furcation involvement
- bleeding on probing
what factors are needed for regeneration?
space provision
PDL cells
wound stability
in regeneration, what cells are available for healing? and what is their outcome after repopulating the root
epithelial cells = long junction epithelium
gingival connective tissue cells = CT attachment or root resorption
bone cells = root resorption and ankylosis
mesenchymal cells from PDL = regeneration
what is the case selection criteria for regeneration?
infrabony defect associated with perio pocket of >6mm (depth of vertical defect >3mm)
class II furcation in mandibular molars
single class II furcation in maxillary molars
what factors improve the prognosis for good regeneration?
narrow defect <25 degrees ideally
higher number of bony walls = better prognosis
what are the different regenerative techniques?
guided tissue regeneration
bone graft materials
enamel matric proteins (EMD)
combinations of above methods:
- GTR and bone
- EMD and bone
what is guided tissue regeneration?
use of mechanical barrier (membrane) to selectively enhance the establishment of PDL and peri-vascular cells in osseous defects to initiate periodontal regeneration
what teeth defects is guided tissue regeneration used for?
teeth with periodontal bone loss and intrabony defects
what are the aims of guided tissue regeneration?
stop rapid downgrowth of epithelial cells
create space for pluripotent cells from PDL to access root surface
improve local anatomy, function and prognosis of teeth
what is the role of the membrane in GTR?
act as a barrier to prevent cells apart from PDL migrating into site
- provide ‘space’ for regeneration
- promotes ‘PDL cells’ for regeneration
what are the types of membranes available for GTR?
- resorbable (less predictable duration/ stability) i.e., collagen
- non-resorbable (require second surgery to remove)
what are the various sources bone grafts and substitutes may come from?
autograft: from a donor site of the same person
allograft: from a different person, but human bone
xenograft: from an animal source
alloplast: synthetic material
how do bone grafts work in regeneration?
they support flap, providing ‘space’ and ‘stability’ for regeneration
describe the terms osteogenic, osteoinductive, and osteoconductive?
osteogenic: can create more bone
osteoinductive: communicate with other parts of bone to regenerate
osteoconductive: relies on external factors
what does emdogain do?
mimics the development of tooth supporting apparatus during tooth formation
accelerates early wound healing
has direct effects on cellular behaviour to promote regeneration (PDL and alveolar bone rely on cementum)
what is the effect of EMD on epithelial cells?
decreased cell proliferation and migration
what is the effect on EMD on gingival fibroblasts?
reduced cell migration
what is the effect of EMD on bone?
increased cell proliferation + migration, support of bone formation but not osteoinductive
what is the effect of EMD on PDL fibroblasts?
increased cell proliferation, migration and attachment
what is the effect of EMD on cementoblasts?
increased in vivo mineralisation
what type of materials are used in DDH for bone grafts?
xenografts
what are the advantages of regeneration?
successful in tx of deep sites of 6mm or greater
healing by primary intention
improvement in volume of supporting tissues of tooth
less recession for pt
what are the disadvantages of regeneration?
technically challenging to get good outcome
can be unacceptable for some patients depending on materials used
expensive materials
what are the 7 options for furcation involved teeth?
- non surgical perio therapy
- odontoplasty
- open flap debridement
- tunnelling procedures
- root resection or separation
- regenerative procedures
- xla
what types of furcation’s is non surgical perio therapy successful for managing?
grade 1 (USS more effecting than hand scaling)
what is an odontoplasty?
drill the root surface to change its shape so it doesnt gather as much plaque
involves raising a flap buccal and lingual
what are the risks of odontoplasty?
can result in hypersensitivity and cariesz
what type of furcations can odontoplasty aid in treating?
grade 1 and shallow grade 2
what type of furcations may OFD treat?
grade 2 furcations
- shallow
- mesial/ distal bone below entrance of furcation
- single in maxilla
why would you use open flap debridement to treat furcation?
to access and clean with direct vision
what is the most predictable regenerative procedure for furcations?
GTF with bone graft
when would regeneration not be effective for furcations?
- entrance of furcation below the height of mesial/ distal bone
- multiple class II defects in maxilla
- class III furcations
what is root resection?
removal of one root of a multi-rooted tooth where there is uneven bone loss
can be termed ‘hemisection’ in mandibular molars (includes removal of portion of the crown)
what needs to be done to a tooth prior to root resection?
RCT
what roots have better success with root resection?
MB or DB roots of upper molars
mesial roots of lower molars
indications for root resection?
class 2/3 furcation involvement
severe bone loss on 1 or more roots
root fracture/ perforation/ deep caries
failed endo tx or inoperable canals
contraindications for root resection?
inadequate bone support on remaining roots
unfavourable anatomy
- fused roots
- long root trunk
significant discrepancies in bone height
remaining roots not restorable
what is a treatment option for extensive furcation where bone loss around both roots is similar?
root separation, restore each as a single tooth - allows to floss in between
when would you perform tunnel preparation?
mandibular molars with deep degree 3 and 3 furcations
- used to improve ability for oral hygiene
state all the treatment options for degree 1 furcation?
NSPT
state al tx options for degree 2 furcations?
resective therapy
- apically repositioned flap
- tunnel
- root amputation/ hemisection
regenerative therapy
- graft + GTR
- biologics + graft
- biologics + graft + GTR
state all available tx for degree 3 furcations?
resective therapy
- apically repositioned flap
- tunnel
- root amputation/ hemisection
xla
what is gingival recession?
location of the marginal tissue apical to the cemento-enamel junction with exposure of the root surface
a hard tissue dehiscence must be present
what are the possible aetiological factors of recession?
traumatic
- toothbrushing, partial dentures, lip/ tongue piercing, self-inflicted
traumatic overbite
periodontal disease
poor restorative margins
- plaque retention
- encroach on biologic width
what factors are related to increased risk of recession?
high muscle attachment/ frenal pull
thin tissue phenotype
alveolar dehiscence
teeth outside alveolar bone after ortho tx (arch expansion, proclination of incisors)
lack of keratinised tissue
what is the non-surgical intervention for management of recession?
monitoring and prevention (measure and take pics!!)
composite restoration (can gather plaque and drive recession further)
gingival prosthesis
ortho?
what is the surgical intervention for management of recession?
frenectomy
grafting surgery
- pedicle flaps
- gingival grafts
- connective tissue grafts
what OHI can be given for recession?
single tufted brush with flicking motion toward the crown
daily
indications for surgical management of recession?
prevention of continued recession
improve ability to perform OH measures
aesthetic concern
sensitivity
root caries
contraindications for surgical management of recession?
poorly controlled diabetes
bleeding disorders
smoking
poor OH
active perio disease
previous failed procedures
self-inflicted injuries
what is a frenectomy?
removal of local muscle insertion - making a nick across the frenum
= no muscle pull on tissue
- stabilises tissue and improved access for OH
indications for frenectomy?
unstable local tissue
- movement
- blanching on retraction
blocking access for OH
non-recession indications
- midline diastema
- shallow vestibule for prosthesis
contraindications for frenectomy?
medical/ bleeding disorders
scar formation will make further procedures more challenging (consider internal frenectomy)
why do we graft for recession?
connective tissue determined overlying epithelial characteristics
- change from thin to thick phenotype
aims for grafting surgery for recession?
improve/ create band of keratinised, attached gingiva
avoid scarring
optimal tissue blend/ colour match
improve access for OH
100% root coverage
list the features of pedicle flap?
local tissue maintaining own blood supply
single site surgery
surgery limited by local anatomy
list the features of free grafts for recession?
material from distant donor site
2 site surgery
larger quantity of CT
more technically demanding
no direct blood supply so risk graft can fail
what is a pedicle flap?
moving adjacent attached gingivae to cover a region of recession using a split thickness flap
can be laterally repositioned or double papilla
indications for pedicle flap for recession?
narrow defect on single tooth
adjacent teeth with thick phenotype or edentulous area
deep vestibule
contraindcations for pedicle flap for recession?
deep perio pocketing
loss of ID tissue
large root prominences
lack of relevant local anatomy
deep root abrasions
advantages of pedicle flap for recession?
1 site surgery
good vascularity to pedicle flap
root coverage possible
disadvantages of pedicle flap for recession?
limited by amount of adjacent keratinised, attached gingivae
risk of recession at donor site
risk of dehiscence at donor site
limited to a single tooth
not as likely to gain root coverage
what is a free gingival graft?
graft from palate formed of epithelium and small amount of underlying connective tissue is placed into a region with localised recession
what is the aim of a free gingival graft?
- to create a band of keratinised mucosa
- remove frenal attachments
- prepare site for second procedure to increase root coverage
indications for free gingival graft?
discomfort during OH measures
ongoing local inflammation
lack of keratinised tissue in regions of recession defect
prevention of further recession
insufficient local keratinised tissue for pedicle flap
contraindications for free gingival graft?
aesthetic region
aim for complete root coverage
donor site tissue poor
medical contraindications
advantages relatively simple surgery?
relatively simple surgery
increases vestibular depth
disadvantages of free gingival graft?
second surgical site
palatal wound heals by 2ndry intention
unaesthetic
- mismatch in colour, texture, and thickness
- misalignment of mucogingival junction
what is connective tissue grafting?
surgical procedure where a split thickness flap is raised, released and then replaced in a more coronal position
when may you want to combine a connective tissue graft with a split thickness flap?
- limited gingivae apical to recession
- shallow sulcus
- buccally placed root
- interdental CAL
advantages of connective tissue grafting?
possible for 1 site surgery
microsurgical technique (better healing)
excellent colour match
better vascularisation of flap (excellent graft survival and wound stability)
best root coverage outcomes with CT graft
disadvantages of connective tissue grafting?
often benefits from CT graft (secondary surgery site)
technically demanding (thin phenotype, graft harvesting)
