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Module 7 > PERIO - perio surgery > Flashcards

PERIO - perio surgery Flashcards

1
Q

what is another name for periodontal surgery?

A

mucogingival surgery

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2
Q

what BSP guideline step does perio surgery fall under?

A

step 3 - managing non responding sites

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3
Q

what does the first step of the BSP guidelines include?

A

implementation of pt motivation strategies
implementation of behaviour changes
control of local risk factors
control of systemic risk factors
PMPR supragingival plaque and calculus

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4
Q

at the end of step 1 of the BSP guidelines, when evaluating, describe an engaging pt?

A

OH improvement >50%
plaque levels <20%
bleeding <30%
meeting targets in self care plan

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5
Q

at the end of step 1 of the BSP guidelines, when evaluating, describe a non engaging pt?

A

insufficient improvement in OH <50%
plaque levels >20%
bleeding >30%
states preference to palliative approach

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6
Q

at the end of step 1, the patient is not engaging, what do you do?

A

repeat step 1

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7
Q

what is step 2 in the bsp guidelines?

A

subgingival instrumentation
US or hand instruments
quadrant wise or full mouth

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8
Q

describe a stable patient at the end of step 2?

A

no perio pockets >4mm with BOP
no remaining deep sites >6mm

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9
Q

describe an unstable patient at the end of step 2?

A

deep sites remain >6mm
BOP in pockets >3mm

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10
Q

when is non surgical periodontal therapy predictable successful?

A

good patient compliance/ buy-in
appropriate professional management

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11
Q

what is the aim of non-surgical periodontal therapy?

A

control microbial load/ composition
reduce inflammatory cell infiltrate

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12
Q

how is step 3 in the bsp guidelines carried out?

A

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

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13
Q

what is periodontal surgery?

A

a collection of surgical interventions involving the supporting tissues of the teeth

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14
Q

what are the 3 types of periodontal surgery?

A

resective
reparative
regenerative

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15
Q

what are the indications for periodontal surgery?

A

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

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16
Q

in step 3, when would periodontal surgery as an intervention be appropriate?

A

residual deep sites (>6mm)
infrabony defects > 3mm
furcation involvement (class II)

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17
Q

when should periodontal surgery not be performed? and why

A

if self-performed OH insufficient
plaque score <20-25% consistently associated with better surgical outcomes

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18
Q

who can perform periodontal surgery?

A

dentists with additional specific training

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19
Q

what are the absolute contraindications for perio surgery?

A

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?

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20
Q

what are the relative contraindications for perio surgery?

A

patient wound healing potential (genetic)
social history - smoking

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21
Q

what is the most important environmental risk factor in periodontitis?

A

smoking

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22
Q

why is smoking a risk factor for periodontitis?

A

impairs wound healing - less attachment gain and PD reduction after surgery in smokers

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23
Q

what are the soft tissue considerations that must be made before perio surgery?

A

phenotype
interdental papilla
volume of keratinised, attached gingival tissue
pocket depth

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24
Q

what are the hard tissue considerations that must be made before perio surgery?

A

defect angulation (<25 degree better than >37 degrees)
number of bony walls of infrabony defect
depth of defect (>3mm)

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25
Q

what is the case selection criteria at DDH for perio surgery?

A
  • 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
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26
Q

what do you consent the patient for pre perio surgery?

A

pain, swelling, bleeding, bruising, post-op infection, recession, scarring

transient mobility of teeth, dentinal sensitivity, failure of procedure, use of biomaterials

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27
Q

what pre-operative advice is given to the patient for perio surgery?

A

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

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28
Q

what are the main principles of flap design for perio surgery?

A

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

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29
Q

what type of relieving incisions do perio surgeries tend to avoid?

A

vertical relieving incisions

they use horizontal relieving incisions instead

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30
Q

if a relieving incision is required for perio surgery, what are the principles?

A

start at 90 degree to gingival margin
vertical direction
extend just past mucogingival junction
avoid cutting over bulbosity such as canine eminence

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31
Q

describe the haemostasis involved in perio surgery?

A

minimal blood loss during surgery
most have primary closure - suturing applies small amount of pressure and wound stability

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32
Q

what materials have been used for perio surgery sutures?

A

traditionally - black silk
present day - synthetic mono-filament suture

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33
Q

what are the properties of the synthetic mono-filament sutures used for perio surgery?

A

resorbable or non-resorbable
non-wicking
low bacterial colonisation
can be difficult to tie as ‘springy’

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34
Q

what advice do you tell the pt whilst sutures are present after perio surgery?

A

no brushing in the region
use chlorhexidine mouthwash to reduce plaque formation

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35
Q

what are the post op instructions for perio surgery?

A

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)

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36
Q

what are the available types of resective perio surgery options?

A

gingivectomy
root resection

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37
Q

what are the available types of repair/ reattachment perio surgery available?

A

OFD (open flap debridement)
MWF (modified windman flap)

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38
Q

describe resective perio surgery?

A

pocket elimination procedures which establish a morphologically normal attachment but with apical displacement of the dento-gingival complex; recession (oldest technique)

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39
Q

what are examples of resective perio surgery?

A

gingivectomy
apically repositioned flaps
root resection
osseous reduction
distal wedge incision

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40
Q

what is gingival overgrowth and what are its causes?

A

abnormal overgrowth of gingival tissues
multiple causes:
- inflammatory (plaque)
- drug-induced
- related to systemic conditions
can be localised or generalised

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41
Q

what is a gingivectomy?

A

management of gingival overgrowth by resection/ recontouring the gingivae

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42
Q

describe the healing process following a gingivectomy?

A

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

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43
Q

indications for gingivectomy?

A

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

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44
Q

contraindications for gingivectomy?

A

narrow attached gingivae
planned osseous recontouring
infra-bony periodontal pockets
medical contraindications (especially bleeding disorders)

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45
Q

what would be your non surgical management of gingival overgrowth?

A

OHI - single tufted brush angulated into gingival margin
eliminate drug

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46
Q

when would scrubbing the gums be fine to do?

A

with a thick gingival phenotype

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47
Q

advantages of a gingivectomy?

A

simple
good vision
can achieve ideal soft tissue morphology

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48
Q

disadvantages of a gingivectomy?

A

limited indications
heal by secondary intention (painful)
risk bone exposure
wastes attached gingivae
excessive recession in pd disease

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49
Q

when could you use electrosurgery for gingival recontouring?

A

for smaller areas of recontouring

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50
Q

what are the advantages of electrosurgery for gingival recontouring?

A

cauterises as you go - less bleeding risk

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51
Q

what is a contraindication of electrosurgery for gingival recontouring?

A

contraindication - pacemakers

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52
Q

describe surgical crown lengthening?

A

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

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53
Q

what is the aim of SCL?

A

surgically maintain biologic width whilst apically repositioning the gingival level

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54
Q

indications for SCL?

A

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

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55
Q

contraindications for SCL?

A

poor plaque control
poor compliance
non-functional teeth or teeth or poor strategic value
periodontal destruction
endodontic compromise
medical history considerations

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56
Q

what are the complications for SCL?

A

poor aesthetics due to black triangles
transient mobility of the teeth
root sensitivity
rebound of marginal tissues
root resorption

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57
Q

after SCL, how long do you wait for the gingival margin to re-establish?

A

2 months

58
Q

describe repair/ reattachment surgery?

A

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

59
Q

describe a partially reflected flap for repair/ reattachment (OFD) surgery?

A

crevicular incision without relieving incisions

60
Q

what are the aims of OFD?

A

access for root surface debridement under direct vision
assessment of root surface (grooves, fractures, enamel pearls, iatrogenic damage)

61
Q

indications for OFD?

A

excellent maintenance
site >6mm with BOP or suppuration
horizontal bone loss pattern
vertical defect <3mm
isolated periodontal pockets remain

62
Q

contraindications for OFD?

A

aesthetic region
need for graft/ membrane
complex furcation/ bone defects

63
Q

advantages of OFD?

A

healing by primary intention
minimal crestal bone resorption
effective in pockets 6-7mm

64
Q

disadvantages of OFD?

A

can be unpredictable - dependant on healing potential
no new true attachment - healing by long junctional epithelium
risk of recession
interdental craters

65
Q

describe regenerative surgery?

A

recreation of the complete attachment apparatus of bone / cementum / functionally orientated periodontal ligament against exposed root surface

66
Q

what is repair vs regeneration?

A

repair
- long junctional epithelium
- crestal remodelling

regeneration
- new cementum
- new PDL
- new alveolar bone

67
Q

what are the aims of regenerative surgery?

A
  1. enhance access for plaque control and 2. maintenance
  2. regenerate defect
  3. remove factors associated with disease progression
68
Q

how does regenerative surgery regenerate defect?

A

gain clinical attachment
minimise soft tissue recession
increase bone volume

69
Q

in regenerative surgery, what factors are removed which are associated with disease progression?

A
  • residual deep sites
  • infrabony defects
  • furcation involvement
  • bleeding on probing
70
Q

what factors are needed for regeneration?

A

space provision
PDL cells
wound stability

71
Q

in regeneration, what cells are available for healing? and what is their outcome after repopulating the root

A

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

72
Q

what is the case selection criteria for regeneration?

A

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

73
Q

what factors improve the prognosis for good regeneration?

A

narrow defect <25 degrees ideally
higher number of bony walls = better prognosis

74
Q

what are the different regenerative techniques?

A

guided tissue regeneration
bone graft materials
enamel matric proteins (EMD)

combinations of above methods:
- GTR and bone
- EMD and bone

75
Q

what is guided tissue regeneration?

A

use of mechanical barrier (membrane) to selectively enhance the establishment of PDL and peri-vascular cells in osseous defects to initiate periodontal regeneration

76
Q

what teeth defects is guided tissue regeneration used for?

A

teeth with periodontal bone loss and intrabony defects

77
Q

what are the aims of guided tissue regeneration?

A

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

78
Q

what is the role of the membrane in GTR?

A

act as a barrier to prevent cells apart from PDL migrating into site
- provide ‘space’ for regeneration
- promotes ‘PDL cells’ for regeneration

79
Q

what are the types of membranes available for GTR?

A
  • resorbable (less predictable duration/ stability) i.e., collagen
  • non-resorbable (require second surgery to remove)
80
Q

what are the various sources bone grafts and substitutes may come from?

A

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

81
Q

how do bone grafts work in regeneration?

A

they support flap, providing ‘space’ and ‘stability’ for regeneration

82
Q

describe the terms osteogenic, osteoinductive, and osteoconductive?

A

osteogenic: can create more bone
osteoinductive: communicate with other parts of bone to regenerate
osteoconductive: relies on external factors

83
Q

what does emdogain do?

A

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)

84
Q

what is the effect of EMD on epithelial cells?

A

decreased cell proliferation and migration

85
Q

what is the effect on EMD on gingival fibroblasts?

A

reduced cell migration

86
Q

what is the effect of EMD on bone?

A

increased cell proliferation + migration, support of bone formation but not osteoinductive

87
Q

what is the effect of EMD on PDL fibroblasts?

A

increased cell proliferation, migration and attachment

88
Q

what is the effect of EMD on cementoblasts?

A

increased in vivo mineralisation

89
Q

what type of materials are used in DDH for bone grafts?

A

xenografts

90
Q

what are the advantages of regeneration?

A

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

91
Q

what are the disadvantages of regeneration?

A

technically challenging to get good outcome
can be unacceptable for some patients depending on materials used
expensive materials

92
Q

what are the 7 options for furcation involved teeth?

A
  1. non surgical perio therapy
  2. odontoplasty
  3. open flap debridement
  4. tunnelling procedures
  5. root resection or separation
  6. regenerative procedures
  7. xla
93
Q

what types of furcation’s is non surgical perio therapy successful for managing?

A

grade 1 (USS more effecting than hand scaling)

94
Q

what is an odontoplasty?

A

drill the root surface to change its shape so it doesnt gather as much plaque
involves raising a flap buccal and lingual

95
Q

what are the risks of odontoplasty?

A

can result in hypersensitivity and cariesz

96
Q

what type of furcations can odontoplasty aid in treating?

A

grade 1 and shallow grade 2

97
Q

what type of furcations may OFD treat?

A

grade 2 furcations
- shallow
- mesial/ distal bone below entrance of furcation
- single in maxilla

98
Q

why would you use open flap debridement to treat furcation?

A

to access and clean with direct vision

99
Q

what is the most predictable regenerative procedure for furcations?

A

GTF with bone graft

100
Q

when would regeneration not be effective for furcations?

A
  • entrance of furcation below the height of mesial/ distal bone
  • multiple class II defects in maxilla
  • class III furcations
101
Q

what is root resection?

A

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)

102
Q

what needs to be done to a tooth prior to root resection?

A

RCT

103
Q

what roots have better success with root resection?

A

MB or DB roots of upper molars
mesial roots of lower molars

104
Q

indications for root resection?

A

class 2/3 furcation involvement
severe bone loss on 1 or more roots
root fracture/ perforation/ deep caries
failed endo tx or inoperable canals

105
Q

contraindications for root resection?

A

inadequate bone support on remaining roots
unfavourable anatomy
- fused roots
- long root trunk
significant discrepancies in bone height
remaining roots not restorable

106
Q

what is a treatment option for extensive furcation where bone loss around both roots is similar?

A

root separation, restore each as a single tooth - allows to floss in between

107
Q

when would you perform tunnel preparation?

A

mandibular molars with deep degree 3 and 3 furcations
- used to improve ability for oral hygiene

108
Q

state all the treatment options for degree 1 furcation?

A

NSPT

109
Q

state al tx options for degree 2 furcations?

A

resective therapy
- apically repositioned flap
- tunnel
- root amputation/ hemisection

regenerative therapy
- graft + GTR
- biologics + graft
- biologics + graft + GTR

110
Q

state all available tx for degree 3 furcations?

A

resective therapy
- apically repositioned flap
- tunnel
- root amputation/ hemisection

xla

111
Q

what is gingival recession?

A

location of the marginal tissue apical to the cemento-enamel junction with exposure of the root surface

a hard tissue dehiscence must be present

112
Q

what are the possible aetiological factors of recession?

A

traumatic
- toothbrushing, partial dentures, lip/ tongue piercing, self-inflicted
traumatic overbite
periodontal disease
poor restorative margins
- plaque retention
- encroach on biologic width

113
Q

what factors are related to increased risk of recession?

A

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

114
Q

what is the non-surgical intervention for management of recession?

A

monitoring and prevention (measure and take pics!!)
composite restoration (can gather plaque and drive recession further)
gingival prosthesis
ortho?

115
Q

what is the surgical intervention for management of recession?

A

frenectomy
grafting surgery
- pedicle flaps
- gingival grafts
- connective tissue grafts

116
Q

what OHI can be given for recession?

A

single tufted brush with flicking motion toward the crown
daily

117
Q

indications for surgical management of recession?

A

prevention of continued recession
improve ability to perform OH measures
aesthetic concern
sensitivity
root caries

118
Q

contraindications for surgical management of recession?

A

poorly controlled diabetes
bleeding disorders
smoking
poor OH
active perio disease
previous failed procedures
self-inflicted injuries

119
Q

what is a frenectomy?

A

removal of local muscle insertion - making a nick across the frenum

= no muscle pull on tissue

  • stabilises tissue and improved access for OH
120
Q

indications for frenectomy?

A

unstable local tissue
- movement
- blanching on retraction

blocking access for OH

non-recession indications
- midline diastema
- shallow vestibule for prosthesis

121
Q

contraindications for frenectomy?

A

medical/ bleeding disorders
scar formation will make further procedures more challenging (consider internal frenectomy)

122
Q

why do we graft for recession?

A

connective tissue determined overlying epithelial characteristics
- change from thin to thick phenotype

123
Q

aims for grafting surgery for recession?

A

improve/ create band of keratinised, attached gingiva
avoid scarring
optimal tissue blend/ colour match
improve access for OH
100% root coverage

124
Q

list the features of pedicle flap?

A

local tissue maintaining own blood supply
single site surgery
surgery limited by local anatomy

125
Q

list the features of free grafts for recession?

A

material from distant donor site
2 site surgery
larger quantity of CT
more technically demanding
no direct blood supply so risk graft can fail

126
Q

what is a pedicle flap?

A

moving adjacent attached gingivae to cover a region of recession using a split thickness flap
can be laterally repositioned or double papilla

127
Q

indications for pedicle flap for recession?

A

narrow defect on single tooth
adjacent teeth with thick phenotype or edentulous area
deep vestibule

128
Q

contraindcations for pedicle flap for recession?

A

deep perio pocketing
loss of ID tissue
large root prominences
lack of relevant local anatomy
deep root abrasions

129
Q

advantages of pedicle flap for recession?

A

1 site surgery
good vascularity to pedicle flap
root coverage possible

130
Q

disadvantages of pedicle flap for recession?

A

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

131
Q

what is a free gingival graft?

A

graft from palate formed of epithelium and small amount of underlying connective tissue is placed into a region with localised recession

132
Q

what is the aim of a free gingival graft?

A
  • to create a band of keratinised mucosa
  • remove frenal attachments
  • prepare site for second procedure to increase root coverage
133
Q

indications for free gingival graft?

A

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

134
Q

contraindications for free gingival graft?

A

aesthetic region
aim for complete root coverage
donor site tissue poor
medical contraindications

135
Q

advantages relatively simple surgery?

A

relatively simple surgery
increases vestibular depth

136
Q

disadvantages of free gingival graft?

A

second surgical site
palatal wound heals by 2ndry intention
unaesthetic
- mismatch in colour, texture, and thickness
- misalignment of mucogingival junction

137
Q

what is connective tissue grafting?

A

surgical procedure where a split thickness flap is raised, released and then replaced in a more coronal position

138
Q

when may you want to combine a connective tissue graft with a split thickness flap?

A
  • limited gingivae apical to recession
  • shallow sulcus
  • buccally placed root
  • interdental CAL
139
Q

advantages of connective tissue grafting?

A

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

140
Q

disadvantages of connective tissue grafting?

A

often benefits from CT graft (secondary surgery site)
technically demanding (thin phenotype, graft harvesting)

Module 7 (62 decks)

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