Periodontal Plastic Surgery Flashcards
What is access therapy in periodontal treatment?
OFD
Part of step 3
If certain sites still have deep pockets
What are the advantages of OFD?
Better vision, better access to complex pockets (direct access to bone crest)
What are the features of resective periodontal surgery?
More historic
- Used before regenerative therapy
- Contributes to bone loss
- Curettage to remove lining of pocket- does not accelerate healing (we want to remove biofilm)
What are the types of resective periodontal therapies that are still used?
Furcation resective tx (tunnel prep- easier to keep clean)
Gingivectomy for hyperplasia
CLS- before prosthetic tx (cheaper than implants?)
What is regenerative perio therapy used for?
- Augment using bone substitute with membranes
- Fix horizontal and vertical infra-bony defects
- Lose of alveolar bone is difficult due to anatomical structures (issues with implants)
What are the different types of mucogingival therapy in periodontal surgery? (focusses on ST)
Gingival augmentation
Root coverage
Gingival preservation at ectopic tooth eruption
Preservation of ridge collapse associated with tooth extraction
What are the ADV/DIS of surgical periodontal treatment?
ADV
- Faster outcomes
- Effective
DIS
- Requires good OH (as it is less useful if patient has poor OH- recontamination)
What are the steps in the periodontal treatment plan?
Emergency treatment
Disease control
Re-evaluation
Surgery
Reconstruction
Supportive care
How does mucogingival deficiency present?
Recession
Black triangles
What is recession?
Gingival recession is the displacement of the gingival soft tissue margin apical to the cement-enamel junction which results in exposure of the root surface
What factors are involved in aetiology of recession? pt 1
- Inflammatory process- perio disease
- PMPR (HPT)- exposes recession, bone is already lost but inflammation is reduced (this may be amenable to reconstructive surgery- but consent patient to this)
- Vigorous tooth brushing esp in patients with thin biotype (teach correct technique)
- Hard bristled toothbrush
- Traumatic incisal relationship- stripping of gingival tissues
What factors are involved in aetiology of recession? pt 2
- Trauma from foreign bodies (piercings)
- Teeth out if alignment of arch- esp with thin biotype and overlying dehiscence
- Orthodontic treatment
- Aberrant frenal attachments- pull on gingival tissues
- High frenal attachment affecting OH
- Iatrogenic damage from restorative treatment- subgingival margins that impinges on SCA
What was the old classification for recession?
Millers
-> superseded by 2017 classification
What are the types of recession?
What types of recession can be surgically fixed?
We can only fix class 1 reliably
Class 2 may or may not be amenable to MG surgery (partially treatable)
-> may not be covered up fully
Class 3- not possible
What are the signs and symptoms which occur as result of recession?
Dentine hypersensitivity
Cervical caries
Cervical abrasion and erosion
Poor aesthetics- can only be corrected by surgery
Loss of vitality- if recession progresses to apex, may lose tooth
What are the treatment options for recession?
- Monitoring
- Use of desensitizing agents, varnishes and dentine bonding agentsto decrease oversensitivness
- Composite restoration
- Prosthetic crown with pink porcelain in the region of the recession
- Removable pink gingival veneers- plaque trap and could worsen disease
- Orthodontics- prevention?
- Surgery
Why are teeth with recession more susceptible to cervical caries?
Cementum covering on exposure of root is lost
Cementum and dentine are softer tissue than enamel- not as resistant to caries
-> F supplements can help- Fluorapatite is more resistant than HA/cover with composite
What are the issues with covering lesions in cervical area caused by recession with composite?
Cervical fillings must be done with precision- no overhangs/very smooth
-> May affect aesthetics/create plaque trap
How are cervical abrasion and erosion treated?
Abrasion- correct toothbrushing
Erosion- correct diet (acidic drinks)
What are the types of gingival graft?
1)Free soft tissue graft (gingival and connective)
2)Pedicled gingival graft- vessels maintained
What are the types of pedicle gingival graft?
Rotational flaps
-> Laterally positioned flap
-> Double papilla flap
Advanced flap
-> Coronally advanced flap
-> Semilunar coronally repositioned flap procedure
What is the difference between a full thickness flap and split thickness?
Full thickness flap- cutting through to bone
Split thickness (basis of MG surgery flaps)- cut through mucosa but leave some tissue, periosteum over bone
-> never expose bare bone to oral cavity- bacterial infection
-> “Borrowing bit of tissue- but some remains over bone”
When is a graft required for mucogingival recession?
Progressive recession (esp in thin biotypes)
Root sensitivity
Poor aesthetics
Patient finding it difficult to keep area clean
Orthodontic/prosthetic treatment planned
What are the steps in a free gingival graft?
- Remove split thickness flap of tissue from palatal side (from first premolar to second molar- avoids palatal arteries)
- Suture this into new area
What are the ADV of a free gingival graft?
Short procedures
Inexpensive
Can be done by GDP
Easy to carry out (if experienced)
Increases keratinized tissue around the teeth, implant or crown
What are the DIS of free gingival graft?
Not ideal for upper arch if they expose gingiva when they smile (colour is not perfect match)
More susceptible to failure than pedicled flaps (no vessels for 1 week- nutrients only come from adjacent tissue)
Recession may recur
What is a connective tissue graft’s benefits?
Can be used to modify biotype
-> Prevents future recession
How is a connective tissue graft carried out?
Same procedure but you take connective tissue from below mucosa, replace and suture
-> uses tunnel technique- semi-lunar flap
What are the steps in taking a coronally advanced flap?
- Cut flap- split thickness
- Move everything coronally and suture over defect
** Add connective tissue graft if you want to thicken biotype
What are the features of a laterally repositioned pedicle flap?
Reposition tissue to left or right
Split thickness flap on one side and rotate over and suture
Good if you cannot do coronally advanced if not enough keratinised gingivae apically
What is a double papilla rotational flap?
Similar to laterally repositioned but done on both sides
-> used if not enough tissue for flap on one side
Why are even small gains with MG therapy worthwhile?
Could be enough to save the tooth
Can prevent extraction- especially if patient only going to lose one tooth as it would affect occlusion
-> or could consider implant (cost?)
