Periodontal surgery Flashcards
Aims of periodontal surgery
- Gain access to previously inaccessible root surfaces
- Reduce probing depths
- Facilitate easier professional management
Evidence for the use of periodontal surgery
- In pockets >6mm, period surgery caused greater increase in clinical attachment level than RSD
Indications for periodontal surgery (5)
- Treatment of residual pockets >5mm and BOP after initial non-surgical tx
- Access to difficult areas e.g. furcations
- Gingival enlargement (false pocketing)
- Mucogingival problems
- Crown lengthening
Contra-indications for periodontal surgery (7)
- Plaque control >20%
- Unmotivated patient
- Poor prognosis teeth
- Restoratively/endodontically compromised teeth
- Complex md hx compromising surgery
- Aesthetic zone
- Smokers
Pre-surgical tx (before periodontal surgery)
- Good plaque control and motivation
= Removal of plaque retentive factors or any controllable risk factors e.g. poorly controlled diabetes - Non-surgical periodontal tx
Evidence for link between smoking and periodontal surgery
- Smoking reduces benefits
- Preber and bergstorm - smokers had worse reduction in probing depts and 2x likely to relapse
- Ah et al - approx 0.5mm less reduction in pocket depths
Why is NSPT required before surgical PT? (4)
- Allows resolution of inflammation thus tissues easier to handle and less likely to bleed
- Gives better indication of tissue morphology therefore better aesthetics after
- Pockets may resolve therefore surgery not required
- Good OH is required before surgery indicated
What are the types of periodontal surgery techniques?
- Gingevectomy
- Replacement flap
- Apically positioned flap
Aim of gingivectomy
Eliminate false pockets and supra bony defects
Improve aesthetics
Technique of gingivectomy
- Mark pocket depth on tissue and try preserve attached gingiva
- Bevelled incision coronally and aimed for base of the pocket from buccal to lingual
- Curette inter proximally to leave exposed bone
- Instrument root surfaces
Disadvantages of gingivectomy
- No access to furcations or infra bony defects
- Limited by the width of attached gingiva
- Poor aesthetics (affects pigmentation)
- Healing by secondary intention
Aims of replacement flaps
- Reduce pocketing via long JE attachment
- Better aesthetics
How do replacement flaps provide good aesthetics?
Maintain the width of attached gingiva and position of the gingival margin
Why are scalloped incisions used in replacement flaps?
Allows good proximal closure
When do you use crevicular incisions (in replacement flaps)>
- Healthy sites
- Thin tissue
Access is difficult - Little attached gingiva
Why are individual incisions done in replacement flaps?
Individual incisions prevent straining the gingiva when they are healing (in comparison to continuous incisions)
What are inverse bevels in replacement flaps?
- Incise down to crestal bone aiming for the base of the pocket
- Extend crevicularly around adjacent healthy teeth
- Or add relieving incisions to allow displacement away from teeth
What is important in flap surgery?
- Keep flap moist
- Prevent excess removal of bone
Closure in replacement flaps
- Consider if flap requires thinning or bone needs to be reshaped (for aesthetics and adaptation to teeth)
- Place the flap with the new gingival margin following tooth and bone
- Use interrupted suture
What type of suture used in replacement flaps?
Interrupted suture
What type of sutures used in apical positioned flaps?
Interrupted, continuous or suspensory
What happens when the flap is placed more apically?
The flap heals with the short JE at the apical extent of attachment loss
Replacement vs apical flaps
- Reccession
Apically aims for recession to eliminate pockets whereas replacement aims to minimise recession
Replacement vs apical flaps
- Extension of the flap
- Replacement flaps are minimal and may not need relieving incisions
- Apical flaps need incisions and extends beyond the mucogingival margin
