Periodontal Surgery Part 1

Question 1

where does periodontal surgery fit?

Answer 1

step 3 - managing non-responding sites

Question 2

what does step 1 do?

Answer 2

builds foundations
- provides preventive and health promotion tools to patient

Question 3

what does step 1 evaluate

Answer 3

Improvement in OH
plaque levels
bleeding
meeting targets in self care plan

Question 4

what is step 2

Answer 4

sub gingival instrumentation

Question 5

what does step 2 evaluate

Answer 5

whether the patient is stable of unstable

Question 6

what is a stable patient

Answer 6

no periodontal pockets over 4mm with BOP
no remaining deep sites over 6mm

Question 7

what is an unstable patient

Answer 7

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

Question 8

what is periodontal surgery

Answer 8

collection of surgical interventions involving the supporting tissues of teeth

Question 9

3 types of periodontal surgery

Answer 9

respective
reparative
regenerative

Question 10

indications for periodontal surgery

Answer 10

pocket reduction
improvement in gingival contour
improvement of access to OH measures
access to inaccessible non responding sites
regain lost clinical attachment

Question 11

when is surgical intervention recommended

Answer 11

residual deep sites over 6mm
infra bony defects over 3mm
furcation involvement (class III)

Question 12

general considerations for surgery

Answer 12

patients wishes and expectations and cooperation
MH, SH
non-surgical periodontal therapy not successful at this site
OH compliance
local factors around tooth (acmes, mobility, infra bony defect)
long term prognosis of tooth
operator experience and resources

Question 13

systemic considerations for surgery - absolute contraindications

Answer 13

bleeding conditions (INR>3-3.5, low platelets)
recent MI or stroke (<6 months)
recent valvular prosthesis placement or transplant (<6-12 months)
significant immunosuppression
active cancer therapy
IV bisphosphonate treamtment

Question 14

systemic considerations for surgery - relative contraindications

Answer 14

patient wound healing potential
social history - smoking

Question 15

smoking and periodontal surgery impact

Answer 15

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

Question 16

local considerations for surgery

Answer 16

oral hygiene
soft tissue considerations
hard tissue considerations
local anatomical structure
access for surgery

Question 17

case selection at DDH

Answer 17

NSPT and RSD under LA carried out at maximum potential
minimal supra/su gingival calculus deposits present
compliance with smoking cessation
good plaque control by PFS >80%
present of PPD >6mm and BOP and/no suppuration
no/minimal mobility
pre-operative radiograph showing bony morphology

Question 18

consent

Answer 18

pain
bleeding
swelling
brusing
post-op infection
recession
scarring
transient mobility of teeth
dentinal sensitivity
failure of procedure
use of biomaterials

Question 19

basic principles of periodontal microsurgery

Answer 19

microsurgical instruments
microsurgical scalpel blades
magnification
minimal wound
gentle handling of soft and hard tissues
retention of pre-operative soft tissue architecture

Question 20

flap design principles

Answer 20

keep flaps as minimal as possible
every design is unique
careful handling of tissues
measure interdental pailla to determine handling

most periodontal surgeries avoid vertical relieving incisions

if receiving incisions required, start at 90 degrees to gingival margin and vertical direction

Question 21

haemostasis

Answer 21

expect minimal blood loss during surgery
local application of LA containing adrenaline can help reduce bleeding
most surgeries have primary closure

Question 22

sutures

Answer 22

synthetic mono-filament suture
- resorbable or non-resorbable
- non -wicking
- low bacterial colonisation
- can be difficult to tie as ‘springey’

while sutures present no bruising in the region and use chlorohexidine mouthwash to reduce plaque formation

Question 23

concerns regarding periodontal dressings

Answer 23

difficult handling and placement
patients don’t like it - aesthetics and function
bacterial growth underneath

Question 24

when are periodontal dressings used

Answer 24

cover raw wound edges in gingivectomy
control healing after gingivectomy
stabilise free gingival graft

Question 25

post-op instructions

Answer 25

take regular analgesia
use ice packs for first 12 hours to reduce swelling
avoid surgical site when brushing until sutures remvoed
suture removal at 5-7 days
no probing or instrumentation of site for 3 months minimum

Question 26

effectiveness of periodontal surgery

Answer 26

reduction in overall PPD
elimination of deep pockets
reduced disease progression

Question 27

effectiveness of pocket reduction is dependant on what

Answer 27

depth of initial site