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Y4 - CAD > Periodontal surgery symposium P1 > Flashcards

Periodontal surgery symposium P1 Flashcards

1
Q

what are the 4 goals of periodontal treatment

A
  • Reduction/resolution of gingivitis to no more than 20-30% BOP
  • Reduction in PPD to <5mm
  • Absence of pain
  • Satisfactory aesthetics and function
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2
Q

what are the 3 stages of periodontal surgery

A
  • Initial therapy
  • Corrective therapy (additional therapeutic measures)
  • Supportive periodontal therapy (maintenance phase)
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3
Q

what is the aim of initial therapy
what is the objective of initial therapy
what things does initial therapy include

A
  • motivating pt to perform optimal plaque control
  • achieve clean and infection-free conditions
  • NSPT, restorations, endodontic treatment, extractions
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4
Q

what things does corrective therapy include

A
  • Additional therapeutic measures
  • Address sequelae of infections
  • Replacement of lost tissue(s)
  • Includes perio/endo/restorative Tx
  • Patient’s cooperation and OH may affect the type of treatment offered
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5
Q

what is supportive periodontal therapy (SPT) aka

A

maintenance phase

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6
Q

what is the aim of spt
what is the objective of spt

A

Aim: to prevent reinfection and disease recurrence
Objectives: continued preservation of
gingival/periodontal health obtained via active
perio Tx. Regular clinical re-evaluation with
appropriate interceptive Tx

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7
Q

What does the recall system of SPT include

A
  • Assessment of deeper sites with BOP
  • Reinstrumentation
  • Fluoride application
  • Ongoing maintenance of restorations,
    assessment of vitality, bitewings
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8
Q

Aims of non-surgical treatment

A
  • Eliminate living microorganisms in the biofilm and calcified microorganisms from the
    tooth surface and adjacent soft tissues
  • Reduction in inflammation, pocketing, BOP
  • Improve plaque control
  • Rationale for calculus removal relates to eliminating surface irregularities harbouring
    bacteria.
  • Complete calculus removal likely over-ambitious
  • Plaque and calculus remain in >90% of sites >5mm deep (Waerhaug 1978)
  • Increased clinician experience -> better removal
  • Periodontal healing will still occur even in the presence of calculus (Jepsen 2011)
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9
Q

what do you do after spt

A

decide
- Further NSPT
- +/- adjunctive systemic antimicrobials
- +/- extraction of teeth
- Surgical options
- Supportive therapy

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10
Q

what patient factors can cause further breakdown

A
  • Increased number of sites >6mm
  • Pts treated without LA (Grbic 1991)
  • % BOP
  • > 20-30% at risk of disease progression (Badersten 1985, 1990; Joss 1994)
  • Extent of baseline attachment loss and pocket depths
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11
Q

what tooth level factors can cause further breakdown

A
  • Furcation involvement
  • Mobility
  • Limited residual support
  • Overhanging restorations etc
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12
Q

what site level factors can cause further breakdown

A

BOP
- BOP -> 30% likelihood of disease progression (Lang 1986)
- No BOP -> 98% likelihood of stability (Lang 1990)
- Short term persistence of deep pockets less useful; but long term observation especially in conjunction with BOP -> risk of further
attachment loss
- PD 5mm and above

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13
Q

what is the optimal time for SPT

A

2-4 years, should be tailored to patients risk level

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14
Q

what do you need to explain to patients in terms of how the chances of disease progression and tooth loss can increase

A
  • Poorer OH
  • Irregular SPT
  • Interleukin polymorphism
  • Smoking
  • Age
  • Initial diagnosis of aggressive/severe disease

surgery will not overcome the above

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15
Q

what are the objectives of periodontal surgery

A
  • Improve the prognosis of the tooth
  • Eliminate pockets >5mm and BOP
  • Facilitate plaque control
  • Elimination of deeper pockets to a more maintainable range
  • Correction of abnormal gingival and bony morphology which interferes with plaque
    control
  • Root sectioning or improvement of tooth morphology to improve oral hygiene
    maintenance
  • Creation of cleansable embrasure spaces
  • ? Regenerate lost periodontium
  • ? Resolution of mucogingival problems e.g.overgrowth/recession
    -> Aesthetic improvement
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16
Q

what are the stages of surgical strategies

A
  1. Controlling disease-
    persistent sites following
    NSPT
    - Pocket reduction
    - Regeneration
  2. Gingivectomy
  3. Surgery for recession
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17
Q

what are 2 effect of periodntal disease

A

infrabony defects
furcation defects

18
Q

what patient factors should you consider for case selection

A

Highly motivated patient
- compliance with OHI and appointments
- Plaque free scores of > 70% on more than 1 occasion
- No medical contraindications
- Non-smoker
- Thorough non-surgical periodontal therapy completed
- Localised residual pocketing
- Surgery is part of comprehensive treatment plan
-> Including ongoing SP

19
Q

what patient factors should you consider for case slection

A
  • No plaque in areas to be treated
  • Surgery in the presence of poor OH leads to further
    destruction
  • Non-mobile teeth
  • Strategic teeth
  • Pocketing >5mm
20
Q

what are strategic teeth

A

Occlusal contacts
-> Consider occlusal relationship e.g. class II div 1 cases
Anterior teeth
-> If molars inappropriate for Tx consider SPT and focus on trying to
keep 5-5

21
Q

Why pockets 6mm+?

A

Matuliene 2008: increased risk of progression (Odds Ratio 2.4)
u Surgery à better access for debridement >6mm (Caffesse 1986)
u Surgery à worse outcomes <6mm (Heitz-Mayfield 2002)
u In shallow pockets, NSPT à less attachment loss (0.5mm)
u 4-6mm: NSPT à 0.4mm more attachment gain
u >6mm: surgery à more PD reduction and 0.2mm more attachment gai

22
Q

surgery for infrabony defect

A

raise soft tissue
make incision
retract the flap carefully to reveal the bone crest and granulation tissue within the pocket
scoop out an unhealthy tissue using standard hand scaler from inside the pocket
use ultrasonic scaler
use cow and mixx with whatever to promotes reattachment, stem cells?
stitch back toegther
moinotr up to 9 months
avpid subgingival probing to allow healing

23
Q

what is the classifictaion for furcation defetcs

A

Class I: Horizontal loss of periodontal support
<3mm
Class II: Horizontal loss of periodontal support
>3mm
Class III: Horizontal ‘through and through’ destruction of the periodontal tissues in
the furcation

24
Q

Problems with furcations

A
  • Harder to debride- residual calculus more likely
    -> Experienced operators: open debridement 32%, closed 56%
    -> Inexperienced: open debridement 57%, closed 92%
  • McGuire 1996: molars with no furcation defect or class I had 90% survival
    over 5 yrs; with no difference between these two groups.
    -> Class II- 75% 5yr survival, Class III- 60%
  • Reduced response- teeth with furcation defects respond less favourably to
    therapy than those without.
  • Furcation-involved teeth 2-5x more likely to be lost
  • Presence of deep proximal furcation defects adversely affects the prognosis
    of the adjacent teeth (Ehnevid 2001).
25
Q

Favourable conditions for regenerative surgery to furcations

A
  • Class II lesions
  • Shallower lesion
  • Narrower lesion
  • Mandible more predictable than maxilla
  • Buccal/lingual sites (?as better access) (Jepsen 2002)
  • Thicker biotype -> less post-op recession
26
Q

Anatomical considerations for furcation defects

A
  • Depth of root trunk
  • Root divergence
  • Length and shape of root cones
  • Amount of remaining support around individual roots
  • Stability of individual roots
  • Access for oral hygiene
27
Q

what is root resection/hemisection

A
  • Sectioning of multirooted teeth to remove the root +/-
    coronal portion
  • Studies vary from around 5% failure to 30% at 10yrs.
  • Shorter root trunk, divergent roots, larger root cones are more favourable
28
Q

what are periodontal indications for root resection/hemisection

A

Severe bone loss around 1+
roots
Class II/III defects
Severe recession/ dehiscence

29
Q

what are endodontic indications for root resection/hemisection

A
  • Inability to treat a canal
  • Root # or perforation
  • Root caries
30
Q

what are prosthetic indications for root resection/hemisection

A

Root trunk # or unrestorable caries

31
Q

contraindictaions for resection/hemisection

A
  • systemic factors
  • poor OH
  • root fusion
  • insufficient remaining tooth tissue
  • post-retained restoration required
32
Q

when isnt surgery feasible

A

Terminal dentition
u Generalised pocketing
u Tooth mobility
u Non-motivated patient
u ?advanced age
u Poor OH
u Poor compliance with Tx
u Large furcation defects, especially in maxilla
u Extensive/hopeless bone loss
u Horizontal bone loss: regeneration not possible

33
Q

What to do when surgery isn’t feasible?

A

Extraction
u If detrimental to remaining dentition
u ‘Palliative’ ongoing supportive therapy
u Accept gradual deterioration
u Extractions as driven by signs/symptoms

34
Q

why would you do a gingivectomy

A

Gingival overgrowth
Crown lengthening procedures e.g. late failure of eruption, short clinical
crown height, facilitate restoration of teeth

35
Q

non surgical amangement for gingival overgrowth

A
  • Rigorous OH reduces overgrowth (Seibel 1989)
  • Professional and home care
  • Mechanical OH, CHX
  • Discuss with medical team re: medication
36
Q

how to carry out gingivectomy

A
37
Q

Gingivectomy techniques

A

Scalpel/ laser/ electrosurgical
u External bevel
u Internal bevel with flap
u Similar patterns of regrowth
u Laser may lead to less post-operative discomfort
u Coe-pak dressing 1/52
u Biopsy
u Case reports have described Kaposi’s sarcoma and SCC, also pemphigus (Vasanthan
2007

38
Q

Only consider surgery for gingival overgworth when…

A
  • Good OH
  • NSPT completed
  • Motivated patient
  • Consider modification of medical risk factors e.g. liaise with GP
    regarding medications
39
Q

when is surgery for management of recession not feasible

A
  • RT3
  • Generalised defects
  • Consider gingival venee
40
Q

role of the gdp

A

Assessment
u Oral hygiene instruction and patient education
u Initial NSPT
u Awareness of surgical options and when these may/may
not be appropriate
u Continued supportive therapy

Y4 - CAD (5 decks)

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