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Y4 - CAD > Periodontal surgery symposium P2 > Flashcards

Periodontal surgery symposium P2 Flashcards

1
Q

Types of surgery in disease sites

A

1, Resection i.e. gingivectomy
2. Open flap debridement: access flap
3. Regenerative

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2
Q

Indications for gingivectomy
What can it be done with

A

Gingival overgrowth
Can be done with scalpel/laser/electrosurgery
Send the resected tissue for biopsy

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3
Q

Access/repair

A

POCKET REDUCTION WITH RECESSION, ALLOWS CLEANING IN DIFFICULT
AREAS, WITHOUT REPLICATION OF NORMAL ATTACHMENT
* OPEN FLAP DEBRIDEMENT

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4
Q

REPAIR VS REGENERATION?

A

REPAIR
* LONG JUNCTIONAL EPITHELIUM
* CRESTAL REMODELLING
* MORE RECESSION
* TYPICALLY ACHIEVED WITH NSPT AND TRADITIONAL
PERIODONTAL SURGERY

REGENERATION
* NEW CEMENTUM
* NEW PDL
* NEW ALVEOLAR BONE
* LESS RECESSION
* CAN ONLY BE TRULY DEMONSTRATED WITH
HISTOLOGY

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5
Q

WHY REGENERATE?

A

HEALING BY REPAIR LEADS TO
* LONG JUNCTIONAL EPITHELIUM
* RECESSION (ASSOCIATED PROBLEMS – SENSITIVITY, AESTHETICS, ROOT CARIES)
* LOWER CONNECTIVE TISSUE ATTACHMENT LEVEL

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6
Q

AIMS OF REGENERATION

A

GAIN TRUE PERIODONTAL LIGAMENT CLINICAL ATTACHMENT
* MINIMISE SOFT TISSUE RECESSION
* ELIMINATE FACTORS ASSOCIATED WITH DISEASE PROGRESSION:
* RESIDUAL DEEP POCKETS (MATULIENE 2008)
* INFRABONY DEFECTS (PAPAPANOU AND WENNSTROM 1991)
* ALONGSIDE TRADITIONAL SURGERY AIMS
* REMOVAL DISEASED TISSUE
* ACCESS FOR ROOT SURFACE DEBRIDEMENT

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7
Q

WHAT TYPES OF CELLS ARE INVOLVED IN HEALING

A

1 + 2. Gingival epithelial and connective tissue cells

Lacks the potential to induce the formation of new connective
tissue attachment to a root surface deprived of its original
periodontal ligament

  1. Bone
    * DOES NOT HAVE THE POTENTIAL TO FORM A NEW CONNECTIVE TISSUE
    ATTACHMENT
    * COMPLICATIONS OF HEALING:
    * ANKYLOSIS
    * ROOT RESORPTION
  2. Periodontal ligament cells
    * GRANULATION TISSUE ORIGINATING IN THE PERIODONTAL LIGAMENT CONTAINS
    PLURIPOTENT MESODERMAL STEM CELLS WHICH HAVE THE POTENTIAL TO FORM A
    NEW CONNECTIVE TISSUE ATTACHMENT.
    KARRING ET AL JCP 1985 12 P51
    * REPOPULATION OF A DETACHED ROOT SURFACE BY CELLS OF THE PERIODONTAL
    LIGAMENT IS A PRE-REQUISITE FOR NEW ATTACHMENT FORMATION
    ISIDOR ET AL 1986 JCP 13
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8
Q

NORMAL HEALING POST NSPT

A

REGENERATION OF THE TISSUES PROCEEDS AT DIFFERENT SPEEDS
* MOST RAPIDLY FROM THE EPITHELIUM - LJE
* SLOWER FOR GINGIVAL CONNECTIVE TISSUE
* VERY SLOW FOR BONE
* EVEN SLOWER FOR PDL CELLS
* REGENERATION WILL NOT OCCUR UNLESS PERIODONTAL PROGENITOR CELLS CONTACT THE ROOT
SURFACE

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9
Q

CLASSIFICATION
OF OSSEOUS
DEFECTS

A
  1. Suprabony
  2. Infrabony
    * Infrabony (1-3 walls, combinations)
    * Craters
  3. inter-radicular (furcation)
    * Horizontal (1, 2, 3) Glickman 1953
    * Vertical (A, B, C) Tarnow 1984
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10
Q

what are suprabony defects

A

BASE OF THE POCKET
IS CORONAL TO THE
MARGINAL BONE
LEVEL

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11
Q

what are infrabony defects

A

BASE OF THE POCKET
APICAL TO THE
MARGINAL BONE

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12
Q

DESIRED CLINICAL OUTCOMES OF REGENERATION

A

PROBING DEPTHS ≤5MM
* BOP –VE
* REGENERATION OF THE DEFECT
* CLINICAL ATTACHMENT GAIN
* REDUCED PROBING DEPTH
* MINIMAL GINGIVAL RECESSION
* RADIOGRAPHIC BONY INFIL
* ENHANCE ACCESS FOR PLAQUE CONTROL AND MAINTENANCE

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13
Q

4 regenerative techniques

A

Bone grafting
guided tissue regenration (GTR)
biologics (enamel matric proteins - EMD)
growth factors (FGF-2, rh-PDGF-BB)

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14
Q

4 combinations of regenratrive techniqesu

A

HTR and grant
GTR and EMD
EMD and graft

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15
Q

GUIDED TISSUE REGENERATION technique aims to

A

– STOP RAPID DOWN GROWTH OF EPITHELIAL CELLS
ADJACENT TO ROOT SURFACE AND HENCE HEALING
BY LONG JUNCTIONAL EPITHELIUM
– CREATE SPACE FOR PERIODONTAL PLURIPOTENT STEM
CELLS TO POPULATE ROOT SURFACE

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16
Q

aims of gtr

A

PROMOTES PERIODONTAL REGENERATION (SCULEAN ET AL 1999)
* TECHNIQUE SENSITIVE (TROMBELLI 1997)
* NON CONTAINED DEFECTS, MEMBRANE MAY COLLAPSE INTO THE
SPACE LIMITING REGENERATION POTENTIAL (TONETTI 1996, CORTELLINI AND
TONETTI 2005)

17
Q

what are the 2 membrane types used

A

NON-RESORBABLE
* GORTEX RESOLUT/ CYTOPLAST DPTFE - SYNTHETIC

RESORBABLE
* BIO-GIDE – PORCINE SOURCE

18
Q

Biomaterials used for bone grafts

A
  • AUTOGRAFT
  • XENOGRAFT
  • ALLOGENIC
  • ALLOPLASTIC
  • BIOACTIVE GLASS (PERIOGLAS) (NEVINS 2000, SCLUEAN 2005)
  • HYDOXYAPATITE (HORVATH 2012)
  • BETA TRICALCIUM PHOSPHATE (STAVROPOULOUS 2010)
  • SOME EVIDENCE THAT AUTOGENOUS GRAFTS/ XENOGRAFTS/ ALLOGRAFTS
    SUPPORT PERIODONTAL REGENERATION
  • USED FOR SPACE MAINTENANCE AND CARRIERS OF BIOLOGIC MATERIALS
19
Q

BIOMATERIALS: ENAMEL
MATRIX PROTEINS

A

SYNTHESISED AND SECRETED DURING TOOTH
DEVELOPMENT BY HERS CELLS
* DEPOSITION ON TO DEVELOPING ROOT SURFACE IS
A KEY STEP IN CEMENTUM FORMATION
* DENTAL FOLLICLE CELLS DIFFERENTIATE TO
CEMENTOBLASTS WHICH FORM ACELLULAR
EXTRINSIC FIBER CEMENTUM
* PDL AND ALVEOLAR BONE FORMATION ARE
DEPENDENT ON CEMENTUM FORMATION

20
Q

what does EMD do

A

restricts
1. Epithelial growth
2. Connective tissue
promotes
3. Bone growth
4. PDL growth
5. Cementum growth
* Wound healing and defense
restricts
bacterial growth

21
Q

emdogain

A
  • PRESENT ON TREATED ROOTS FOR UP TO 4 WEEKS POST APPLICATION (SCULEAN 2002)
  • TECHNICALLY SENSITIVE BUT LOWER COMPLICATIONS THAN GTR
  • IN NON-CONTAINED DEFECTS, FLAP MAY COLLAPSE LIMITING THE AVAILABLE SPACE
22
Q

BIOMATERIALS AND EMD

A

EMD +NBM (BOVINE)
* LEKOVIC 2000
* VELASQUEZ-PLATA 2002
* ZUCCHELLI 2003
* SCULEAN 2003, 2008
EMD + DFDBA (BOVINE)
* GURINSKY 2004
EMD + AUTOGENOUS BONE
* GUIDA 2007
* YILMAZ 2011

23
Q

diff between endogain and Gtr

A

Emdogain and GTR have similar results, however, GTR is more
challenging to perform, requires more invasive flap, greater
complications

24
Q

SURGICAL CONSIDERATIONS: SOFT TISSUES

A

SURGICAL FLAP DESIGN
* MINIMALLY INVASIVE
* BETTER POST-OP EXPERIENCE
* MAINTAIN PAPILLAE (GRAZIANI 2012) AND INTERDENTAL TISSUE
* REDUCE RECESSION
* IMPROVED VASCULARIZATION
* IMPROVED WOUND STABILITY

25
Q

MINIMALLY INVASIVE SURGICAL TECHNIQUE

A
  • Preserve the papillae
  • Minimal extension of flap
  • Reveal only 1-2mm of bone crest
  • No periosteal release
  • Avoid relieving incision
  • Careful/stable suturing technique
  • (modified internal mattress)
  • Magnification
  • Microsurgical instruments
26
Q

patient factors for case selection

A
  • PATIENT FACTORS
    ➢ COMPLIANCE - <15-30% PLAQUE SCORES
    ➢ PATIENT COPING SKILLS/ACCESS
    ➢ SMOKING STATUS
  • MEDICAL HISTORY:
    ➢ BLOOD DISORDERS – I.E. HAEMOPHILLIA
    ➢ ANTICOAGULANTS – I.E. WARFARIN
    ➢ BISPHOSPHONATES – I.E. ALONDRONATE
    ➢ POORLY CONTROLLED DIABETES
    ➢ UNCONTROLLED HYPERTENSION
    ➢ IMMUNOCOMPROMISED PATIENTS
27
Q

LOCAL FACTORS THAT INFLUENCE TECHNIQUE/ OUTCOME

A
  • BONY DEFECT ANATOMY (KAO 2015)
  • HAS TO HAVE AN INFRABONY DEFECT
  • NUMBER OF ROOT SURFACES
  • NUMBER OF WALLS (1-,2-,3-WALLED DEFECTS)
  • ANGLE
  • TOOTH MOBILITY – SPLINT DURING WOUND HEALING (CORTELLINI 2001)
  • TOOTH VITALITY (CORTELLINI & TONETTI 2001)
  • ANATOMY OF THE TOOTH (SINGLE/MULTI-ROOTED - FURCATIONS)
  • POSITION OF TOOTH IN THE ARCH (ACCESS/AESTHETICS)
28
Q

case solution factors for infrabony defects

A

DEFECT FEATURES
* DEPTH >3MM
* ANGULATION <25°
* HIGHER NUMBER OF BONY
WALLS
TRUE ANATOMY ONLY CLEAR AFTER FLAP
RAISED

29
Q

which tehcnique would you use for wide and non-contained infrabony component

A

EMD + graft
Graft + GTR

30
Q

which technique would you use for wide contained infrabony component

A

EMD + grafts

31
Q

which technique would you use for narrow contained infrabony component

A

EMD

32
Q

furcation decision making

A

class 1
- nspt
class 2
- extraction
- Gtr/regenerative
- resective surgery (root resection or tunnel prep)
class 3
- extraction
- resective surgery (tunnel prep or root resection/hemisection)

33
Q

LDI GUIDELINES FOR
PERIODONTAL SURGERY

A
  • NSPT CARRIED OUT TO MAXIMUM POTENTIAL
  • MINIMAL SUPRA/SUBGINGIVAL CALCULUS
    DEPOSITS
  • COMPLIANCE WITH SMOKING CESSATION
  • GOOD PLAQUE CONTROL (PFS ≥ 70%)
  • PRESENCE OF PPD ≥ 6MM & BOP
  • RADIOGRAPHIC DEMONSTRATING BONY
    ANATOMY
34
Q

CONSENTING FOR PERIODONTAL SURGERY

A
  • PAIN
  • SWELLING
  • BRUISING
  • BLEEDING
  • RECESSION
  • PARAESTHESIA
  • SENSITIVITY
  • STITCHES
  • DAMAGE TO ROOT SURFACES
  • BIOMATERIALS!
35
Q

Post-op care

A
  • SUTURE REMOVAL AT 14 DAYS
  • 0.2% CHLORHEXIDINE MOUTHWASH BDS UNTIL SUTURE REMOVAL
  • NO MECHANICAL CLEANING AROUND SURGICAL SITE UNTIL SUTURES ARE REMOVED
  • AVOID INTERDENTAL CLEANING FOR 6 WEEKS, RESUMING NORMAL REGIME FROM THEN ON
  • NO PROBING OR SUBGINGIVAL INSTRUMENTATION FOR 9 MONTHS
  • IF GRADE 2/3 MOBILITY, SPLINT DURING POST-OP PERIOD

Y4 - CAD (5 decks)

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