Periodontics Part 4: Surgical Therapy Flashcards
Flap Design
- Wider base-adequate blood supply
- Incisions over intact bone– NOT over bondy defects or eminences
- Rounded Corners
- Vertical Releases at Line angles
- Avoid Vital Structures
Partial vs Full Thickness Flap
Partial Thickness Flap
* includes: Gingiva/mucosa, submucosa
* mucogingival surgery-unecessary to expose bone, leaves vascular bed intact
Full Thickness Flap
* Gingiva/mucosa, submucoa, periosteum
* osseous surgery & periodontal regeneration to permit primary closure
* exposes bone-expect 1mm of bone resorption and remodeling
Papilla Preservation Flap
=Papilla Preservation Flap:
* preserve the papilla
Dont want conventional flap
-splits papilla
Full thickness flap: what types of incisions are used
3 horizontal incisions:
internal or reverse bevel:
* 1 mm from gingival margin
* removes pocket lining, but preserves outer gingiva
Sulcular or crevicular
* through base of pocket to alveolar crest
interdental or interproximal
* removes tissue collar
Periodontal Pack
- consists of ZOE
placed for 1 week following surgery
protect surgical wound
minimize discomfort
maintain tissue placement
prevent post-op bleeding
* do NOT enhance healing
Gingival Surgery: Gingivectomy vs Gingivoplasty
Gingivectomy
* excision of suprabony pockets or enlarged gingiva
Gingivoplasty:
* excise gingiva to reshape tissue deformities
Gingival Surgery: Distal Wedge
FOR Pocket reduction
* Distal to terminal molars
* common after 3rd molar ext
Maxillary: Full thickness flap w/parallel incisions
Mandible: Full thickness flap w/v-shaped incisions
What are the different types of Mucogingival Surgery
- Free Gingival Graft
- Connective Tissue Graft
- Frenectomy
- Frenotomy
- Vestibuloplasty
Free Gingival Graft
to widen keratinized tissue
* Adds more attached gingiva
ADVANTAGES
Increase:
* esthetics
* Plaque Removal
Decrease:
* inflammation around abutment teeth and implants
What is the advantages of adding more attached gingiva with a Free Gingival Graft?
Increase:
* esthetics
* Plaque Removal
Decrease:
* inflammation around abutment teeth and implants
Connective Tissue Graft
Root Coverage
* occurs above gingival margin
Graft:
* palate
* Inner Connective tissue ONLY, (No epithelium)
Donor site requires enough attached gingiva
What is the most common donor site for Free Gingival Graft vs Connective Tissue Graft
Palate for BOTH!
Frenectomy
Complete removal of frenum
Frenotomy
Freenum Incision
- incision of Freenum
Vestibuloplasty
Deepen vestibule
What is the purpose of Osseous Surgery?
Visualize
Bony architecture
* Positive, Negative, Flat
Bone Defect
* type
* extent
Positive vs Negative vs Flat architecture
Osseous Surgery: Positive vs Negative vs Flat Architecture
positive architecture:
* interproximal bone is above radicular bone (Around root)
* normal/ideal
flat Architecture
* interproximal and radicular bone=same level
Negative architecture:
* interproximal bone is below radicular bone
What are the different type of osseous surgery?
Ostectomy
Osteotomy
Osseous Surgery: Ostectomy vs Osteotomy
Ostectomy
* remove supporting alveolar bone
Osteotomy
* remove nonsupporting bone
* bone away from tooth
What are the mechanisms of healing after osseous surgery?
Regeneration:
* Completely restore architecture and fxn
Repair:
* does NOT completely restore architecture & fxn
* form long JE (Scarring)
Reattachment:
* epithelial and CT reconnect w/root surface
New Attachment:
* New PDL fibers connect to New cementum
Periodontal Regeneration
Guided Tissue Regeneration (GTR):
* regenerate bone, cementum, & PDL
Required materials: (3 B’s)
1.Barrier Membrane: (TANK)
2.Bone Graft (Damge)
3.Biologic Agent: (HEALER)
4.medicine
GTR: Biologic Agent
creates environment conductive for tissue formation
GTR: Barrier Membrane
1.Barrier Membrane: (TANK)
* prevents soft tissue downgrowth
* allows bone ingrowth
GTR: Bone Graft
Bone Graft
* regenerate bone
* osteoconductive, osteoinductive, &/or osteogenic
Periodontal Regeneration Healing: Cells that populate the wound from fastest to slowest
Cells that populate wound: (fastest to slowest)
1. epithelial cells
2. CT Cells
3. PDL Cells
4. Bone Cells
What happens during healing if we opted to do nothing instead of periodontal regeneration?
Long Junctional Epithelium
* Repair, NOT regeneration
Root Surface Treatment
Chelating agents: EDTA & Citric Acid
* demineralize–>expose collagen
* improve new attachment
Osteogenic vs Osteoinductive vs Osteoconductive
Osteogenic:
* Make bone
Osteoinductive:
* convert progenitor cells into osteoblasts
Osteoconductive:
* scaffold
Types of Bone Graft
Autograft
Allograft
Xenograft
Alloplast
Autograft
- From yourself
- osteoconductive
- osteoinductive
- Osteogenic
Allograft
from another human
* usually cadavear
Osteoonductive
osteoinductive
Xenograft
from another animal
* usually cows
Osteoconductive
Alloplast
Synthetic
Osteoconductive
Periodontal Surgery Summary: Additive vs Subtractive
Additive:
* Periodontal regeneration
* FGG
* CTG
* Coronally advanced flap
Subtractive: bring levels down & reduce PD
* Resective osseous surgery (ostectomy)
* Gingivectomy
* Apically positiioned flap
What is the necessary treatment for infrabony defects?
(1-2-3-4- wall defects)
1/2-wall defects
* Resection (ostectomy)
* recontour bone to restore positive architecture
3/4-wall defects
* Regeneration
* better blood supply & cell source proximity
What scenarios are ideal for regneration?
(infrabony, furcation, recession)
Deep Narrow 3-wall
* infrabony
Hamp Class II
* buccal upper or either buccal or lingual lower
* furcation
Miller Class I
* w/thick gingival biotype & wide band of Keratinized tissue (at least 2 mm)
* 100% root coverage w/CTG
* recession
What is the most important procedure after periodontal surgery?
Post-op plaque control
When bone is exposed, how much bone resorption should be expected?
1mm of bone resorption and remodeling
Modified Widman Flap
Modified Widman Flap
3 Horizontal incisions: internal/reverse bevel
Sulcular/crevicular
Interdental/interproximal
Access subgingival areas for debridement
* Goal=New attachment
Apically Repositioned Flap
3 incisions + vertical releasing
internal/reverse bevel
Sulcular/crevicular
Interdental/interproximal
incisions made beyond mucogingival jxn
* pocket reduction
Tetracyclines
Congregate in GCF
* Doxycycline: 1 dose per day
