Principles of surgery

Question 1

Surgery Def

Answer 1

-Any surgical procedure used to treat periodontitis or to modify the morphology of the periodontium -Surgical manipulation of periodontal soft tissues, root and bone

Question 2

Goal of periodontal surgery

Answer 2

To create an oral environment that is conducive to maintaining the patient’s dentition in health, comfort, function and esthetics

Question 3

Indications for periodontal surgery

Answer 3

Indications: #1 Access to the root surface and bone Regeneration Pre-prosthetic Surgery Abscess treatment Mucogingival surgery Gingival enlargement Implant placement Exploratory surgery

Question 4

Types of pre prosthetic surgery

Answer 4

Crown lengthening Gingival augmentation Ridge augmentation Sinus floor elevation Ridge augmentation Tori reduction Tuberosity reduction

Question 5

Contraindications for periodontal surgery

Answer 5

Medical - uncontrolled disease Poor plaque control High caries risk Patient desires

Question 6

Deferent surgical therapies

Answer 6

Gingivectomy/Gingivoplasty Curtain Procedure Modified Widman Flap Flap Curettage Osseous therapy Laser Surgery

Question 7

Types of Osseous therapy

Answer 7

Resective Regenerative -GTR -Bone grafts -EMD, PDGF…

Question 8

Surgical Approach is based on…

Answer 8

Type of disease Severity of disease Location of disease Morphology of osseous defects

Question 9

Surgical Objectives

Answer 9

1 - Provide access Modify osseous architecture Repair / regenerate the periodontium Pocket reduction Establish acceptable soft tissue contours

Question 10

Surgical Objectives #1 Access

Answer 10

Opened approach to debridement: Increased visibility Increased efficiency Less tissue trauma

Question 11

Surgical Objectives Osseous Modification

Answer 11

Re-create physiologic contour Eliminate osseous defects Resection Regeneration Provide a maintainable periodontium

Question 12

Surgical Therapy Repair/Regenerate

Answer 12

Reattachment Repair New Attachment Regeneration

Question 13

Reattachment

Answer 13

To attach again The reunion of epithelial and connective tissue with a root surface following separation by incision or physical injury (not by disease). Not to be confused with new attachment.

Question 14

Repair

Answer 14

Healing of a wound with tissue that does not fully restore the architecture or function of the original part. LJE and scar

Question 15

New Attachment

Answer 15

The union of connective tissue or epithelium with a root surface that has been deprived of its original attachment apparatus. This new attachment may be epithelial adhesion and/or connective adaptation or attachment and may include new cementum. i.e. DISEASED

Question 16

Regeneration

Answer 16

Reproduction or reconstitution of a lost or injured part in a manner similar or identical to its original form. In periodontics, refers to the formation of new bone, cementum, and a functionally-oriented periodontal ligament at a site deprived of its original attachment apparatus. In edentulous spaces, refers to the surgical augmentation of a resorbed ridge.

Question 17

Surgical Objectives - Pocket Reduction

Answer 17

Reduce probing depth to a manageable level Improve subgingival access - Easier plaque control Improve long term stability of the periodontium

Question 18

Surgical Objectives Acceptable Contours

Answer 18

Provide acceptable soft and hard tissue contours to: Reduce pocket depths Improve plaque control Improve esthetics

Question 19

Surgical Principles

Answer 19

Know your patient Develop thorough treatment plan Know anatomy of surgical sites Provide profound anesthesiaAtraumatic tissue managementAseptic technique HemostasisNon-irritating sutures Obliterate dead space Quiescent wound healing

Question 20

Atraumatic Tissue Management

Answer 20

Sharp, smooth incisions and dissection Adequate flap release Conserve vascular supply Keep it wide at base (2:1 width to height) Avoid - overthinning, excessive flap tension, perforation/tears Don’t desiccate the flap and bone, keep them well hydrated

Question 21

Aseptic Technique

Answer 21

Sterile peri-operative field Sterile instruments and gloves Pre-operative mouthrinse/ peri-oral alcohol wipe Prophylactic antibiotics prn

Question 22

Infections Post-surgically

Answer 22

1% infection rate post-surgery (<1% without, 2% with antibiotics) Pack & Haber, 1983 4.2% of 498 cases No difference if bone removed or teeth ext. Quad surgeries infected more often then sextant No difference between group with prophylactic antibiotics and those without BL: low rate of infection following periodontal surgery; use of antibiotics to prevent infection not warranted

Question 23

Surgical Hemostasis

Answer 23

Preoperative Medical history Medications/coagulation disorders Intraoperative Pressure Vasoconstrictors Local agents Surgicel, Avitene, topical thrombin, HemCon (chitosan), bone wax, Gelfoam Bovie

Question 24

Blood loss during surgery

Answer 24

134 ml, mean blood loss from periodontal flap surgery (range 16-592ml) Duration of surgery and amount of anesthetic used correlated with blood loss Mand surg ~151 ml Max surg ~ 110 ml

Question 25

Post op hemostasis

Answer 25

rest wound stability Tranexamic acid

Question 26

Surgical Principles Atraumatic Suturing

Answer 26

Small needle/fine suture Select suture with less tissue reactivity Use least number as is necessary Minimize flap tension Place in keratinized tissue when possible Take adequate “bite” of tissue

Question 27

Surgical Principles Obliterate Dead Space

Answer 27

Attain hemostasis Primary closure Flap pressure

Question 28

Pain Management Preoperative Assessment

Answer 28

medical / dental history past response to surgery/analgesics substance abuse

Question 29

Pain Management Preemptive measures

Answer 29

administer analgesic 1-2 hrs prior long acting local anesthetics

Question 30

Pain Management Postop care

Answer 30

appropriate analgesics Motrin 800mg x 40 tabs, take 1 tab q8h prn pain Tylenol 500mg x 40 tabs, take 2 tabs q6-8h prn pain Tylenol #3 x 12 tabs, take 1 tab q4-6h prn pain Others..Percocet, Norco, Ultram……

Question 31

Stress Management

Answer 31

Patient - provider rapport Profound anesthesia Consider IV or oral sedation

Question 32

Quiescent Wound Healing

Answer 32

Wound Stabilization Flap adaptation / hemostasis Appropriate suturing technique Avoid post-operative trauma limit oral hygiene delay suture removal periodontal dressing? Optimize infection control

Question 33

Wound Stability

Answer 33

0-1 d - Fibrin linkage and clot adhesion - weak strength 3d - Granulation tissue - weak 14 D - Epithelial attachment and collagen adhesion - mod strength 21 d Maturation of CT and Cementum Formation - strong

Question 34

Wound stability of full thickness flaps/sutures in dogs

Answer 34

2-3 d 225 gms flap separation 7 d 340 gms flap separation 14 d 1,700 gms suture pull through 1, 4, 6 mo 1,700 gms suture pull through

Question 35

Types of incisions

Answer 35

External bevel Internal bevel Sulcular Releasing Thinning (dissecting) Stepback Cutback Periosteal release

Question 36

External Bevel

Answer 36

Coronally directed Gingivectomy

Question 37

Internal Bevel

Answer 37

–Apically directed –Inverse bevel –Reverse bevel

Question 38

Sulcular incisions

Answer 38

Question 39

Vertical Releasing locations

Answer 39

•Unfavorable –Interdental –Midfacial •Favorable –Line angles

Question 40

Vertical Releasing advantages

Answer 40

–Increase access –Avoid non-diseased sites –Eliminate flap tension –Allows flap positioning

Question 41

Vertical Releasing contraindications

Answer 41

–Distal to second molars –Exostoses –Mandibular concavities

Question 42

Flap design considerations

Answer 42

–Anatomical constraints –Blood supply –Tissue morphology –Required access –Degree of flap mobility required –Final flap position

Question 43

Flap design

Answer 43

To maintain adequate blood supply to the flap the ratio of flap height to flap base should not exceed 2 to 1.

Question 44

Full thickness flap

Answer 44

Elevation of entire soft tissue complex

Question 45

Full thickness advantages

Answer 45

–Increased visibility –Access to alveolar bone –Easier, quicker procedure

Question 46

Full Thickness disadvantages

Answer 46

–Exposure of root dehisence/fenestration –More alveolar bone loss?

Question 47

Split Thickness flap

Answer 47

Elevation of only the superficial epithelialized portion of soft tissue leaving the periosteum intact

Question 48

Split Thickness advantages

Answer 48

–Does not expose root dehisence/fenestrations –Reduced alveolar bone loss –Leaves a soft tissue bed for graft placement

Question 49

Split Thickness disadvantages

Answer 49

–Not indicated in areas of thin tissue –More technically demanding and time consuming –Risk of perforation

Question 50

Flap Reflection "Mopuse hole"

Answer 50

* Don’t “mouse hole” * Increases surgical trauma * Poorer visibility * Inadequate debridement * Increased operator fatigue/frustration * Inferior surgical results

Question 51

Type of flap repositioning

Answer 51

* Replaced * Apically positioned * Coronally positioned

Question 52

what type of positioning is this

Answer 52

Coronal

Question 53

What kind of repositioning is this

Answer 53

Apical

Question 54

Suture needle facts

Answer 54

–Stainless steel –3/8s, half, 5/8s –tappered, cutting, reverse cutting

Question 55

Suture selection

Answer 55

–tissue reactivity –handling properties –knot security –tissue type