Soft Tissue Management_Surgery

Question 1

What are the methods available for tissue management?

Answer 1

• Gingival retraction (cord and astringents)
• Electrosurgery
• Chemical cautery (TCA-Trichloroacetic acid)

Question 2

What gingival anomalies should you be cautious of on top of the standard gingival assessment?

Answer 2

• Clefting/recession
• Probing depth
• High frenum insertion
• Blunted papilla
• Gingival asymmetry
• Ridge defect (for alveolar ridge in case of missing tooth)

Question 3

What should you assess on PA radiographs re the periodontal tissues?

Answer 3

• PA area
• Crestal bone height
• Widening of PDL
• Subgingival margin location

Question 4

What is the biological width? How long is it normally? What is the implication of this?

Answer 4

Distance from tip of alveolar crest to base of gingival sulcus.
Normally 2mm in length
Therefore margin must be 2mm above alveolar crest or crown lengthening should be considered

Question 5

What is the process for gingival recontouring? What are some methods for carrying this out? What are the adavantages and disadvantages of each method?

Answer 5

Process: Gigivectomy (removal of gingival tissue) + gingivoplasty (recontouring of remaining tissue)

Methods:

• Mechanical (surgical): gingivoplasty, apically repositioned flap
• Mechanical: rotary diamonds
• Electrosurgery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879725/

Question 6

What are some indications for gingival recontouring?

Answer 6

• Aesthetics: create a harmonious gingival contour
• Elimination of deep gingival pockets to improve access for crown margins
• Crown lengthening

Question 7

What are some problems with subgingival margins?

Answer 7

• Poor access for tooth prep
• Poor access for impression
• Poor access for post core
• Nil tooth structure for ferrule

Question 8

What is electrosurgery/how does it work?

Answer 8

Through heat production, attempts to achieve:

Electro-coagulation

• 45 degrees: White (protein coagulates, tissue turns white)
• 60 degrees: Dessication (water driven out of cell, haemostasis achieved without long term tissue damage)
• Over 60 degrees: Black coagulation (cellular disintegration/carbonisation, formation of oxygen, nitrogen, hydrogen, carbon)

Electro section

• High voltage build up at electrode tip, causing fulguration whereby arc jumps from electrode to tissue when current density is high enough, thus probe does not need to contact tissue
• Causes temperatures to rapidly exceed 100 degrees
• Rapid heating causes moisture to rapidly burst from the cell and vaporise, creating a vapour layer
• Temperatures can rise to 400-600 degrees in microsecond intervals
• Sequence is concentrated, rapid and intense, thus nearby cells unaffected
• Tissue is left charred and sloughs off in days

*NB between 35-45 degress reversible tissue changes occur

Question 9

What types of electrosurgery units are there?

Answer 9

Monopolar

• Current travels to oral site then, gets disappated through body, and travels to plate placed behind patient’s back
• Path taken beyond operator’s control, though nerves and blood vessels more conductive than fat tissue, bone, dentine, cementum and air spaces

Bipolar

• Two electrodes located on the cutting tip, so current travels between the electrodes while remaining in the tip and goes straight back to the machine
• Results in a broader cut but removes need for the ground pad
• Lower voltage used
• No electric arcing thus safer
• Less heat and current spread thus reduced tissue charring
• Beter control

https://image.slidesharecdn.com/energydevices-150417011907-conversion-gate01/95/energy-devices-6-638.jpg?cb=1429417122

Question 10

What are some indications for electrosurgery?

Answer 10

• Crown lengthening (gingivectomy + gingivoplasty)
• Gingivoplasty alone
• Excision of hyperplastic tissue
• Haemostasis
• Exposing of tooth margins

Question 11

What precautions should be taken when preforming electrosurgery?

Answer 11

• Avoid contact with teeth and metal fillings, as current can be directed towards pulp
• Also avoid electrosurgery around implants
• Avoid in heart pacemaker patients (applies to monopolar only)
• Avoid in radiation therapy and acutely immuno comporomised patients
• Do not use near alveolar bone
• Do not use near flammable vapours/ liquids
• Do not use with N2O or O2
• Do not retract tissues with metal instruments
• Avoid prolonged tissue contact
• Have good ventilation/suction
• Adjust current for optimal use

Question 12

What should be done after electrosurgery is complete?

Answer 12

• Irrigate site with 02.% chlorhex solution on cotton pellet

- Remove carbonised tissue debrise from inactive probe with alcohol on gauze

Question 13

What steps should be taken when performing electrosurgery?

Answer 13

• Plan procedure
• Give LA
• Set up ESU, ensure connections correct, prepare plastic retractors and suction tips
• Test LA
• Rehearse movement/access
• Choose correct probe and settings
• Activate
• Wipe eschar off with alcohol gauze when probe off
• Wipe tissue debris away with chlorhex solution
• Assess surgical site and re-enter if required