Surgery In Perio Disease_26th Feb_8am

Question 1

What are the treatment modalities available in periodontics?

Answer 1

• Non surgical (debridement)
• Surgical
• Combination

Question 2

What are the objectives of non-surgical therapy?

Answer 2

• Removal of plaque and calculus from all supra+subgingival tissues with minimal trauma to existing tissues
• Determination of correct time intervals for supportive periodontal therapy
• Motivating patient to maintain hygiene at healthy level in particular to each patient

Question 3

What are the advantages/disadvantages of hand instruments vs ultrasonics?

Answer 3

-Hand
Adv: -better tactile sense, more through removal in experienced hands
Dis: If inexperienced, less thorough removal and risk of dmg to tooth structure

Ultra:
Adv: Ease of use even in inexperienced hands, lavage, cellular disruption, increase access to difficult areas
Dis: Decreased sensitivity, potential dmg to tooth structure, patient comfort

Question 4

What are the benefits of scaling + root debridement combined with personal hygiene maintenance?

Answer 4

• Decreased inflammation
• Change in microflora to less pathogenic
• Decreased probing depth
• Increase in attachment
• Less disease progression

Question 5

What is the healing process after scaling/root debridment? What should you take into account during this time?

Answer 5

• During treatment pocket epithelium + most junctional epithelium removed, exposing underlying CT. Tissue adjacent to dentogingival junction is also removed (Both factors apply for both hand and ultra). However some strands of epithelium may survive on wound surface.
• Leukocytes accumulate on surface of necrotic zone layer–>provide protection against bacteria + facilitate healing
• Epithelium proliferates to cover exposed CT. Starts from gingival margin and remaining strands of epithelium

-Blood clot starts to disintegrate
(This all happens between 8-24 hours)

After 7 days:

• Most CT covered by epithelium
• New attachment to root surface
• Leukocytes protect uncovered spaces

Takes 10-12 weeks to heal (around 3 months), do NOT probe in this time

Question 6

What is the general decrease of pocket depth following non-surgical treatment?

Answer 6

1-2mm

Question 7

What are some reasons for carrying out periodontal therapy?

Answer 7

• Improve access to root surfaces in tmt of periodontitis
• Remvoal of diseased tissues (granulation tissue) or hyperplastic tissue
• Pocket elimination
• Regenerative techniques
• Exploration of defects/cracks
• Restorative (crown lengthening)
• Removing exccess perio tissue after ortho extrusion

Question 8

T/F Pocket depth is completely elimiminated by perio surgery?

Answer 8

F

Question 9

What is a healthy pocket?

Answer 9

• Pocket > 3mm that does not bleed
• May be a sign of inactive disease (i.e. a 6mm pocket tht has healed to a 4mm pocket)
• As can only heal 1-2mm, may remain at a 4mm pocket and stabilise, thus healthy pocket

Question 10

How is subgingival debridment with direct vision performed?

Answer 10

-Root surface exposed (via mucoperiosteal flap or gingivectomy
-Root surface debrided
(We no longer plane after debridement)

Question 11

What time must you wait to do your crown prep after crown lengethening?

Answer 11

2-3months

Question 12

When can you do periodontal surgery?

Answer 12

• AFter you have done the initial scaling/debridement and it has not worked
• Both methods try to achieve the same goal but with different techniques

Question 13

At what stage of periodontitis can be treated with intial debridement/what stages need surgery?

Answer 13

Initial: mild to moderate
Surgery: Severe or aggressive

Question 14

What are the most important retentive areas for plaque/ bacteria? what are some other niches?

Answer 14

Most important: periodontal pocket

Ohter niches: furcations, tooth malposition, depressions, iatrogenic (overhangs)

Question 15

What is a side effect of eliminiating gingival inflammation?

Answer 15

-Tissue shrinkage: recession + sensitivity, but sensitivity tends to settle

Question 16

What are the types of resective surgery?

Answer 16

Gingivectomy: removal of pocket epithelium, CT and mucosal epithelium
Modified Whitman Flap: removal of pocket epithelium, CT and potentially some bone. Leave behind mucosal epithelium (remove 1-2mm and reflect flap)

Question 17

What are the indications/contraindications of each type of resective surgery?

Answer 17

Gingvectomy:
-Gingival hyperplasia (removal of pseudopocket) with adequate width of keratinised mucosa (attached gingiva), else you’re sitting on alveolar mucosa
Contra:
-Vertical/angular bone loss (if you remove the pocket via gingivectomy, gingiva is either gonna look weird at an angle or you’re going to still have a pocket in the area)
-Insufficient width of keratnised mucosa
-Aesthetic area

Modified Widman Flap
-Pocket depth reduction associated with horizontal bone loss with adequate thickness of keratinised mucosa
-Aesthetic areas (because you are following gingival margin contour rather than estimating with postage stamp, you are far more likely to preserve aesthetics)
Contra:
-Insufficient keratinised mucosa

*Gingivectomy was used for pocket reduction in the past, nowadays most people use gingivectomy only for hyperplastic tissue, and modified Widman flap for pocket reduction/ (33mins 47 seconds, also 5mins 20 seconds in next lecture, confirmed with Kaur in person)

Question 18

How is a gingivectomy done?

Answer 18

1. Create postage stamp (e.g. creating the dots 2mm from the gingival margin if want to reduce by 2mm)
2. Use surgical Kirkland knife or electrosurg to remove tissue
3. Clean area
4. Place periodontal pack to cover wound for 1 week ideally, but usually will fall off after 24 hours in real life, instruct patient not to clean area for 24 hours

Question 19

How is a modified Widman flap done?

Answer 19

1. Cut off 1-2mm of tissue which is then removed (confirmed with kaur + @34mins 8 seconds), this bit is why it is resective
2. reflect flap,
3. Subgingival debridement + removal of granulation tissue if present
4. Suture flap

Question 20

What kind of incisions can be used for raising a flap? What are the advantages/disadvantages?

Answer 20

Sulcular incision (alone): Cutting through the sulcular area to break the periodontal fibres around tooth, requires a larger access area to allow a sufficient amount of gingiva to be raised (creates an opening like the opening of a bag)

Vertical incision: Cutting vertical incisions in a trapezoidal shape to allow a section of gingiva to be completely reflected back. Apical area (towards the alveolar mucosa) must be wider to facilitate blood supply from periosteum. Disadvantage: leaves scars, unaesthetic anteriorly

Question 21

How long must you wait before probing/ scale and cleaning a site that has been treated with gingivectomy?

Answer 21

-2-3weeks

Question 22

How long must you wait before probing/ scale and cleaning a site that has been treated with flap surgery? What post op instructions should you give

Answer 22

3-6months.

Palliation: Ibuprofen (Anti-inflammatory) + Paracetamol. First 3 days painful
CHx 0.2% Mouthwash x2/day in lieu of toothbrushing until toothbrushing tolerable
Resume toothbrushing in area once no pain
Contact ADH if acute flare up / pain
Pain should reduce by 7-10 days
Recall Appointment 7-10 to remove sutures + review healing