Surgical/Non-surgical therapy

Question 1

What studies show the effectiveness of SRP?

Answer 1

• A literature review by Cobb1 found pocket depth reduction of 1.29 mm
  and attachment gain of 0.55 mm in 4- to 6-mm pockets and pocket depth reduction of 2.16 mm and attachment gain of 1.79 mm in pockets greater than 7 mm. Stambaugh et al2 found curette efficacy of 3.73 mm (plaque and
  calculus-free surface) when SRP was performed by hygienists with the
  patient under local anesthesia. The effective instrumentation limit was 6.21 mm. The average time working on each tooth was 35 minutes.
• Buchanan and Robertson3 noted that premolars and molars are more difficult to clean without a flap. They found that more than 60% of molar sites had residual calculus.
• Waerhaug found that after SRP was performed, more than 90% of cases had deposits of plaque and calculus remaining in sites with pocket depths greater than 5 mm.

Question 2

Is open flap or closed flap SRP more effective?

Answer 2

1-3mm - both open and closed 86%
4-6mm - Open 76% closed 43%
6+mm - Open 50%, closed 32%

Question 3

What are the critical probing depths?

Answer 3

Lindhe et al
SRP will cause AL in PD 2.9mm or less
With surgery Attachment loss will occur in PD 4.2mm or less

Question 4

How effective is brushing and flossing? What is the best
sequence for brushing and flossing?

Answer 4

Graves et al20 found that brushing decreases BOP by 35%, and additional flossing decreases BOP by 67%. Floss is the most widely used method of interdental cleaning, and the American Dental Association (ADA) reports that
up to 80% of interdental plaque may be removed by this method, resulting in a significantly reduced incidence of caries and prevention of periodontal disease.
Mazhari et al found flossing followed by brushing is preferred to reduce interdental plaque and allow maximum fluoride concentration.

Question 5

What is the Bass technique?

Answer 5

In the Bass technique, the bristles of a toothbrush are placed at 45
degrees to the tooth surface at the gingival margin. The bristles of the brush are moved in a back-and-forth motion.

Question 6

If complete removal of plaque is not accomplished, how
long does it take for gingivitis to develop?

Answer 6

Lang et al found that intervals of 48 hours are compatible with gingival
health; however, if intervals between complete removal of plaque exceed 48 hours, gingivitis develops. Plaque first appears on interproximal areas of premolars and last on the facial surfaces of molars and premolars.

Question 7

Is there a difference between an electric and manual brush?

Answer 7

Rapley and Killoy32 compared a counter-rotational electric toothbrush and a manual toothbrush. The manual group had 30.57% plaque-free interproximal
surfaces and the electric group had 53.23% plaque-free interproximal
surfaces.

Question 8

By how much is the blade of a Gracey curette offset?

Answer 8

A Gracey curette has a blade that is laterally offset by 70 degrees relative to the shank. The blade of the universal curette is situated perpendicular to the edge of the terminal shank.

Question 9

At what angle should the face of the curette be toward the
root?

Answer 9

The face of the curette should be oriented at 60 degrees to the root surface.

Question 10

When is it an appropriate time to reevaluate a patient following
SRP?

Answer 10

Lowenguth and Greenstein concluded that prior to reevaluation following mechanical nonsurgical therapy, a minimum 3- to 4-week period should elapse, during which soft tissue healing and maturation can occur.
Longer than 2 months may be too long to wait for the reevaluation because pathogenic bacteria have already repopulated periodontal pockets.
The reevaluation of tooth mobility after occlusal therapy should occur after 6 to 12 months.

Question 11

What factors should be considered in developing an optimal
maintenance schedule?

Answer 11

BOP >25%
PD >4mm
Tooth loss (greater than 8-28 teeth)
Age in relation to loss of periodontal support
Systemic and genetic factors (eg diabetes)
Environment (eg smoking
Oral hygiene (amount of plaque)
Compliance

Question 12

What are indications and contraindications for gingivectomy?

Answer 12

indications - treating horizontal bone loss with increased PD. Reduce DIGO. remove soft tissue craters. Improve gingival esthetics in patients with delayed passive eruption. For crown lengthening when ostectomy is not required.
Contraindications - presence of osseous defects. Inadequate KT. base of the pocket is apical to the mucogingival junction. Inadequate vestibular depth. Inadequate OH

Question 13

What are some general principles of periodontal surgery?

Answer 13

• The flap should have a broad base to enable sufficient blood supply
• The proportion of length to width should not exceed 2:1
• The flap should be large enough to provide good access to the roots and bony defects
• Partial thickness flaps should not be too thin (to allow blood vessels to be part of the flap)
• The apical portion of periodontal flaps should be full thickness when possible
• Partial-thickness flaps should not be used in areas of thin connective tissue because necrosis of the soft tissue may occur
• There should be minimal tension during suturing

Question 14

What is the rationale for osseous surgery?

Answer 14

Establish access for root debridement
Create physiologic osseous topology (positive bone architecture)
Decrease PD
Preserve the teeth
Facilitate plaque control
Improve prognosis
Decrease BOP

Question 15

What are contraindications for osseous surgery?

Answer 15

proper follow up and maintenance not possible
advanced bone loss (long term prognosis and value of the tooth is questionable
Shallow pockets
3-wakk defects (regen?)
poor OH
medical contraindications
Esthetic zone
Poor crown to root ratio

Question 16

What can lead to failure when performing osseous surgery?

Answer 16

poor operator technique
presence of calculus
reverse architecture
improper flap placement
failure to remove widow’s peaks
inadequate maintenance

Question 17

Describe the apically repositioned flap

Answer 17

First described by Nabers in 1954,10 the apically repositioned flap is a
full-thickness reverse-beveled scalloped incision with vertical releasing
incisions to the mucogingival junction. The soft tissue is displaced in an
apical direction. It allows preservation of the keratinized tissue while apically
displacing the gingival margin following surgery.

Question 18

Describe the distal wedge excision

Answer 18

With a distal wedge excision, excessive tissue distal to the last remaining
tooth in the mouth can be excised to reduce the pocket. The flaps are raised,
and a wedge of tissue is removed. Before suturing, the flaps are thinned,
elevated, and approximated.

Question 19

What is an envelope flap

Answer 19

In an envelope flap, the horizontal incision is made at the gingival margin
away from the areas with pockets that are being treated and without any
vertical incisions. The incision is used to create access.

Question 20

Describe the palatal approach to soseous surgery according to Oschenbein and Bohanan

Answer 20

In 1963, Ochsenbein and Bohannan11 described different types of defects
(various interdental crater depths) and the approach that should be taken for
each (Table 10-1; see next page). The majority of osteoplasty and ostectomy
is done from the palatal aspect.
Ochsenbein and Bohannan11 advocated the palatal approach for several
reasons:
* Decreased ostectomy
* Increased embrasure space
* Less resorption—greater cancellous bone
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Different Surgical Techniques
* Avoidance of exposure of the buccal furcation (maxilla root trunk is 3 mm)
* Apical slope of crest toward the palate
* Better esthetics

Question 21

What are the advantages of the lingual approach to osseous surgeyr described by Tibbets et al 1976

Answer 21

• The external oblique ridge is avoided.
• The furcation on the lingual is in a more apical position.
• Craters are located more lingually.
• There is better access and wider embrasure.
• The defect is located more lingually because of the lingual incline of the
  molars.
• The root length on the facial aspect is shorter.
• The buccal furcation is avoided (mandible root trunk is about 4 mm).
• There is greater vestibular depth on the lingual aspect.

Question 22

What are the options for pockets found in the anterior segment?

Answer 22

• Papilla preservation flap (see below), as described by Takei et al,13 where
  a palatal incision is made to allow the papilla to move in a buccal direction.
  However, adequate width (> 2 mm) of the papilla is necessary as well as a
  sufficient embrasure space.
• Continuous SRP.
• Perioscopy: Allows real-time indirect visualization of the root during SRP.
  According to Stambaugh,14 it “can offer many patients an alternative to
  periodontal surgery in carefully selected sites.”
• No treatment.

Question 23

Describe minimally invasive surgery

Answer 23

Minimally invasive surgery (MIS)15 consists of an initial intrasulcular incision
around the teeth neighboring the defect (Fig 10-2). The two initial
incisions are connected on the surface (buccal or lingual) where the
access flap will be elevated. This connecting incision is made apical to the
col tissue. The col tissue and the papilla on the nonsurgical side remain
intact and are not elevated. When the surgery is in an esthetic area, such
as the maxillary anterior, this horizontal incision will usually be placed on
the palatal aspect of the papilla. This will help to preserve the shape of the
papilla as well as cover the grafted site with soft tissue. In a nonesthetic
area, the horizontal incision can be placed either buccally or lingually as
needed to better cover the grafted site with soft tissue. The papilla is
sharply dissected from the underlying bone. The connective tissue within
the osseous defect is dissected with a blade and eliminated with curettes
and ultrasonic instruments, and the root debrided. The defect is grafted
with bone and a resorbable mesh, and the flap is sutured with vertical
parallel mattress sutures to obtain primary closure.

Question 24

Describe papilla preservation technique

Answer 24

Papilla preservation technique, as described by Takei et al,13 where a palatal
incision is made to allow the papilla to move in a buccal direction (Fig
10-3). However, adequate width (> 2 mm) of the papilla is necessary as
well as sufficient embrasure space.
A semilunar incision along the lingual aspect of the tooth across the interdental papilla from lingual prominence to lingual prominence

Question 25

What are indications for minimally invasive surgical approaches

Answer 25

• Defects that extend from buccal/lingual in an interproximal site
• Defects that border on an edentulous area
• Isolated, interproximal bone defect, not extending beyond the interproximal site
• Multiple separate defect sites within a single quadrant

Question 26

Contraindications for minimally invasive surgery

Answer 26

• Generalized horizontal bone defect
• Multiple interconnected vertical defects, walls

Question 27

Describe healing following surgery

Answer 27

• 24 hours: Blood clot connects the flap and the tooth or bone surface.
• 1 to 3 days: The space between the flap and the tooth or bone is thinner,
  and epithelial cells migrate to the site at a rate of 0.5 mm per day.
• 1 week: Epithelial attachment to the root occurs.
• 2 weeks: Collagen fibers form parallel to the tooth surface.
• 1 month: Fully epithelialized gingival crevice.

Question 28

What are the advantages of surigcal dressing

Answer 28

• Protects the wound.
• Increases comfort of the patient.
• Stabilizes the flap.
• Retains the graft material.

Question 29

What are the disadvantages of surgical dressing?

Answer 29

• Increases postoperative pain.
• Irritating.
• Plaque retention (increased bacteria): Powell et al39 found that the use of a postsurgical dressing demonstrated a slightly higher rate of infection (8 infections in 300 procedures, 2.67%) than nonuse of a dressing (14 infections in 753 procedures, 1.86%).
• Jones and Cassingham40 found that when a dressing was used, patients reported more pain and discomfort and an increased severity of pain and discomfort postoperatively. They concluded that surgical dressings were unnecessary when
  performing periodontal flap surgery.

Question 30

What is surgicel made of? Avitene?

Answer 30

Surgicel (Ethicon) is oxidized cellulose polymer (the unit is polyanhydroglucuronic
acid). It is used to stop postsurgical bleeding. It can be cut in different shapes and placed over the area that is bleeding.
Avitene (Davol) is microfibrillar collagen and another effective hemostatic agent. It is placed on the bleeding site with forceps.

Question 31

What are the ideal properties of sutures

Answer 31

Ease of handling
Strength
Decreased tissue reaction
Nonallergenic
Sterilizable
Secure knot is achievable