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Periodontics > Surgical Periodontal Therapy 1 > Flashcards

Surgical Periodontal Therapy 1 Flashcards

1
Q

What are the true end points (1) and surrogate end points (2) of periodontal therapy?

A

true end point: prevent tooth loss

surrogate end points:

  • no bop
  • pocket ‘closure’ (≤ 4mm)
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2
Q

Is non-surgical therapy effective alone?

A
  • effective in reducing PD and reducing bop in majority of the cases and sites
  • however it only postpones tooth loss
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3
Q

What are the objectives of periodontal surgery? (3, 3)

A
  1. Improve the prognosis of the tooth by:
  • creating accessibility for effective root surface debridement
  • improving the gingival or tooth morphology to facilitate patient’s self care
  • regenerating lost periodontal attachment
  1. Periodontal Plastic surgery:
  • correction of gingiva-alveolar mucosal problems
  • preparation of adequate periodontal architecture prior to restorative treatment
  • aesthetic improvement
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4
Q

What are the medical contraindications of periodontal surgery? (4)

A
  1. bleeding disposition (blood disorders e.g. haemophilia, anticoagulants e.g. warfarin resulting in high INR)
  2. poorly controlled diabetes
  3. uncontrolled hypertension
  4. immunocompromised patients (blood disorders e.g. leukaemia, immunosuppressive drugs e.g. cyclosporine A)
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5
Q

What are the 3 areas of the gingival epithelium? Which are more easily damaged and why? (3, 2)

A
  • junctional epithelium (base of sulcus)
  • sulcular epithelium (lines sulcus)
  • oral epithelium (covers free and attached gingiva)

SE and JE are non-keratinised, more susceptible/permeable to inflammatory products and injury insults

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6
Q

Give the 2 types of pocket classification and how they present (2,2)

A

Suprabony pockets:

  • base of sulcus coronal to the alveolar bone
  • can be a true pocket or pseudo pocket

Infrabony pockets:

  • base of pocket apical to alveolar bone
  • always a true pocket
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7
Q

What are the types of intra/frabony osseous defects? (4) What is the importance?

A

3 walled defect (best prognosis)

2 walled defect

1 walled defect

Combined defect e.g. half of wall lost compared to other walls

Importance: changes tx approach, 3 walled is most easily managed, ideal for bone graft due to ‘box’ like architecture, they are not done on 1 walled defects

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8
Q

What are the sequelae of pocket therapy goals?

A

active → inactive → healed

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9
Q

What are the 3 configurations of a healthy sulcus?

A
  • absolutely healthy (soft tissue shrunk to bone level)
  • normal PD but bone loss present
  • restored periodontium (no recession, no loss of soft/hard tissues, done by regenerative tx)
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10
Q

What are the 4 possible resulting pockets after pocket therapy?

A
  • recurrence of pocket
  • root resorption/ankylosis (happens as small islands)
  • long JE (most common, due to apical migration of JE cannot clinically differentiated but most common cos epithelial cells are fastest healing)
  • new attachment (replacement of all tissues)
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11
Q

What are the indications for periodontal surgery? (6)

A
  1. irregular bony contours or any defects
  2. persistent inflammation esp mod to deep pockets
  3. deep pocket in areas with difficult access (especially molars and premolars)
  4. grade 2 and 3 furcations
  5. infrabony pockets on distal surfaces of last molars pockets, complicated by mucogingival problems
  6. areas with normal or shallow pockets but persistent inflammation due to mucogingival problem
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12
Q

What are the general principles of periodontal surgery? (6)

A
  1. patient preparation
  • re-evaluation after phase I therapy
  • premedication: abx prophylaxis, CHX, NSAIDs
  • smoking - quit or stop for 3-4wks
  • informed consent
  1. emergency equipment
  2. PPE (includes sharps disposal and minimising aerosol)
  3. anaesthesia and sedation
  4. tissue management (biggest factor in determining what happens to tissue after procedure)
  • observe gently and carefully
  • observe the patient at all times
  • use sharp instruments only (least traumatic)
  1. thorough scaling and root debridement
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13
Q

Explain one method of achieving haemostasis during periodontal surgery. Name some other methods.

A

Gelfoam (absorbable gelatin sponge)

  • may be cut into various sizes and applied to bleeding surface
  • adverse effect: may form nidus for infection or abscess if overpacked

Oxidised cellulose (oxycel)

Oxidised regenerated cellulose (can interfere with healign and bone formation)

Thrombin (allergic reaction in patients with sensitivity to bovine products, must not be injected as can cause severe (possibly fatal) clotting

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14
Q

What are the broad types of periodontal surgical instruments

A
  1. excisional and incisional instruments
  2. surgical curettes and sickles
  3. surgical chisels
  4. surgical files
  5. scissors
  6. hemostats and tissues forceps
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15
Q

What is the instrument shown? What is it used for, what is the shape and characteristics? What makes it unique? (5)

A

Kirkland (gingivectomy) knife

  • commonly used, mainly for gingivectomy
  • kidney shaped blade
  • sterilisable
  • double ended
  • used to place external bevel incision (to remove tissues)
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16
Q

What is the instrument shown? What is it used for and how? (3)

A

Orban (interdental) knife

  • used for interdental incisions
  • inserted into suclus and moved interproximal to severe attachement
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17
Q

Names 3 scalpel blades, which is the most common for perio and why?

A

15

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18
Q

What is a periosteal elevator used for in perio surgery? Does it do blunt or sharp dissection

A

to reflect flap after incision full thickness includes periosteum

(blunt dissection) after (sharp) incision, partial thickness would use scalpel

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19
Q

What is the instrument shown, what makes it different and what is it used for? (3)

A

Castroviejo Needle Holder

smaller than regular needle holder for smaller areas and to do multiple sutures at one time

20
Q

What are the 3 types of horizontal and vertical incisions? (6)

A

Horizontal:

external bevel

internal bevel

sulcular

Vertical:

releasing incision

cutback incision

periosteal incison

21
Q

EBI, IBI and SI (direction used, action, indications) (3x3)

A

External bevel incision (bevels ends externally)

  • blade coronally directed
  • to remove excess tissue
  • indications: gingivectomy, crown lenghtening, ginivoplasty

Internal bevel incision

  • blade apically directed, placed at crest of gingival margin or stepped back 0.3-2mm (towards bone)
  • for other procedures when don’t intend to remove height of tissue
  • indications: excisional new attachment procedure, modified Widman flap, flap and curettage, crown lengthening, gingival enlargement

Sulcular Incision

  • blade apically directed, placed into gingival crevice and toward alveolar crest
  • indication: when preservation of gingiva is critical (esthetic areas or areas of minimal keratinised tissue) and GTR procedures

atleast 2 used at a time

22
Q

What is a releasing incision and indications? (2)

A
  • perpendicular to gingival margin at line angles of teeth (on either side of flap)
  • indication: to increase access by allowing apical or coronal positioning of flap
23
Q

What is a cutback incision, what does it allow and what are indications? (3)

A
  • small incision at apical aspect of releasing incision and directed towards the base of the flap
  • allows greater movement and to change direction of flap
  • indication: pedicle flaps that are laterally positioned
24
Q

What is a periosteal incision and why is it used? (2)

A
  • incision at the base of the flap to sever underlying periosteum
  • indication: to release flap tension allowing coronal advancement of flap
25
Q

What are the 2 different types of periodontal dressings available. Give an example for the most common.

A
  • eugenol based and eugeneol free (most common)

comes in:

  • two pack system e.g. Coe-Pak (chemically cured)
  • Barricaid (light cured gel)
  • cyanoacrylate
26
Q

The benefits of using periodontal dressing is highly debated. What are some supposed benefits? (6)

A
  • patient comfort (biggest reason)
  • improved flap adaptation to underlying bone and root surface
  • control of immediate postoperative bleeding
  • wound protection and immobilisation
  • helps retain osseous graft material
  • temporary splinting of mobile teeth
27
Q

Give some examples of surgical procedures falling under Pocket reduction, Pocket elimination (soft and hard tissues) and Regenerative Procedures.

A
28
Q

What are the 3 broad classifications of surgical periodontal therapy approaches?

A
  1. conservative (preserving tissues)
  2. resective (removing tissues)
  3. reconstructive (regenerating tissues)

other classification:

  • pocket reduction surgery (resective and regenerative)
  • correction of anatomic or morphological defects (plastic surgery to widen attached gingiva, esthetic surgery, crown lengthening etc, implants)
29
Q

What factors determine the surgical approach you should use? Give an example of each (3, 3, 2, 2)

A
  1. Anatomy of residual pocket
  • suprabony or infrabony
  • amount of keratinised gingiva (need for sutures and healing)
  1. Anatomy of tooth
  • single or multi-rooted
  • with or without furcation involvement
  1. Position of the tooth in the dental arch
    * cosmetic area
  2. Complexity and predictability
    * patient and operator factors
30
Q

What can periodontal pocket reduction surgery limited to gingival tissues only (not involving ossoeus structures) without use of flap surgery (AKA gingival surgery) be classified as? (2)

A
  • gingival curettage
  • gingivectomy
31
Q

What are the 4 types of gingivectomy techniques?

A
  • conventional
  • electrosurgery
  • laser
  • chemosurgery
32
Q

What is gingival currettage and what are the 3 types? (4)

A

= Scraping of the gingival wall of a periodontal pocket to remove diseased soft tissue

3 Types:

Gingival currettage (A): removal of inflamed soft tissue lateral to the pocket wall and JE

Subgingival curettage (C): apical to JE and that severs connective tissue attachment down the osseous crest

Inadvertent currettage: unintentional currettage occuring during scaling and root planing

33
Q

What is the rationale for gingival currettage? (i.e. What does the lateral wall of pocket contain (3) Why is it debated? (2)

A

The lateral wall of pocket contains:

  • granulation tissues
  • areas of chronic inflammation
  • pieces of dislodged calculus and bacterial colonies → hinder healing

Usually after SRP alone, granulation tissue is slowly resorbed and residual bacteria are destroyed by host defence mechanism

Curettage aims to remove the lateral wall of the pocket, however the need for curettage to eliminate inflamed granulation tissue appears questionable

34
Q

What are the indications for gingival curettage? (3)

A
  1. moderately deep intrabony pockets located in accessible areas
  2. as a non-definitive procedure in cases contraindicated for flaps, to reduce inflammation
  3. during recall visits as a method of maintenance treatment for areas of recurrent inflammation and PD, especially where pocket reduction surgery has previously been performed
35
Q

When should curettage occur in relation to SRP and why? And what are the steps of curettage? (3)

A

Should always be preceded SRP as currettage does not eliminate the causes of inflammation (plaque and calculus

Step 1: LA (essential)

Step 2: select curette so cutting edge is against tissue

Step 3: engage inner lining of pocket and scrape along soft tissue (usually in horizontal stroke with gentle external finger pressure to support)

36
Q

What differentiates gingival and subgingival curettage?

A

in subgingival, tissues attached between bottom of pocket and alveolar crest are removed with scooping motion of currette

37
Q

What is ENAP? Give the 3 steps. Why is the name misleading? (1,3,1)

A

Excisional New Attachment Procedure (ENAP)

= definitive subgingival curettage performed with knife

Step 1) Internal bevel incision (A)

Step 2) Remove excised tissue with curette and SRP (B)

Step 3) Sutures and perio dressing

Misleading cos doesnt actually give new attachment (historical procedure done in 60s by US naval dental corps)

38
Q

Other than scalpel and curette, what other 3 techniques can be used to perform gingival curettage? Which are used/not used currently and why.

A
  • ultrasonic devices - result in narrow band of nerotic tissue (microcauterisation) which strips off inner lining of pocket
  • laser assisted ENAP (marketed as best due to minimal bleeding)
  • caustic drugs (e.g. phenol, sodium sulphide) not used anymore due to inability to control how much tissue is burned
39
Q

Explain the process of healing after curettage. (5) What is the result of healing in terms of new attachment? (2)

A
  1. blood clot forms immediately
  2. rapid proliferation of granulation tissue with decrease in # of small blood vessels as tissue matures
  3. restoration and epithelialisation of sulcus (including JE) in 2-7 days
  4. immature collagen fibres in 3 weeks
  5. complete healing in 5-6 weeks (dont probe until then as will disturb healing)

Results in formation of long, thin JE with no (or rarely small areas of) new connective tissue attachment

40
Q

What is a gingivectomy and when is it commonly used?

A
  • excision of the soft tissue wall of periodontal pocket, aiming for pocket elimination
  • gingival overgrowth characterised by enlargement of gingival tissues without apical migration of JE = PSEUDOPOCKET
41
Q

What are the indications and contraindications of gingivectomy? (3,3)

A

Indications:

  • Elimination of gingival enlargements (most common)
  • Elimination of suprabony pockets (regardless of depth) if pocket wall is fibrous and firm
  • Elimination of suprabony periodontal abscesses

Contraindications:

  • need for osseous surgery or examination of bone morphology
  • bottom of pocket apical to mucogingival junction
  • aesthetic consideration, particularly in anterior maxilla
42
Q

What are the steps of surgical gingivectomy?

A

Step 1) Pockets explored with perio probe and marked with pocket marker (bleeding points to guide incision)

Step 2) Kirkland gingivectomy knife - 45o incision on F and L surfaces, Orban knife for interdental incisions

Step 3) Remove excised pocket wall

Step 4) Curette the granulation tissue, any remaining calculus and necrotic cementum to leave smooth and clean surface

Step 5) Cover area with surgical pack

43
Q

What are the advantages (2) and disadvantages (3) of using electrosurgery for gingivectomy?

A

Advantages:

  • allows adequate contouring of tissue
  • controls bleeding

Disadvantages:

  • contraindicated in patients with incompatible or poorly shielded cardiac pacemakers
  • unpleasant odour
  • if the electrosurg tip:

touches bone → irreversible damage

close to bone → heat generated can cause tissue damage and loss of periodontal support

touches root → cementum can burn

44
Q

What is a gingivoplasty? (1) When is it indicated? (3)

A

reshaping of gingiva to create physiological gingival contours with sole purpose of recontouring the gingiva in ABSENCE of pockets

Indications:

  • gingival clefts and craters (natural)
  • crater-like interdental papillae caused by NUG
  • gingival enlargements
45
Q

What are different electrodes used for?

A

needle: incisions and draining abscesses
loops: removing/scraping tissue
ball: haemostasis

46
Q

How to determine how to treat DIGO?

A

if after non surgical tx, enlargement persists

small areas (less than 6 teeth) and only horizontal bone loss → gingivectomy

large areas (>6 teeth) + osseous defects → periodontal flap surgery

47
Q

Describe the flap technique for removing gingival enlargements.

A

First remove bulk of tissue (via EBI) then raise flap and remove additional tissue prior to suturing

Periodontics (8 decks)

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