Ultimate Guide Flashcards
Soft Tissue Grafting Indications/Rationale-
- anything that causes —–
- recession that is —–
- esthetic concerns
- ————- around teeth scheduled for full coverage restorations
- ——— prior to orthodontic treatment- thicken with tissue graft
root sensitivity
progressing
limited soft tissue support
thin tissue biotype
Free gingival graft-
soft tissue graft completely detached from one site and moved to another
FGG Indications-
increase keratinized/attached gingiva, increase vestibular depth, achieve root coveraage
FGG Contraindications-
root coverage not predictable, esthetic concern (different color), complication at donor site; Can be submarginal to modify root coverage
Pedicle graft-
A soft tissue graft that is laterally positioned to correct an adjacent defect [base remains attached to the donor site], you still have to do SCTG
Pedicle graft Indications/Contraindications-
Connective tissue graft- detached connective tissue graft placed between partial thickness flap
Indications- thicken thin tissue for necessary procedures, esthetics
Contra- not enough tissue to do a split thickness flap
CAF + Connective Tissue Graft is most successful @
root coverage
CAF, SGCT, frenectomy, and vestibuloplasty are all
SPLIT THICKNESS FLAP
FGG techniques FGG-
bring soft tissue from donor site, apically position flap, add soft tissue from donor site to recipient site above the flap you just brought down; use some sort of template to know how much tissue to take
Pedicle technique-
leave base intact, cut flap and slide over; lateral sliding flap, double papilla flap
SGCT technique-
split thickness flap (or tunnel technique) with graft added and sandwiched between
Mucogingival deformities-
deviation from normal relationship between gingiva and alveolar mucosa
Gingival recession-
recession of attached/keratinized gingiva sometimes resulting in exposure of root surface
Mucogingival defect-
deviations from normal in relationship between MGJ and gingival margin, closer to gingival margin
What is sufficient zone of attached gingiva?
Don’t need an amount unless the pt cannot keep teeth clean, there is no ideal number, do surgery if there is attachment loss
Frenectomy-
surgical excision of a frenum- V shaped is most common, Z-plasty also an option
Frenotomy-
cutting of a frenum
Vestibuloplasty-
apically positioning flap to increase vestibular depth
Frenum-
A small band or fold of integument or mucous membrane that controls, curbs, or limits the movement of organ or part.
Aberrant Frenum-
Atypical/ abnormal insertion of labial, buccal, or lingual frenula capable of retracting gingival margins, creating diastemas, and limiting lip and tongue movements.
Classification of labial frenum? Mucosal- Gingival- Papillary- Papillary penetrating-
attaches in alveolar mucosa
attached between MGJ and base of interdental papilla- MOST COMMON
attaches between base and top of interdental papilla
attaches in interdental papilla and penetrates to palatal aspect- more often in younger children
Etiology of aberrant frenum?
After eruption of centrals, labial frenum normally transpositions in an apical direction. Sometimes it is unable to migrate during alveolar growth. Tooth development also implicated.
Surgery before or after orthodontic treatment??
Surgery should be done AFTER ortho treatment because it can lead to scarring which would resist orthodontic movement
What is LASER?-
Light amplification by stimulated emission of radiation
Advantages/disadvantages of LASER tx-
Advantages——
Disadvantages-
hemostasis, rapid healing, accuracy, reduced inflammation, lack of scar tissue, low level of discomfort
technical difficulties, lack of precision in depth of cut, hazardous, tissue not available in histopathology, dispersal of virus particles in plume
Gingivectomy Implant uncover Frenectomy Uncovering soft tissue Impactions LANAP- adjunct to SRP PDT- use of free radicals to break down plaque
Periodontal Applications in LASERS-
Recession Defects: Miller Classification
Class I- —– bone loss, recession ———-
Class II- —— bone loss, recession ———-
Class III- —— bone loss, recession ——–
Class IV- — bone loss extends past recession
no IP, does not extend to MGJ
no IP, may extend to or past MGJ
IP, may or may not extend past MGJ
IP
Complete root coverage expected in —–defects, partial coverage expected in — defects, none in—–
I and II
III
IV
Healing Phases of Gingival Grafting
Initial Phase- 0-3 days; —-
Revascularization Phase- 2-11 days; ——
Tissue Maturation Phase- —–
“plasmatic circulation” from recipient bed, avascular
anastomoses between the blood vessels of the recipient bed and those in the grafted tissue; capillary proliferation; re-epithelization
11=42 days
Which teeth usually impacted?-
max canine> mand 1st premolar > mand 2nd premolar > mand canine > max premolars
Incidence of max canine impaction?-
2%
General location of impacted max canine?-
66-85% are palatally impacted
- failure of deciduous tooth roots to fully resorb
- abnormal position (eruption path)
- supernumerary teeth
- crowding
- dentigerous cyst
- thickened oral soft tissues
- oral soft tissue pathology
- hard tissue pathology
- premature extraction of deciduous teeth
- childhood diseases
- genetic syndromes
- hereditary diseases
Etiology of impacted tooth?
- palatal or labial malposition of impacted tooth
- migration of impacted teeth
- internal root resorption
- external root resorption
- dentigerous cyst formation
- referred pain
- any combination of above
Site Effects of impacted tooth?
Open techniques-
window or apically positioned flap
Closed techniques-
flap is opened ortho appliance applied, and then flap is closed (better healing, less discomfort).
Periodontal Abscess- treatment includes
drainage and SRP and sometimes amoxicillin for 3 days
NUP-
Necrotic lesion of the papilla initially then progressing to gingival margin. Punched-out appearance; spontaneous and painful-
NUP Microbiology-
Treponema sp., Selenomonas sp— treated by lowering microbial load and removing necrotic tissue
Pericoronitis-
surrounds crown of partially erupted tooth
Gingival abscess-
marginal gingiva or interdental papilla, less painful
Pericoronal abscess-
surrounding crown of partially erupted tooth, less painful
Periodontal abscess -
tissues adjacent to periodontal pocket, PA
Periapical abscess-
involving pulp remnants and tissue surrounding apex of tooth, PA
When do we prescribe systemic antibiotics for periodontal problems?
- Poor response to initial therapy and continued attachment loss
- Pts with biofilm tests positive for P. gingivalis and A.a.
- Severe cases with generalized deep pocket depths
- Periodontitis with secondary systemic involvement
- Aggressive periodontitis
• Amox-
bactericidal
• Metro-
bactericidal
• Tetracyclines-
bacteriostatic, inhibits collagenase
• Clinda-
potent bacteriostatic activity (alternative to amox)
• Macrolides-
anti-inflamatory, bactericidal
• Aggressive periodontitis/Severe chronic periodontitis
antibiotics
o Amox 500mg 3x/day with Metro 250mg 3x/day for 8 days
o Azithromycin 500mg starting dose, 250 mg per day for 4 days; Metro 500mg 3x/day 7 days
When do we prefer local delivery of antibiotics instead of systemic antibiotic prescription?
• Localized slight to moderate chronic periodontitis pt with limited amt of sites that are unresponsive to non-surgical therapy; adjunct to SRP for limited sites with greater than 5mm probing depths
Advantages/Disadvantages for both local delivery and systemic antibiotic usage.
• Local dis- allergies to specific antimicrobial reagent, several sites/mouth with residual periodontal pockets following SRP, applications without performing SRP
Surgical Periodontal Therapy
Indications?
7mm+ pockets, in advanced periodontitis pts
Ostectomy
(sufficient remaining bone or establishing physiologic contours without attachment compromise, no esthetic or anatomic limitations, elimination of interdental craters, intrabony defects not amenable to regeneration, horizontal bone loss with irregular marginal bone height, moderate to advanced furcation involvement, hemisepta);
osteoplasty-
reshaping of the alveolar process to achieve a more physiologic form without removing alveolar bone proper, tori reduction, intrabony defects adjacent to edentulous ridges incipient furcations, reduction of thick heavy ledges or exostoses, shallow osseous craters
Crown lengthening-
not enough space for the fixed prosthesis, potential violation of biologic width, to help with removable prostheses
What is a forest plot?-
Forest plot is a way of charting study results. Horizontal lines show confidence interval at 95%. Vertical line marks zero effect and the dot shows effect estimate and weight for each study
describe rationales for periodontal maintenance.
-tooth loss inversely proportional to PMT frequency; reduced risk of future attachment loss despite incomplete plaque removal; monitoring; plaque removal
analyze rationale for duration and frequency of maintenance therapy.
-In patients with a history of periodontal disease, every 3 months, appointments around an hour long to cover everything; extend to 6 mo if they are doing well with OH or don’t have history of disease
evaluate differences between implant and tooth periodontal maintenance.
-implants need just as good or better care than real teeth
Areas of periodontal breakdown may need additional treatment.
–poor plaque control = no surgical treatment, clean and OHI
–single site = nonsurgical treatment
–continued inflammation = surgical treatment
–attachment loss = S/RP + antibiotics or surgery
–Increasing mobility = occlusal adjustment
Office visits for implants-
A typical maintenance visit should include:
–Probe implants w/ plastic probe
–Assess soft tissue. Look for BOP and suppuration
–Examine prosthesis- May have to remove
–Occlusal exam. Look for wear, loosened screws or cylinders, broken abutments, screws or implants
–Evaluate stability Remove any plaque and calculus
–Use plastic curette, and rubber cup w/ polishing paste
–Can also irrigate w/CHX–Check/modify OH Radiographs
–Monitor bone with vertical BW or PA at least once a year
Discuss the rationale for pre-implant surgical procedures.
-preserve ridge dimensions and contour when immediate implant placement not possible
-wound stability and space maintenance need to be paid attention to- membrane, grow bone in socket
•
Non-resorbable membranes-
for space maintenance, but will require second surgery, sticks through; worried about dehiscience, thick gingival biotype
• Resorbable membranes-
less surgery, thinner
-contraindicated if infection, implants can be placed immediately, and soft tissue limitations
Endosseous dental implant-
interfaces with bone
Implant abutment-
connects to the endosseous dental implant, serves as base for crown
Abutment Screw-
holds together abutment and implant
Osseointegration-
intergrating with bone
Risk factors/indicators for implant failure:
periodontitis, thin tissue biotype, resorbed ridges
Autogenous (from patient)-
osteogenesis, osteoconduction, osteoinduction
Allograft (from human donor)-
Osteoconductive and osteoinductive
Xenograft-
osteoconductive (basically scaffold)
Synthetics-
just filler
Role of barrier- space maintenance (don’t allow wrong tissue type to invade) and wound stability
- e-PTFE
- Titanium reinforced e-PTFE
- Cross-linked collagen barrier
- Polylactic acid based membranes
- Subepithelial connective tissue graft
- Free gingival graft
Minimal flap elevation especially in
esthetic region (if possible)- FULL THICKNESS
ARP- Generally successful in preventing alveolar bone height loss. •Does not eliminated alveolar ridge width loss (approximately —– width loss with socket preservation, nothing we can do). •Presence of residual material following healing.
2.5 mm
Immediate-
implant placed immediately following extraction
- less surgery and less overall treatment time
- optimal use of existing bone
- site morphology and tissue type could complicate optimal use of existing bone
- may not have enough keratinized epithelium for flap
- technique sensitive procedure
- metal surface of implant may become visible due to buccal resorption
Early-
implant placed where soft tissue has healed and covers socket
- easier implant placement
- allows for resolution of local pathology
- site morphology may complicate optimal treatment
- longer treatment time
- varying amount of bone resorption at socket walls
- technique sensitive
—– OF FOUR SOCKET WALLS MUST BE INTACT FOR THESE FIRST TWO
THREE
Late-
placed after substantial amounts of new bone have formed (typically over 16 weeks later)
- clinically healed ridges and mature soft tissue
- increased treatment time
- large variation in bone volume available (longer waiting time increases bone loss)
Conventional-
implant placed in fully healed ridge
- extraction site lined with keratinized mucosa on dense cortical bone
- rate of new bone formation decreases after 3-4 months
Bone Defects- Classification I
Extraction sockets [5-wall defect]
Dehiscence defects [4-wall defect]
Horizontal defects [2-3 wall defect]
Vertical defects [1-wall defect]
Alveolar Ridge Defects- Classification II
Horizontal (B-L) loss only
Vertical (C-A) loss only
Loss in both vertical and horizontal directions
—– minimal bone thickness for surrounding bone (for osseointegration to occur)
—– minimal bone thickness on the buccal aspect (for both bone/soft tissue integrity and for restorative reasons)
——- minimal distance between a tooth and an implant
—— minimal distance between two implants
Implant has to be placed —— apical to adjacent CEJ in patients with no attachment loss (2-5 mm is the working range)
—— interocclusal (interarch) distance for the crown (regular implant-supported screw-retained crown)
1 mm
2 mm
2 mm
3 mm
2 mm
7 mm
Cover screw vs healing abutment-
cover screw is flat and can be healed over, healing abutment then put on so gingiva can heal around it
If placing more than one implant…..
- Importance of a good surgical stent (guide)
- Parallelism
- Angulation
- Spacing (mesial-distally, buccal-lingually but also amount of penetration into bone [apical-coronally])
- Vertical bone augmentation is difficult to achieve
- Inter-implant papillae cannot predictably be re-established.
Per-implant disease-
pathology must be noted after loading (already has a crown) and not related to placement complications
Peri-implant mucositis-
analogous to gingivitis- reversible, no bone loss
Peri-implantitis-
analogous to periodontitis- loss of peri-implant bone
Per-implant disease diagnosed on…
Bleeding on probing around the implant Suppuration around the implant Probing depth around the implant Mobility of the implant Radiographic evidence of bone loss around the implant
Failing Implant-
progressive alveolar bone loss, pocket formation, bleeding on probing, or suppuration
Failed Implant-
-hopeless and nonfunctional implant requiring removal
–may exhibit loss of osseointegration, mobility, or pain
Treating Failing Implants- need to do ——- to get rid of grooves
- resolve ———
- correct ————
- re-osseointegration- ———
implantoplasty
inflammation (debride plaque, improve oral hygiene, adjunctive antibiotics as indicated)
unfavorable soft tissue morphology by flap surgery or gingivectomy
decontaminate implant surface with citric acid solutions, guided bone regeneration
Peri-implant defects and treatments
Class I- \
Slight horizontal bone loss with minimal peri-implant defects
Treatment- Surgical reduction of pocket depth, thinning of mucosal flaps and apical repositioning of flaps at a bone edge level, using the corresponding suture technique. The implant surface is cleaned and decontaminated. Implantoplasty is only performed if threads are exposed.
Peri-implant defects and treatments
Class II-
Moderate horizontal bone loss with isolated vertical defects Treatment- Similar to class 1, but repositioning is performed more apically, leaving more implant surface exposed, thus requiring an implantoplasty. If local vertical resorption has three or more walls, this bone defect is restored using classical GTR techniques. In cases where the defect involves one or two walls, osteoplasty or bone leveling is performed to favor soft tissue repositioning, to fulfill self-cleaning criteria.
Peri-implant defects and treatments
Class III-
moderate to advanced horizontal bone loss with broad, circular bony defects
Treatment-Presence of vertical defects almost always requires GTR techniques.
Peri-implant defects and treatments
Class IV-
advanced horizontal bone loss with broad, circumferential vertical defects, as well as loss of the oral and/or vestibular bony wall
Treatment- Same as III
How do you sequence treatment?
- Etiologic phase of treatment (correct faulty restorations
- Prepros surgery (crown lengthening, mucogingival procedures, ridge augmentation)
a. Something you can do for a denture - Restoration design
- Pre-implant surgery
- Post prosthetic surgery
- Maintenance
