W2 - Surgical Perio Therapy Part 1 - Sharma Flashcards
How can prognosis of the periodontically involved tooth be improved? (3)
- Create accessibility for effective debridement
- Improve gingival or tooth morphology to improve pt self-care
- Regenerate lost periodontal attachment
What is the True End point of periodontal therapy VS Surrogate end points?
True End point: Prevention of tooth loss
Surrogate end points: No BOP, pocket “closure” (<4mm)
What are some relative medical contraindications to perio surgery? (4)
Relative bc you can still do perio surgery, just be cautious. Very few conditions exist where surgery should not commence
- Bleeding disorders (haemophilia, anticoagulants)
- Poorly contolled diabetes
- Uncontrolled hypertension
- Immunocompromised patients (leukemia, pt taking cyclosporin)
Wall defect card
What are the 4 possible pocket therapy results
- Recurrence of pocket
- Root resorption / ankylosis
- Long junctional epithelium
- New attahcment: regeneration GTR
What is the most common pocket therapy result? Why?
Long junctional epithelium
- they are the fastest growing cells
Indications for Periodontal Surgery (6)
- Irregular bony contours / structure
- Persistent inflammation in moderate-deep pockets
- Deep pockets on teeth where complete removal of root irritants is not clinically possible (posterior)
- Grade II or III furcation
- Infrabony pockets on distal surfaces of last molars causing irritation (pericoronitis)
- Areas with shallow pockets but persistent inflammation due to mucogingival problem
List 5 examples of hemostasis products
- Gelfoam
- Oxycel
- Surgicel absorbable hemostat
- CollaCote/CollaTape/CollaPlug
- Thrombostat
Kirkland knife used for gingivectomy
Orban (interdental) knife
Periosteal elevator
What are the 6 types of incisions in periodontal surgery?
- External bevel
- Internal bevel
- Sulcular
- Releasing
- Cutback
- Periosteal
What is an external bevel and what is it used for?
Coronally directed incision
- Used for gingivectomy, crown lengthening
- to remove height of soft tissue
What is an internal bevel and what is it used for?
Apically directed incision
- Removes thickness but not height, height remains the same
- Excisional new attachment procedure, flaps, gingival enlargement
What is a sulcular incision and what is it used for?
Apically directed incision, placed in gingival crevice and directed toward alveolar crest
- Used when preservation of gingiva is critical (aesthetic areas or guided tissue regeneration procedures)
2 Types of periodontal dressing
Eugenol-based
Eugenol-free (more common)
Examples of eugenol-free periodontal dressing
Coe-Pak (GC) - chemical cured
Periocare - chemical cured
Barricaid - light cured
Benefits of using periodontal dressings (6)
- Improved flap adaptation to underlying bone and root surface
- Control of immediate post-op bleeding
- Wound protection and immobilisation
- Helps retain bone graft materials
- Patient comfort
- Temporary splinting of mobile teeth
What are the 3 surgical approaches
- Conservative (preserving tissues)
- Resective (removing tissues)
- Reconstructive (regenerating tissues)
What factors govern the surgical approach? (4)
- Anatomy of the residual pocket - Supra/infrabony? amount of keratinized gingiva?
2. Anatomy of the tooth - single or multi rooted? Furcation?
- Position of tooth in dentition - cosmetic area?
- Complexity and predictability - patient and operator factors
What are gingivectomies and gingival curettage surgeries?
Periodontal pocket reduction surgery limited to the gingival tissues only, not involving underlying osseous structures, without flaps
What is meant by gingival curettage?
Scraping of the gingival wall of a periodontal poclet to remove diseased soft tissue
Arrow A
Inadvertent curettage - unintentional curettage during S/C
What is subgingival curettage?
Incision performed apical to the junctional epithelium that severs the connective tissue attachment down to the osseous crest
Arrow B
Rationale behind gingival curettage
Lateral wall of pocket contains granulation tissues, inflamation, bacterial colonies
- If SRP done alone, this tissue is slowly resorbed and bacteria slowly killed off by host defense mechanism
- Curettage speeds up this process by just cutting it all out
- However, need for curettage is debated according to recent studies
Indications for curettage (3)
- Moderately deep intrabony pockets in accessible areas
- As a non-definitive procedure in cases contraindicated for flaps, to reduce inflammation
- As a method of maintenance for recurrent inflammation and pockets
Basic technique of curettage (3)
Should always be preceded by S/C
- LA
- Select curette and place cutting edge against tissue
- Engage inner lining of pocket and scrape along soft tissue in horizontal stroke while supporting the external surface
Describe the Excisional New Attachment Procedure technique
Type of subgingival curettage
Step 1: Internal bevel incision
Step 2: Remove excised tissue with curette and SRP
Step 3: Suture and dress
Note that this hardly ever actually ends up with new attachment
How do the tissues heal after curettage?
Blood clot fills pocket area
Rapid proliferation of granulation tissue with decrease in small blood vessels
Restoration/epithelialisation of sulcus in 2-7 days (JE)
Immature collagen fibers appear within 21 days
Indications for gingivectomy (3)
Elimination of suprabony pockets
Elimination of gingival enlargement
Elimination of suprabony periodontal abscesses
Contraindications for gingivectomy (2)
Need for osseous surgery or examination of bone morphology
Bottom of pocket is apical to the mucogingival junction
Steps of gingivectomy (5)
Step 1: Use pocket marker to mark depths
Step 2: Kirkland knife on a 45 degree angle to cut the marks, Orban knife for interdental areas
Step 3: Remove excised pocket wall
Step 4: Curette the granulation and remove any remaining calc and necrotic cementum to leave a clean surface
Step 5: Cover the area with a surgical pack
What is a gingivoplasty and what are the indications?
Purpose is to reshape the gingiva and recontour in the absence of pockets
Indications: gingival clefts, craters, NUG (crater-like interdental papillae)
Disadvantage of using electrosurgery for gingivectomy
- Cannot be used for pacemaker pts
- Odour
- Very large risks if you touch bone, root, metal
What are needle shaped electrodes used for (electrosurgery) (2)
Abscess drainage
Incisions
What are loop shaped electrodes used for (electrosurgery) (2)
Frenum and muscle reattachment/relocation
Scraping away tissue
What are ball shaped electrodes used for (electrosurgery)
Hemostasis
