W2 - Surgical Perio Therapy Part 1 - Sharma

Question 1

How can prognosis of the periodontically involved tooth be improved? (3)

Answer 1

1. Create accessibility for effective debridement
2. Improve gingival or tooth morphology to improve pt self-care
3. Regenerate lost periodontal attachment

Question 2

What is the True End point of periodontal therapy VS Surrogate end points?

Answer 2

True End point: Prevention of tooth loss

Surrogate end points: No BOP, pocket “closure” (<4mm)

Question 3

What are some relative medical contraindications to perio surgery? (4)

Answer 3

Relative bc you can still do perio surgery, just be cautious. Very few conditions exist where surgery should not commence

1. Bleeding disorders (haemophilia, anticoagulants)
2. Poorly contolled diabetes
3. Uncontrolled hypertension
4. Immunocompromised patients (leukemia, pt taking cyclosporin)

Question 4

Wall defect card

Question 5

What are the 4 possible pocket therapy results

Answer 5

1. Recurrence of pocket
2. Root resorption / ankylosis
3. Long junctional epithelium
4. New attahcment: regeneration GTR

Question 6

What is the most common pocket therapy result? Why?

Answer 6

Long junctional epithelium

• they are the fastest growing cells

Question 7

Indications for Periodontal Surgery (6)

Answer 7

1. Irregular bony contours / structure
2. Persistent inflammation in moderate-deep pockets
3. Deep pockets on teeth where complete removal of root irritants is not clinically possible (posterior)
4. Grade II or III furcation
5. Infrabony pockets on distal surfaces of last molars causing irritation (pericoronitis)
6. Areas with shallow pockets but persistent inflammation due to mucogingival problem

Question 8

List 5 examples of hemostasis products

Answer 8

1. Gelfoam
2. Oxycel
3. Surgicel absorbable hemostat
4. CollaCote/CollaTape/CollaPlug
5. Thrombostat

Question 9

Answer 9

Kirkland knife used for gingivectomy

Question 10

Answer 10

Orban (interdental) knife

Question 11

Answer 11

Periosteal elevator

Question 12

What are the 6 types of incisions in periodontal surgery?

Answer 12

1. External bevel
2. Internal bevel
3. Sulcular
4. Releasing
5. Cutback
6. Periosteal

Question 13

What is an external bevel and what is it used for?

Answer 13

Coronally directed incision

• Used for gingivectomy, crown lengthening
• to remove height of soft tissue

Question 14

What is an internal bevel and what is it used for?

Answer 14

Apically directed incision

• Removes thickness but not height, height remains the same
• Excisional new attachment procedure, flaps, gingival enlargement

Question 15

What is a sulcular incision and what is it used for?

Answer 15

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)

Question 16

2 Types of periodontal dressing

Answer 16

Eugenol-based

Eugenol-free (more common)

Question 17

Examples of eugenol-free periodontal dressing

Answer 17

Coe-Pak (GC) - chemical cured

Periocare - chemical cured

Barricaid - light cured

Question 18

Benefits of using periodontal dressings (6)

Answer 18

• 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

Question 19

What are the 3 surgical approaches

Answer 19

1. Conservative (preserving tissues)
2. Resective (removing tissues)
3. Reconstructive (regenerating tissues)

Question 20

What factors govern the surgical approach? (4)

Answer 20

1. Anatomy of the residual pocket - Supra/infrabony? amount of keratinized gingiva?

2. Anatomy of the tooth - single or multi rooted? Furcation?

3. Position of tooth in dentition - cosmetic area?
4. Complexity and predictability - patient and operator factors

Question 21

What are gingivectomies and gingival curettage surgeries?

Answer 21

Periodontal pocket reduction surgery limited to the gingival tissues only, not involving underlying osseous structures, without flaps

Question 22

What is meant by gingival curettage?

Answer 22

Scraping of the gingival wall of a periodontal poclet to remove diseased soft tissue
Arrow A

Inadvertent curettage - unintentional curettage during S/C

Question 23

What is subgingival curettage?

Answer 23

Incision performed apical to the junctional epithelium that severs the connective tissue attachment down to the osseous crest

Arrow B

Question 24

Rationale behind gingival curettage

Answer 24

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

Question 25

Indications for curettage (3)

Answer 25

1. Moderately deep intrabony pockets in accessible areas 2. As a non-definitive procedure in cases contraindicated for flaps, to reduce inflammation 3. As a method of maintenance for recurrent inflammation and pockets

Question 26

Basic technique of curettage (3)

Answer 26

*Should always be preceded by S/C* 1. LA 2. Select curette and place cutting edge against tissue 3. Engage inner lining of pocket and scrape along soft tissue in horizontal stroke while supporting the external surface

Question 27

Describe the Excisional New Attachment Procedure technique

Answer 27

*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*

Question 28

How do the tissues heal after curettage?

Answer 28

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

Question 29

Indications for gingivectomy (3)

Answer 29

Elimination of suprabony pockets Elimination of gingival enlargement Elimination of suprabony periodontal abscesses

Question 30

Contraindications for gingivectomy (2)

Answer 30

Need for osseous surgery or examination of bone morphology Bottom of pocket is apical to the mucogingival junction

Question 31

Steps of gingivectomy (5)

Answer 31

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

Question 32

What is a gingivoplasty and what are the indications?

Answer 32

Purpose is to reshape the gingiva and recontour in the absence of pockets Indications: gingival clefts, craters, NUG (crater-like interdental papillae)

Question 33

Disadvantage of using electrosurgery for gingivectomy

Answer 33

* Cannot be used for pacemaker pts * Odour * Very large risks if you touch bone, root, metal

Question 34

What are needle shaped electrodes used for (electrosurgery) (2)

Answer 34

Abscess drainage Incisions

Question 35

What are loop shaped electrodes used for (electrosurgery) (2)

Answer 35

Frenum and muscle reattachment/relocation Scraping away tissue

Question 36

What are ball shaped electrodes used for (electrosurgery)

Answer 36

Hemostasis

Question 37

Answer 37