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Dr Sharma > Week 2- Periodontal Surgery Intro > Flashcards

Week 2- Periodontal Surgery Intro Flashcards

1
Q

What are the goals of periodontal therapy?

A
  • Prevention of tooth loss
  • No BOP
  • Pocket depth <4mm
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2
Q

Is non-surgical therapy alone sufficient?

A

Yes, in most cases and sites

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3
Q

How can you improve the prognosis of a tooth?

A
  • Creating accessibility for effective root surface debridement
  • Improving gingival or tooth morphology to facilitate pt self care.
  • Regenerating lost periodontal attachment
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4
Q

What are medical contraindications for periodontal surgery?

A
  • Bleeding predisposition (medication or disorders)
  • Poorly controlled diabetes or hypertension
  • Immunocompromised pt (medication or disorders)
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5
Q

What is the anatomy of the gingival sulcus?

A
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6
Q

How does oral epithelium differ to junctional and sulcular epithelium?

A
  • Oral epithelium is keratinised
  • Sulcular and junctional epithelium is non-keratinised and therefore more permeable to inflammatory products
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7
Q

What is the difference between suprabony and infrabony pockets?

A
  • Supra: base of pocket coronal to alveolar bone (can be true or pseudo pocket)
  • Infra: base of pocket apical to alveolar bone (always true pocket)
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8
Q

How do one/two/three-walled pockets differ in terms of management?

A

3 walled defect is easier to manage and ideal for bone graft and regenerative treatment. It has box architecture to fill in with material to help heal pocket.
2 walled may be fine.
1 wall has very poor prognosis for bone grafts and regenerative therapy.

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9
Q

What are the 4 pockets results following therapy?

A
  • New attachment
  • Long junctional epithelium
  • Root resorption/ankylosis
  • Recurrence of pocket
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10
Q

Why is long junctional epithelium the most common type of healing?

A

Epithelial cells have fastest regenerative rate

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11
Q

What are indications for periodontal surgery?

A
  • Irregular bony contours, deep craters etc.
  • Persistent inflammation with moderate/deep pockets
  • Deep pockets where complete removal of root irritant not possible.
  • Grade 2 or 3 furcation
  • Infrabony pockets on distal of molars
  • Shallow pockets or normal sulcus with persistent inflammation
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12
Q

What are the general principles of periodontal surgery?

A
  • Re-evaluate after phase 1
  • Premedication
  • Quit smoking for 3-4 weeks
  • Informed consent
  • PPE, sharps disposal, infection control
  • Anaesthesia, sedation
  • Operate gently
  • Use sharp instruments only
  • Thorough scaling and root debridement as part of surgery
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13
Q

List 5 haemostasis products

A
  • Gelfoam
  • Oxyvel
  • Surgical absorbable hemostat
  • CollaCote
  • Thrombostat
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14
Q

What is a Kirkland knife?

A

Kidney shaped blade used for external bevel excisions.

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15
Q

What is an Orban knife used for?

A

Used to release attachment in sulcus and IP

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16
Q

What scalpel blades are most commonly used?

A

15

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17
Q

What is a periosteal elevator used for?

A

Used to retract the flap. This is a blunt instrument.

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18
Q

What are the 3 types of incisions?

A
  • External bevel
  • Internal bevel
  • Sulcular
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19
Q

What are external bevels used for?

A

Used to cut off excess tissue (overall reduction in height). Bevel ends up on outside of tissue

E.g. indicated for: gingivectomy, crown lengthening, gingivoplasty

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20
Q

What are internal bevels used for?

A

If you want to conserve height when removing tissue. Bevel ends up on inside of tissue.

e.g. indicated for: excisional new attachment procedure, flaps, crown lengthening, gingival enlargement

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21
Q

What is sulcular incision?

A

Blade goes directly into sulcus to make incision.

E.g. when preserving gingiva is critical (aesthetic areas, areas of minimal keratinised tissue, tissue regeneration procedures)

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22
Q

What is a periodontal dressing used for?

A

Protective material applied over a wound created by periodontal surgical procedures.

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23
Q

What are the types of periodontal dressings?

A

Eugenol and Eugenol Free (most common)

  • 2 paste system (chemical-cured): Coe-Pak, Periocare
  • Visible light-cured gel
  • Cyanoacrylate
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24
Q

How long should a dressing stay in place ideally?

A

Hopefully 1 week

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25
Q

What are benefits of using periodontal dressings?

A

Highly Debated

  • Improved flap adaptation
  • Control of immediate post op bleeding
  • Wound protection
  • Help retain osseous graft materials
  • Pt comfort
  • Temp splinting of mobile teeth
26
Q

What are the 3 approaches to surgical periodontal therapy?

A
  • Conservative
  • Resective
  • Reconstructive
27
Q

What 4 factors govern the surgical periodontal approach?

A
  • Anatomy of residual pocket (supra or infrabony, amount of keratinised gingiva)
  • Anatomy of tooth (# of roots, furcation)
  • Position of tooth in dental arch (cosmetic)
  • Complexity and predictability (pt and operator factors)
28
Q

What is the issue with not having enough keratinised gingiva?

A

Issues with healing and placing sutures

29
Q

What are pocket reduction procedures?

A
  • Open flap debridement
  • Papillae preservation technique
  • Simplified papilla preservation
  • Modified Widman flap
30
Q

What are soft tissue pocket elimination procedures?

A
  • Gingivectomy
  • Apically reposition flap
31
Q

What are hard tissue pocket elimination procedures?

A
  • Osseous surgery (osteoplasty, ostectomy)
  • Furcation involved teeth (furcation plasty, root resection, hemi-section)
32
Q

What are regenerative procedures?

A
  • Guided tissue regeneration
  • Root surface modification
  • Other grafting biomaterials
33
Q

What are 2 gingival surgical techniques?

A
  • Gingival currettage
  • Gingivectomy
34
Q

How can gingivectomy be carried out?

A
  • Conventional
  • Electrosurgery
  • Laser
  • Chemosurgery
35
Q

What is the difference between gingival and subgingival curettage?

A

Difference is how deep we go with instruments.

  • Gingival: removal of the inflamed soft tissue lateral to pocket wall and junctional epithelium (A)
  • Subgingival: performed apical to junctional epithelium. Severs the connective tissue attachment down to the osseous crest (B)
36
Q

What is the rationale for curettage?

A

Removal of lateral wall of periodontal pocket.

37
Q

What are indications for curettage?

A
  • Moderately deep intrabony pockets in accessible areas
  • Non-definitive procedure in cases contraindicated for flaps to reduce inflammation.
  • Maintenance treatment (esp in areas where pocket reduction surgery has been done previously)
38
Q

What should curettage be preceded by?

A

Scaling and root planing as curettage does not eliminate the causes of inflammation.

39
Q

What are the steps of curettage?

A
  1. LA essential
  2. Select curette so cutting edge is against the tissue
  3. Engage inner lining of pocket wall and scrape along soft tissue in horizontal stroke with a gentle finger pressure to support
40
Q

What are the steps of excisional new attachment procedure?

A
  1. Internal bevel incision
  2. Remove excised tissue with curette and SRP
  3. Sutures and periodontal dressing
41
Q

What are other methods for curettage?

A
  • Ultrasonic devices
  • Laser
  • Caustic drugs (not used anymore due to lack of control)
42
Q

Describe healing after curettage

A
  1. Blood clot fills pocket immediately
  2. Rapid proliferation of granulation tissue with a decrease in number of small blood vessels as tissue matures
  3. Restoration of sulcus (including JE) in 2-7 days
  4. Immature collagen fibres appear within 21 days
43
Q

What is gingivectomy?

A

Excision of soft tissue wall of the periodontal pocket aiming for pocket elimination.

44
Q

What are indications for gingivectomy?

A
  1. Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm
  2. Elimination of gingival enlargements
  3. Elimination of suprabony periodontal abscesses
45
Q

What are contraindications for gingivectomy?

A
  • Need for osseous surgery
  • Bottom of pocket apical to mucogingival junction
  • Aesthetic consideration (anterior mx)
46
Q

What are the steps for gingivectomy?

A
  1. Mark pockets with pocket marker
  2. Incisions (kirkland knife 45° on facial & lingual surfaces)
  3. Remove excised pocket wall
  4. Curette granulation tissue and remove calculus/necrotic cementum
  5. Cover area with surgical pack
47
Q

What is a gingivoplasty?

A

Reshaping gingiva to create physiological gingival contours with the sole purpose of recontouring gingiva in absence of pockets

48
Q

What are indications for a gingivoplasty?

A
  • Gingival clefts and craters
  • Crater like interdental papillae caused by NUG
  • Gingival enlargments
49
Q

What are the advantages of gingivectomy using electrosurgery?

A
  • Permits adequate contouring of tissue
  • Control of haemorrhage.
50
Q

What are disadvantages of gingivectomy using electrosurgery

A
  • Cannot be used in pt with incompatible pacemakers
  • Unpleasant odour
  • Touching bone with tip can cause irreversible damage.
  • If tip is close to bone, there can be tissue damage and loss of perio support.
  • If it touches root, areas of cementum can burn
51
Q

What are needle electrodes used for?

A
  • Abscess drainage
  • Incisions
52
Q

What are loop or diamond electrodes used for?

A
  • Shaving motion
  • Frenum and muscle attachment relocation
53
Q

What are ball electrodes used for?

A

Haemostasis

54
Q

What should you suggest to pt with drug induced gingival enlargement?

A
  • OH reinforcement
  • CHX gluconate rinses
  • Scaling and root planing
  • Possible drug substitution
  • Professional recalls
55
Q

What should you do about gingival enlargement if it persists after first measures taken?

A

Periodontal surgery

56
Q

When is periodontal flap vs gingvectomy indicated when there is gingival overgrowth?

A

Gingivectomy: small areas of enlargement (6 teeth), abundance of keratinised tissue & no AL or horizontal bone loss

Flap: large area of enlargement (>6 teeth), presence of osseous defects, limited keratinised tissue.

57
Q

What is the difference between internal bevel and sulcular incision?

A

Both are apically directed

  • Internal Bevel: placed at the crest of
    the gingival margin or stepped back
    from the margin 0.3-2 mm
  • Sulcular: placed in the gingival crevice and directed toward the alveolar crest
58
Q

What does lateral wall of pocket contain?

A
  • Granulation tissues
  • Areas of chronic inflammation
  • Pieces of dislodged calculus and bacterial colonies
59
Q

What does lateral wall of pocket contain?

A
  • Granulation tissues
  • Areas of chronic inflammation
  • Pieces of dislodged calculus and bacterial colonies
60
Q

What is the difference between gingivectomy and gingivoplasty?

A
  • Gingivectomy involves excising the soft tissue wall of the periodontal pocket aiming for pocket elimination.
  • Gingivoplasty involves re-contouring gingiva in the absence of pockets
61
Q

What is excisional new attachment procedure?

A

ENAP is a definitive subgingival curettage technique to eliminate sot tissue wall of pocket surgically

62
Q

How is excisional new attachment procedure different from gingival curettage?

A
  • Gingival curettage is performed with curette with intention of eliminating inflamed lateral wall of pocket
  • ENAP is a subgingival curettage technique, reaching deep to the bone and utilises a surgical blade to place internal bevel incision

Dr Sharma (4 decks)

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