Week 2- Periodontal Surgery Intro Flashcards
What are the goals of periodontal therapy?
- Prevention of tooth loss
- No BOP
- Pocket depth <4mm
Is non-surgical therapy alone sufficient?
Yes, in most cases and sites
How can you improve the prognosis of a tooth?
- Creating accessibility for effective root surface debridement
- Improving gingival or tooth morphology to facilitate pt self care.
- Regenerating lost periodontal attachment
What are medical contraindications for periodontal surgery?
- Bleeding predisposition (medication or disorders)
- Poorly controlled diabetes or hypertension
- Immunocompromised pt (medication or disorders)
What is the anatomy of the gingival sulcus?
How does oral epithelium differ to junctional and sulcular epithelium?
- Oral epithelium is keratinised
- Sulcular and junctional epithelium is non-keratinised and therefore more permeable to inflammatory products
What is the difference between suprabony and infrabony pockets?
- 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)
How do one/two/three-walled pockets differ in terms of management?
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.
What are the 4 pockets results following therapy?
- New attachment
- Long junctional epithelium
- Root resorption/ankylosis
- Recurrence of pocket
Why is long junctional epithelium the most common type of healing?
Epithelial cells have fastest regenerative rate
What are indications for periodontal surgery?
- 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
What are the general principles of periodontal surgery?
- 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
List 5 haemostasis products
- Gelfoam
- Oxyvel
- Surgical absorbable hemostat
- CollaCote
- Thrombostat
What is a Kirkland knife?
Kidney shaped blade used for external bevel excisions.
What is an Orban knife used for?
Used to release attachment in sulcus and IP
What scalpel blades are most commonly used?
15
What is a periosteal elevator used for?
Used to retract the flap. This is a blunt instrument.
What are the 3 types of incisions?
- External bevel
- Internal bevel
- Sulcular
What are external bevels used for?
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
What are internal bevels used for?
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
What is sulcular incision?
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)
What is a periodontal dressing used for?
Protective material applied over a wound created by periodontal surgical procedures.
What are the types of periodontal dressings?
Eugenol and Eugenol Free (most common)
- 2 paste system (chemical-cured): Coe-Pak, Periocare
- Visible light-cured gel
- Cyanoacrylate
How long should a dressing stay in place ideally?
Hopefully 1 week
What are benefits of using periodontal dressings?
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
What are the 3 approaches to surgical periodontal therapy?
- Conservative
- Resective
- Reconstructive
What 4 factors govern the surgical periodontal approach?
- 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)
What is the issue with not having enough keratinised gingiva?
Issues with healing and placing sutures
What are pocket reduction procedures?
- Open flap debridement
- Papillae preservation technique
- Simplified papilla preservation
- Modified Widman flap
What are soft tissue pocket elimination procedures?
- Gingivectomy
- Apically reposition flap
What are hard tissue pocket elimination procedures?
- Osseous surgery (osteoplasty, ostectomy)
- Furcation involved teeth (furcation plasty, root resection, hemi-section)
What are regenerative procedures?
- Guided tissue regeneration
- Root surface modification
- Other grafting biomaterials
What are 2 gingival surgical techniques?
- Gingival currettage
- Gingivectomy
How can gingivectomy be carried out?
- Conventional
- Electrosurgery
- Laser
- Chemosurgery
What is the difference between gingival and subgingival curettage?
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)
What is the rationale for curettage?
Removal of lateral wall of periodontal pocket.
What are indications for curettage?
- 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)
What should curettage be preceded by?
Scaling and root planing as curettage does not eliminate the causes of inflammation.
What are the steps of curettage?
- LA essential
- Select curette so cutting edge is against the tissue
- Engage inner lining of pocket wall and scrape along soft tissue in horizontal stroke with a gentle finger pressure to support
What are the steps of excisional new attachment procedure?
- Internal bevel incision
- Remove excised tissue with curette and SRP
- Sutures and periodontal dressing
What are other methods for curettage?
- Ultrasonic devices
- Laser
- Caustic drugs (not used anymore due to lack of control)
Describe healing after curettage
- Blood clot fills pocket immediately
- Rapid proliferation of granulation tissue with a decrease in number of small blood vessels as tissue matures
- Restoration of sulcus (including JE) in 2-7 days
- Immature collagen fibres appear within 21 days
What is gingivectomy?
Excision of soft tissue wall of the periodontal pocket aiming for pocket elimination.
What are indications for gingivectomy?
- Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm
- Elimination of gingival enlargements
- Elimination of suprabony periodontal abscesses
What are contraindications for gingivectomy?
- Need for osseous surgery
- Bottom of pocket apical to mucogingival junction
- Aesthetic consideration (anterior mx)
What are the steps for gingivectomy?
- Mark pockets with pocket marker
- Incisions (kirkland knife 45° on facial & lingual surfaces)
- Remove excised pocket wall
- Curette granulation tissue and remove calculus/necrotic cementum
- Cover area with surgical pack
What is a gingivoplasty?
Reshaping gingiva to create physiological gingival contours with the sole purpose of recontouring gingiva in absence of pockets
What are indications for a gingivoplasty?
- Gingival clefts and craters
- Crater like interdental papillae caused by NUG
- Gingival enlargments
What are the advantages of gingivectomy using electrosurgery?
- Permits adequate contouring of tissue
- Control of haemorrhage.
What are disadvantages of gingivectomy using electrosurgery
- 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
What are needle electrodes used for?
- Abscess drainage
- Incisions
What are loop or diamond electrodes used for?
- Shaving motion
- Frenum and muscle attachment relocation
What are ball electrodes used for?
Haemostasis
What should you suggest to pt with drug induced gingival enlargement?
- OH reinforcement
- CHX gluconate rinses
- Scaling and root planing
- Possible drug substitution
- Professional recalls
What should you do about gingival enlargement if it persists after first measures taken?
Periodontal surgery
When is periodontal flap vs gingvectomy indicated when there is gingival overgrowth?
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.
What is the difference between internal bevel and sulcular incision?
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
What does lateral wall of pocket contain?
- Granulation tissues
- Areas of chronic inflammation
- Pieces of dislodged calculus and bacterial colonies
What does lateral wall of pocket contain?
- Granulation tissues
- Areas of chronic inflammation
- Pieces of dislodged calculus and bacterial colonies
What is the difference between gingivectomy and gingivoplasty?
- 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
What is excisional new attachment procedure?
ENAP is a definitive subgingival curettage technique to eliminate sot tissue wall of pocket surgically
How is excisional new attachment procedure different from gingival curettage?
- 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
