46. Surgical Treatment Of Periodontal Diseases Flashcards
Key considerations in current periodontal surgery
- Conservation of keratinized gingiva
- Maintain aesthetics
- Adequate access
- Minimal postsurgical discomfort and bleeding
Why gingivectomy often not favored in modern periodontal surgery
- Does not adequately satisfy the key considerations=>
- Conservation of keratinized gingiva
- Minimal tissue loss and postoperative discomfort
Gingivectomy and its primary purpose
- Surgical excision of gingiva=>
- Visibility and accessibility for complete calculus removal and root smoothing=>
- Removing pocket wall=>
- Creates favorable environment for gingival healing and contouring
Indications for performing a gingivectomy
- Elimination=>
- Suprabony pockets with a fibrous and firm wall
- Gingival enlargements
- Suprabony periodontal abscesses
Contraindications for gingivectomy
- Situations requiring bone surgery
- Pockets where bottom is apical to mucogingival junction
- Aesthetic considerations=> anterior maxilla
Surgical procedure for a gingivectomy
- Explore pockets w/ periodontal probe and mark w/ pocket marker
- Incision=> Directed coronally to avoid exposure of the bone
- Removal of the excised pocket wall
- Cleaning area=>
- Curetting granulation tissue, removing calculus and necrotic cementum=>
- Covering area with surgical pack.
Incisions w/ periodontal knives (Kirkland and Orban knives), Bard-Parker blades, and scissors.
How gingivoplasty differs from gingivectomy
- Reshapes gingiva to create physiological contours=>
- Prevent plaque accumulation and disease aggravation
- Addresses deformities caused by gingival and periodontal disease
Indications for gingivoplasty
- Gingival clefts and craters
- Crater-like interdental papillae => acute necrotizing ulcerative gingivitis
- Gingival enlargement
Gingivoplasty technique
- Tapering the gingival margin
- Creating a scalloped marginal outline
- Thinning the attached gingiva
- Creating interdental grooves
- Shaping the interdental papillae
It can be performed using periodontal knives, scalpels, rotary coarse diamond stones, or electrodes
Healing process after a surgical gingivectomy
- Blood clot formed=>
- Replacement w/ granulation tissue within 24 hours=>
- marked by increase in connective tissue cells, primarily angioblasts
- Accumulation of young fibroblasts by the third day
- Growth of highly vascular granulation tissue coronally=>new free gingival margin and sulcus
- Migration of capillaries from periodontal ligament vessels into granulation tissue=>
- connect w/ gingival vessels within two weeks
- Epithelial cell migration over the granulation tissue=> after 12 to 24 hours and peaking at 24 to 36 hours.
- Surface epithelialization=> complete within 5 to 14 days
- Complete epithelial repair=>t one month
- Complete repair of connective tissue taking about seven weeks
Primary purposes of using flaps in pocket therapy
- Increase accessibility to root deposits => scaling and root planing
- Eliminate or reduce pocket depth
- Gain access for osseous resective surgery
- Expose the area for regenerative methods
Three categories of flap techniques used in periodontal surgery
- Modified Widman Flap=>Facilitates instrumentation for root therapy=>
- Eliminates pocket lining but does not reduce pocket depth
- Undisplaced Flap=> Aims for root surface access and reduction or elimination of pocket depth
- Apically Displaced Flap=>Similar to undisplaced flap=>
- Also includes apical repositioning of the flap
Apically displaced flap variations-Full-thickness (mucoperiosteal) flap. and Split-thickness (mucosal) flap.
Factors that influence choice between undisplaced flap and apically displaced flap
- Pocket depth
- Location of the mucogingival junction
Steps involved in apically displaced flap
- Internal Bevel Incision:
- Crevicular Incisions and Initial Elevation
- Vertical Incisions
- Displacement and Suturing:
- Postoperative Care
1)incision to preserve keratinized and attached gingiva=> directed to the bone crest.
2)Follow with crevicular incisions=>elevate the flap, and perform interdental incisions to remove the tissue wedge containing the pocket wall
3)Extend beyond the mucogingival junction. For full-thickness, elevate by blunt dissection. For split-thickness, elevate by sharp dissection, leaving a layer of connective tissue on the bone.
4)After removing granulation tissue, scaling, root planing, and osseous surgery=> displace the flap apically. Full-thickness flaps use sling sutures to prevent movement. Partial-thickness flaps are sutured to the periosteum.
5)Remove dressings and sutures after 1 week, repack for another week=> instruct the patient to use chlorhexidine mouthrinse or topical application for 2-3 weeks.
ENAP procedure and its technique
- Subgingival curettage procedure performed with a knife=>achieve new attachment
1. Internal Bevel Incision
2. Tissue Removal and Root Planing
3. Wound Approximation:
1) Make incision from gingival margin apically below pocket bottom, interproximally on both facial and lingual sides
2) Excise tissue with curette, perform root planing on exposed cementum, and preserve attached connective tissue fibers
3) Approximate the wound edges, recontour the bone if needed for good adaptation, and place sutures and a periodontal dressing.
