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Perio II Test 2 > Ch 30 Perio Surgical Concepts > Flashcards

Ch 30 Perio Surgical Concepts Flashcards

(113 cards)

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1
Q

Indications for periodontal surgery

A

-when perio cannot be controlled with no surgical therapy alone
-to provide access for perio instrumentation of the root surface
-reduce pocket depth
-provide access to defects in the alveolar bone
-to resect or remove tissue
-regenerate periodontium lost due to disease
-graft bone materials into bone defects
-improve the appearance of periodontium
-enhance prosthetic dental care
-allow for placement of a dental implant

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2
Q

Perio surgery contraindications: most contraindications for perio surgery are relative contraindications (may make surgery inadvisable) which are

A

Patients who:
-have certain systemic diseases are totally noncompliant with care
-have a high risk for dental caries
-have unrealistic expectations for the outcomes of perio surgery

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3
Q

Relative contraindications: Systemic diseases and conditions

A

Recent history of heart attack
Uncontrolled hypertension
Uncontrolled diabetes
Certain bleeding disorders
Kidney dialysis
History of radiation to the jaws
HIV infection

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4
Q

Relative contraindications: high risk for dental caries

A

Perio surgery can expose portions of the tooth roots
-pts at high risk for caries can be devastated with rampant root caries

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5
Q

Terminology used to describe surgical wound healing

A

Healing by repair
Healing by reattachment
Healing by new attachment
Healing by regeneration

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6
Q

Healing by repair

A

Repair-healing of a wound by formation of tissues that do NOT precisely restore the original function of the body part
-example: formation of a scar during healing of a cut to a finger
-healing after periodontal instrumentation results in a long Junctional epithelium
-a long JE does NOT precisely duplicate the original periodontal tissues (no formation of new bone, no formation of new cementum, no formation of perio ligament)

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7
Q

Healing by reattachment

A

Reattachment: healing by the reunion of the periodontal connective tissue and tooth roots where the two tissues have been separated by incision or injury but NOT by disease
-example; temporarily moving healthy tissue away from the tooth root or bone during periodontal surgery

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8
Q

Healing by new attachment

A

New attachment- healing that occurs when epithelium and connective tissues are newly attached to a tooth roots where where periodontitis had previously destroyed this attachment
-new attachment occurs in an area damaged by disease
-reattachment occurs in the absence of disease

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9
Q

Healing by regeneration

A

Regeneration- regrowth of the precise tissues that were present before the disease or damage to the tissues occurred
-for healing of the periodontium to be described as regeneration the healing would have to result in the reformation of list cementum, lost PDL, and lost alveolar bone
-regeneration of the periodontium is possible with modern surgical procedures
-unfortunately the periodontium cannot be regenerated predictably in all sites with current surgical techniques

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10
Q

Terminology to describe the degree of wound closure

A

Healing by primary intention
Healing by secondary intention
Healing by tertiary intention

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11
Q

Primary intention

A

-occurs when the wound margins are closely adapted to each other
-ideally, all wounds created by periodontal surgery won’t heal by primary intention, but often this is not possible
-difficult in periodontitis since one edge of the surgical wound is the tooth root that cannot contribute any living cells to the wound healing

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12
Q

Secondary intention

A

-margins or edges of the wound are not in close contact with each other
-granulation tissue must form to close the space between the wound margins and then the epithelial cells grow over the surface of the wound
-many wounds in perio surgery involve healing by secondary intention

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13
Q

Tertiary intention

A

Healing of a wound that is temporarily left open with the specific intent of surgically closing that wound at a later date
-not normally a type of healing that applies to perio surgery involve

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14
Q

Periodontal flap is a periodontal surgical procedure in which

A

Incisions are made in the gingiva or mucosa to allow for separation of the epithelium and connective tissues from the underlying tooth roots and underlying alveolar bone

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15
Q

Periodontal flap procedure description

A

-incision made to allow for separation of the soft tissue from the roots and alveolar bone
- the soft tissue is lifted temporarily from the teeth and alveolar bone
- improved visualization of both the tooth roots and alveolar bone contours

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16
Q

Elevation or reflection of tissue

A

-elevation: separating the epithelium and connective tissues from the underlying root and alveolar bone
-once these tissues are elevated they can be replaced at the original position or moved to a different location

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17
Q

Indications for a periodontal flap

A

-to provide access to tooth root surfaces for completion of meticulous periodontal instrumentation that has begun as part of the nonsurgical periodontal surgery
-to provide access to reshape or treat alveolar bone defects resulting from periodontitis

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18
Q

Classification of periodontal flaps

A

Based on bone exposure:
-full thickness flap
-partial thickness flap

Based on location of the flap margin
-non displaced flap
-displaced flap

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19
Q

Full thickness flap

A

-also called a mucoperiosteal flap
-lifting of the entire thickness of the soft tissue
-provides complete access to the underlying alveolar bone
-blunt instruments are used to elevate the flap in a manner quite similar to lifting the peel off an orange

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20
Q

Partial thickness flap

A

-elevation only of the epithelium and a think layer of underlying connective tissue
-sharp instruments are used for a partial thickness flap

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21
Q

Non displaced flap

A

-a flap that is sutured with the margin of the flap placed at its original relationship to the CEJ of the tooth

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22
Q

Displaced flap

A

-a flap that is sutured with the margin of the flap placed at a position other than its original position in relation to the CEJ
-a displaced flap can be positioned apically, coronally or laterally in relationship to its original position

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23
Q

Types of incisions used during periodontal flap surgery

A

-Horizontal: run parallels to the gingival margin in a mesiodistal direction (crevicular incision, internal bevel incision)
-vertical incisions: run perpendicular to the gingival margin in an apico-occlusal direction

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24
Q

Periodontal surgery: Flap for access

A

-also called modified widman flap surgery
-provides access to tooth roots for improved root preparation
-tissue is lifted long enough for the procedures
-after completion of the procedure, tissue is replaced at the original position
-sutured in place

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25
Special considerations for the DH in flap for access surgery
-difficult to remove all calculus deposits in pocket depths deeper than 5 mm in nonsurgical periodontal instrumentation -flap for access surgery allows more efficient and meticulous instrumentation of root surfaces
26
Periodontal surgery: open flap debridement
Similar to flap access except: -more extensive flap elevation -may displace flap margin to a new location
27
Steps / procedure in open flap debridement
1. Horizontal incisions being made to bone within the sulcus or pocket base 2. Elevation of full-thickness flap to expose tooth roots and alveolar bone 3. Periodontal instrumentation of tooth roots
28
Periodontal surgery : osseous resective surgery
-corrects deformities of the alveolar bone resulting from advanced periodontitis -main goal is to eliminate periodontal pockets -ostectomy: removal of the alveolar bone attached to the tooth -osteoplasty: reshaping of the alveolar bone without removing the supporting bone
29
Periodontal surgery: apically positioned flap with osseous resective surgery
-combines displaced flap in the apical direction with the resective osseous surgery -gingival margin apical to CEJ -increased root exposure -reduced pocket depths -expect reasonable patient self care and professional periodontal maintenance
30
Apically positioned flap with osseous resective surgery steps/procedure
1. Bevel incision and vertical releasing incision 2. Removal of collar of soft tissue following flap elevation 3. Ostectomy 4. Inspection of final bone contours after ostectomy and osteoplasty 5. Suturing: note that the flap margin is displaced in an apical position compared to its original position 6. Placement of periodontal dressing to stabilize the flap at its new position
31
Special consideration for DHS for apically positioned flap surgery with osseous resective surgery
-during surgery it is common for the gingival margin to be positioned against the teeth in a more apical position than is originally occupied -this exposes a portion of the root to the oral cavity -exposure of a portion of the root may be an esthetic concern for the patient -exposure of a portion of the tooth can lead to root caries -temporary dental sensitivity is a frequent post surgical complaint -before surgery the pt should be informed about anticipated changes in appearance and the potential for dentinal sensitivity
32
Periodontal surgery: bone replacement grafts
-procedure used to encourage the body to rebuild the alveolar bone lost due to periodontal disease -bone grafts are common in medicine but are more challenging in dentistry
33
Challenges of bone grafts in dentistry
-bone grafts in periodontal defects are subject to constant contamination from bacteria and saliva travelling along the roots adjacent to the grafts site -healing of bone grafts can be disrupted by the growth of epithelium into the wound that can lead to graft failure
34
Terminology associated with bone replacement grafts
-osteogenesis: potential for new bone cells to develop following bone graft -osteoconduction: grafting materials form a framework outside the graft during the formation of the new bone -osteoinduction: cells within the grafting materials form are converted into bone forming cells to form the new bone
35
Categories of materials used for bone replacement grafts
-Autograft: bone taken from the patients own body -allograft: bone taken from another human -xenograft: bone taken from another species (bovine bone) -alloplast: synthetic bone like material
36
Specific materials for bone grafting
-autogenous bone from intraoral sites -autogenous bone from extra oral sites -freeze dried bone allografts harvested from another human -bovine derived bone -plaster of Paris -bio active glass -calcium phosphate -autographs have the most osteogenic potential (already contains living bone cells and viable bone growth factors) -if there are many sites to fill a combination of grafting materials can be used
37
Harvesting bone intraorally/exteaorally
-bone removed during ostectomy or osteoplasty -exostoses removed during surgery -edentulous ridges -healing extraction sites -chin -Distal most bone in jaws -Iliac crest
38
Special considerations for DHS bone replacement grafting
-the site of bone graft should not be disturbed for several months -DONNOT PROBE until appropriate interval has lapsed -meticulous plaque control is critical to maintain health in the area
39
Periodontal surgery: guided tissue regeneration
-surgical procedure to encourage regrowth of lost periodontal structures (lost cementum, alveolar bone, and periodontal ligament)
40
Potential sources of cells in healing
the healing of a wound after periodontal surgery may involve cells from several different sources : -gingival epithelial cells -gingival connective tissue cells -bone cells -periodontal ligament cells
41
Guided tissue regeneration: use of barrier membrane
-guided tissue regeneration techniques involve the use of a barrier membrane -the membranes purpose is to delay the normally rapid growth of epithelium from the flap margin into the wound -if the epithelium covers the wound, it prevents the slower growing cells from growing -delaying the ingrowth of epithelium allows for undifferentiated cells to populate the root area and develop into cementum, PDL, and alveolar bone -the membranes purpose delays the growth of epithelial cells along tooth root -this provides time for the cementum, PDL, and bone to form next to the root
42
Goal of guided tissue regeneration
-guided tissue regeneration can result in true regeneration of the periodontium -although regeneration of the cementum, PDL and alveolar bone is the ultimate goal of periodontal surgery - regeneration of the periodontium is NOT completely predictable with techniques in use today
43
Steps in guided tissue regeneration
-the flap is incised and elevated -periodontal instrumentation and debridement of the osseous defect -barrier membrane is sutured into place -the flap is sutured into place, completely covering the barrier material
44
Barrier materials
-some barrier materials in current use require removal following healing of the wound; this necessitates a second surgical procedure to remove the barrier -other barrier materials are resorbable and no not require removal
45
Special considerations for DHS guided tissue regeneration
-effort is made during surgery to close the wound to cover the barrier material -during postoperative visit if part of the barrier is exposed, measures should be employed to minimize bacterial contamination of the material -the patient may need to apply topical antimicrobial agents to surgical site -sites treated by guided tissue regeneration should not be probed for several months following surgery
46
periodontal surgery: periodontal plastic surgery
-periodontal surgery that is directed toward correcting the problems with the gonna or alveolar mucosa -procedures can be used to improve esthetics of the dentition, enhance prosthetic dentistry and deal with damage from periodontitis -Mucogingival surgery: any procedure that corrects a deformity associated with the gingiva and mucosa -Reconstructive surgery: a procedure that reconstructs periodontal tissues
47
Goals of periodontal plastic surgery
To alter the periodontal tissues in a positive way -improve function
48
Common plastic surgery procedures
-free soft tissue autograft -subepithelial connective tissue autograft -laterally positioned flap -coronally positioned flap -semilunar coronally repositioned flap -frenectomy -can lengthening surgery
49
Periodontal surgery: free soft tissue autograft
-type of plastic surgery used to augment width of the attached gingiva and cover areas of recession of the gingival margin -requires harvesting sonar section of tissue, usually from the palate -includes surface epithelium and underlying connective tissue -2 wounds; sonar site and recipient site
50
Steps in free soft tissue autograft
-a tissue graft is obtained from a donor site in the it’s mouth (palate) -the graft is sutured into place the area with recession of the gingival margin -both the donor site and the recipient site are covered with periodontal dressing
51
Healing expected with free soft tissue autograft procedure
-usually results in successful augmentation of the gingiva and coverage of roots -colour match at sonar site not ideal
52
Periodontal surgery: sub epithelial connective tissue autograft
-another type of plastic surgery used to augment width of the attached gingiva and cover areas of recession of the gingival margin -also used to contour alveolar ridges and improve esthetics of some dental prostheses -uses only the connective tissue (no epithelium) form the donor site
53
Healing expected after subepithelial connective tissue autograft
Reasonable root coverage expected -excellent tissue colour match
54
Acellular dermal matric allograft
-substitute for autogenous tissue -carefully screened to remove HIV-1 virus and hep c -structural framework consists of a 3D arrangement of blood vessel channels, collagen, elastin and proteoglycans -advantage is that no donor site is needed
55
Periodontal surgery: laterally positioned flap
-used to cover root surfaces of gingiva in isolated sites of gingival recession -donor sites adjacent to recipient sites -tissue from the sonar site is elevated and rotated laterally to cover the recipient site -the laterally positioned flap maintains its own blood supply unlike the free gingival graft -provides excellent root coverage
56
Periodontal surgery: coronally positioned flap
-type of plastic surgery used to repair minor gingival recession -tissue at the site of the gingival recession is displaced coronally - does not require a second surgical site to provide donor tissue -difficult to stabilize in the new position
57
Periodontal surgery: semilunar coronal repositioned flap
-type of plastic surgery used to repair minor recession and where there is adequate thickness of keratinized tissue -a curved incision is made from on interdental area to the adjacent interdental area over the tooth root -the flap is displaced coronally
58
Periodontal surgery: frenectomy
-plastic surgery procedure used to remove a frenum including the attachment of frenum to bone -if the frenum is attached too close to the gingival margin it can result in repeated pulling of the gingival margin away from the tooth surface resulting in persistent inflammation in the tissues -healing following frenectomy includes elimination of the gingival margin movement caused by the frenum pull
59
Crown lengthening
Surgery that creates a longer clinical crown for a tooth by removing gingival and alveolar bone from necks of teeth
60
Functional crown lengthening
Performed when the existing tooth structure is inadequate to support a necessary restoration -decay below gingival margin
61
Esthetic crown lengthening
Performed to improve appearance of teeth when there is excess gingiva in relation to clinical crowns
62
Crown lengthening surgical procedure
-flap is elevated to allow access to to bone -bone is recontoured -tissue is sutured back in place -final healing results in a normal attachment at a more apical position on the root
63
Special considerations for the DHS in crown lengthening
-pt may experience some temporary dentinal hypersensitivity -aid the pt in plaque billion control until healing allows the patient to resume normal self care
64
Gingivectomy
Surgical removal of the gingival tissue -results in more apical position of the gingival margin away -allows for better self care in select sites -plays a greatly reduced role in modern periodontal surgery
65
Disadvantages of gingivectomy
-leaves large open connective tissue wound -slower healing than other surgeries -more discomfort for the patient during healing -teeth appear longer
66
Special considerations for DHS in regard to gingivectomy
-healing phase can be very uncomfortable for the pt -can be managed with a perio dressing over the wound -prescribe analgesics -dressing may need to be changed at several post surgical visits until total epithelialization has occurred (CT tissue totally covered by the epithelium )
67
Periodontal surgery: surgery for dental implant placement
Dental implant: an artificial tooth root placed into the alveolar bone to hold a replacement tooth -requires exposure of alveolar bone using flap surgery -a precise hole is drilled into bone and metallic implant screw (artificial root) is inserted
68
Surgery for dental implant placement: one stage (non submerged) approach
Implant or abutment emerges from soft tissue at any time of implant placement
69
Two staged (submerged) approach for dental implant placement
-implant and cover screw are completely covered by the flap -requires a second surgical procedure after osseointegration to expose top of implant
70
Healing expected following dental implant placement
-osseointegration: direct structural and functional connection between living bone and implant surface is critical for implant stability and a prerequisite for long term success -implant is not surrounded by cementum and does not have a PDL attachment -peri implantitis is inflammation around the implant: loss of osseointegration, can be seen on radiographs
71
Special considerations for DHS: implant placement
-self care following placement is critical. Assist with plaque control during healing period -after healing, area surrounding implant is tended to the same as natural teeth
72
Periodontal surgery: microsurgery
-periodontal surgery performed with the aid of a surgical microscope -perio surgery performed using microsurgery techniques can result in procedures performed more precisely
73
Periodontal surgery: laser therapy
-light amplification by stimulated emission of radiation -focuses a beam of light of a single wavelength at the periodontal site -can incise and coagulate soft tissues with efficiency -have the capability to stimulate periodontal regeneration
74
Benefits of laser therapy
-beam is bactericidal against pigmented periodontal pathogens -able to deliver a precise, intensive energy to the pocket without damaging adjacent tissues -can seal a pocket orifice with a thermal fibrin clot creating a physical barrier to epithelial down growth
75
AAP & ADA statement regarding use of laser therapy
There is insufficient evidence to support the use of lasers as a single form of treatment in periodontitis patients at this time
76
Biological enhancement
Attempts to enhance the outcomes of periodontal surgery by using chemical or biologic mediators to influence healing following periodontal surgical procedures
77
Biological enhancement methods studied to date
-root surface modification -growth factors -enamel matrix derivative (EMD) -platelet rich plasma (PRP) -platelet rich fibrin -bone morphogenetic proteins (BMP)
78
Root surface modification
Chemical and biologic mediators used in an attempt to enhance the healing of the gingiva adjacent to the tooth roots
79
Root conditioning agents
-EDTA gel applied to root surfaces may remove endotoxins buried deep below the root surface -tetracycline may enhance migration of fibroblasts to root surfaces during healing
80
Growth factors
-naturally occurring proteins that regulate both cell growth and development -are being studied for their effect in enhancing periodontal regeneration of the periodontium
81
Enamel matrix derivative (EMD)
-research into the use of EMD instead of barrier materials to deter the early growth of epithelium next to the root surface, allowing time for growth of the cementum, PDL and alveolar bone
82
Platelet Rich Plasma (PRP)
-being studied for its possible ability to enhance the healing process -blood is drawn from patient through venipuncture -patients blood is mixed with bovine thrombin and calcium to activate platelets -delivered by a syringe to surgical site
83
Platelet rich fibrin
-second generation platelet concentrate -obtained from the patients own blood
84
Bone morphogenetic proteins (BMP)
-studied for its osteoinductive effects that might enhance bone regeneration -however BMP has resulted in ankylosis -much further study of BMP’s is needed
85
Management of the patient during the __ phase following periodontal surgery can be as important to the surgical outcomes as the skill of the surgeon performing the surgery
Healing
86
Suture
-aka stitch is a device place by a surgeon to hold tissues together during healing -many periodontal surgical procedures, such as periodontal flaps, require the placement of sutures
87
Characteristics of suture materials
-must be nontoxic, flexible and strong -should not have wicking effect (wicking effect- allowing bacteria to travel down the suture and contaminate the surgical wounds) Should not place tension on the flap (if the material places tension in the flap, the suture material will pull out of the tissues during healing and fail to stabilize the tissue)
88
Classification of sutures
-multifilament suture- black silk and gut suture; smaller strands braided or twisted together (disadvantage is wicking; can absorb and retain fluid and bacteria) -monofilament- polypropylene or nylon suture; single strand
89
Types of suture material
-non absorbable: suture material that does dissolve in body fluids; must be removed by the clinician -absorbable: designed to dissolve harmlessly in body fluids over time (don’t normally require removal, some absorbable sutures do not dissolve well in saliva)
90
Examples of suture materials: non absorbable
-braided silk -monofilament nylon -expanded polytetrafluoroethylene -braided polyester -polypropylene
91
Examples of suture materials: absorbable
-plain and chromic gut -polyglactin 910 -poliglecaprone 25
92
General indications for common suture techniques
-interrupted suture: closure of vertical incisions, closure of non displaced flaps -sling suture: closure of displaced flaps -continuous sling suture: closure of displaced and nondisplaced flaps
93
Interrupted interdental suture
-used to hold the tissues together during in place after a periodontal flap procedure -a separate suture is placed and tied in each of the interdental sites
94
Steps in interrupted suture
1. A suture is placed through the papilla in the facial aspect 2. The suture is placed through the papilla on the lingual aspect 3. The suture is returned to the facial aspect 4. Knot is tied in the suture on the facial aspect
95
Continuous loop suture
-preferred by many clinicians for suturing flaps -suture material is placed through two interdental papillae and the end of the suture is looped around the tooth to reach the next interdental papillae and so on
96
Sling suture
Used to suspend the tissues around the cervical area of a tooth rather than to tie soft tissue to soft tissue -if a sling is needed on both aspects of a tooth, a separate sling suture is placed on the facial aspect and another sling suture on the lingual aspect
97
Steps in a sling suture
1. A suture is placed through the facial papilla 2. The suture material is looped around the lingual surface of the tooth 3. The suture material continues back to the facial aspect under the contact area and penetrates the facial papilla in the distal aspect of the tooth 4. The suture continues back on the same path and is tied on the surface where it first penetrated the facial papilla
98
General guidelines for suture removal
-remove sutures in a timely manner; non absorbable usually removed after 1 week of healing, most absorbable can be left in place for 1-3 weeks -read the surgical note in the patient chart to learn the number and type of sutures placed -understand the typical sizing system used for periodontal sutures -never allow the knot to be pulled through the tissue -always confirm that all of the sutures have been removed
99
Purpose of periodontal dressings
-periodontal dressing (or perio pack) is a protective material applied over a periodontal surgical wound -used somewhat like a bandage to cover a finger wound -modern periodontal surgical techniques may or may not require a periodontal dressing
100
Steps in proper placement of dressing
1. Dressing is placed into interdental spaces with gentle finger pressure on the facial aspect 2. Dressing is looped around the distal most tooth 3. Dressing is gently pressed into the interdental spaces on the lingual aspect 4. Gentle finger pressure is used to join the dressing in the facial and lingual aspects 5. Dressing can be brushed across an edentulous area 6. Amount of dressing material should be kept to a minimum to avoid contact of the dressing with the teeth in opposite arch
101
Management of perio dressing
-retention is gained by pushing some material into embrassure spaces to lock the dressing around the necks of teeth - less is better. Use just enough to cover the wound -replace every 5-7 days until the wound is healed enough to be exposed -when removing, loosen slightly before pulling
102
Types of periodontal dressing
-chemical cure paste: requires the mixing of paste from two tubes to form a dressing with a putty-like consistency -light-cured paste- a light cured gel that contains a resin
103
Post surgical instructions
-call office immediately with questions or concerns -take medications as prescribed -expect some bleeding and swelling: use an ice pack first 8-10 hours -eat soft food only on day of surgery; no hot beverages on day of surgery, avoid chewing at surgical site -rinse with prescribed mouth rinse starting day after surgery -brush lightly if dressing is placed
104
Restrictions on home self care
-a Chlorhexidine rinse is recommended for use twice daily until the pt can safely resume mechanical self care -areas of the dentition not involved by the surgery may be cleaned with routine self care techniques
105
Resumption of routine patient self care techniques
-following routine flap surgery or gingivectomy the patient usually can resume self care in 10-14 days -following guided tissue regeneration or bone grafting the patient should not resume self care for up to 4-6 weeks
106
Post surgical medications
-if systemic antibiotics are prescribed, it is very important to caution the patient to take ALL of the prescribed -pain medications may be prescribed
107
Post surgical complications
Facial swelling, bleeding, smoking
108
Complications facial swelling
Facial swelling is common Usually is not a sign that healing is compromised Can be minimized by intermittent use of ice packs for the first 8-10 hours
109
Surgical patients should be cautioned not to __ during the healing phase
Smoke
110
Following periodontal flap surgery the patient most often returns for the first post surgical visit in
5-7 days
111
An elevated ___ at the first post surgical visit can indicate a developing infection
Temperature
112
Examination of the surgical site at post surgery appt
Excessive granulation tissue that occasionally forms in the surgical site should be removed with a sharp curette
113
After initial post surgical visit, the pt is reappointed for a second post surgical visit when?
2-3weeks following the surgery

Perio II Test 2 (3 decks)

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