PERIO - perio surgery Flashcards
(140 cards)
1
Q
what is another name for periodontal surgery?
A
mucogingival surgery
2
Q
what BSP guideline step does perio surgery fall under?
A
step 3 - managing non responding sites
3
Q
what does the first step of the BSP guidelines include?
A
implementation of pt motivation strategies
implementation of behaviour changes
control of local risk factors
control of systemic risk factors
PMPR supragingival plaque and calculus
4
Q
at the end of step 1 of the BSP guidelines, when evaluating, describe an engaging pt?
A
OH improvement >50%
plaque levels <20%
bleeding <30%
meeting targets in self care plan
5
Q
at the end of step 1 of the BSP guidelines, when evaluating, describe a non engaging pt?
A
insufficient improvement in OH <50%
plaque levels >20%
bleeding >30%
states preference to palliative approach
6
Q
at the end of step 1, the patient is not engaging, what do you do?
A
repeat step 1
7
Q
what is step 2 in the bsp guidelines?
A
subgingival instrumentation
US or hand instruments
quadrant wise or full mouth
8
Q
describe a stable patient at the end of step 2?
A
no perio pockets >4mm with BOP
no remaining deep sites >6mm
9
Q
describe an unstable patient at the end of step 2?
A
deep sites remain >6mm
BOP in pockets >3mm
10
Q
when is non surgical periodontal therapy predictable successful?
A
good patient compliance/ buy-in
appropriate professional management
11
Q
what is the aim of non-surgical periodontal therapy?
A
control microbial load/ composition
reduce inflammatory cell infiltrate
12
Q
how is step 3 in the bsp guidelines carried out?
A
holistic approach
- focus on residual sites: access, eliminate or regenerate lesions
interventions
- repeated subgingival instrumentation +/- adjunctive antimicrobials
- periodontal surgery (resective, repair, or regenerative) for pockets >6mm
13
Q
what is periodontal surgery?
A
a collection of surgical interventions involving the supporting tissues of the teeth
14
Q
what are the 3 types of periodontal surgery?
A
resective
reparative
regenerative
15
Q
what are the indications for periodontal surgery?
A
pocket reduction
improvement of gingival contour
improvement of access for OH measures
access to inaccessible, non responding sites for diagnosis and management
regain lost clinical attachment
16
Q
in step 3, when would periodontal surgery as an intervention be appropriate?
A
residual deep sites (>6mm)
infrabony defects > 3mm
furcation involvement (class II)
17
Q
when should periodontal surgery not be performed? and why
A
if self-performed OH insufficient
plaque score <20-25% consistently associated with better surgical outcomes
18
Q
who can perform periodontal surgery?
A
dentists with additional specific training
19
Q
what are the absolute contraindications for perio surgery?
A
bleeding conditions (INR >3-3.5, low platelets)
recent MI or stroke (<6 months)
recent vascular prosthesis placement or transplant (<6-12 months)
significant immunosuppression
active cancer therapy
IV bisphosphonate treatment?
20
Q
what are the relative contraindications for perio surgery?
A
patient wound healing potential (genetic)
social history - smoking
21
Q
what is the most important environmental risk factor in periodontitis?
A
smoking
22
Q
why is smoking a risk factor for periodontitis?
A
impairs wound healing - less attachment gain and PD reduction after surgery in smokers
23
Q
what are the soft tissue considerations that must be made before perio surgery?
A
phenotype
interdental papilla
volume of keratinised, attached gingival tissue
pocket depth
24
Q
what are the hard tissue considerations that must be made before perio surgery?
A
defect angulation (<25 degree better than >37 degrees)
number of bony walls of infrabony defect
depth of defect (>3mm)
25
what is the case selection criteria at DDH for perio surgery?
- NSPT and RSD under LA at max potential carried out
- minimal supra/ subgingival calculus deposits present
- compliance with smoking cessation
- good plaque control demonstrated by PFS >80%
- presence of PPD >6mm + BOP +/- suppuration
- no/minimal mobility, or able to splint grade I/II mobility teeth
- pre-operative radiograph clearly showing bony morphology
26
what do you consent the patient for pre perio surgery?
pain, swelling, bleeding, bruising, post-op infection, recession, scarring
transient mobility of teeth, dentinal sensitivity, failure of procedure, use of biomaterials
27
what pre-operative advice is given to the patient for perio surgery?
wear loose clothing, especially layers
unless having GA or sedation, have a good breakfast/ lunch
take all regular medication unless told otherwise
if concerned about getting home, have someone with you
long procedure - put enough money in parking meter
can change mind about going ahead if they wish - even if signed consent forms
28
what are the main principles of flap design for perio surgery?
keep flaps as minimal as possible
every design is unique to the clinical situation
careful handling of tissues at all times
measure interdental papilla to determine handling
29
what type of relieving incisions do perio surgeries tend to avoid?
vertical relieving incisions
they use horizontal relieving incisions instead
30
if a relieving incision is required for perio surgery, what are the principles?
start at 90 degree to gingival margin
vertical direction
extend just past mucogingival junction
avoid cutting over bulbosity such as canine eminence
31
describe the haemostasis involved in perio surgery?
minimal blood loss during surgery
most have primary closure - suturing applies small amount of pressure and wound stability
32
what materials have been used for perio surgery sutures?
traditionally - black silk
present day - synthetic mono-filament suture
33
what are the properties of the synthetic mono-filament sutures used for perio surgery?
resorbable or non-resorbable
non-wicking
low bacterial colonisation
can be difficult to tie as 'springy'
34
what advice do you tell the pt whilst sutures are present after perio surgery?
no brushing in the region
use chlorhexidine mouthwash to reduce plaque formation
35
what are the post op instructions for perio surgery?
take regular analgesia - paracetamol and ibuprofen
use ice pack for first 12 hours to reduce swelling
avoid surgical site when brushing until sutures removed - use CHX mouthwash
suture removal at 5-7 days - longer grafting surgery to ensure stability
no probing or instrumentation of site for 3 months (9-12 months if biomaterials used)
36
what are the available types of resective perio surgery options?
gingivectomy
root resection
37
what are the available types of repair/ reattachment perio surgery available?
OFD (open flap debridement)
MWF (modified windman flap)
38
describe resective perio surgery?
pocket elimination procedures which establish a morphologically normal attachment but with apical displacement of the dento-gingival complex; recession (oldest technique)
39
what are examples of resective perio surgery?
gingivectomy
apically repositioned flaps
root resection
osseous reduction
distal wedge incision
40
what is gingival overgrowth and what are its causes?
abnormal overgrowth of gingival tissues
multiple causes:
- inflammatory (plaque)
- drug-induced
- related to systemic conditions
can be localised or generalised
41
what is a gingivectomy?
management of gingival overgrowth by resection/ recontouring the gingivae
42
describe the healing process following a gingivectomy?
a raw wound is left
- healing by secondary intention (0.5mm re-epithelialisation per day)
- periodontal dressing pack (coe-pack) is used to cover for 7-14days
*very painful for some patients
43
indications for gingivectomy?
gingival enlargement/ overgrowth persists despite non-surgical care
supra-bony periodontal pocketing
trauma caused by gingival overgrowth
interference with speech or aesthetics
excellent at home care
wide zone of attached gingivae
44
contraindications for gingivectomy?
narrow attached gingivae
planned osseous recontouring
infra-bony periodontal pockets
medical contraindications (especially bleeding disorders)
45
what would be your non surgical management of gingival overgrowth?
OHI - single tufted brush angulated into gingival margin
eliminate drug
46
when would scrubbing the gums be fine to do?
with a thick gingival phenotype
47
advantages of a gingivectomy?
simple
good vision
can achieve ideal soft tissue morphology
48
disadvantages of a gingivectomy?
limited indications
heal by secondary intention (painful)
risk bone exposure
wastes attached gingivae
excessive recession in pd disease
49
when could you use electrosurgery for gingival recontouring?
for smaller areas of recontouring
50
what are the advantages of electrosurgery for gingival recontouring?
cauterises as you go - less bleeding risk
51
what is a contraindication of electrosurgery for gingival recontouring?
contraindication - pacemakers
52
describe surgical crown lengthening?
a surgical procedure which apically repositions the soft tissue and alveolar bone to expose more tooth structure, and increase the length of the clinical crown
- normally a resective procedure depending on amount of attached gingiva available
53
what is the aim of SCL?
surgically maintain biologic width whilst apically repositioning the gingival level
54
indications for SCL?
toothwear
poor gingival aesthetics
restoration of subgingival lesions
replacement of crowns with deep margins
management of coronal third fractures
management of infringement of biologic width
develop ferrule for pulpless teeth restored with posts
55
contraindications for SCL?
poor plaque control
poor compliance
non-functional teeth or teeth or poor strategic value
periodontal destruction
endodontic compromise
medical history considerations
56
what are the complications for SCL?
poor aesthetics due to black triangles
transient mobility of the teeth
root sensitivity
rebound of marginal tissues
root resorption
57
after SCL, how long do you wait for the gingival margin to re-establish?
2 months
58
describe repair/ reattachment surgery?
pocket reduction surgery, but without replication of the normal attachment - healing is by formation of a long junctional epithelium
normally managed with partially reflected flap
referred to as open flap debridement
59
describe a partially reflected flap for repair/ reattachment (OFD) surgery?
crevicular incision without relieving incisions
60
what are the aims of OFD?
access for root surface debridement under direct vision
assessment of root surface (grooves, fractures, enamel pearls, iatrogenic damage)
61
indications for OFD?
excellent maintenance
site >6mm with BOP or suppuration
horizontal bone loss pattern
vertical defect <3mm
isolated periodontal pockets remain
62
contraindications for OFD?
aesthetic region
need for graft/ membrane
complex furcation/ bone defects
63
advantages of OFD?
healing by primary intention
minimal crestal bone resorption
effective in pockets 6-7mm
64
disadvantages of OFD?
can be unpredictable - dependant on healing potential
no new true attachment - healing by long junctional epithelium
risk of recession
interdental craters
65
describe regenerative surgery?
recreation of the complete attachment apparatus of bone / cementum / functionally orientated periodontal ligament against exposed root surface
66
what is repair vs regeneration?
repair
- long junctional epithelium
- crestal remodelling
regeneration
- new cementum
- new PDL
- new alveolar bone
67
what are the aims of regenerative surgery?
1. enhance access for plaque control and 2. maintenance
2. regenerate defect
3. remove factors associated with disease progression
68
how does regenerative surgery regenerate defect?
gain clinical attachment
minimise soft tissue recession
increase bone volume
69
in regenerative surgery, what factors are removed which are associated with disease progression?
- residual deep sites
- infrabony defects
- furcation involvement
- bleeding on probing
70
what factors are needed for regeneration?
space provision
PDL cells
wound stability
71
in regeneration, what cells are available for healing? and what is their outcome after repopulating the root
epithelial cells = long junction epithelium
gingival connective tissue cells = CT attachment or root resorption
bone cells = root resorption and ankylosis
mesenchymal cells from PDL = regeneration
72
what is the case selection criteria for regeneration?
infrabony defect associated with perio pocket of >6mm (depth of vertical defect >3mm)
class II furcation in mandibular molars
single class II furcation in maxillary molars
73
what factors improve the prognosis for good regeneration?
narrow defect <25 degrees ideally
higher number of bony walls = better prognosis
74
what are the different regenerative techniques?
guided tissue regeneration
bone graft materials
enamel matric proteins (EMD)
combinations of above methods:
- GTR and bone
- EMD and bone
75
what is guided tissue regeneration?
use of mechanical barrier (membrane) to selectively enhance the establishment of PDL and peri-vascular cells in osseous defects to initiate periodontal regeneration
76
what teeth defects is guided tissue regeneration used for?
teeth with periodontal bone loss and intrabony defects
77
what are the aims of guided tissue regeneration?
stop rapid downgrowth of epithelial cells
create space for pluripotent cells from PDL to access root surface
improve local anatomy, function and prognosis of teeth
78
what is the role of the membrane in GTR?
act as a barrier to prevent cells apart from PDL migrating into site
- provide 'space' for regeneration
- promotes 'PDL cells' for regeneration
79
what are the types of membranes available for GTR?
- resorbable (less predictable duration/ stability) i.e., collagen
- non-resorbable (require second surgery to remove)
80
what are the various sources bone grafts and substitutes may come from?
autograft: from a donor site of the same person
allograft: from a different person, but human bone
xenograft: from an animal source
alloplast: synthetic material
81
how do bone grafts work in regeneration?
they support flap, providing 'space' and 'stability' for regeneration
82
describe the terms osteogenic, osteoinductive, and osteoconductive?
osteogenic: can create more bone
osteoinductive: communicate with other parts of bone to regenerate
osteoconductive: relies on external factors
83
what does emdogain do?
mimics the development of tooth supporting apparatus during tooth formation
accelerates early wound healing
has direct effects on cellular behaviour to promote regeneration (PDL and alveolar bone rely on cementum)
84
what is the effect of EMD on epithelial cells?
decreased cell proliferation and migration
85
what is the effect on EMD on gingival fibroblasts?
reduced cell migration
86
what is the effect of EMD on bone?
increased cell proliferation + migration, support of bone formation but not osteoinductive
87
what is the effect of EMD on PDL fibroblasts?
increased cell proliferation, migration and attachment
88
what is the effect of EMD on cementoblasts?
increased in vivo mineralisation
89
what type of materials are used in DDH for bone grafts?
xenografts
90
what are the advantages of regeneration?
successful in tx of deep sites of 6mm or greater
healing by primary intention
improvement in volume of supporting tissues of tooth
less recession for pt
91
what are the disadvantages of regeneration?
technically challenging to get good outcome
can be unacceptable for some patients depending on materials used
expensive materials
92
what are the 7 options for furcation involved teeth?
1. non surgical perio therapy
2. odontoplasty
3. open flap debridement
4. tunnelling procedures
5. root resection or separation
6. regenerative procedures
7. xla
93
what types of furcation's is non surgical perio therapy successful for managing?
grade 1 (USS more effecting than hand scaling)
94
what is an odontoplasty?
drill the root surface to change its shape so it doesnt gather as much plaque
involves raising a flap buccal and lingual
95
what are the risks of odontoplasty?
can result in hypersensitivity and cariesz
96
what type of furcations can odontoplasty aid in treating?
grade 1 and shallow grade 2
97
what type of furcations may OFD treat?
grade 2 furcations
- shallow
- mesial/ distal bone below entrance of furcation
- single in maxilla
98
why would you use open flap debridement to treat furcation?
to access and clean with direct vision
99
what is the most predictable regenerative procedure for furcations?
GTF with bone graft
100
when would regeneration not be effective for furcations?
- entrance of furcation below the height of mesial/ distal bone
- multiple class II defects in maxilla
- class III furcations
101
what is root resection?
removal of one root of a multi-rooted tooth where there is uneven bone loss
can be termed 'hemisection' in mandibular molars (includes removal of portion of the crown)
102
what needs to be done to a tooth prior to root resection?
RCT
103
what roots have better success with root resection?
MB or DB roots of upper molars
mesial roots of lower molars
104
indications for root resection?
class 2/3 furcation involvement
severe bone loss on 1 or more roots
root fracture/ perforation/ deep caries
failed endo tx or inoperable canals
105
contraindications for root resection?
inadequate bone support on remaining roots
unfavourable anatomy
- fused roots
- long root trunk
significant discrepancies in bone height
remaining roots not restorable
106
what is a treatment option for extensive furcation where bone loss around both roots is similar?
root separation, restore each as a single tooth - allows to floss in between
107
when would you perform tunnel preparation?
mandibular molars with deep degree 3 and 3 furcations
- used to improve ability for oral hygiene
108
state all the treatment options for degree 1 furcation?
NSPT
109
state al tx options for degree 2 furcations?
resective therapy
- apically repositioned flap
- tunnel
- root amputation/ hemisection
regenerative therapy
- graft + GTR
- biologics + graft
- biologics + graft + GTR
110
state all available tx for degree 3 furcations?
resective therapy
- apically repositioned flap
- tunnel
- root amputation/ hemisection
xla
111
what is gingival recession?
location of the marginal tissue apical to the cemento-enamel junction with exposure of the root surface
a hard tissue dehiscence must be present
112
what are the possible aetiological factors of recession?
traumatic
- toothbrushing, partial dentures, lip/ tongue piercing, self-inflicted
traumatic overbite
periodontal disease
poor restorative margins
- plaque retention
- encroach on biologic width
113
what factors are related to increased risk of recession?
high muscle attachment/ frenal pull
thin tissue phenotype
alveolar dehiscence
teeth outside alveolar bone after ortho tx (arch expansion, proclination of incisors)
lack of keratinised tissue
114
what is the non-surgical intervention for management of recession?
monitoring and prevention (measure and take pics!!)
composite restoration (can gather plaque and drive recession further)
gingival prosthesis
ortho?
115
what is the surgical intervention for management of recession?
frenectomy
grafting surgery
- pedicle flaps
- gingival grafts
- connective tissue grafts
116
what OHI can be given for recession?
single tufted brush with flicking motion toward the crown
daily
117
indications for surgical management of recession?
prevention of continued recession
improve ability to perform OH measures
aesthetic concern
sensitivity
root caries
118
contraindications for surgical management of recession?
poorly controlled diabetes
bleeding disorders
smoking
poor OH
active perio disease
previous failed procedures
self-inflicted injuries
119
what is a frenectomy?
removal of local muscle insertion - making a nick across the frenum
= no muscle pull on tissue
- stabilises tissue and improved access for OH
120
indications for frenectomy?
unstable local tissue
- movement
- blanching on retraction
blocking access for OH
non-recession indications
- midline diastema
- shallow vestibule for prosthesis
121
contraindications for frenectomy?
medical/ bleeding disorders
scar formation will make further procedures more challenging (consider internal frenectomy)
122
why do we graft for recession?
connective tissue determined overlying epithelial characteristics
- change from thin to thick phenotype
123
aims for grafting surgery for recession?
improve/ create band of keratinised, attached gingiva
avoid scarring
optimal tissue blend/ colour match
improve access for OH
100% root coverage
124
list the features of pedicle flap?
local tissue maintaining own blood supply
single site surgery
surgery limited by local anatomy
125
list the features of free grafts for recession?
material from distant donor site
2 site surgery
larger quantity of CT
more technically demanding
no direct blood supply so risk graft can fail
126
what is a pedicle flap?
moving adjacent attached gingivae to cover a region of recession using a split thickness flap
can be laterally repositioned or double papilla
127
indications for pedicle flap for recession?
narrow defect on single tooth
adjacent teeth with thick phenotype or edentulous area
deep vestibule
128
contraindcations for pedicle flap for recession?
deep perio pocketing
loss of ID tissue
large root prominences
lack of relevant local anatomy
deep root abrasions
129
advantages of pedicle flap for recession?
1 site surgery
good vascularity to pedicle flap
root coverage possible
130
disadvantages of pedicle flap for recession?
limited by amount of adjacent keratinised, attached gingivae
risk of recession at donor site
risk of dehiscence at donor site
limited to a single tooth
not as likely to gain root coverage
131
what is a free gingival graft?
graft from palate formed of epithelium and small amount of underlying connective tissue is placed into a region with localised recession
132
what is the aim of a free gingival graft?
- to create a band of keratinised mucosa
- remove frenal attachments
- prepare site for second procedure to increase root coverage
133
indications for free gingival graft?
discomfort during OH measures
ongoing local inflammation
lack of keratinised tissue in regions of recession defect
prevention of further recession
insufficient local keratinised tissue for pedicle flap
134
contraindications for free gingival graft?
aesthetic region
aim for complete root coverage
donor site tissue poor
medical contraindications
135
advantages relatively simple surgery?
relatively simple surgery
increases vestibular depth
136
disadvantages of free gingival graft?
second surgical site
palatal wound heals by 2ndry intention
unaesthetic
- mismatch in colour, texture, and thickness
- misalignment of mucogingival junction
137
what is connective tissue grafting?
surgical procedure where a split thickness flap is raised, released and then replaced in a more coronal position
138
when may you want to combine a connective tissue graft with a split thickness flap?
- limited gingivae apical to recession
- shallow sulcus
- buccally placed root
- interdental CAL
139
advantages of connective tissue grafting?
possible for 1 site surgery
microsurgical technique (better healing)
excellent colour match
better vascularisation of flap (excellent graft survival and wound stability)
best root coverage outcomes with CT graft
140
disadvantages of connective tissue grafting?
often benefits from CT graft (secondary surgery site)
technically demanding (thin phenotype, graft harvesting)
