What are the indications for periodontal surgery?
- To improve access for improved periodontal instrumentation
- To reduce pocket depth
- Provide access to perio osseous defects
- Resect or remove tissue
- Regenerate periodontium lost due to disease
- Graft bone or bone-stimulating materials
- Improve appearance of the periodontium
- Enhance prosthetic dentistry
- Place dental implants
Possible contraindications for dental surgery
- Uncontrolled diabetes/hypertension
- Recent cardiovascular event
- Bleeding disorders
- Kidney dialysis
- Radiation to the jaw
- Total non-compliance with self-care
- Pts at high risk for caries
- Pts w/ unrealistic expectations of surgical outcomes
What ar ethe possible outcomes of periodontal surgery?
- Healing by long junctional epithelium: LJE attaches to the tooth along the root surface
- Healing by tissue shrinkage: Recession of gingiva apically
- Healing by regeneration: New bone, CT and cementum
Terminology associated with wound healing
- Repair
- Reattachment
- New attachment
- Regeneration
Terminology associated with degree of wound closure
Primary intention
Secondary intention
Tertiary intention
What is repair?
Healing of a wound by formation of tissues that do not fully restore the original architecture or original function of the body part
- Scar tissue
- Healing by LJE
- No regeneration of new perio tissues
What is reattachment?
Healing of a periodontal wound by reunion of the connective tissue and roots where they were separated by a surgical incision or injury but not disease
What is new attachment?
- The union of a pathologically exposed root w/ connective tissue or epithelium
- Only in area damaged by disease
- Newly attached epithelium and CT
What is regeneration?
- Complete restoration
- Formation of: new cementum, functional PDL and AB
- Possible but not predictable
What is primary intention?
Close approximation of margins
What is secondary intention?
Margins not in close contact:
- granulation tissue followed by epithelial migration over wound
What is tertiary intention?
Left open to clear potential infection
How are periodontal flaps classified?
- Based on AB exposure
- Based on location of flap margin
What are the two classifications of periodontal flaps based on AB exposure?
Full-thickness flap
Partial-thickness flap
What are the classifications of periodontal flaps based on location of flap margin?
Nondisplaced flap (replaced in original position)
Displaced flap:
- Apical
- Coronal
- Lateral
What are the types of incisions?
- Horizontal: crevicular (sulcular) and internal (inverse) bevel
- Vertical: vertical releasing incisions
Types of periodontal surgery
- Flap for access (modified Widman flap)
- Open flap debridement
- Osseous resective surgery
- Apically positioned flap w/ osseous surgery
- Bone replacement grafts
- Guided tissue regeneration
- Perio plastic surgery
- Frenectomy
- Crown lengthening
- Gingivectomy/gingivoplasty
- Laterally positioned flap
- Coronally positioned flap
- Semilunar coronally positioned flap
- Free soft tissue autograft
- Subepithelial CT graft
- Implant surgery
- Perio microsurgery
- Laser surgery
What type of incision would be made for a flap for access (modified widman) for an open flap debridement and what would this be done for?
- Inverse bevel incision to remove pocket epithelium
- Full thickness flap
- Access to root surface (modified widman)
- Access to root surfaces and bone crest (open flap)
- Purpose is to clean the root surfaces, remove granulation tissue and place a healthy CT surface against the clean root surface
What type of incision would be made for an apically positioned flap w/ osseous surgery and what would this be needed for?
Inverse bevel incision to remove pocket epithelium
- Full thickness flap
- Bone defects are reduced or removed, bone recontoured
- Tissue is apically positioned, and particularly w/ apically positioned flap may expose significant root surface
- Ostectomy: removal of supporting bone around teeth
- Osteoplasty: Recountouring of non-supporting bone
What is osteogenesis?
Formation of new bone by viable, living cells contained in the graft material
WHat is osteoinduction?
Molecules contained in the graft material (bone morphogenic poteins (BMPs) have the ability to attract osteoblasts to the site to form new bone
What is osteoconduction?
The graft acts as a scaffold for host bone-forming cells outside the graft to migrate, attach and grow on
What are the 4 types of bone replacement grafts?
- AUTOGRAFTS
- ALLOGRAFTS
- XENOGRAFTS
- ALLOPLASTS
What are autografts?
- From the patient themselves
- Intraoral, hip, chin, skull
