1
Q
Fromatechnicalstandpoint,itisimpossible to —— a palatal flap.
A
apically position
2
Q
Thinned palatal flap
A
Cut off gingiva above bone, scallop out gingiva near bone, close.
3
Q
A distal wedge is a periodontal surgical procedure for removing excessive soft tissue
A
distal to a terminal tooth
4
Q
• A term “wedge” refers to a process for —— by removal of a
A
internal thinning
block of tissue
5
Q
Typical sites for wedges
\
A
- Maxillary tuberosity
* Mandibular retromolar area • Edentulous ridges
6
Q
Distal wedge advantages
• Provide access to ———
• Allow internal thinning of ———
• It is possible to obtain ——— of the wound after reduction of bulky tissue
A
bone and furcations
bulky tissue
primary closure
7
Q
Distal wedge Triangular:
A
least difficult, least invasive
• Square: provides best access
• Linear: most effective at preserving keratinized gingiva
8
Q
Distal wedge
• Square:
A
provides best access
9
Q
Distal wedge
• Linear:
A
most effective at preserving keratinized gingiva
10
Q
Conservative Flap Designs
• Intended to minimize —–
• Good for ——–
A
recession
maxillary anterior teeth
11
Q
Conservative flap designs
A
-Modified Widman Flap
– Flap curettage (open flap debridement
12
Q
Modified Widman Flap
A
- A scalloped, replaced mucoperiosteal flap accomplished with an internal bevel incision
- Provides access for root planing
- Conservative design permits primary closure of the flap
13
Q
modified Widman flap is elevated only
A
2 to 3 mm apical to the alveolar crest
14
Q
With conservative flaps, there is little or no ——-. The flap is adapted to obtain primary closure
A
bone resection
15
Q
Interrupted sutures
A
Simple loop modification Figure 8 modification
16
Q
Sling sutures
A
Single sling suture
Continuous sling suture
17
Q
Sutures should be inserted through the ——– first
A
more mobile flap
18
Q
Sutures should be placed no closer than —– mm from the edge of the flap
A
2-3
19
Q
In the interdental papilla, should enter and exit the tissue at a point located below the line that forms the
A
base of the triangle of the interdental papilla
20
Q
Periodontal dressings
A
- To protect the wound postsurgically
- For patient comfort
- To obtain and maintain a close adaptation of the mucosal flaps to the underlying bone
21
Q
Post operative plaque control
A
- 0.12% chlorhexidine (Peridex, Periogard)
22
Q
Maintain good postsurgical wound stability
A
- adequate suturing technique
- protection of wound from mechanical trauma during healing
23
Q
Suture removal
A
- Use mouthrinse to clean the wound
- Cut the suture close to the tissue as possible to avoid dragging bacteria into the wound
- When removing continuous sutures, each section should be cut and pulled out individually
24
Q
Annual rate of Attachment Loss = 0
A
.22 mm
25
SURGICAL THERAPY
| • ADVANTAGES
– Direct vision while working on root surface – Easier manipulation/removal of tissues
26
Surgery • DISADVANTAGES –
Morbidity
| – Esthetic compromises – Cost (?)
27
Gingivectomy
– External bevel
| – Exposed tissue during healing
28
Flap
– Internally beveled
– Provides access to bone
– Tissues not exposed during healing
29
Perio flaps contexts for use
Contexts for use:
– Resection (removal of hard or soft tissue) – Conservative (for access only)
– Regeneration (new periodontal support)
• Flaps preserve keratinized gingiva • Flaps can be closed by suturing
30
Elevation past the ------- will fully reflect the flap
mucogingival junction
31
Elevation is very difficult if the primary incision does not extend to the
bone
32
• Exostoses require special attention to
direction of elevation
33
Partial-thickness flaps
* Also known as “split-thickness flaps”
* Periosteum remains on bone, protecting it from resorption
* Requires sharp dissection
* Technique is relatively difficult
* Facilitates an increase in the width of keratinized gingiva
34
Vertical incisions
• Provide access without -------
• Help with -------
• Must be made -------- near line angles (never over a root prominence)
• Should ------- apically for vascular integrity
flap extension to adjacent areas
flap positioning
interproximally
diverge
35
```
Flap positioning
• ---------- positioned
– For regeneration or root coverage
• Replaced
– For -------- (minimal recession)
• Apically positioned
– For -------
```
Coronally
conservative flaps
pocket elimination or crown lengthening
36
Gingivectomy Indications
-hyperplastic tissue -suprabony pockets
37
Gingivectomy Contraindications
-osseous involvement -mucogingival involvement -furcation involvement
38
Gingivoplasty
-reshaping of the gingiva -recreating physiological contours
39
------ are typically used for gingivoplasty
Diamond burs
40
Phases of Postsurgical Healing
* Inflammation
* Fibroblastic granulation
* Matrix formation and remodeling
41
Healing immediate response
* Formationofbloodclotbetweenmarginsof wound and between flap and tooth or bone
* Clotincludesfibrin,neutrophils,platelets, red cells, cell debris, and capillaries at the edge of the wound
42
Healing: first 24 hours
* Neutrophils infiltrate the connective tissue
| * Epithelium begins to migrate from the wound margins
43
Healing: 1-3 days
* Space between the flap and tooth or bone narrows
| * Epithelial cells migrate over the border of the flap, contacting the tooth
44
Healing: 3-7 days
* Epithelialmigrationcontinues
* Neutrophilsarereplacedbymacrophages,which eliminate dead/damaged cells
* Bloodclotisreplacedbygranulationtissue
* Revascularizationbegins
45
Healing: 1 week
* Epithelium attaches to the root
* Blood clot is replaced by granulation tissue derived from gingival connective tissue, bone marrow and/or periodontal ligament
46
Healing: 2 weeks
* Collagen fibers are oriented parallel to tooth surface (nonfunctional)
* Union of flap to tooth is weak • Collagen fibers are immature
47
Healing: 1 month
* Inflammatory cells are mostly gone
* Fibroblasts proliferate, synthesize collagen
* Revascularization process regresses
* Gingival crevice is fully epithelialized
* Epithelial attachment is well defined
* Functional arrangement of supracrestal fibers
48
Healing: 2 months
* Collagenhasremodeledandcross-linked
| * Thewoundhasregainedmostofitsoriginal tensile strength
49
• When the bone is exposed by a full thickness flap, superficial bone necrosis occurs after
1 to 3 days
50
• Typically, ---- of bone is lost when bone is exposed to the oral environment
1 mm
51
Healing by secondary intention exhibits:
* A more vigorous inflammatory response
* Formation of a larger volume of granulation tissue to fill the defect
* More pronounced wound contraction during healing
52
The blood clot is a major initial source of
growth factors and cytokines.
53
PDGF:
induces fibroblast and macrophage migration, fibroblast proliferation and macrophage activation
54
• EGF:
induces epithelial proliferation
55
• TGF-ß:
induces migration of inflammatory cells and proliferation of fibroblasts
56
Growth factors released from the blood clot
PDGF
EDF
TGF-beta
57
Factors released by fibroblasts and macrophages
TNF, IL1beta
58
• TNF: activates
endothelium, induces neutrophil migration
59
• IL-1ß: activates
endothelium, induces neutrophil migration
60
• Repair:
damaged tissues are replaced by tissues that don’t duplicate the function or architecture or the original tissues.
61
• Regeneration:
damaged tissues are replaced by tissues that duplicate the structure and function of the original tissues.
62
• Thin bone =
horizontal bone loss •
63
Thick bone =
vertical bone loss
64
• Bone formation always occurs in areas of bone
resorption
65
Increased resorption in the presence of
normal or increased bone formation
66
• Decreased formation in the presence of
normal resorption.
67
• Increased resorption combined with
decreased formation.
68
Central buttressing bone
Central –occurs within the jaw
69
Peripheral buttressing bone
Peripheral- occurs on the external surface of the jaw
• Creates a deformity in the overlying mucosa • Looks like a ledge
• Severe plaque trap
70
Horizontal bone loss •
Suprabonypocket
71
• Angular bone loss (vertical, infrabony, angular) •
Infrabonypocket
72
Osseous surgery
Full thickness flap, Apically positioned flap
73
• Regenerative surgery
Full thickness flap, Coronally positioned flap
74
Physiologic architecture
When the crest of the interdental gingiva or bone is located coronal to its midfacial or midlingual margins
75
Reverse architecture
When the crest of the interdental bone or gingiva is located apical to its mid- facial and mid-lingual margins
76
Ostectomy-
Removal of bone that is attached to the tooth
77
Ostectomy
| Indications
* Sufficient remaining bone for establishing physiologic contours without attachment compromise
* No esthetic or anatomic limitations
* Elimination of interdental craters
* Intrabony defects not amenable to regeneration
* Horizontal bone loss with irregular marginal bone height
* moderate to advanced furcation involvement
* Hemisepta
78
Ostectomy
| Contraindications
* Insufficient remaining attachment
* Unfavourably affect adjacent teeth
* Anatomic limitations
* Esthetic limitations
* Effective alternative treatment
79
Ostectomy
| Advantages
* Predictable pocket elimination
* Physiologic gingival and osseous architecture
* Favorable prosthetic environment
80
Ostectomy
| Disadvantages
* Loss of attachment
* Esthetic compromise
* Increased root sensitivity
81
Osteoplasty
Reshaping of the alveolar process to achieve a more physiologic form without removing alveolar bone proper
82
Osteoplasty
| Indications
* Tori reduction
* Intrabony defects adjacent to edentulous ridges
* Incipient furcations
* Reduction of thick heavy ledges or exostoses
* Shallow osseous craters
83
Tissue regeneration in periodontics
* Bone grafts
| * Guided tissue regeneration
84
Guided tissue regeneration (GTR)- Definition
• Procedures allowing the repopulation of a periodontal defect by cells capable of forming new connective tissue attachment and alveolar bone.
85
Materials used in GTR
| • 1st:Non-Resorbable –
ePTFE
86
• 2nd:Resorbable
– Cross-linked collagen membranes
– Calcium sulfate
– Poly-lactic/poly galactic acid (PLA/PGA) – Doxycycline 4%
87
• 3rd: Stem cells,
functionally graded membranes
88
e-PTFE
• Expanded Poly Tetra Fluoro Ethylene
• Non-resorbable
• Second stage surgical procedure required
• Remove4-6weekspostop – Use small incision
– Do not disturb tissue
– Cover new tissue with flap
89
PLA/PGA
– Polylactic acid + citric acid ester – Degradation: 4-6 weeks
– One-stage surgery
90
Collagen
– Cross linked
| – Adding zinc prevents breakdown of collagen – Bovine or porcine source
91
Osteogenesis –
Viable cells
92
• Osteoinduction
– Uncommitted CT cells induced
93
• Osteoconduction
– Non viable scaffold
94
Autogenous grafts
| – Advantages
• ‘Gold standard’-predictable results- Marx 1994 • Osteogenic
95
Autogenous grafts
| – Disadvantages
• Secondsurgicalsite
• Insufficient material
• Membranousbone(IO)vascularizesfasterthanendochondral(EO)
-Kusiak 1985
• IO bone resorbs slower than EO - Smith 1974, Zins 1983
96
Allografts
```
Advantages
– Availability
– No donor site
– Reduced surgical time – Fewer complications
Disadvantages
– Antigenicity
– Longer healing – Less volume
```
97
Alloplasts and xenografts
* Hydroxyapatite
* Bovinederivedanorganicbonematrix
* Tricalciumphosphate
* Syntheticbonematerial(eg.Osteogen)
* Coralline
* Hard tissue replacement polymer
* Bioactiveglass
98
* Enamel matrix proteins
| * rhBMP -recombinant human bone morphogenetic protein
Biological mediators
99
Root Trunk
| Represents the
undivided region of the root.
| The height of the root trunk is the distance between the CEJ and the separation line between two root cone
100
Fornix:
the roof of the furcation
101
Mand molars
100%,99% mesial and distal root depressions/concavities
102
Cervical Enamel Projections
• 13% of molars have CEPs
• May favor the onset of periodontal lesions in the affected furcation
• Incidence of enamel pearls:
1.1% - 9.7%
• Maxillary 2nd molar found near the CEJ extending into molar bifurcations
103
Glickman
| Class 1:
early, catch in the probe, NO radioluscency
104
Glickman
| • Class 2:
varies from catch to deep penetration, radiographically visible, cul-de- sac or ‘blind alley’
105
Glickman
| • Class 3:
through and through
106
Glickman
| • Class 4:
clinically visible
107
Pulpal pathosis may some times cause a lesion in the
periodontal tissues of the furcation
108
Trauma from occlusion may cause inflammation and tissue destruction within the ---- area of a multirooted tooth
interradicular
109
Osseous Surgery
| • Most effective in grade ----- furcation
II
110
Osteoplasty and ostectomy techniques
• Remove the lip of defect to reduce ------
• Bone ramps into the ------- to enhance plaque control
• Reduce --------
horizontal depth
furcation
probing depths
111
Root Resection done for
grade II, III
112
Root Resection
| Contraindications
```
Inadequate bone support
• Fused roots
• Inoperable
endodontically
• Patient considerations
```
113
Sequence of treatment at RSR
* Endodontic treatment
* Provisional restoration
* RSR
* Periodontal surgery
* Final prosthetic restoration
114
Hemisection
* Mandibular molars
* Grade III furcation
* Need widely separated roots
* Soft tissue positioned below level of pulp chamber
115
Tunneling
* Grade III furcation
* Permits plaque removal
* Root caries (4% stannous fluoride)
* 25% failure rate at 5 years
* Recurrent periodontitis
116
Guided tissue regen for furcation defects - only effective with degree
II
117
Periodontal problem zones with fixed replacements
1- Supragingival crown margins (if possible) with precise marginal adaptation 2- Open interdental spaces, crown contour follows natural tooth contour
3- Point- or line-shape contact of pontic with tissue
4- Occlusion, articulation
118
All subgingival margins should be placed within ------ mm apical to the free gingival margin whenever possible
1 to 2
119
Avoid -------------- cantileveredpontic
distally extending
120
Smoking • Causes
peripheral vasoconstriction— Decreases tissue perfusion
121
Restorative perio indications
INDICATIONS:
• Pocketsadjacenttoedentulousregions...
- To establish a healthy gingival sulcus
- To eliminate extraneous mucosal tissue to permit adequate vertical space for the replacements
-To provide a firm, healthy mucosal base for placement of saddles or pontics
122
• Esthetic Crown lengthening:
Excessive gingival display or lack of gingival line symmetry
123
• Functional Crown Lengthening:
Exposure of sound tooth structure for restoration
124
Crown Lengthening to Treat Excessive Gingival Display
| • Indicated if not
enough of the anatomic crown of the tooth is exposed (altered passive eruption)
125
Crown Lengthening to Treat Excessive Gingival Display
• Contra-indicated if problem is
hypermobile lip or skeletal problem (vertical maxillary excess)
126
Dentogingival complex (DGC):
* gingival sulcus
| * epithelial attachment (junctional epithelium) • connective tissue attachment
127
From sound tooth structure to alveolar crest: (allowance to drop margin during prep):
– Textbook: general rule- at least 4 mm
| – Others state from at least 3 mm to as much as 5.25 mm
128
External Bevel
– Leaves gingiva as an open wound that must heal by secondary intention (granulate in)
129
External Bevel
– Indications:
* Adequate keratinized tissue
| * adequate biologic width after surgery
130
External Bevel
| – Contraindications:
• Inadequate keratinized tissue • Biologic width invasion
131
Electro-cautery (ElectroSurg)
• Limited to cauterizing soft tissue that interferes with impression taking
• Contraindicated if encroaches on biologic width: risk of
bone necrosis
132
Apically Positioned Flap without osseous resection
– Preserves -------
– However tissues may --------
keratinized tissue
rebound
133
Two options for lengthening clinical crown with osseous surgery:
– Submarginal (scalloped) incisions- if adequate keratinized tissue
– Sulcular incisions and apical positioning- if limited keratinized tissue
134
Management of mucogingival
| problems
```
• Lackofkeratinizedand/orattachedgingiva - abutment teeth
- edentulous site
• Shallowvestibulardepth
- for partial removable denture
- for total removable denture
```
135
If correct procedure for crown lengthening was done, wait at least
6 weeks
136
Ridge Augmentation Procedures
| INDICATIONS:
• Tocorrecttheexcessivelossofalveolarbonethat occurs due to:
- advanced periodontal disease, - periapical lesion,
- traumatic tooth extractions,
- external trauma
137
Ridge Augmentation Procedures
* Placementofathickmucosalautograftobtainedfrom palate or the tuberosity
* Placementofaconnectivetissuegraftbeneathafullor partial thickness flap or in a “tunnel” created by a lateral incision
* Therolltechniquewhichconsistsofelevatingaflapover the deformed area, de-epithelizing its terminal half, and rolling it under the flap
* Guidedboneregeneration
138
GTR materials 3 classes
resorbable, nonresorbable, stem cells
139
Layer facing bone - SL - bone side
, hydroxyapatite encorporated
140
Layer facing bone - facing epithelium
metronidazole incorporated to prevent infection
141
Core layer
protein in the middle of surface layers
142
Space maintenance
Reinforces the membrane, create a scaffold with tentings crews, fillers (bone, bone subs, collagen)
143
Mechs of graft integration
oteogenesis
Osteoinductive
osteoconductive
144
Osteogenesis –
Viable cells
145
• Osteoinduction
| –
Uncommitted CT cells induced
146
• Osteoconduction
– Non viable scaffold
147
Autograft
conductive, inductive, genic
148
Allograft
conductive, maybe inductive, not genic
149
Alloplast/xenograft (bovine bone, synthetic stuff)
conductive, not inductive, not genic
150
Allografts problems
antigenicity, longer healing, less volume.
151
----- return at best for grafts (especially for allografts)
70%
152
Allograft benefits:
Availability
– No donor site
– Reduced surgical time – Fewer complications
153
Biological mediators in grafts
* Enamel matrix proteins
| * rhBMP -recombinant human bone morphogenetic protein
154
Easiest root to remove
DB root
Perio 2 exam 2
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