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What movement causes pocket formation?
- coronal movement of gingival margin
- apical movement of junctional epithelium
- destruction of CT
- bone loss
- plaque, inflammation
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What are approximate depths of sulcus subgingival penetration of traditional means of oral hygeine?
- .5-.9mm manual
- 1.3-1.7mm power driven
- .2mm mouthwash
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What are the modes of pocket elimination?
- repair: adapt ging to tooth surface w/ LONG JUNCTIONAL EPITHELIUM via SR/P, flap surgery
- resection: eliminate pocket wall->gingival recession via gingivectomy, apical flap
- regeneration
- extraction
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What are the advantages of SR/P?
- predictable up to 5mm depth
- little recession
- limitations: posterior (access, furcations), deep or vertical defect pockets
- why: OHI improvement, definitive therapy, facilitates surgery (tissue mgt, hemostasis, anesthetic)
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When should you re-evaluate results of S/RP?
3 weeks, assess OH, pocket depth
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What are advantages for flap surgery for access?
- predictable for >6mm
- posterior access
- least aggressive surgery
- limitations: recession
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What are advantages of gingivectomy?
- simple, quick easy, good for gingival enlargement(pseudo-pockets)
- limitations: no access to bone, healing 2ndry intention, no conservation of keratinized tissue, painful
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What are some causes of gingival enlargement?
- cyclosporine
- nifedipine(Ca2+ channel blocker)
- dilantin (phenytoin): antiepileptic
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What is the process of apically positions flap w resective osseous surgery?
apical displacement of gingival margin with bony recontouring to acheive physiologic osseous profile
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What is positive osseous architecture?
- proximal bone is more coronal than buccal and lingual
- What are 2 ways to resstablish positive bone architecture?
- regrow or reshape(osteoplasty, ostectomy)
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What are indications for surgery?
- deep pockets
- furcations
- root anatomy
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What should always be done pre-operatively (before surgery)?
S/RP
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When is surgery containdicated?
- poor OH, small pockets,
- poor prognosis (systemic), HTN, CV, clotting, diabetes
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What are adv & disadv of open socket extractions?
- adv: simple, mucogingival junction maintained, w or w/o flap
- disadv: graft inc infection risk, increased bone width loss
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What are adv & disadv of closed flap extractions?
- adv: more predictable bone growth, maintain ridge width, hemostasis
- disadv: more complete technique, may change mucogingival juntion, narrow application
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How does goretex affect closed flap surgeries?
- minimizes width (height) loss especially if not exposed
- maximizes socket fill
- same results w/ resolut(resorbable membrane)
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How does BMP affect periodontal socket changes?
- less change in height,
- change in width 75% socket length none 1.65 BMP 2.68
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What is the most widely used flap surgery?
modified widman flap
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What is the process of modified widman flap?
- sulcular or reverse bevel incision to create full thickness (includes mucoperiosteum) flap
- debride, remove granulation tissue, (S/RP), suture
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What are goals for flaps?
thin & close to bone
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What is osteoplasty & ostectomy?
- osteoplasty: reshaping non-supportive bone to give physiological contours
- 1. interdental grooving
- ostectomy: remove supporting bone for positive architecture
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What are the goals of osseous surgery?
- calculus removal
- pocket reduction
- + architecture
- furca protection
- OH acess
- granulation tissue removal
- apical positioning of gingiva
- crater elimination
- harmony of gingiva and bone
- process 1. gingivectomy 2. mucoperiosteal flap 3. osseus surgery + arch 4. apical flap
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What is the consequence of negative bone architecture?
- soft tisse contours that are unstable and have post-surgical pocket formation and gingival inflammation
- negative: facial bones coronal to interproximal
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What defines positive architecture?
- periradicular bone apical to interproximal
- mid-facial bone is apical to interproximal
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What is the palatal approach to osseous surgery?
- more emphasis on bone reduction(ostectomy on the palate than buccal
- reduce risk of removing too much healthy bone in buccal furcation
- leads to soft tissue healing that gives palatal access to besial and distal furcations for interproximal plaque removal by patient
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How should a flap be positions with respect to mucogingival junction?
beyond to allow movement
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What kind of incision is used on the palatal?
reverse bevel since there is no free movement
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With respect to an upper molar where are the pockets located?
- mesial and distal
- mesial edentulous: mesial wedge technique with parallel incisions over ridge to expose bone defects and root surfaces
- distal wedge technique: vertical inicisions at most distal portion, incisions to expose bone defects and root surfaces
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What is the trap-door approach?
- 2 parallel inceision run distally to allow elevation of trap door or distal flap of tissue
- Used when bone graft materials are to be placed in distal intrabony defects
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What is the technique for hyperplastic gingival tissues?
- 1. gingivectomy
- 2. labial & lingual flaps elevated for root planing and osseous surgery
- 3. apically positioned flaps sutured close to bone margins
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What are the choices for an interrupted suture?
- U-shaped: pulls tissue coronoally
- figure 8: pulls tissue closer to bone
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What is the technique for the continuous sling suture?
- enter buccally, go around each tooth
- then wrap around last tooth then repeat lingual
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What technique do you use for palatal suturing?
mattress: 2 bites to hold tissue down better
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What is the papilla preservation technique?
double mattress, lingual and buccal to preserve papilla
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What tissues are targets of regeneration?
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What is the only way to evaluate regeneration?
- histologically
- notch root in most apical margin of calculus
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What is the gold standard of bone grafts?
- autogenous bone
- adv: no rejection, disease, cost, commercial sponsor
- disadv: quantity availability small, min data, limited clinical results
- study: better probing depth, clinical attachment, defect fill
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What is osseous cagulum?
- bone from burring, collected with scraper
- mostly cortical
- contaminated(H2O oil)
- combined w/ osseous surgery
- leads to higer fill than curretage
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What are the features of hip marrow graft?
cancellous, fresh vs frozen, morbitity at donor site
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What are the types of allografts?
- 1. decalcified freeze-dried w/ alloplasts (HA fom coral)
- variable osteogenic capacity, viral particles killed, limited success in furcations, particles & putty
- 2. calcified freeze-dried
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What factors seem to increase success of new bone formation in grafts?
- donor age
- decrease: smokers
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What are the types of resorbable membranes?
- periosteum
- polylactide
- polylactide-glycolide
- collagen(most common)
- CaSO4
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What increases efficacy of goretex membrane?
- Porous HA (hydroxyapatite)
- goretex: polytetraflourethylene
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What is Bio-Gide?
- porcine collagen resorbable membrane
- smooth toward mucosa, rough under to facilitate cell growth
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What is Bio-Oss?
xenograft: bovine
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What bioactive molecules aid bone reformation in platelet rich proteins?
- PDGF: polypeptide stim protein synth in bone, resoption, collagen and matrix production and angiogenesis
- TGF-beta: polypeptide (3) stim angiogenesis collagen, ground substance and fibronectin production. Inhibits osteoclasts, stimulates osteoblast division
- PDEGF: stim keratinocyte & fibroblast proliferation
- PDAF: stim new blood vessel production
- IGF-1: stim cartilage, bone matrix production & osteogenic stem cells
- PF-4: chemoattractant for fibroblasts and PMNs
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What is BMP?
- aka osteogenin
- Bone Morphogenetic proteins: TGF-B subgroup
- BMP1 not part of superfamily is procollagen protease.
- BMP induce osteoprogenitor cell formation
- Most bound to carrier of bovine type I collagen sponge
- ideal carrier still not found
- discovered 1965 UCLA at URIST
- BMP7 not effective in sinus elevation
- BMP2 & 7 > BMP5
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What is amelogenin?
- Emdogain: amelogenin from ameloblasts and reduced enamel epithelium of root sheaths
- enamel matrix derivative
- molecule from end of developing roots that stimulates bone formation
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What are tests for adequate keratinized gingiva?
- roll up w/ probe
- tension test, pull on lips/cheeks, keratinized resists muscle pull
- should not blanch/move
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What layers of tissues does a graft include?
- keratinized epithelium
- dense collagen
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When is gingival graft used?
no esthetic problem, not adequate keratinized gingiva
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When is gingival graft for root coverage used?
- esthetic prolem & inadequate keratinized tissue
- also gingival graft and coronally repositioned flap
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When is gingival graft and coronally repositioned flap used?
- esthetic problem & inadequate keratinized tissue
- also gingival graft for root coverage
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When is Coronally Repositioned Semi-Lunar Flap used?
esthetic problem, adequate keratinized tissue, recession less than 2mm
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When is lateral sliding flap used?
esthetic problem, adequate keratinized tissue, more than 2mm recession, and ADEQUATE adjacent donor site
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When is connective tissue graft used?
estheic problem, adequate keratinized tissue, more than 2mm recession, inadequate adjacent donor site and ADEQUATE Palatal site
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WHen is coronally repositioned flap with membrane or emdogain used?
esthetic problem, adequate keratinized tissue, more than 2mm recession, inadequate adjacent or palatal site.
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