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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
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
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
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)
When should you re-evaluate results of S/RP?
3 weeks, assess OH, pocket depth
What are advantages for flap surgery for access?
- predictable for >6mm
- posterior access
- least aggressive surgery
- limitations: recession
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
What are some causes of gingival enlargement?
- nifedipine(Ca2+ channel blocker)
- dilantin (phenytoin): antiepileptic
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
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)
What are indications for surgery?
- deep pockets
- root anatomy
What should always be done pre-operatively (before surgery)?
When is surgery containdicated?
- poor OH, small pockets,
- poor prognosis (systemic), HTN, CV, clotting, diabetes
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
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
How does goretex affect closed flap surgeries?
- minimizes width (height) loss especially if not exposed
- maximizes socket fill
- same results w/ resolut(resorbable membrane)
How does BMP affect periodontal socket changes?
- less change in height,
- change in width 75% socket length none 1.65 BMP 2.68
What is the most widely used flap surgery?
modified widman flap
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
What are goals for flaps?
thin & close to bone
What is osteoplasty & ostectomy?
- osteoplasty: reshaping non-supportive bone to give physiological contours
- 1. interdental grooving
- ostectomy: remove supporting bone for positive architecture
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
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
What defines positive architecture?
- periradicular bone apical to interproximal
- mid-facial bone is apical to interproximal
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
How should a flap be positions with respect to mucogingival junction?
beyond to allow movement
What kind of incision is used on the palatal?
reverse bevel since there is no free movement
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
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
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
What are the choices for an interrupted suture?
- U-shaped: pulls tissue coronoally
- figure 8: pulls tissue closer to bone
What is the technique for the continuous sling suture?
- enter buccally, go around each tooth
- then wrap around last tooth then repeat lingual
What technique do you use for palatal suturing?
mattress: 2 bites to hold tissue down better
What is the papilla preservation technique?
double mattress, lingual and buccal to preserve papilla
What tissues are targets of regeneration?
What is the only way to evaluate regeneration?
- notch root in most apical margin of calculus
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
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
What are the features of hip marrow graft?
cancellous, fresh vs frozen, morbitity at donor site
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
What factors seem to increase success of new bone formation in grafts?
- donor age
- decrease: smokers
What are the types of resorbable membranes?
- collagen(most common)
What increases efficacy of goretex membrane?
- Porous HA (hydroxyapatite)
- goretex: polytetraflourethylene
What is Bio-Gide?
- porcine collagen resorbable membrane
- smooth toward mucosa, rough under to facilitate cell growth
What is Bio-Oss?
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
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
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
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
What layers of tissues does a graft include?
- keratinized epithelium
- dense collagen
When is gingival graft used?
no esthetic problem, not adequate keratinized gingiva
When is gingival graft for root coverage used?
- esthetic prolem & inadequate keratinized tissue
- also gingival graft and coronally repositioned flap
When is gingival graft and coronally repositioned flap used?
- esthetic problem & inadequate keratinized tissue
- also gingival graft for root coverage
When is Coronally Repositioned Semi-Lunar Flap used?
esthetic problem, adequate keratinized tissue, recession less than 2mm
When is lateral sliding flap used?
esthetic problem, adequate keratinized tissue, more than 2mm recession, and ADEQUATE adjacent donor site
When is connective tissue graft used?
estheic problem, adequate keratinized tissue, more than 2mm recession, inadequate adjacent donor site and ADEQUATE Palatal site
WHen is coronally repositioned flap with membrane or emdogain used?
esthetic problem, adequate keratinized tissue, more than 2mm recession, inadequate adjacent or palatal site.