perio spr14

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perio spr14
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  1. Beneficial effects of scaling and root planing combined with personal plaque control
    • •Reduction of clinical inflammation
    • •Microbial shifts to a less pathogenic subgingival flora
    • •Decreased probing depth
    • •Gain of clinical attachment
    • •Less disease progression
  2. Factors limiting success of scaling and root planing
    • •Root anatomy (e.g., concavities, furrows)
    • •Furcations
    • •Deep probing depths
    • •Overhanging/poorly contoured restorations
  3. avg root concavities
    • MANDIBULAR
    • M: 100%, 0.7mm
    • D: 99%, 0.5mm
    • MAXILLARY
    • MB: 94%, 0.3mm
    • DB: 34%
    • P: 17%
  4. PD and ability to clean
    • <3: 83%
    • 3-5: 39%
    • >5: 11%
  5. Post Re-eval options
    • 1. perio maintenance
    • 2. repeat SRP (re-eval)
    • 3. Flap surgery (re-eval)
  6. Critical Probing Depth
    • •Critical probing depth is the probing depth above which when a treatment is rendered, the result is gain of clinical attachment and below which a loss of clinical attachment may occur
    • •Critical probing depth for flap surgery: 4.2mm
  7. Contraindications to Surgical Therapy
    • •Poor Oral Hygiene
    • •Systemic Issues
    • •Myocardial infarction or cerebrovascular accident within 6 months
    • •Poorly controlled diabetics HbA1c >6.5%
    • •Poorly controlled hypertension
    • •Immunocompromised
    • •IV Bisphosphonate
    • •Smoking
  8. Perio surgery classification
    • 1. Pocket:
    • a.resective (gingivectomy, flap, resection/extration) b. regenerative
    • 2. Plastic
    • 3. Pre-prosth
  9. Gingivectomy
    • Indications
    • •Abundant keratinized attached gingiva
    • •No osseous defects
    • •Irregular gingival contour
    • Incisions:
    • scalloped, straight
    • beveled (angled coronally)
    • Contraindications
    • •Minimal keratinized attached gingiva
    • •Osseous defects
    • •Patients with high risk of post-operative bleeding (e.g., patients taking Plavix or Coumadin, etc.)
  10. Problems related to gingivectomy
    • •Reduced zone of keratinized attached gingiva
    • •Osseous defects, if present cannot be visualized
    • •Open wound which heals by secondary intention
    • •Potential post-operative bleeding
    • •Potential excessive post-operative discomfort due to an open wound
  11. Flap Fundamentals
    • •Incisions
    • •Horizontal: mesial-distal direction
    • •Bevel vs. Internal Bevel
    • •Scalloped vs. Straight
    • •Sulcular
    • •Vertical: coronal-apical direction
    • •Flap elevation
    • •Flap coaptation
    • •Flap suturing
  12. Bevel Incision
    • Angulation of bevel varies with thickness of tissue.
    • Goal: thin and properly festooned margin
  13. Inverse Bevel Incision
    • a.k.a.
    • Reverse Bevel
    • Internal Bevel
    • Inverse bevel incisions typically parallel long-axis of tooth
  14. Advantages of internal bevel incision
    • •Inflamed pocket lining is excised
    • •Conserve keratinized attach gingiva
    • •Produce a sharp, thin flap margin
    • •Allow for primary closure of the wound and healing by primary intention
    • •Reduce post-operative discomfort
  15. Horizontal Incisions
    • Scalloped or Straight
    • Both can be bevel or reverse bevel incisions. Bevel incisions are utilized in gingivectomy; reverse bevel incisions are utilized in flap surgery
    • Sulcular Incision (a.k.a. Intrasulcular, Crevicular, Intracrevicular)
    • ALWAYS Reverse bevel

    • How much to scallop? How far from the margin should be scalloped incision be?•Depends on
    • •Probing depth Typically, half to two-third the deepest probing depth at each tooth
    • •Width of keratinized tissue•Preserve at least 3 mm of keratinized tissue
    • •Depth of palatal vault
    • •Shallow palate = less scalloping
    • •Deep palate = more scalloping
  16. Advantages of vertical incisions
    • •Increased flap mobility
    • •Improve access
    • •Allow for displacement of flap
  17. Problems related to vertical incisions
    • •Poorly planned vertical incisions may compromise blood supply
    • •Delayed healing
    • •Flap necrosis
    • •Lingual vertical incisions may severe neurovascular bundles
    • •Lingual nerve
    • •Greater palatine artery
  18. Avoid in vertical incisions
    • Splitting papilla
    • Incision over radicular surface of a tooth
    • Long, narrow flap
    • Base < Margin
    • Anatomy:
    • greater palatine a.
    • lingual nerve
    • mental nerve
  19. Flap Elevation
    • •Full-Thickness Flap (MucoperiostealFlap)
    • •Partial-Thickness (Split-Thickness Flap)
  20. Flap Coaptation
    • Bone defect within the attached gingiva:
    • •Non-displaced flap (full-thickness only)
    • Bone defect beyond mucogingivaljunction:
    • •Apically displaced flap (preserve keratinized tissue)
    • full or split
  21. Distal Flap Techniques
    • •Distal Wedge
    • •Modified Distal Wedge
    • INDICATIONS
    • •Periodontal pocket on distal surface of the most distal tooth in a quadrant
    • •Distal angular bony defects
    • •Distal furcation
  22. Distal Wedge
  23. Modified Distal Wedge
  24. Sutures
    • Simple loop
    • Figure-8
    • Anchor
    • Continuous Sling
  25. continuous sling
  26. Regenerative Surgery
    Papilla preservation Flap

    Conventional
  27. Papilla Preservation


  28. Conventional Flap
  29. Perio Surgery Classifications
  30. Modified Widman
  31. ______ with periodontal regeneration is
    the ideal outcome of therapy because it results in obliteration of the pocket and reconstruction of the periodontitum
    New attachment
  32. Non-Graft
    Reconstructive Therapy
    • •In
    • an ideal three-wall osseous defect

    • •Good
    • access for scaling and root planing - the flap is not reflected

    • •Graft
    • material is not used
  33. Deeper
    pockets require
    •shorter curette blades

    •thinner curette blades

    •longer shanks
  34. Bone cannot form against a
    mobil tooth ~ primary stability
  35. •Bleeding Osseous Surface in The
    Pocket
    • Cortical
    • Bone Penetration
    • •Perforation into cancellous bone
    • –Stem cells
    • –Blood supply
  36. Osteogenesis
    • formation or development of new bone by cells contained in the graft.
    • autografts.
  37. Osteoinduction
    • chemical process by which molecules contained in the graft (bone morphogenic proteins) convert the neighboring
    • cells into osteoblasts, which in turn form bone.
  38. Osteoconduction
    • physical effect by which the matrix of the graft forms a scaffold that
    • favors outside cells to penetrate the graft and form new bone.
  39. Autografts
    material obtained from the same individual.
  40. Allografts
    different individual of the same species.
  41. Xenografts
    different species.
  42. Synthetics
    manufactured bone graft material
  43. Problems Related To Bone Regeneration
    • Migration of the epithelium to create a long Junctional Epithelium
    • Migration of the connective tissue into the osseous defect
    • Lack of clot stabilization in the defect
    • Maintenance of space
  44. Cells Occupying Periodontal Osseous Defect
    • Gingival Epithelial Cells
    • Gingival Connective Tissue Cells (Fibroblast)
    • Bone Cells (Osteoblast)
    • Periodontal Ligament Cells (PDL)
    • Undifferentiated Mesenchymal Cells (From the PDL)
    • Cementoblast
  45. Guided Tissue Regeneration
    • prevention of epithelial migration along the cemental wall of the pocket that has gained wide attention is guided tissue regeneration (GTR).
    • GTR consists of placing barriers of different types to cover the osseous defect & periodontal ligament, thus temporarily separating them from the gingival epithelium & connective tissue
    • Excluding the epithelium and the gingival connective tissue from the root surface during the postsurgical healing phase prevents epithelial migration into the defect and favors repopulation by cells from the periodontal ligament and the bone
  46. if epithelial cells repopulate first
    long juntional epithelium
  47. if gingival CT cells repopulate first:
    parallel collagen fibers
  48. if bone cells repopulate first:
    bone resorption and ankylosis
  49. if PDL cells repopulate first:
    new attachment with formation of cementum and functional fibers
  50. WHY DOES CHRONIC INFLAMMATION DEVELOP WHERE THE BW IS VIOLATED?
    bacteria is smaller than margin
  51. Biologic width
    • EA + CTA: average 2.04 mm
    • EA + CTA + sulcus: average 2.73 mm
  52. CROWN LENGTHENING INDICATIONS
    • Subgingival caries
    • Subgingival crown fracture
    • Subgingival perforation
    • Prosthetic retention
    • Improve aesthetics (gummy smile)
  53. Whole segment crown lengthening
    • Gingivectomy
    • Apically positioned flap
    • Buccal and lingual flap elevation
    • Degranulation of the interproximal spaces
    • Usually requires osseous resection
  54. Complete healing time for restorative treatment to be initiated
    • 6 months (Rosenberg et al, CCED, 1999)
    • 12 months (Pontoriero & Carnevale, JP, 2001)
  55. schneiderian membrane
    • mucosa of max sinus
    • ciliated
  56. Orthodontic extrusion
    • Surgical approach contra-indicated
    • Forced tooth eruption (rapid movement: 1 mm/week)
    • Maintenance of gingival line and bone crest position
    • Considerations: Tooth vitality
    • Vital pulp
    • Rapid extrusion may result in pulpal necrosis
    • Slow extrusion (i.e., 2-3 mm over 4-8 mo) will result in the need of a secondary surgical procedure
    • Endodontically treated tooth (most common clinical situation)
    • No apparent problems, even the presence of endodontic overfill
  57. Ortho Relapse
    • Retention/relapse
    • Principal fibers of the PDL re-arrange in 8-9 weeks
    • Supra-alveolar fibers my take longer (12 weeks)
    • Post-extrusion fiberotomy may aid in prevent relapse
  58. Most common isolated tooth crown lengthening clinical situation
    coronal movement of the gingival margin and/or alveolar bone following extrusion
  59. EXCESSIVE GINGIVAL DISPLAY ETIOLOGY/DIAGNOSIS
    • VME
    • short/hyper lip
    • Coronal position of the gingival margin (altered passive eruption)
  60. tx of skeletal excessive gingiva
    • Middle third of the face is too long
    • Class II division 2 occlusion
    • Treatment
    • Excessive gingival display ≤ 4 mm
    • Orthodontic intrusion
    • Excessive gingival display > 4 mm
    • Orthognatic surgery combined with orthodontics
    • Periodontal crown lengthening combined with restorative dentistry is a shortcut
  61. ALTERED PASSIVE ERUPTION
    • Eruption process
    • Active (until occlusion)
    • Passive (apical migration of gingival tissue)
    • End of adolescence: gingival margin 1-2 mm coronal to CEJ
    • Altered passive eruption
    • Passive phase of eruption does not occur or is incomplete
    • Etiology is unknown
  62. Titanium – Epithelial Interface (Attachment)
    • Hemidesmosomes
    • Hemidesmosomal - basal lamina system
  63. If the implant emerges through _____ dense gingival fibers promote close adaptation of the mucosa around the implant resulting in a gingival cuff (arrow) similar to the sulcus formed around natural teeth.
    keratinized mucosa,
  64. Gingival grafts can be done to improve the amount of dense keratinized mucosa around implants to enhance the resistance to
    retraction and inflammation.
  65. Bone Loss / Implant Failure
    • !Infection Theory
    • !Biomechanical Overload Theory
    • !Additional Factors
    • !Compromised Healing / Adaptation Theory
  66. Best quality and most quantity
    Anterior Mandible
  67. Least quantity and worst quality
    Posterior Maxilla
  68. history of periodontitis does not appear to adversely affect implant survival but it may have a
    negative influence on implant success rates, particularly over longer periods.
  69. Advantages of internal bevel incision
    • •Inflamed pocket lining is excised
    • •Conserve keratinized attach gingiva
    • •Produce a sharp, thin flap margin
    • •Allow for primary closure of the wound and healing by primary intention
    • •Reduce post-operative discomfort
  70. non-displaced flap refers to
    mucogingival junction
  71. Crown Lengthening Indications
    • Biologic
    • •Biologic Width Violation
    • Esthetic
    • •Gingival imbalance
    • •Excessive gingival display
    • Prosthetic
    • •Inadequate axial height
    • •Inadequate ferrule
    • •Inadequate access for margin placement
  72. Crown Lengthening Contraindications
    • •Single tooth in the esthetic zone
    • •Crown lengthening resulting in furcation involvement
    • •Inadequate alveolar bone height from alveolar crest to sinus floor
    • •10 mm rule: distance from alveolar crest to inferior alveolar canal < 10 mm
  73. Miller Classification
    • •Class I: marginal tissue recession not extending to the mucogingivaljunction. No loss of interdental bone or soft tissue.
    • •Class II: marginal tissue recession extends to or beyond the mucogingivaljunction. No loss of interdental bone or soft tissue.
    • •Class III: marginal tissue recession extends to or beyond the mucogingivaljunction. Loss of interdental bone or soft tissue is apical to the CEJ, but coronal to the apical extent of the marginal tissue recession.
    • •Class IV: marginal tissue recession extends beyond the mucogingivaljunction. Loss of interdental bone extends to a level apical to the extent of the marginal tissue recession.

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