Final Exam

• Types of periodontal surgery

  • Periodontal flap
  • Bone replacement graft
  • Guided tissue regeneration
  • Apically positioned flap with osseous surgery
  • Mucogingival plastic surgery
  • Dental implant placement
• Periodontal flap surgery (modified Widman flap)

  * Most modern periodontal surgical procedures require periodontal flaps as part of the procedure

  • Provides access to tooth roots for improved root preparation
• Periodontal flap surgery

  Healing

  • Healing by REPAIR
  • Involves formation of LONG JUNCTIONAL EPITHELIUM
  • Can be maintained by client and professional care

  Indications

  • Performed to provide access for treatment of tooth roots or bone
  • Flap can be elevated for periodontal instrumentation
  • Flap can be elevated to access alveolar bone to reshape or fill defects
• Periodontal flap surgery special considerations for the DH

  • TO REACH Pocket depths deeper than 5 to 7 mm
  • Flap for access surgery allows more efficient instrumentation of root surfaces
• Periodontal flap classifications

  Based on degree of bone exposure:

  • Full-thickness flap
  • Partial-thickness flap

  Based on location of the flap margin:

  • Nondisplaced flap
  • Displaced flap
• Periodontal flap classification - degree of bone exposure

  Full thickness flap

  • Also called a blunt dissection
  • Lifting of the entire thickness of soft tissue
  • * Provides complete access to the underlying alveolar bone when bone replacement grafting or periodontal regeneration procedures anticipated
  • Blunt instruments are used to elevate the flap in a manner quite similar to lifting the peel off an orange ( blunt dissection)

  
• Periodontal flap classification - degree of bone exposure

  Partial thickness/split flap

  • * Elevation only of the epithelium and a thin layer of the underlying connective tissue
  • Sharp instruments are used to elevate the flap. ( sharp dissection)

  
• Periodontal flap surgery - location of the flap margin

  Nondisplaced flap

  • A flap that is sutured with the margin of the flap placed at its original relationship to the CEJ of the tooth

  Displaced flap

  • A flap that is sutured with the margin of the flap placed at a position other than its original position in relation to the CEJ
  • A displaced flap can be positioned apically, coronally, or laterally in relationship to its original position

  Full thickness and partial thickness flaps can be displace or nondisplaced.

  ●
• Bone replacement graft description

  • Surgery used to encourage the body to rebuild alveolar bone lost from periodontal disease
  • Involves:
  • Elevation of a flap
  • Cleaning granulation tissue from bone
  • Treating roots as needed
  • Placement of grafting material into defect

  Materials used for a bone graft

  • autograft
  • taken from clients body; jaw
  • Allograft
  • taken from a cadaver or living donor
  • xenograft
  • treated cow bone
  • alloplast
  • synthetic bone material
• Bone replacement graft healing

  • * Partial or complete rebuilding of alveolar bone
  • Reformed bone may not actually be attached to cementum by periodontal ligament fibers
• Bone replacement graft special considerations for the DH

  • Site of bone graft should not be disturbed for many months
  • Do not probe until appropriate interval has lapsed
  • Meticulous plaque control is critical to maintain health in the area
• Guided tissue regeneration

  • Surgical procedure to encourage regrowth of lost periodontal structures (lost cementum, alveolar bone, and periodontal ligament)

  Goal

  • Guided tissue regeneration can result in true regeneration of the periodontium
  • Although regeneration of the cementum, periodontal ligament, and alveolar bone is the ultimate goal of periodontal surgery, regeneration of the periodontium is NOT completely predictable with techniques in use today
• Guided tissue regeneration - use of membrane barrier

  • * Guided tissue regeneration techniques involve the use of a barrier membrane
  • * The membrane’s purpose is to delay the normally rapid growth of epithelium along the root from the flap margin into the wound
  • This provides time for the cementum, PDL, and bone to form next to the root.
  • If the epithelium covers the wound, it prevents the slower growing cells from growing
  • * Delaying the ingrowth of epithelium allows for undifferentiated cells to populate the root area and develop into cementum, PDL, and alveolar bone
• Guided tissue regeneration special considerations for the DH

  • EVERY Effort is made during surgery to close the wound to cover barrier material
  • * During postsurgical visit, if part of barrier is exposed, minimize bacterial contamination
  • * CLIENT MAY NEED TO APPLY topical antimicrobial AGENTS TO THE SITE
  • Ex: chlorhexidine
  • Do not probe site for several months
• Apically positioned flap with osseous surgery description

  • * Designed to eliminate or minimize pocket depths
  • Flap is sutured in a more apical position to its original level
  • * Ideal for minimizing pocket depth in patients with moderate periodontal disease

  Involves:

  • Elevation of flap
  • Removal of granulation tissue
  • Treatment of roots
  • Correction of bone contours to mimic healthy alveolar bone – osseous resective surgery
• Apically positioned flap with osseous surgery healing

  • Results in REDUCED POCKET DEPTHS WITH GINGIVAL MARGIN APICAL TO CEJ
  • NEWLY EXPOSED ROOT SURFACES
  • The root exposure may cause hypersensitivity,  client may be prone to root caries and/ or stain.
  • Outcome depends on meticulous home care by the client combined with professional maintenance visits

  
• osseous resective surgery (apically positioned flap)

  • Corrects deformities of the alveolar bone resulting from advanced periodontitis
  • Main goal — to eliminate periodontal pockets
  • Ostectomy — removal of the alveolar bone attached to the tooth
  • Osteoplasty — reshaping the alveolar bone without removing the supporting bone
• apically positioned flap special considerations for the DH

  • Surgery results in more root exposure in the oral cavity
  • Client may experience temporary root sensitivity
  • NEWLY EXPOSED ROOTS ARE AT RISK FOR CARIES AND STAIN
  • ESTHETIC CONCERNS FOR CLIENT
• Mucogingival surgery (periodontal plastic surgery or reconstructive surgery)

  • Designed to alter components of attached gingiva
  • Procedures can be used to improve esthetics of the dentition, enhance prosthetic dentistry, and deal with damage from periodontitis
  • Restores gingiva to tooth surface as a result of disease or trauma
  • May alter the appearance of the tissue

  Types

  • Free soft tissue autograft (Free gingival graft)
  • (Subepithelial) connective tissue graft
  • Laterally positioned flap
  • Coronally positioned flap
  • Semilunar flap
  • Frenectomy
  • Crown lengthening surgery
• Periodontal plastic surgery

  Free soft tissue autograft

  • Previously called “free gingival graft”
  • Type of plastic surgery used to augment width of the attached gingiva and cover areas of recession of the gingival margin
  • Requires harvesting donor section of tissue, usually from the palate
  • Includes surface epithelium and underlying connective tissue
  • Two wounds — donor site and recipient site

  Healing

  • Usually results in successful augmentation of the gingiva and coverage of roots
  • * Color match at donor site not ideal
• Periodontal plastic surgery

  Subepithelial Connective Tissue Graft

  • Another type of plastic surgery used to augment width of the attached gingiva and cover areas of recession of the gingival margin
  • Also used to contour alveolar ridges and improve esthetics of some dental prostheses
  • *Uses only the connective tissue (no epithelium) from the donor site
  • *Two wounds — donor site and recipient site

  Healing

  • Reasonable root coverage expected
  • * Excellent tissue color match
• Frenectomy

  • Plastic surgery procedure used to remove a frenum including the attachment of frenum to bone
  • If the frenum is attached too close to the gingival margin, it can result in repeated pulling of the gingival margin away from the tooth surface resulting in persistent inflammation in the tissues
  • Healing following frenectomy includes elimination of the gingival margin movement (recession) caused by the frenum pull
• Crown lengthening

  • Crown lengthening — surgery that creates a longer clinical crown for a tooth by removing gingival and alveolar bone from necks of teeth
  • Functional crown lengthening — performed when the existing tooth structure is inadequate to support a necessary restoration — decay below the gingival margin
  • Esthetic crown lengthening — performed to improve appearance of teeth when there is excess gingiva in relation to clinical crowns●
• * gingivectomy

  • surgical removal of gingival tissue
  • Results in more apical position of GM
  • Allows for better self-care in select sites
  • Tissue overgrowth may be caused by medications or periodontal disease

  Disadvantages

  • Leaves large open connective tissue wound
  • Slower healing than other surgeries
  • More discomfort for the patient during healing
  • Teeth appear longer

  Healing

  • can be very uncomfortable for patient
  • Can be managed with periodontal dressing
  • Prescribe analgesics
  • Dressing may need to be changed at several postsurgical visits until total epithelialization has occurred
• * Gingivectomy special considerations for the DH

  • Donor site on palate can actually bother the client more than wound at site
  • Discuss post-surgical discomfort with the client INCLUDING TEMPORARY ROOT SENSITIVITY
  • Do not disturb grafted sites during early stages of healing
  • Encourage client to maintain good plaque control
• Healing after mucogingival surgeries

  • Harvesting from a donor site creates two wounds that have to heal
  • Expected new attachment
  • Can result in root exposure
  • Stain
  • Caries
  • Sensitivity
• Patient management

  • Management of the patient during the healing phase following periodontal surgery can be as important to the surgical outcomes as the skill of the surgeon performing the surgery
  • In some cases, sutures will be placed to hold soft tissue in place and close a wound
  • In some cases a protective periodontal dressing will be placed immediately after surgery
  • In all cases, postoperative instructions will be given
• Sutures

  Purpose

  • A suture, or a stitch to hold tissues together during healing
  • Many periodontal surgical procedures ( periodontal flaps) require the placement of sutures

  Characteristics

  • Must be nontoxic, flexible, and strong
  • Should not have wicking effect
  • Should not place tension on the flap

  Materials

  • Nonabsorbable: suture material that does not dissolve in body fluids; must be removed by the clinician
  • Absorbable: suture material designed to dissolve harmlessly in body fluids over time
  • Do not normally require removal
  • Some absorbable sutures do not dissolve well in saliva
• Suture removal

  • Nonabsorbable sutures - removed as part of routine postsurgical visits
  • Remnants of absorbable sutures are removed to avoid inflammation
  • Sutures should be removed when they are loose in the tissues
  • Sutures are usually loose in the tissue 1 week after surgery
  • Nonabsorbable sutures usually are removed after 1 week of healing
  • Most absorbable sutures can be left in place 1 to 3 weeks
  • They become irritants if left in the tissue too long
  • Count the number of sutures placed and enter it in the treatment notes
• suture removal how to:

  • removed by cutting material near the knot and grasping the knot with pliers
  • Gently pull through the tissue
  • Never allow the knot to be pulled through the tissues
  • Always confirm that all of the sutures have been removed
  • Usually not painful for the client
• Periodontal dressings

  • * Periodontal dressing (or periodontal pack) - a protective material applied over a periodontal surgical wound
  • Used somewhat like a bandage to cover a finger wound
  • Modern periodontal surgical techniques may or may not require a periodontal dressing
• Surgical wound dressing

  • Periodontal surgical wound dressing
  • Material from two tubes is mixed together for a putty-like consistency e.g. Coe-Pak
  • Light-cured gel or chemical cured
  • Does not stick to the tissue
  • Is retained by pressing firmly interdentally
  • * Use the least amount possible!
  • Just enough to cover the wound
  • Should be no dressing on occlusal surfaces
  • Take care not to trap sutures in dressing!

  
• * Postsurgical instructions

  • * verbal & written instructions minimizes confusion
  • chlorhexidine rinse is recommended for use 2 x daily until the patient can safely resume OSC
  • dentition not involved by the surgery may be cleaned with routine OSC
  • Call office immediately with questions/concerns
  • Take medications as prescribed
  • Expect some bleeding/swelling, use an ice pack first 8 - 10 hours
  • Eat soft food only on day of surgery; no hot beverages on day of surgery, avoid chewing at surgical site
  • Rinse with prescribed mouth rinse starting day after surgery
  • Brush lightly if dressing is placed
• * Resumption of Routine Patient Self-Care Techniques

  • Following routine flap surgery or gingivectomy, the patient usually can resume self-care in 10 to 14 days
  • Following guided tissue regeneration or bone grafting, the patient should not resume self-care for up to 4 to 6 weeks
• * Post Surgical Medication

  • If systemic antibiotics are prescribed, it is very important to caution the patient to take ALL of the prescribed medication!
  • Pain medications may be prescribed
• * Dietary Changes

  • Recommend a soft or liquid diet for 24 to 48 hours
  • Chewing should be limited to the side of the mouth not involved by the surgery, especially during the early phases of healing
• * Post Surgical Complications

  • Facial swelling
  • Bleeding
  • Reassure the patient that minor bleeding is to be expected
  • If excessive bleeding occurs, the patient should call the office’s emergency number immediately
  • Smoking
  • Surgical patients should be cautioned NOT to smoke during the healing phase
• Post surgical visits

  • 5 to 7 days for the first postsurgical visit
  • It is the dentist’s responsibility to manage postsurgical problems
  • The dental hygienist performs most of the postsurgical management
  • * vital signs
  • Elevated temperature may indicate a developing infection!
• periodontal maintenance

  • continuing care provided by dental team to help patient maintain periodontal health following completion of nonsurgical/ surgical therapy
  • term periodontal maintenance applies to treated periodontitis patients not gingivitis or healthy
  • any measures used to keep disease under control
  • essential of successful periodontal therapy
  • W/o regular maintenance, patients exhibit decrease in OSC & recurrence of periodontitis
  • If recurrence during maintenance, clinician should stop maintenance
  • NSPT or surgical intervention
  • After successful re-eval -> back on maintenance program
• * Goals Of Periodontal Maintenance

  1. To minimize the recurrence and progression of periodontal disease
  2. To reduce the incidence of tooth loss
  3. Increase the probability of detecting and treating other oral conditions

  • The expected outcome of achieving these goals is to maintain the dentition throughout the life of the patient