peri 765 ~ 13 introduction to periodontal surgery 2013 6 slides per page

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11/21/20

SPECIAL TOPICS IN

PERIODONTAL THERAPY

PERI 765

LECTURE # 13

2013

Loma Linda UniversitySchool of Dentistry

Department of Periodontics

Introduction to PeriodontalSurgery

By ADRIAN MOBILIA D.D.S.

Periodontal Therapy

Data collection, Periodontal Diagnosis and Treatment Plan

Motivation and OHC

Modification of overhanging restorations, S&RP, polishing , fluoride topical

Interim evaluation

Re-evaluation

Diagnosis and treatment of acute infections

Supplemental Therapy

Re S&RP

Medication

Surgery

MAINTENANCE

Scheduling for Perio Surgery

Following initial therapy and re-evaluation

(for plaque related periodontal destruction)


• After temporary splinting of mobile teeth


• After temporary splinting of mobile

teeth



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Prior to Ortho, Restorative,

Prosthodontics

Patient Preparation for Surgery

• Oral Hygiene Assessment

• Psychological

• Pre-surgical records

Radiographs

Charting

Etc.

• Pre-medication

• Nutritional and diet preparation

• Pre-operative medical assessment

Post-operative Care

• Inform patient verbally

• Also have written instructions

Objectives of the Periodontal Surgery

1.Access and visibility of the calculus

Increase SRP effectivenessLess tissue trauma

2. Pocket Depth Reduction

Improve long term stabilityEnhance maintenance by the patient and therapist

Objectives of the Periodontal Surgery

3. Modification of Osseous Defects

Establish physiologic architecture for the bone and soft tissues through

regeneration or resection

4. Repair or Regenerate the Periodontium

5. Provide Acceptable Soft Tissue ContoursEnhance plaque control and maintenanceImprove esthetics

Pocket Depth Deposit RemovalCaffesse et al

Probing Depths Roots Cleaned

1-3 mm 83%

4-6 mm 43%

>6 mm 32%



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Molars vs. non-molarsNordland, et al.

Limited accessibility at molar furcation

defects reduces the efficacy of non-surgical

therapy (S/RP).

Drug induced overgrowth Drug induced overgrowth

Potential Disadvantages:

• Increased bone loss resulting from trauma,dehydration, prolonged surgical exposure

• Generally 0.5-1.0mm of crestal bone loss

after surgery• Up to 2.5mm loss in thin bony places if

poor flap adaptation

• Heat-induced osseous necrosis whenremoving bone:

≥ 47° C ≥ 1 min.

Surgical treatments

Resective

1.Gingivectomy / Gingivoplasty2.Distal Wedge3.Modified Widman4.Osseous5.Crown Lengthening with bone removal6.Tooth Hemisection7.Root Amputation



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Reconstructive

1.Flap Debridement2.Pedicle Soft tissue Grafts3.Free soft tissue Grafts4.Hard tissue grafts5.Guide tissue regeneration

Surgical treatments

POCKET MANAGEMENT

RESECTIVE

Gingivectomy

Osseous

NEW ATTACHMENTRepair

Regeneration

MUCOGINGIVALGingival width

Root Coverage

PRE -PROSTHETICCrown lengthening

Ridge Augmentation

CLASSIFICATION BASED ON GOALS

Principles of Periodontal Surgery

1.Know you patient’s health history

2.Develop a treatment plan related to therestorative treatment plan

3.Know the anatomy of the surgical site

4.Profound anesthesia

5.Aseptic technique

6.Atraumatic tissue management (smooth

incisions, careful flap reflection, carefulflap manipulation)

Principles of Periodontal Surgery

7. Hemostasis

8. Atraumatic suturing techniques(smallest needles for the area, sutures inkeratinized tissue, take adequate bites oftissue)

9. Obliterate dead space between flap andbone

10. Promote an stable wound healing

Surgical Anatomy Surgical Anatomy



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Surgical Anatomy

• External bevel

• Sulcular

• Internal bevel

• Scalloped

• Linear

• Vertical releasing

Types of Incisions

• External bevel

Types of Incisions

External bevel

Types of Incisions

• Sulcular

Types of Incisions Types of Incisions

• Internal bevel



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• Internal bevel

Types of Incisions

• Scalloped

Types of Incisions

• Linear

Types of Incisions

Vertical releasing

Increases access and allowsdisplacement of the flap

Types of Incisions

Types of Incisions


Dr. Adrian Mobilia


Types of Incisions



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Incorrect placement of a

Vertical incision

Center of the tooth

Center of the papillae

Over the bone defect

Cut back incision

Used in pediculate flaps that are laterallydisplaced

Types of Incisions

Cut back incision

Used in pediculate flaps that are laterallydisplaced

Types of Incisions

Dr. Stephen Silston

Dr. Stephen Silston Dr. Stephen Silston



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Periosteal incision

Releases flap tension allowingdisplacing coronally the flap

Types of Incisions

Dr. Adrian Mobilia



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Dr. Adrian Mobilia Adrian Mobilia DDS

Adrian Mobilia DDS Adrian Mobilia DDS

Adrian Mobilia DDS



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Classification of Flaps

• Full thickness (epithelium, connective and periosteum)

• Partial (split) thickness (epithelium and connective)

• Undisplaced

• Displaced (Pediculate flaps)

• Apically displaced

• Coronally displaced

• Laterally displaced

Pediculate Flaps

Designed to be placed in a position different thanthe original

Most of the time have two vertical incisions

The base of the flap should be equal or larger thanthe coronal portion

To preserve a good irrigation the high/base ratioshould not exceed 2:1

Pediculate Flaps

The ratio flap height : flap base should not exceed 2:1

Periodontics Medicine, Surgery and Implants. Rose & Mealey

Pediculate Flaps

Periodontics Medicine, Surgery and Implants. Rose & Mealey


• Full thickness • Full thickness




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• Partial (split) thickness


• Partial (split) thickness


• Undisplaced


• Displaced – apically


• Displaced – apically


• Displaced - coronally




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• Displaced - laterally


• Displaced - laterally


Flap Elevation

• Full thickness by blunt dissection

• Partial thickness by sharp dissection

• Begin flap reflection interdentally

• Elevate beyond mucogingival junction if

flap to be displaced

Flap Elevation

Flap Debridement Procedure

Advantages

Conservation of tissue

Root planning with direct vision

Minimal post-op pain

Disadvantages

No immediate pocket reduction accomplished

Flap Debridement Procedure



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Flap Debridement Procedure Flap Debridement Procedure

SutureObjective:

Flap adaptation and stabilization of the wound

• Flap must achieve its position passively

• Do not rely in sutures to pull beyond the passiveposition

• Any tension in the flap increases the chance ofcomplications

Purpose of Suturing

Approximation of flap (wound) edges, asmuch as possible, for Primary or SecondaryIntention closure.

Adaptation of soft tissues to teeth, rootstructure or implants.

Compression of flap to the underlyingconnective tissue or bone to minimize

hematoma formation, (dead space).

Ideal Suture

• Biologically inert

• Strong

• Dissolves/absorbs in body fluids after

serving its purpose• Loses strength at the same rate that the

tissues gain strength

• Easy to handle

• Easy to sterilize

• High knot security

Choice of Suture material

Depends upon:

• Properties of the suture material

• Absorption rate

• Handling characteristics

• Knotting properties

• Size of the suture material

• Type of needle to be used



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Sutures are classified according tothe number of strands

Monofilament vs. MultifilamentStrands


Monofilament sutures:

• Single strand of material.

• Less resistance as they pass through

tissues:

•

Less infection.


Multifilament sutures:

• Several filaments, or strands, twisted orbraided together.

• Greater tensile strength, pliability andflexibility.

• May be coated to help them pass relativelysmoothly through tissues/ enhance handlingcharacteristics.


Absorbable vs.Non-Absorbable

Sutures are classified according to theirdegradation properties:

1- Absorbable

2- Non-Absorbable

Absorbable Sutures:

• Lose their tensile strength in less than 60

days.

• Natural absorbable sutures are destroyed by

proteases (proteolysis) while synthetic

absorbable sutures are hydrolyzed.




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Non-Absorbable Sutures:

• Maintain tensile strength for longer

than 60 days.

• Ultimately encapsulated by the body's

fibroblasts.


• Silk

• Nylon

• Polypropylene

• Polyester

Non-Absorbable Suture

Absorbable Sutures-Natural & Synthetic-

• Gut

• Dexon - Polyglycolic (hydroxyacetic) acid

• Vicryl – Polyglactin 910 (1974)

• PDS* II - (Polydioxanone)- synthetic

monofilament (1982)

• Maxon - Polyglycolic acid and trimethylene

carbonate (1985)

• Monocryl - Poliglecaprone 25 (1993)

87

Suture Material

Suture Techniques

Lindheet a l, Clinical Periodontology and Implant Dentistry , 2003.

peri 765 ~ 13 introduction to periodontal surgery 2013 6 slides per page

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