Perio Sheet #3 By Sarah Waia

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Perio Sheet #3 By Sarah Waia

Post by Sura on 16/10/2012, 3:08 am

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Re: Perio Sheet #3 By Sarah Waia

Post by Shadi Jarrar on 12/11/2012, 9:18 pm

Periodontics lecture #3

Dr nikola



Ways of treating periodontal disease?

1-simple instructions to the patient

2-simple instructions and scaling and polishing

3-simple instruction,scaling and polishing and root planning

*Closed technique of root planning : I access the area blindly.

*Open technique of root planning : I expose the area .

-How can I access the area in the open technique ?

By elevating a flap.

What is a flap : a section of the gingiva and/or the mucosa surgically separated to improve visibility and access to the bone and root surface.

*We get a scalpel,we have 2 releasing points, till this point the gingival margin is still attached , then I make an incision following the scalloping of the tissues, so now I have 3 releasing points, I get the mucoperiosteal elevator and start elevating the flap.



Why should I raise a flap ?

1-accessibility

2-visibility

3-reconstructing bony defects

4-regenerating defective areas

-When I finish my work I suture for one week . (We should know the reason for that)

*Objectives of raising a flap?

1-improvement of the prognosis

Prognosis : is the prediction of the outcome of our treatment.

2-improvement of the aesthetics

3-pocket therapy ,proper debridement and sometimes bone osteotomy if we have bony defects.

*Goals of our flaps before we start the surgery

1-to expose root surfaces that are not accessible such are those associated with deep pockets or furcations to improve the efficiency of scaling and root planning.

*Efficacy : using a medication, for an object inside the patient’s body

*Efficiency : improving a procedure that we perform.

2-the surgical reduction of pockets ‘’resective pocket surgery’’

3-the induction of adaptation, new attachments and bone regeneration in periodontal pockets.

-What’s the difference between reattachment and new attachment?

Pocketing is the apical migration of the junctional epithelium, when I perform scaling and root planning ,turnover of the junctional epithelium occurs within 2 weeks and it migrates coronally.

In root planning we should direct the working surface of the curette towards the root.

*Curettage:If we direct the curette towards the tissues ,we remove the granulation tissue ,soft cementum and endotoxins from the pocket’s wall.>>turnover within 2 weeks>>migration coronally>> this is called reattachment.(no new tissues ,we only reconditioned the old ones and removed the diseased parts)

New attachment: the original epithelium and connective tissue attachment is lost so we induce new attachment by using bone grafts , GTR and then we allow the periodontal ligament to regrow.

4-the correction of gingival and mucoginigival defects and deficiencies (dehisense,fenestrations,recession,loss of contour,...)

*Pocket reduction surgery :

We have different types of flaps for the treatment of pockets :

1-Gingivectomy: one of its indications is removal of suprabony pockets

2-Apically displaced flaps : with or without osseous resection.

3- Regenerative flap with graft guided tissue regeneration and coronally repositioned flap : we put bone and that is what’s called osteoinduction or osteoconduction,this works as a template to regenerate bone.

*What cells will regenerate when we reposition the flap ?

The epithelial pocket wall

*The epithelium alone won’t provide the full attachment as the connective tissue is also lost.

So we use GTR (guided tissue regeneration) : we put it over the bone and we close the flap.

Using the GTR we get epithelium and periodontal ligament ,but the repopulation of the epithelium is faster so in order to retard the epithelial growth we apply this special type of membrane so that we also get the stronger more favorable periodontal ligament.

4-Plastic surgery techniques to widen the attached gingival using a graft .

*A person who suffers from recession but the attached gingiva is of small width,what should you do?

We take free gingival from a donor site ,mostly from the palate.

-How much is the width of the attached gingival ?

5-Aesthetic surgery ,root coverage and recreation of the gingival papilla.

6-Preprosthetic techniques. eg.crown lengthening

Crown root ratio should be 1/3 to 2/3 if it was less we think of creating a space by crown lengthening either using cuttary (removing a bit of the gingival margin) or scalpel (raising a flap and placing it more apically)

It is very important to restore the biological width after surgery.(will be discussed in details later on)

*The biological width : 2.96 mm and in some books up to 3 mm.



Basic principles of periodontal surgery
*Classification of flap surgery

The first classification is according to thickness depending of the exposure of the bone

Full thickness flap: exposing the bone and root and removing the periosteum.(a mucoperiosteal flap) this procedure is indicated when resective osseus surgery is to be done.As it requires exposure of the bone for GTR.

Partial thickness flap (split thickness) : Reflecting only the epithelium and a layer of the underlying connective tissue,the bone remains covered by the periosteum and a layer of connective tissue.

This is indicated when the flap is to be positioned apically or when the dentist doesn’t wish to expose bone.(the bone is intact and we don’t have bone resorption)

*We have 3 types of incisions : (for full thickness and all types of flaps):

1-Inverse bevel incision :the scalpel is placed lateral to the tissue and should touch the bone

2-crevicular incision

3-removal of the interdental papilla

In the partial thickness : it’s the same thing using the inverse bevel incison but we leave the periosteum on the bone.

The 2nd classification is according to the placement of the flap after surgery

a.non-dispaced (un-repositoned): the flap is sutured in its original place.

Uses : access to the roots for proper debridement.

b.displaced apically (can be utilized through full or partial thickness flaps.)

c.displaced coronally

d.displaced laterally (left or right)

*This should planned carefully before starting the surgery.



The 3rd classification is according to the management of the interdental papilla

If the teeth were very close to each other and I wanted to raise a flap,I excise subginivially using the scalpel and do scalloping of the tissue then I split the papilla (labially and lingually)

*The first technique is called the conventional splitting of the papilla.

*The 2nd technique is called papillary preservation flap which incorporates the entire papilla within the flap .Here we need spacing between the teeth.

The surgeon should know the anatomy really well,the attached gingival , mucogingival line,…

The mucogingival line demarcates the end of the attached gingival.

*3 types of incisions : horizontal,internal bevel,crevicular

The vertical incision is harder to imagine

It is very important to know where to start in the vertical incision , check the diagram in the chapter fig57-10

It is incorrect to split the papilla in 2 ,as this causes recession .

The proper start point is at the line angle of the tooth so that the entire papilla is included or excluded with the flap.

The internal bevel incision is done lateral to the gingival margin.

I leave 0.5 up to 1 mm from the gingival margin.

So lateral means downwards.

Then we do the crevicular incison and use the mucoperiosteal elevator, & the Orban knife to release the interdental papilla.

Then we suture for one week.



Please refer to the chapter for the diagrams.

Sarah Waia
































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Shadi Jarrar
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