Dental Decks - Perio Page 3-20

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Questions and Answers

What is the primary objective of a gingivectomy?

To reshape the gingiva to create a more physiologic architecture

To provide access for instrumentation and remove pocket walls (correct)

To promote periodontal regeneration

To eliminate periodontal pockets regardless of their depth

What is the main difference between a gingivectomy and a gingivoplasty?

The depth of the pocket

The amount of attached gingiva required

The objective of reshaping the gingiva versus eliminating pocket walls (correct)

The type of incision used

When is a gingivectomy contraindicated?

When the gingiva is healthy and free of deformities

When the base of the pocket is located at the mucogingival junction or apical to the alveolar crest (correct)

When the patient demonstrates good oral hygiene

When the pocket wall is fibrous and firm

What is the primary goal of a periodontal flap procedure?

To provide access for instrumentation Signup and view all the answers

Why is the removal of granulation tissue important?

Because it contains epithelium and potential presence of bacterial infiltration Signup and view all the answers

What type of incision is basic to most periodontal flap procedures?

Internal beveled incision Signup and view all the answers

When is surgery contraindicated in periodontal treatment?

When the patient fails to demonstrate adequate oral hygiene during initial therapy Signup and view all the answers

What is the term used to describe the restoration of lost periodontal tissues?

Periodontal regeneration Signup and view all the answers

What is the term used to describe the reunion of epithelium or connective tissue with the root surface or bone?

Reattachment Signup and view all the answers

What is the term used to describe the union of connective tissue or epithelium with the root surface that has been deprived of its original attachment apparatus?

New attachment Signup and view all the answers

What are the three important objectives of the internal bevel incision?

Removes the pocket lining, conserves the outer surface of the gingiva, and produces a sharp flap margin Signup and view all the answers

What is the main purpose of the modified Widman flap?

To facilitate instrumentation and remove the pocket lining Signup and view all the answers

What are the two important anatomic landmarks that determine the choice of flap technique?

Pocket depth and location of the mucogingival junction Signup and view all the answers

What is the difference between the modified Widman flap and the undisplaced flap?

The modified Widman flap removes the pocket lining, while the undisplaced flap removes the pocket wall Signup and view all the answers

What is the advantage of the pedicle graft over the connective tissue graft?

The pedicle graft provides better esthetics Signup and view all the answers

What is a contraindication for the pedicle graft?

All of the above Signup and view all the answers

What is the most amenable type of defect for regeneration using guided tissue regeneration (GTR)?

Deep and narrow defect Signup and view all the answers

What is a contraindication for guided tissue regeneration (GTR)?

All of the above Signup and view all the answers

What is the effect of furcation involvement on guided tissue regeneration (GTR)?

It decreases the predictability of GTR Signup and view all the answers

What is the purpose of evaluating the defect morphology in guided tissue regeneration (GTR)?

To evaluate the width and depth of the defect Signup and view all the answers

What is the primary goal of osseous resective surgery in treating periodontal disease?

To reduce periodontal pocket depth and improve tissue contour Signup and view all the answers

What is the main consideration in determining whether a tooth should be extracted or periodontal surgery performed?

The amount of attachment loss Signup and view all the answers

What type of bone graft is obtained from a different species?

Xenograft Signup and view all the answers

What is the ability of molecules contained in the graft to convert neighboring cells into osteoblasts?

Osteoinductive Signup and view all the answers

What is the primary reason for performing osseous resective surgery?

To arrest etiologic factors that resulted in the formation of the defect Signup and view all the answers

What is the result of horizontal bone loss caused by periodontal disease?

It is not reversible Signup and view all the answers

What is the ability of the graft material to serve as a scaffold that favors outside cells to penetrate the graft and form new bone?

Osteoconductive Signup and view all the answers

What is the first step in treating an infrabony defect?

Eliminating clinically detectable inflammation by scaling and root planing Signup and view all the answers

What is the term used to describe the removal of tooth-supporting bone?

Ostectomy Signup and view all the answers

What is the result of osteotomy to a positive architecture?

Loss of attachment on the facial and lingual root surfaces Signup and view all the answers

What is the goal of osseous surgery?

To eliminate the bony components of the pockets and create a positive bony architecture Signup and view all the answers

What is the most common pattern of bone loss in periodontal disease?

Horizontal bone loss Signup and view all the answers

What is a characteristic of angular defects?

They can have one, two, or three osseous walls Signup and view all the answers

What is the only sure way to determine the presence and configuration of vertical osseous defects?

Surgical exposure Signup and view all the answers

What percentage of decalcification of the bone has to take place before bone loss can start showing on a radiograph?

55-60% Signup and view all the answers

What is the term used to describe the reduction of the interdental bone to the same height as the radicular bone?

Flat architecture Signup and view all the answers

What is the term used to describe the bone pattern that cannot be improved without significant osseous removal that would be detrimental to the overall result?

Compromised osseous reshaping Signup and view all the answers

What is the technique of ostectomy best applied to?

Patients with early to moderate bone loss Signup and view all the answers

What is the main reason why results with this technique are often poor?

Impaired blood supply due to suturing over the root surface Signup and view all the answers

What is the best indicator of success of a periodontal flap procedure?

Postoperative maintenance and plaque control by the patient Signup and view all the answers

What is the objective of an apically positioned flap (APF) in periodontal therapy?

To retain the keratinized gingiva and surgically eliminate deep pockets Signup and view all the answers

What is a contraindication for an apically positioned flap (APF)?

A patient at risk for root caries Signup and view all the answers

What is the main difference between a free mucosal autograft and a free gingival graft?

The presence of epithelial cells Signup and view all the answers

What is the result of epithelial differentiation in a free mucosal autograft?

Formation of keratinized tissue Signup and view all the answers

Why are free gingival grafts often used in conjunction with a frenectomy?

To prevent reformation of high frenal attachments Signup and view all the answers

What is the main event that occurs immediately after suturing in flap surgery?

Formation of a blood clot Signup and view all the answers

What occurs 1 week after flap surgery?

Establishment of an epithelial attachment to the root Signup and view all the answers

What is a characteristic of the healing process after flap surgery?

Degeneration of the epithelium of free gingival grafts Signup and view all the answers

What should be considered for a wide and deep osseous defect if the tooth is important in the arch?

Regenerative efforts Signup and view all the answers

What is the advantage of the free connective tissue autograft technique?

The donor tissue is obtained from the undersurface of the palatal flap, which is sutured back in primary closure Signup and view all the answers

What is the main difficulty in achieving complete root coverage with a free gingival autograft?

The graft is placed over a root surface also devoid of a blood supply Signup and view all the answers

What is the key difference between a free gingival graft and a positioned flap?

The vascular supply to the flap Signup and view all the answers

What is the purpose of the apically positioned flap?

To increase the width of attached gingiva apical to the area of recession Signup and view all the answers

What is the significance of the number of remaining bony walls in regeneration?

The greater the number of remaining walls, the greater the predictability of regeneration Signup and view all the answers

What is the purpose of the free gingival autograft?

To create a widened zone of keratinized attached gingiva with the possibility of gaining root coverage Signup and view all the answers

What is the characteristic of the healing process in a free gingival graft?

The top layers of the graft are the last to be revascularized, resulting in necrotic slough Signup and view all the answers

What is the indication for the laterally positioned flap?

To cover isolated, denuded roots with adequate donor tissue laterally and vestibular depth Signup and view all the answers

What is the purpose of the 'double papilla flap'?

To cover roots denuded by isolated gingival defects with a flap formed by joining the contiguous halves of the adjacent interdental papillae Signup and view all the answers

What is the primary factor that determines the success of periodontal bone grafting?

Number of bony walls of the defect Signup and view all the answers

Which type of defect is also known as a hemiseptum?

One-wall vertical defect Signup and view all the answers

What is the most common side effect of osseous grafting?

Root resorption Signup and view all the answers

What is the term used to describe a loss of the buccal or lingual bone overlaying the root portion of a tooth?

Dehiscence Signup and view all the answers

What is the purpose of a vertical releasing incision in a periodontal flap?

To increase flap mobility Signup and view all the answers

What is the difference between a full-thickness and a split-thickness periodontal flap?

Thickness of the flap Signup and view all the answers

What is the term used to describe a saucer-shaped defect of soft tissue or bone?

Crater Signup and view all the answers

What is the ideal location for a vertical releasing incision in a periodontal flap?

At the line angles Signup and view all the answers

What is the purpose of a periodontal flap in osseous resective surgery?

To expose the underlying bone Signup and view all the answers

What is the amount of bone loss associated with a full-thickness mucoperiosteal flap?

0.5 mm Signup and view all the answers

What is formed 2 weeks after surgery from the gingival connective tissue, bone marrow, and periodontal ligament?

Granulation tissue Signup and view all the answers

What is the result of full-thickness flaps, which denude the bone?

All of the above Signup and view all the answers

What is the advantage of apically displaced flaps?

Preserving the outer portion of the pocket wall and transforming it into attached gingiva Signup and view all the answers

What type of incision is used in a periodontal flap procedure?

Both horizontal and vertical incisions Signup and view all the answers

What is the purpose of the crevicular incision?

To create a collar of tissue around the tooth Signup and view all the answers

What is the term used to describe the position of interdental bone in relation to radicular bone?

Negative architecture Signup and view all the answers

What is the characteristic of a split thickness flap?

Results in less bone loss than a full-thickness flap Signup and view all the answers

What is the result of osteoclastic resorption in full-thickness flaps?

Loss of 1mm of bone Signup and view all the answers

What is the purpose of vertical or oblique releasing incisions?

To allow for the release of the flap to be displaced apically or laterally Signup and view all the answers

What is the characteristic of a displaced flap?

The flap is physically attached at its apical base by a pedicle of lining mucosa and an intact blood supply Signup and view all the answers

Study Notes

Osseous Resective Surgery

Does not cure periodontal disease
Horizontal bone loss caused by periodontal disease is not reversible
Performed in combination with apically positioned flaps to reduce periodontal pocket depth and improve tissue contour
Other treatment options to consider before choosing osseous resection or recontouring:
- Maintenance with periodic root planing
- Osseous regenerative procedures
- Hemisection or root amputation
Clinically detectable inflammation must be eliminated by scaling and root planing and optimal patient plaque control

Periodontal Regeneration

Restoration of lost periodontium or supporting tissues
Types of regeneration:
- Reattachment: reunion of epithelium or connective tissue to root surface or bone
- New attachment: union of connective tissue or epithelium with root surface that has been deprived of its original attachment apparatus
- Repair: healing of wound by tissue that doesn't fully restore architecture or function

Gingivectomy

Excision of the gingiva
Provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots
Indicated for:
- Elimination of suprabony pockets
- Elimination of gingival enlargement
- Elimination of suprabony periodontal abscesses
Important: adequate amount of attached gingiva must be present before performing a gingivectomy

Gingivoplasty

Reshaping of the gingiva and papilla of a tooth for correction of deformities
Objectives:
- Provide a more physiological tissue contour
- Correct tissue contours resulting from necrotizing gingivitis

Periodontal Flap Procedures

Objective: to provide access for instrumentation and improve accessibility
Types of flaps:
- Modified Widman flap
- Undisplaced flap
- Apically displaced flap
Internal bevel incision:
- Removes the pocket lining
- Conserves the relatively uninvolved outer surface of the gingiva
- Produces a sharp, thin flap margin for adaptation to the bone-tooth junction

Osseous Defects

Evaluation:
- Depth and width analysis
- Number of bony walls
- Defect morphology
Treatment:
- Regenerative efforts
- Apically positioned flap with or without osseous resection
- Maintenance therapy

Pedicle Graft

First periodontal plastic surgery procedure used for root coverage
Provides a superior result from an esthetic standpoint
Major advantages:
- Predictable correction of gingival recession
- Postoperative discomfort is usually minor
- Good esthetics

Periodontal Plastic Surgery

Techniques used to increase the width of attached gingiva:
- Free gingival autograft
- Free connective tissue autograft
- Apically positioned flap
Techniques used for gingival augmentation coronal to the recession:
- Free gingival and connective tissue autograft
- Pedicle autografts
- Subepithelial connective tissue graft
- Guided tissue regeneration

Flap Surgery

Objective: to surgically eliminate deep pockets
Indications:
- Moderate or deep pockets
- Furcation-involved teeth
- Crown lengthening
Contraindications:
- Patient at risk for root caries
- Excessive root surfaces exposed
- Unesthetic tooth exposure

Healing After Flap Surgery

Immediately after suturing (up to 24 hours): a connection between the flap and the tooth or bone surface is established by a blood clot
1-3 days after surgery: epithelial cells migrate over the border of the flap, usually contacting the tooth at this time
1 week after surgery: an epithelial attachment to the root has been established
1 month after surgery: a fully epithelialized gingival crevice with a well-defined epithelial attachment is present
Functional arrangement of supracrestal fibers is initiated### Incisions in Periodontal Surgery
The first incision, also called the initial incision or reverse bevel incision, is made from the mucogingival junction to the base of the pocket.
The second incision, or crevicular incision, is made from the base of the pocket to the crest of the bone.
The third incision, or interdental incision, separates the collar of gingiva from the tooth.
Vertical or oblique releasing incisions can be used on one or both ends of the horizontal incision to allow for flap mobility and access to the operative area.

Osseous Architecture

Positive architecture refers to the radicular bone being apical to the interdental bone.
Negative architecture refers to the interdental bone being more apical than the radicular bone.
Flat architecture is the reduction of the interdental bone to the same height as the radicular bone.
Ideal osseous form is characterized by a consistent, more coronal bone height on interproximal surfaces than on facial and lingual surfaces.

Osseous Reshaping Techniques

Osteoplasty refers to reshaping the bone without removing tooth-supporting bone.
Ostectomy includes the removal of tooth-supporting bone to produce the desired results.
Definitive osseous reshaping implies that further osseous reshaping would not improve the overall result.
Compromised osseous reshaping indicates a bone pattern that cannot be improved without significant osseous removal that would be detrimental to the overall result.

Classification of Osseous Defects

Horizontal bone loss is the most common pattern of bone loss in periodontal disease.
Vertical or angular defects occur in an oblique direction, leaving a hollowed-out trough in the bone alongside the root.
Angular defects can have one, two, or three walls.
Combined osseous defects have a different number of walls in the apical and occlusal portions.

Periodontal Bone Grafting

The relative degree of success of periodontal bone grafting varies directly with the number of bony walls of the defect and inversely with the surface area of the root against which the graft is implanted.
A narrow, three-walled angular defect usually yields the greatest success.
Osseous grafting techniques and materials include osseous coagulum, autogenous intra-oral bone, and freeze-dried bone allograft.

Important Notes

55% to 60% of decalcification of the bone has to take place before bone loss can start showing on a radiograph.
Root resorption is the most common side effect of osseous grafting.
A dehiscence is a loss of the buccal or lingual bone overlaying the root portion of a tooth, leaving the area covered by soft tissue only.
A crater is a saucer-shaped defect of soft tissue or bone often seen interdentally.

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Description

Learn about the limitations and techniques of osseous resective surgery in treating periodontal disease, including its combination with apically positioned flaps and alternative treatment options.