Dr.

Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

questions

Periodontal Surgery
January 25, 2012

milie Vachon, D.M.D. Graduate Periodontology vach0028@umn.edu 7th floor

Carranza 10th ed
Chapter 64 p. 926-936 Chapter 65 p. 937-949

Overview

Surgical Procedures
- Gingivectomy - Periodontal Flaps - Osseous Contouring - Bone Grafts - Laterally Sliding Flap - Free gingival Graft

Surgical Procedures

Incision Design

Flap indications

Pain Management

Periodontal aps
Increase access to root Reduce pocket depth Expose area for regeneration Crown lengthening

Overview

Surgical Procedures

Incision Design

Flap indications

Pain Management

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Incision Design Horizontal Incision

VS

Vertical Incision

HORIZONTAL INCISION
Incision Design

Incision Design
Internal bevel scalloped

3 types of incisions

Internal bevel

Sulcular incision

Interdental incision

Incision Design

Incision Design

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Incision Design
1. modied widman 2. undisplaced 3. apically displaced

Incision Design
Internal Bevel Scalloped

Incision Design HORIZONTAL INCISION

Internal Bevel Scalloped sulcular incision

Review gingival anatomy

Alveolar mucosa Mucogingival junction Attached gingiva

Vertical releasing Incision

Incision Design

Vertical releasing Incision

Incision Design

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Armamentarium
1. #15 Blade 2. #11 Blade 3. #12 Blade 4. #12B Blade

Armamentarium

Flaps Full Thickness Flap

VS

Partial Thickness Flap

Full Thickness Flap Partial Thickness Flap

Full Thickness Flap

Partial Thickness Flap

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Full Thickness Flap

Full Thickness Flap

6 months Post FTF Bone Loss on Premolar

FLAP DESIGN

CONVENTIONAL FLAP TECHNIQUE

2 BASIC FLAP DESIGN 1. CONVENTIONAL FLAP 2. SULCULAR INCISION FLAP

SULCULAR INCISION

Repositioned Flap VS Apically Positioned Flap

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Apically Positioned Flap

Apically Positioned Flap

Apically Positioned Flap

Apically Positioned Flap

Probing Beyond Mucogingival Junction

Flap Indications

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Surgical Crown Lengthening

Biologic Width
Restorative margin cannot be placed closer than 2 mm to crestal bone or will disrupt attachment structure

Biologic Width

Biologic Width
Expose 3-4 mm of tooth coronal to bone during surgery to accommodate 2 mm biologic width

Surgical Crown Lengthening

Surgical Crown Lengthening

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Primary Incision
Internal Bevel

Primary Incision

Primary Incision

Primary Incision
Flap Reected

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Secondary Incision

Buck or Orban Knives

Remove Interproximal Tissue

Full Thickness Flap Reected

Full Thickness Flap Reected

Suturing

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Suturing

Interrupted Sutures

Coe Pack Placed

Dressing Removal Times

General Guidelines

-Minimum - 3 to 4 days -Maximum - 7 to 10 days

Post-Surgical Hemorrhage

Chlorhexidine Rinses

- Pressure - Remove pack, sutures, clot - Identify source/stop bleeding

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

4 Weeks Postoperative

Free Gingival Grafting

Recession, no attached gingiva

FREE GINGIVAL GRAFTING

Incision

Partial Thickness Flap

FREE GINGIVAL GRAFTING

FREE GINGIVAL GRAFTING

Remove Keratinized Epithelium

Tin Foil Template on Donor Site

Suture Alveolar Mucosa

Donor Site Incision Palate

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

FREE GINGIVAL GRAFTING

FREE GINGIVAL GRAFTING

Suture to Reect Graft

Place Graft on Recipient Site Donor Surgical Site

Free Gingival Graft

Place Coe Pack over Recipient Site Coe Pack over Donor Site

FREE GINGIVAL GRAFTING

initial presentation...

10 Days Post Surgery

Pain Management

6 Weeks Post Surgery

A Flexible Analgesic Strategy

If aspirin-like drugs are indicated

A Flexible Analgesic Strategy

If aspirin-like drugs are contraindicated

Mild Pain Moderate Pain

200 to 400 mg ibuprofen or 650 mg aspirin

Inadequate pain relief

Mild Pain

600 to 1000 mg acetaminophen

Inadequate pain relief

600 to 800 mg ibuprofen

Inadequate pain relief

400 mg ibuprofen plus nonnarcotic/narcotic combination analgesic equivalent to 60 mg codeine

Inadequate pain relief

Moderate Pain

600 to 1000 mg acetaminophen and narcotic equivalent to 60mg codeine or hydrocodone

Inadequate pain relief

Severe Pain

600 to 800 mg ibuprofen plus non-narcotic combination analgesic equivalent to 10 mg oxycocodone

Severe Pain

1000 mg acetaminophen and narcotic equivalent to 10mg oxycocodone

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Types of Incision Design for Distal Wedges Surgical Procedures

Distal Wedge Procedures

Types of Incision Design for Distal Wedges Surgical Procedures

Distal Wedges Surgical Procedures

Distal Wedge

Distal Wedge

Distal Wedge - Diverging Incisions

Distal - 2nd Molar - 7 mm Pocket

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Dr. Emilie Vachon Periodontology III Spring Semester, 2012 School of Dentistry University of Minnesota

Distal Wedge
Full-Thickness Flap Reected

7 Days Post Surgery

Flap Approximation

Flap sutured

Distal Pocket Elimination

Distal Pocket Elimination

distal parallel incision

Internal bevel and sulcular incisions

distal parallel incision

Internal bevel and sulcular incisions

Full thickness reflection

Flap thinned

Full thickness reflection

Flap thinned

Summary
Biologic width: ~2mm (1mm connective tissue attachment, 1mm epithelial attachment) Vertical releasing incisions extend beyond the MGJ, improves visibility and mobility of ap Horizontal incisions include the internal bevel, sulcular and interdental incision Full thickness ap includes the periosteum into the ap while partial-thickness ap leaves the periosteum over the bone Apically displaced ap is aimed at reducing pocket depth

questions
milie Vachon, D.M.D. Graduate Periodontology vach0028@umn.edu 7th floor
Carranza 10th ed
Chapter 64 p. 926-936 Chapter 65 p. 937-949

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