Introduction to Periodontal and Implant Surgery

Transcription

1 Introduction to Periodontal and Implant Surgery Professor Jon B. Suzuki, DDS, PhD, MBA Temple University Professor of Microbiology and Immunology (Med) Professor of Periodontology and Oral Implantology (Dent) Associate Dean for Graduate Education Director, Periodontology Residency Program

2 DIAGNOSIS Initial Therapy S/RP (2-4 Appts) Surgery Non-Surgery Maintenance

3 Treatment Plan 1. Review Med/Dental Hx 2. Dx: Periodontitis 3. Initial Tx: -OHI -Occlusal Control -Rx CHX, phenol, Cetylpyridium rinses -Ultrasonics Scaling/RP/Polish - Evaluation (4-6 weeks) 4. Periodontal Surgery 5. Maintenance ( q 3 mos)

4 Antimicrobials* Chlorhexidine, 0.12% (Peridex, Periogard, Oris) Phenols/Essential Oils (Listerine) Cetylpyridium Cl (Crest ProHealth) Stannous Fluoride *FDA Approved

5 PRE-PROCEDURAL RINSING Safety for both Patient and Clinician A pre-procedural rinse of 0.12% CHX reduces risk of IE (formerly SBE ) (Pts) and reduces airborne oral microbes (Staff) Worrall, SF,. Br Dent J 1987;163:

6 American Society of Anesthesiology ASA I: A patient without systemic disease: a normal healthy patient ASA II: A patient with mild systemic disease ASA III: A patient with severe systemic disease that limits activity, but is not incapacitating ASA IV: A patient with incapacitating systemic disease that is a constant threat to life

7 Measured Blood Pressure Systolic Diastolic Follow-up Normal <130 <85 Annual Recheck High Normal 130 to to 89 Annual Recheck Dental Treatment OK OK Hypertns Stage I (mild) 140 to to 99 2 Month Recheck Stage II (Moderate) 160 to to 109 Refer to MD OK OK Stage III (Severe) 180 to to 119 Refer to MD ASAP Emergencies no Epi Stage IV (Very Severe) Refer to MD ASAP Emergencies no Epi

8 Measured Blood Pressure (extractions/surgery) Systolic Diastolic Follow-up Normal <130 <85 Annual Recheck High Normal 130 to to 89 Annual Recheck Hypertns Stage I (mild) 140 to to 99 2 Month Recheck Stage II (Moderate) 160 to to 109 Refer to MD No Stage III (Severe) 180 to to 119 Stage IV (Very Severe) Refer to MD ASAP Refer to MD ASAP PerioSX/Extr Treatment OK OK Caution/No Emergencies no Epi Emergencies no Epi

9 Medical (examples) BP: excess bleeding Liver: excess bleeding Heart: Rx Antibiotics Lungs: coughing during sx Diabetes mellitus: impaired wound healing CT diseases: impaired wound healing Arthritis (Rheum or Osteo): Oral Hygiene

10 Medications (examples) Blood thinners: Bleeding Steroids: Impaired wound healing Inhalants: Coughing during Sx Bisphosphonates (IV, Oral): ONJ Organ Transplant meds: Wound Healing Antineoplastic meds: Wound Healing

11 Treatment Plan 1. Review Med/Dental Hx 2. Dx: Periodontitis /Insurance Codes 3. Initial Tx: -OHI -Occlusal Control -Rx CHX, phenol, Cetylpyridium rinses -Ultrasonics Scaling/RP/Polish - Evaluation (4-6 weeks) 4. Periodontal Surgery 5. Maintenance ( q 3 mos)

12 Periodontal Therapies: Surgical Suprabony pockets Flap Surgery Pseudopockets Gingivectomy Infrabony pockets Regeneration* *Regeneration Approaches Osseous Defects Extraction Sockets Implants

13 Healthy Periodontium Plaque Pockets Systemic Diseases Medication Stress Smoking Pregnancy Hormones OHI S/RP Polish Non Sx Sx Three Types of Pockets 1. Antimicrobials Rx Pseudo (gingival) Pockets Suprabony Pockets Infrabony Pockets 2. Antibiotics 3. Periostat Gingivectomy Modified Widman Flap Resection Regeneration 4. NSAID? APF -Bone Grafts -GTR -Amelogenin -Combinations

14 Periodontal Surgeries Gingivectomy: Crown Lengthening (soft tissue) Gingival Hyperplasia Osseous Sx: Crown Lengthening (hard tissue) Resection Free Gingival Grafts: Keratinized Gingiva Connective Tissue Grafts: Root Coverage Regeneration: New Bone, PDL, Cementum Implants: Replace Missing Teeth

15 Steps of Periodontal Surgery A. Patient selection B. Instrument selection C. Patient Documentation D.CHX prerinse E.Surgical Incisions F.Debridement and S/RP E.Suture G.Post Op Instructions and Rx

16 Two (2) Surgical Kits Always have a sterilized back-up surgical kit A. Infection controlled maintained if you drop an instrument B. You will not have to interrupt the surgery C. Patient peace of mind

17 Steps of Periodontal Surgery A. Patient selection B. Instrument selection C. Patient Documentation D. CHX prerinse E. Surgical Incisions F. Debridement and S/RP E.Suture G. Post Op Instructions and Rx

18 Summary of Periodontal Surgeries Flap Surgery open flap debridement osseous resection regenerative implant placement ridge modification / graft harvest Mucogingival Procedures free gingival graft connective tissue graft pedicle flaps semi-lunar flap

19 Other Periodontal Surgeries frenectomy gingivectomy canine exposure vestibuloplasty fiberotomy

20 Incision Design external bevel incision marginal / internal bevel incision submarginal incision sulcular incision crestal para-crestal

21 Incision Design Marginal vs. Sulcular Histological study of sulcular incision flaps vs. internal bevel incision flaps in humans By 21 days of healing, the 2 surgical methods were indistinguishable histologically It is suggested that the inverse bevel primary incision traditionally advocated for apically positioned flap surgeries may be replaced by the more rapid and simple sulcular incision as the preferred technique. Pippin 1990

22 Incision Design external bevel incision marginal / internal bevel incision submarginal incision sulcular incision crestal para-crestal

23 Incision Design Edentulous ridge incisions crestal preferred design para-crestal access keratinized tissue incision line placement

24 Incision Design loss of blood flow in area coronal to horizontal incisions loss of vascularity as the width of the flap decreased; recommended the width be at least half the height of the flap loss of vascularity when flaps were placed under tension Mormann, 1977

25 Periodontal Dressings 3 major reasons to use to protect wounds postsurgically to obtain and maintain close adaptation of flap to bone for patient comfort

26 Periodontal Dressings Coe-Pak (mix), Barricaid (light cure) incorporating antibacterial components probably is not effective Sanz et al., 1989: dressings with CHX rinses were better than dressings with a placebo rinse in terms of plaque formation, GI, and probably patient comfort antibacterial mouth rinsing alone may be more effective than rinsing with a dressing