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GENERAL PRINCIPLES OF PERIODONTAL SURGERY 10.02.07 MT is on OCT 30th.

Basic objectives of surgery - create a cleansable environment - augment keratiniazed gingival - improve esthetics - establish biologic width - regeneration Indications for surgery - soft tissue defects - perio pockets (unmaintainable) - inadequate attached gingival - inadequate biologic width - esthetics Contraindication for surgery - poor plaque control - medical o radiation therapy o uncontrolled diabetes this impacts healing o bleeding disorders maybe do a med consult o hypertension - psychology o you need to have realistic expectations o are they psychologically balanced? - Age o There really is not a cut off in this category evaluate each case. - teeth too seriously involved - failure to accept entire treatment plan - esthetic considerations - patient wishes Selection of surgical techniques is influenced by: - objective - predictability - cost / benefit Gingivectomy indications - not really done nowadays o common in older patients - pocket reduction (gingival enlargement)

establish healthy contours o altered passive eruption gummy smile can be due to normal crown length but overgrown gingival

Gingivectomy procedure 1. probe pocket 2. make bleeding points at the depths of those probings 3. Kirklan blade (looks like a kidney bean) 4. Make an external bevel incision at a 45 degree angle towards bleeding point. 5. Orband spear / knife used to detach interproximal tissue 6. Debridement 7. Possibly integrate a gingivoplasty smooth the contoures of the gingival to create nice contoure. a. Use back side of kirklan blade (I think?) 8. takes 4-6 weeks to heal a. remove epithelium and some connective tissue b. the epithelium takes a while to come back fully Contraindications for gingivectomy: - inadequate keratinized gingival - infrabony defects - esthetics Gingivectomy v. flap - gingivectomy do not expose bone! - Flap DOES expose bone! o Provide access to roots o Reduce pockets o Preserve or create adequate zone of attached gingiva o Access to underlying bone for treatement of osseous defects Informed consent: - Diagnosis - Prognosis - Reason for proosed treatment - Nature of the therapy - Risk of the therapy - Prospects for success - Expected outcome without treatment Hypertension - BP elevated to 140/90 or greater - More prevalent in blacks than whites - Increases with age in all groupes

Avoid Surgery when BP is: - 160 (systolic) or 100 (diastolic) to prevent excessive bleeding Anticoagulant therapy: - Coumadin o Consult physician o 2x normal prothrombin time o Take instructions from physician regarding reducing dosing - Asprin o Probably leave them on the asprin dose HIV / CARE surgical patients - platelet count - PMN - T-cell For Corticosteroid Therapy, prior to surgery do the following: - consult physician - rule of twos adrenocortical suppression should be suspected if o If they have been taking a dose of 20mg or more of cortisone or equvlanet o for a continuous period of 2 weeks or longer o within 2yrs of dental treatment. - Provide 2-4x dose of corticosteroids Problems (likely to slough off): - Graft is yellow - Graft is super white Primary reason for placing a periodontal dressing (on exam): - Patient comfort! o Cover edge of would o No overextension o No occlusal problems o One other thing? Placing periodontal pack - cover edge of wound - no overextension - no occlusal interference - *wait until bleeding has stopped Swelling - best prevented by immediate use of ice packs - after swelling develops, use hot moist packs and frequent lavage with warm saline solution - antibiotic (broad spectrum)

Persistent bleeding after surgery: - remove back - find area of bleeding - apply pressure / local anesthetic - sutured / pressure / electrocautery - place pack when bleeding is controlled Verbal and written post-surgery instructions are necessary. - ibuprophen (asprin / motrin) - others PRN Diet: normal diet avoid tart or spicy foods fruit juices (may want to use straw) avoid smoking for at least 24hrs. o irritates gingival o delays healing

Consider antibiotics following surgery when the pt is / has: - diabetic - guided tissue regeneration - extensive procedures or long duration - infection

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