牙周病手術(shù)治療

CommonsurgeryPeriodontalDepartmentDengyuquanGingivalsurgeryHealthygumsareanimportantpartofaperson'sgeneraloralhygieneandappearance.Sometimesincertainpeoplethegumscangrowandbuildupoverthefronttoothsurface.Theformationofextragumcanchangethebalancebetweenthelengthoftheteethandtheheightofthegumline,insomecasesleadingtoapersonhavingabadsmile.Thesuffix“…ectomy”Normallyisusedastheterminationofawordthatdescribestheorganremoved–e.g.,“appendectomy”.Thesuffix“…plasty”Meanstoreshapethetissueororganwithoutremovingit.GingivalsurgeryGINGIVECTOMY

Theexcisionofaportionofthegingiva.Theobjectiveistodecreasepocketdepthandexposemoretooth.GINGIVOPLASTY

Thereshapingofthegingivatissuetoaphysiologicalarchitecture,withoutreducingitscoronal-apicaldimension.

Whiletheseprocedureshavedifferentobjectives,theyarefrequentlyperformedtogether.GingivalsurgeryGingivalhypertrophyorhyperplasyShallowsuprabonypocketChronicperiodontalabscessnearcrownGingivacovercrowntoomuchtoaffectfilling,repairorpericoronitisIndicationsThebottomofthepocketisapicaltothemucogingivaljunctionTheneedforbonesurgeryorexaminationoftheboneshapeandmorphologyContraindicationsBuckknifeElectroknifeInstrumentBlakeknifeStep1:ThepocketsareexploredandmarkedStep2:Incsionsonthefacial,lingualorsomedistalsurfaceStep3:Removetheexcisedwall,cleantheareaStep4:Carefullycuretteoutthegranulationtissue,remainingcalculusandnecroticcementumStep5:CovertheareawithasurgicalpackGingivectomyGingivalEnlargementBeforetreatment,chronicinflammatorygingivalenlargementwithtumorlikearea.Thepocketsoneachsurfaceareexploredwithaperiodontalprobeandmarkedwithapocketmarker.Eachpocketismarkedinseveralareastooutlineitscourseoneachsurface.Angletheknifeapproximately45otothelongaxisoftheteeth,keepingtheincisionapicaltothebleedingpoint.thethickerthetissue,themoreapicalthepenetrationofthebladetoachievea45degreeanglewhichterminatesjustapicaltothebaseofthepocket.FreeandRemoveInterproximalTissueSpear-shapedknivesareused.Extendtheinitialincisionintotheinterproximalandconnectitwiththeoppositeincision.Carefullycuretteoutthegranulationtissueandremoveanyremainingcalculusandnecroticcementumsoastoleaveasmoothandcleansurface.BeforetreatmentAftertreatmentGingivoplastyGingivoplastyissimilartogingivectomy,butitspurposeisdifferent.Gingivectomyisperformedtoeliminateperiodontalpocketsandincludesreshapingaspartofthetechnique.Gingivoplastyisareshapingofthegingivatocreatephysiologicgingivalcontours,withthesolepurposeofrecontouringthegingivaintheabsenceofpockets.Aperiodontalflapisasectionofgingivaand/ormucosasurgicallyseparatedfromtheunderlyingtissuestoprovidevisibilityofandaccesstoboneandrootsurface.Theflapalsoallowsthegingivatobedisplacedtoadifferentlocationinpatientswithmucogingivalinvolvement.PeriodontalflapsurgeryOutlineClassificationofflapsDesignoftheflapIncisions-Horizontalincisions-VerticalincisionsElevationoftheflapSuturingtechniques-Technique-Ligation-TypesofsuturesHealingafterflapsurgeryThepurposesforpockettherapyIncreaseaccessibilitytorootdepositsEliminateorreducepocketdepthbyresectionofthepocketwallExposetheareatoperformregenerativemethods.InstrumentDiagnostics:

MirrorPeriodontalprobeStraightprobeTweezersFlaps:

ScalpelhandlesPeriostealelevatorRootplaning:

UniversalcurettesGraceycurettesSuturing:

TissueforcepsNeedleholderArteryforcepsScissorClassificationofflapsBoneexposureafterflapreflection--full-thickness--partial-thicknessflaps

Placementoftheflapaftersurgery--nondisplaced--displaced(apical,coronal,lateral)flapsManagementofpapilla

--conventional

modifiedWidmanflap

nondisplacedflap

apicallydisplacedflap--papillapreservationflapsFullThicknessFlapVsPartialThicknessFlapA,Diagramoftheinternalbevel-incision(firstincision)toreflectafullthickness(mucoperiosteal)flap.Notethattheincisionendsonthebonetoallowforthereflectionoftheentireflap.B,Diagramoftheinternalbevelincisiontoreflectapartialthicknessflap.Notethattheincisionendsontherootsurfacetopreservetheperiosteumonthebone.RepositionedFlapVsApicallyPositionedFlapBasedonflapplacementaftersurgeryApicallypositionedflapcaneliminatethepocketandincreasingthewidthoftheattachedgingivatheconventionalflapIntheconventionalflaptheinterdentalpapillaissplitbeneaththepointofthetwoapproximatingteethtoallowreflectionofbuccalandlingualflaps.Theincisionisusuallyscallopedtomaintaingingivalmorphologywithaspapillaaspossible.Theconventionalflapisusedwhen1)theinterdentalspacesaretoonarrow,therebyprecludingthepossibilityofpreservingthepapilla,and2)whentheflapistobedisplaced.papillapreservationflapsA:Incisionsaredepictedbyinterruptedlines.Preservedpapillacanbeincorporatedintofacialorlingual-palatalflap.B:Thereflectedflapexposestheunderlyingbone.Severalosseousdefectsareseen.C:Flapreturnedtooriginalpositioncoveringentireinterdentalspaces.IncisionsdesignforperiodontalflapVerticalincisionsHorizontalincisionsInternalbevelincisionStartsatadistancefromthegingivalmarginandisaimedatthebonecrest.CrevicularincisionStartsatthebottomofthepocketandisdirectedtothebonemargin.InterdentalincisionPerformedaftertheflapiselevated.ThreeincisionsnecessaryforflapsurgeryInternalbevelincisionTheinternalbevelincisionisbasictomostperiodontalflapprocedures,fromwhichtheflapisreflectedtoexposetheunderlyingboneandroot.Theinternalbevelincisionaccomplishesthreeimportantobjectives:1)itremovesthepocketlining;2)itconservestherelativelyuninvolvedoutersurfaceofthegingiva,which,ifapicallypositioned,becomesattachedgingiva;and3)itproducesasharp,thinflapmarginforadaptationtothebone-toothjunction.LocationsoftheinternalbevelincisionsforthedifferenttypesofflapsTheinternalbevelincisionshouldbescallopedtopreserve,asmuchaspossible,theinterdentalpapilla.Thisallowsbettercoverageoftheboneatboththeradicularandtheinterdentalareas.Dependingonthedesignandpurposeoftheflap,verticalorobliquereleasingincisionscanbeusedononeorbothendsofthehorizontalincision.Iftheflapistobeapicallydisplaced,verticalincisionsatbothendsarenecessary.Verticalincisionmustextendbeyondthemucogingivalline,reachingthealveolarmucosa.Ingeneral,verticalincisionsinthelingualandpalatalareasareavoided.Facialverticalincisionsshouldnotbemadeinthecenterofaninterdentalpapillaorovertheradicularsurfaceofatooth.VerticalincisionsVerticalincisionsIncisionsshouldbemadeatthelineanglestopreventsplittingofapapillaorincisingdirectlyoveraradicularsurface.DISTALMOLARSURGERYTreatmentofperiodontalpocketsonthedistalsurfaceofterminalmolarsisoftencomplicatedbythepresenceofbulbousfibroustissueoverthemaxillarytuberosityorretromolarpadsinthemandible.

Deepverticaldefectsarealsocommonlypresentinconjunctionwiththeredundantfibroustissue.Thegingivectomyincisionisthemostdirectapproachintreatingdistalpocketsthathaveadequateattachedgingivaandnoosseouslesions.Atransversalincisionismadeatthedistalendofthetwoparallelincisionssothatalong,rectangularpieceoftissuecanberemoved.Theseincisionsaremadestraightdownintotheunderlyingbonewhereaccessisdifficult.MaxillarysecondmolarMandibularmolarsIncisionsforthemandibulararchdifferfromthoseusedforthetuberosity,owingtodifferencesintheanatomyandhistologicfeaturesoftheareas.Theretromolarpadareadoesnotusuallypresentasmuchfibrousattachedgingva.Thekeratinizedgingivamaynotbefounddirectlydistaltothemolar.elevationofaflapWhenafullthicknessflapisdesired,thereflectionisaccomplishedbybluntdissection.Aperiostealelevatorisusedtoseparatethemucoperiosteumfromthebonebymovingitmesially,distally,andapicallyuntilthedesiredreflectionisaccomplished.Sharpdissectionisnecessarytoreflectapartialthicknessflap.Asurgicalscalpelisused.SuturingAfterallthenecessaryproceduresarecompleted,theflapisplacedinthedesiredposition,whereitshouldremainwithouttension.Theterm“suture”describesanystrandofmaterialutilizedtoligatebloodvesselsorapproximatetissues.Theprimaryobjectiveofdentalsuturingistopositionandsecuresurgicalflapsinordertopromoteoptimalhealing.NeedledesignandsuturinginstrumentsTypesofsuturematerialsNonresorbableSilkPolyesterNylonPTFEResorbableNaturalPlaingutChromicgutSyntheticCoatedvicryl

Suturingtechniques

Somecommonmethods:InterruptedsuturesSimpleloopsutureFigure8sutureSlingsuturesIndependentslingsutureContinuousslingsutureSuturingtechniquesInsertedthroughthemoremobileflapfirst.Shouldbeplacednocloserthan2-3mmfromtheedgeoftheflap.Intheinterdentalpapillashouldenterandexitthetissueatapointlocatedbelowtheimaginarylinethatformsthebaseofthetriangleoftheinterdentalpapilla.Theknotshouldnotbeplacedovertheincision.SimpleLoopsutureAsimpleloopsutureisusedtoapproximatethebuccalandlingualflaps.Theneedlepenetratestheoutersurfaceofthefirstflap.Theundersurfaceoftheoppositeflapisengaged,andthesutureisbroughtbacktotheinitialside,wheretheknotistied.Figure8sutureTheneedlepenetratestheoutersurfaceandtheoutersurfaceoftheoppositeflap.Thesutureisbroughtbacktothefirstflap.Andtheknotistied.Aninterruptedfigure-eightsutureisusedtoapproximatethebuccalandlingualflaps.SingleinterruptedSlingSutureNeedleengagestheoutersurfaceoftheflapandencirclesthetooth.Outersurfaceofthesameflapoftheadjacentinterdentalareaisengaged.Sutureisreturnedtotheinitialciteandtheknottied.Asingle,interruptedslingsutureisusedtoadapttheflaparoundthetooth.Thecontinuous,independentslingsutureContinuous,independentslingsutureusingahorizontalmattresssuturearoundwideinterdentalareas.Thismattresssutureisutilizedonboththebuccalandthelingualsurfaces.Continuationofsutureonlingualsurfacesandcompletedsuture.Thecontinuousindependentslingsutureisusedwhenthereisbothafacialandalingualflapinvolvingmanyteeth.AnchorsutureThissutureclosesthefacialandlingualflapsandadaptsthemtightlyagainstthetooth.Theneedleisplacedatthelineangleareaofthefacialorlingualflapadjacenttothetooth,anchoredaroundthetooth,passedbeneaththeappositeflag,andtied.Anchorsutureisusedtocloseaflapmesialordistaltoatooth.

PeriodontalDressingsToprotectthewoundpostsurgicallyMinimizesthelikelihoodofpostoperativeinfectionandhemorrhageToobtainandmaintainacloseadaptationofthemucosalflapstotheunderlyingbonePreventingsurfacetraumaduringmasticationCoe-PakCoe-Pak,commonlyusedOnetubecontainsoxidesofvariousmetals(mainlyzincoxide)andlorothidol(afungicide).Thesecondtubecontainsnon-ionizingcarboxylicacidsandchlorothymol(abacteriostaticagent).Equalpartsfrombothtubesaremixedtogetherimmediatelypriortoinsertion.PeriodontalDressingsAstripofpackishookedaroundthelastmolarandpressedintoplaceanteriorly.Thelingualpackisjoinedtothefacialstripatthedistalsurfaceofthelastmolarandfittedintoplaceanteriorly.Gentlepressureonthefacialandlingualsurfacesjoinsthepackinterproximally.Post-operativecarePostoperativeplaquecontrol-softtoothbrushes-0.12%chlorhexidine(Peridex,Periogard)Maintaininggoodpostsurgicalwoundstability-protectionfrommechanicaltraumaSutureRemovalUseadisinfectingmouthwashtocleanthewoundofalldebris.Thesutureknotiselevatedoffthetissueutilizingcottonpliers.Thesutureiscutasclose