1

1. Gingivectomy (excisional periodontal surgery)

It's a procedure of excision of the gingiva performed to treat the pathological effects of gingivitis,
periodontitis, gingival enlargements (fibrous firm ones) and supra bony periodontal pockets and
abscesses. A gingivectomy is not to be performed if osseous recontouring is needed. Healing is by
secondary intention with formation of a protective clot and epithelial migration, and connective tissue
repair.

Advantages - it's a technically simple procedure, and it's predictable that the pocket will be completely
eliminated, and also it has predictable end morphological results.

Disadvantages - the primary disadvantage of any excisional periodontal surgery is that the procedure
does not permit access to infrabony pockets, those below the crest of the alveolar bone, a highly
common occurrence in periodontitis,loss of attached gingiva and exposure of root surface, and some
times some remodeling of the alveolar bone occurs despite there being any operative interference.

Contraindications - inadequate oral hygiene, edematous and severely inflamed gingiva, inadequate
attached and keratinized gingiva, and presence of infrabony defects and interdental osseous craters that
would need more visualization and a flap incisional surgery.

2. Gingivoplasty (excisional periodontal surgery):

A procedure performed to reshape the gingival tissues after gingivectomy for an instance where there
are deformities as clefts and craters or any deformities in the interdental papillae. It's usually done
simultaneously with a gingivectomy procedure. It's NOT performed to reduce or eliminate any kind of
periodontal pocket. It's a complementary procedure.

Both procedure above are called as excisional periodontal surgeries; and as the name suggests they're
excisional meaning that they remove the pocket or deformity and reshape what's left.

3. Apically displaced flap (incisional periodontal surgery):

The most common and usually technique used for pocket reduction and elimination with flap surgery.
The procedure is used to expose alveolar bone and it also includes osseous surgery which is important in
correcting infrabony defects. It allows for excellent access to the root surface for complete debridement
and recon touring of alveolar bone as well. Healing occurs by the primary intention and primary closure
of the wound.

Advantages - exposure of alveolar bone with controlled bone loss, exposure of furcation areas, and
keratinized gingiva is preserve.

Disadvantages - root exposure that might esthetically unpleasing and also might lead to caries and
sensitivity susceptibility, there'll be also increased loss of alveolar height and of course increased width
of attached gingiva, gingival scarring.

Contraindications - the most important one is patients with gingival recession because you'll actually
increase that recession with such a procedure so that's one important contraindication.
 2

A laterally and coronally displaced flaps are under the muccogingival surgeries meaning that they are
procedures done to correct the relationship between the gingival and oral mucous membranes;
correcting local gingival defects and providing a functionally adequate zone of keratinized attached
gingiva.

Indications for both flaps would be for any of the following:

• Where change in the morphology of the gingival margin would improve the plaque control (as deep
areas of recession and high frenal attachments)

• Areas where recession creates root sensitivity that cannot be controlled with fluoride or desensitizing
agents

• Esthetic problems

• a very thin layer of attached gingiva overlying a tooth to be moved orthodontic ally or to receive
prosthetic or restorative treatment.

These are flaps where the coronal portion of the flap is elevated from an area adjacent to the recipient
site and freed but the base is still connected to the underlying donor site tissue and in these procedures
the vascular supply to the flap is still maintained.

Other techniques under the muccogingival surgeries are grafts as well as the free gingival grafts,
connective tissue grafts, and pedicle grafts as well.

Modified widman flap is another procedure that enables open debridement of the root surface with the
minimum amount of trauma. There's no attempt to excise the pocket wall although a superficial collar
of tissue is removed during this procedure. There's no intention to eliminate or reduce the pocket
depth, except for the reduction that occurs in healing by the tissue shrinkage.

Advantages - allows close adaptation of the soft tissues to the root surface with minimal trauma and
exposure of underlying bone and connective tissue thus causing fewer problems with postoperative
sensitivity and esthetics.

Disadvantages - interproximal bone and elimination of infrabony defects by osseous recontouring is not
carried out.

This procedure is only used for visibility and access to the bone so that another procedure be done.

The undisplaced (unrepositioned) flap improves accessibility for instrumentation, but it also removes
the pocket wall, thereby reducing or eliminating the pocket. This is essentially an excisional procedure of
the gingiva. The incision of an undisplaced flap can be accomplished only if sufficient attached gingiva
remains apical to the incision. Therefore, the two anatomic landmarks-the pocket depth and the
location of the mucogingival junction-must be considered to evaluate the amount of attached gingiva
that will remain after the surgery has been completed. Because the pocket wall is not displaced apically,
the initial incision should eliminate the pocket wall. It differs from the modified widmann's flap in that
the soft tissue pocket wall is removed with the initial incision, thus it maybe considered as an "internal
bevel gingivectomy".

This flap and gingivectomy are the ONLY 2 techniques that surgically remove the pocket wall.
 3

Pedicle graft, the very first periodontal plastic surgery used for root coverage and recession. The base of
the graft still attached to the donor site to maintain the blood supply as I mentioned earlier.

With such grafts or flaps since they're still attached to their base at the donor site, there's less concern
about the nutrient flow from the graft bed to the graft unlike the free gingival graft for instance.

Advantages - predictable correction of gingival recession is possible because of the continuous blood
supply, there's minor postoperative discomfort, and there's good esthetic results.

It's indicated for areas with inadequate attached gingiva and for isolated areas with root exposure and
fungal recessions.

Disadvantages - not a good procedure for generalized recession defects as such areas won't have
suitable adjacent sites but that's for all autogenous grafts of course either laterally or coronally or
apically displaced flaps.

Operative Burs

Carbide bur uses: Carbide burs are used most commonly for excavating and preparing cavities, finishing
cavity walls, finishing restoration surfaces, drilling old fillings, finishing crown preparations, contouring
bone, removing impacted teeth, and separating crowns and bridges. Carbide burs are defined by their
shank and by their head. The type of hand piece being used determines which type of shank is needed.

Diamond Burs: Diamond burs are generally used for reducing tooth structures to place crowns or
porcelain veneer. Diamonds may also be used to smooth, refine, and polish composite or porcelain
Material. Diamond is the hardest of all known materials. When bonded to stainless steel through a
special metallurgical process, it can be used to create a cutting edge with superior cutting ability and
durability

Round burs - initial entry into the tooth, caries removal and (deep excavation of caries as well. also for
creating access points and channels and locks and grooves (retention grooves in class II and Class IV and
III and V).

Straight fissure burs - initial cavity preparations and also for smoothening walls and floors. For amalgam
and composite cavities and gold as well.

Inverted cone - flatten pulpal floors and also smoothening floors and walls for retention for amalgam
restorations cavities.

Pear shaped - for a tapered finish line on walls with no undercuts. Gives converged finish of walls. Good
for amalgam and also for on lays and inlays cavity preparations.

Coarse Flame shaped (small) - beveling enamel surface for composite restorations

Chamfer/torpedo bur - chamfer finish line for metals prostheses deep chamfer for in PFMs

Straight flat end - shoulder finish line in porcelain prostheses and also for occlusal reduction and all.

. Operative, or cavity preparation burs, have deep and wide flutes which allow for more aggressive
enamel cutting with higher speed and efficiency. These operative burs are usually either straight-bladed
 4

(plain) or crosscut. Straight-bladed burs cut smoothly but more slowly, especially with harder materials.
Crosscut burs have additional cuts across the blades (these are the crosscuts) to

create increased cutting efficiency. While the benefit of these extra blades has been minimized in recent
years with the advent of high-speed handpieces (which cut more efficiently), crosscut burs can generally
cut more quickly because debris does not build up on the bur. Trimming and finishing burs have more
blades than operative burs, and the blades are closer together and shallower, which makes these burs
ideal for the fine finishing and polishing of dental materials. Each type of bur shape has a number
designation, with the head of the bur generally increasing in size as the number gets larger within a
particular shape series. For example, round burs come in sizes from 1⁄4 to 8, with 8 having a much larger
head than 1⁄4.

CARBIDE BURS VS. DIAMOND BURS

Restorative tooth preparation requires complete removal of enamel, existing restorative materials, and
caries. Diamond burs will safely accomplish this and are unlikely to cause enamel fracture. However,
while cutting through porcelain is best accomplished with diamonds, they are slow to cut

enamel and slower at cutting metal-based restorations or sectioning cast metal copings or crowns.
Diamond surfaces can also fill with debris and clog, wear smooth, and cause burnishing and overheating.
Therefore, carbide burs are more often used to easily accomplish these tasks. Carbide burs should be
used to trim and finish macro-filled composites and hybrid composites.

Carbides and diamonds also produce different outcomes: carbide burs slice or chip away at material,
leaving the tooth surface smooth and more aesthetically pleasing. Diamond burs grind away at material,
leaving a rough tooth surface which requires more polishing in the end.

Furcation Grading - Glickman Classification

Grade I

Incipient.

Just barely detectable with examination hand instruments.

Grade II

Early bone loss.

Examination hand instrument goes partially into the furcation, but not all the way through.

Furcation may be grade II on both sides of the tooth, but are not connected.

Grade III
 5

Advanced bone loss.

Examination hand instrument goes all the way through furcation, to other side of tooth.

Furcation is through-and-through.

Grade IV

Through-and-through, plus furcation is clinically visible due to gingival recession.

Tests
1. Irreversible Pulpitis= Thermal( sensory to hot)
2. Diff b/w Irreversible and reversible pulpitis =Thermal (less than 5 sec=reversible, >5sec
irreversible.
3. Acute apical abscess= percussion positive(+clinical sign swelling)
4. Chronic apical abscess= percussion—ive
5. Apical periodontitis= percussion positive( + c/s Biting sensitivity)
6. Chronic periodontitis= percussion –ive
7. Test for pdl abcess= Thermal
8. Abscess= periapical/endo abscess usually (tooth non vital)
9. Periodontal abcess= tooth vital
Cavity Prep
Basically cavity preparation has several steps that are stated and formed by GV black..
1. Outline form
2. Resistance and retention forms
3. Convenience form
4. Removal of remaining caries
5. Finishing of the cavity walls
6. Toilet of the cavity

This basically goes for any preparation on the tooth, the numbers may vary of course
depending on the caries extent and also on the type of restorative material to fill that
tooth.
So the outline form, it's basically the shape of the cavity you're preparing we've 2 outline
forms the external (margins and boundaries) and internal (shape of the internal walls)
forms.
All weakened undermined enamel should be removed. All caries should be removed of
course. Always extend to sound tooth structure. Margins of the cavity preparation should
all end on sound areas that are easily accessible for finishing by the dentist and also for
cleaning by the patient.
Penetration into dentin should be kept at minimum.. For amalgam, accepted minimal
dimensions are 1.5-2 mm occlusal, 0.5 mm into dentin beyond the DEJ.
 6

For gold, it's the same as amalgam.

For composite, there's a minimum of 1 mm to provide function and strength against
forces.
Cavosurface margins for amalgam is 70-90 degrees butt joint. More than 90 degrees
(135degrees) obtuse angle for gold. Also for gold it's more than 90 degrees.
Resistance and retention, basically resistance is the feature of the cavity preparation that
allows the tooth and restoration to withstand masticatory forces without fractures.
That's basically achieved by flat smooth floors and walls (for amalgam and gold and
indirect inlays/onlays) and also by providing sufficient depth and thickness for the filling
material (for amalgam we said 1.5-2mm, for gold it's 1-2 mm and for inlays/onlays
it's 2mm) and having round internal line angles, and parallel walls.

Retention is basically the design feature of the cavity preparation that would allow it to
retain and hold the filling during function.
Retention is achieved by having long walls so that they retain the filling inside, also by
having convergent walls (buccal and lingual) to hold the filling in and dovetail as well
on mesial or distal sides which are divergent.

Convenience form is the form that allow for visibility and accessibility to the prepared
cavity..
It's simply achieved by removing all the infected and affected dentin if possible till sound
tooth structure is seen.
Finishing is just finishing and smoothening of the walls and floors of the cavity after
the complete excavation of caries
Lastly, toilet of cavity is just cleaning the cavity and drying it thoroughly to remove
dentin chips, saliva, any remnants and thus provide good adaptation of the restoration on
the prepared cavity.
On lays (cuspal coverage) and inlays are similar to amalgam and gold in preparation
but the only thing is that their walls are all divergent because they rely on the luting
cement to adhere to the tooth. They are stronger and less chances of leakage. Porcelain or
gold is used. Inlay "in" just the inside of the tooth like a filling with no Cuspal coverage
On lay "on" Cuspal coverage is done it's like a filling extending to the cusps as well.
Crown cutting
PFM basically the finish line is deep chamfer
For porcelain its shoulder
For gold it's feather edge or knife edge or bevel all are same names since gold doesn't
need that much deep preparation
For labial veneers it's chamfer too.
Finish lines/margins of any crown/bridge are to be placed supragingivally 0.5-1mm
not to encroach on the biological width and affect the periodontium.. That's the
recommended and best option.
Equigingival or subgingival is done only in cases of esthetics where the supragingival
margin would be seen and esthetics and appearance would be affected.
 7

So in veneers we sometimes put subgingival (aesthetics)

Pulp test
to differentiate between irreversible and reversible pulpitis-- thermal test

to diff between acute and chronic apical periodontitis-- percussion

between necrosis and vital pulp--etp

(for board exam...chronic is not etp positive)

Acute and chronic both will be percussion positive

for immature teeth, primary teeth and metal crowns--- thermal test

Endo abscess and periodontal abcess...either thermal or ept

Acute apical periodontitis… Painful response to biting and percussion.

Chronic apical periodontitis… Per radicular radiolucency without clinical symptoms.

Periodontal abscess. Lateral percussion

And for non-metal crown....we use thermal too or we have to do a cavity test? Ans. first
is thermal. But even then if the test fails then we do test cavity (last resort), cavity test we
do only as a last option when we are sure that the pulp is necrotic.
Inverse Square Law
simply it says that when you increase the distance between the object and light source,
the intensity of the light will be decreased by square (square root) the distance so let's just
say distance is 2 feet so the intensity of the light will be 1/ square power the distance so
1/square power 2 which is 4.. So 1/4.
Let's just say distance is 8 so the intensity will 1 over the square of 8 which is 64.. So
1/64 is the intensity of the light when you take the object 8 feet away from the light
source, so 1/64 is decreased intensity because the object to source distance has increased
by 8 feet
REGARDING PERIODONTAL SURGERY
Periodontal Surgical Flaps can be Full Thickness or Partial Thickness
Full thickness you reflect the periosteum as well
Partial thickness you leave the periosteum on bone
Flaps can be replaced (replaced at the same position)
Flaps can be apically positioned (Help in Pocket Reduction and increasing attached
gingiva with, if it is already present)
Flaps can be coronally positioned (Help in covering exposed roots. Can not increase the
attached gingiva)
 8

Partial thickness heal quickly as compared to full thickness,flaps

Single tooth Recession with wide area visible- Lateral Pedunculated Flap- Provided
adjacent tooth has adequate attached gingiva
Multiple root recession- Full Thickness graft or Subepithelial graft.
If adequate attached gingiva is present- coronally positioned flap.
Autogenous Free Gingival Graft can be used to increase he attached gingiva.. and in
second stage coronally positioned flap can be done to cover the root.
In Autogenous Free Gingival Graft - as it is taken from palate- Greater Palatine nerve and
vascular bundles are at risk.
Modified widman flap for accessing hidden sites of plaque, if you can not reach
otherwise. Crestal bone recontouring can also be done.
Deep bony defects and GTR and GBR- Full Thickness flaps with/ without vertical
releasing incisions.
Gingivectomy- Suprabony Fibrotic pockets more than 5 mm.
Currettage- To remove sulcular necrotic tissue and necrotic cementum with calculus and
plaque. CONTRAINDICATED IN GINGIVAL HYPERPLASIA.( by dr.zuberi)
Regarding Local Anesthesia:(by dr zuberi)
Amides- with two "I's" in name
Esters- with One "I" in name
Amides- Metabolized in Liver
Esters- Metabolized by Serum Cholinesterase Enzyme
Lidocaine- Pregnancy Category B- Quickest Onset because of lower Pka It has 64%
Protein Binding
Bupivacaine- 96% protein binding- Longest Duration of action
Procaine has Longer Onset because of Higher Pka
The lower the pKa , the more the unionized form, the greater the lipid solubility.
Cartridge volume in North America is 1.8 ml or cc
2% solution means 20 mg/ ml or 36 mg in one cartridge
3% solution means 30 mg/ ml or 54 mg in one cartridge
4% solution means 40 mg/ ml or 72 mg in one cartridge
0.25% solution means 2.5 mg/ ml or 4.5 mg in one cartridge
0.75% solution means 7.5 mg/ ml or 13.5 mg in one cartridge
Example to calculate:
How many Maximum cartridges of 2% lidocaine 1;100,000 epinephrine
75 kg body weight
Max. Recommended Dose- 300 mg (4.4 mg/ Kg)
75 Kg X 4.4 mg/ Kg = 330 mg
We can not Exceed 300 mg as it is suggested in the given MAX RECOMMENDED
DOSE
300 Max Recommended dose / 36 mg (Amount of lidocaine in one cartridge) = 8.3
cartridges~ 8 cartridges
Another Example to calculate:
How many maximum cartridges of 4% prilocaine
 9

Body weight 23 Kg
Max Recommended dose 8 mg/ Kg
23 Kg X 8 mg/ kg = 184 mg (Dose which can be given based on body weight)
184 mg/ 72 mg (Amount of Prilocaine in one cartridge= 2.55 cartridges~ 2.6 cartridges
Another Example to Calculate:
How many Cartridges of Mepivacaine 3%
Body weight 80 Kg
Maximum Recommended Dose- 400 mg (6.6 mg/ Kg)
80 Kg X 6.6 mg/ Kg = 528 mg (Dose based on Body Weight)
But MAX RECOMMENDED DOSE is 400 mg WE CAN'T EXCEED THAT
400 mg/ 54 mg (Quantity in one Cartridge) = 7.4 Cartridges ~ 7 Cartridges
Another Example to Calculate:
How many Cartridges of Mepivacaine 2% with vasoconstrictor
Body weight 18 Kg
Max Recommended Dose - 6.6 mg/ Kg
18 Kg X 6.6 mg/ Kg= 118.8 mg (Dose based on Body weight)
118.8/ 36 mg (quantity in one cartridge)= 3.3 Cartridges
Regarding Epinephrine:
In one Cartridge of 2% lidocaine with 1:100, 000 adrenaline, adrenaline is .018 mg
(REMEMBER IT AS A STANDARD)
1;50,000= .036 mg adrenaline
1: 200,000= .009 mg adrenaline
In a cardiac patient you can give .04 mg max amount of adrenaline
1 Cartridge of 1:50,000
2 Cartridges of 1:100,000
4 Cartridges of 1:200,000
In a Healthy adult you may give 0.2 mg of adrenaline
PROSTHO
INTERFRENCE(wear) Selective Grinding(correction)
Working
LUBL BULL
NON working
BULL LUBL
Protrusive

DUML MUDL
Retrusive
MUDL DUML