Dental Plaque Dental plaque is a biofilm, usually colourless, that develops naturally on the teeth.

It is formed, as in any bio film, by colonizing bacteria trying to attach itself to a smooth surface (of a tooth)[1]. It has been also speculated that plaque forms part of the defence systems of the host by helping to prevent colonization by microorganisms which may be pathogenic[2].

The film is soft enough to come off by using finger nail. It starts to harden within 48 hours; in about 10 days the plaque becomes dental calculus (tartar), rock-hard and difficult to remove[3]. Dental plaque can give rise to dental caries (tooth decay)the localised destruction of the tissues of the tooth by acid produced from the bacterial degradation of fermentable sugars[2]and periodontal problems such as gingivitis and chronic periodontitis.

calculus or tartar is a form of hardened dental plaque. It is caused by the continual accumulation of minerals from saliva on plaque on the teeth. Its rough surface provides an ideal medium for further plaque formation, threatening the health of the gingiva.

Brushing and flossing can remove plaque from which calculus forms; however, once formed, it is too hard and firmly attached to be removed with a toothbrush. Routine dental visits are necessary so that calculus build up can be professionally removed with ultrasonic tools and specialized sharp instruments.

Prevention The best way to prevent the build up of calculus is through twice daily tooth brushing and flossing and regular cleaning visits based on a schedule recommended by the dental health care provider. Calculus accumulates more easily in some individuals, requiring more frequent brushing and dental visits. There are also some external factors that facilitate the accumulation of calculus, including smoking and diabetes. While toothpaste with an additive ingredient of zinc citrate has been shown to produce a statistically significant reduction in plaque accumulation, it is of such a small degree that its clinical importance is questionable

Dental Flossing Dental floss is either a bundle of thin nylon filaments or a plastic (Teflon or polyethylene) ribbon used to remove food and dental plaque from teeth. The floss is gently inserted between the teeth and scraped along the teeth sides, especially close to the gums. Dental floss may be flavoured or unflavoured, and waxed or un waxed. An alternative tool to achieve the same effect is the intra dental brush.

Dental floss is held between the fingers. The floss is guided between each tooth and under the gum line to remove particles of food stuck between teeth and dento-bacterial plaque that adhere to such dental surfaces. Ideally using a C-shape, the floss is curved around a tooth and placed under the gum line, and then moved away from the gum line, the floss scrapes the side of each tooth, and can also clean the front or back of the tooth. Gently moving the floss from below the gum line to away from the gum line removes dento-bacterial plaque attached to teeth surfaces above and below the gum line. A clean section of floss can be used to clean each tooth to avoid transmitting plaque bacteria from one tooth to another.

PERIODONTITIS :Inflammation of the tissue around the teeth, often causing shrinkage of the gums and loosening of the teeth.

TREATMENT: The treatment of periodontal disease begins with the removal of sub-gingival calculus (tartar). This is commonly addressed by the surgical procedures known as root planing and scaling. These procedures debride calculus by mechanically scraping it from tooth surfaces.

Dental calculus, commonly known as tartar, consists almost entirely of calcium phosphate salt, the ionic derivative of calcium phosphate (the primary composition of teeth and bone). Clinically, calculus stuck to teeth appears to be hardened to the point requiring mechanical scraping for removal.

Newer less invasive methods for treatment of periodontal disease involve the use of an orally administered antibiotic,

Periostat (Doxycycline). Periostat has been clinically proven to decrease alveolar bone loss and improve
the conditions of periodontal disease with minimal side-effects.

Topical Anesthesia Topical anesthesia is always used prior to injection of local anesthesia. Topical anesthetic ointment, with

20% benzocaine is applied to a cotton roll, placed in the buccal

vestibule opposite the surgical area and left in place for 2-3 minutes.

Infiltration anesthesia will be utilized on both the buccal and palatal regions.

Two percent lidocaine with 1:100,000 concentration of vasoconstrictor is slowly injected into the buccal mucosa. The needle is slowly advanced and the patients response in monitored so that there is minimal discomfort while the infiltration anesthesia is carried out.

When the buccal infiltration is completed, a few drops of anesthetic solution are injected into each of the interdental papillae. This will give vasoconstriction, and also gives some initial anesthesia on the palatal surface, which will make it more comfortable for the patient when the palatal infiltration anesthesia is carried out.

The palatal infiltration is begun in the areas of vasoconstriction near the interdental papillae. This will reduce the discomfort of the palatal injections. Palatal infiltrations are completed by beginning in the areas of vasoconstriction, and progressively covering the entire area of the palatal surgery.

The pockets that are present are checked with a periodontal probe. A color-coded periodontal probe with 3mm spacing is used. There is evidence of 6mm pockets in the interproximal regions , of the mesial of the molar,

and 5mm of the distal of the premolar. There are also 5mm pockets that can be probed between the two premolars from the palatal side and a 6mm pocket on the mesial of the first premolar and the distal of the cuspid. There is no abnormal pocket depth on the straight palatal tissue on any of the teeth.

On the buccal side, the interproximal pockets are present, while the pocket depth on the buccal surfaces are within normal limits.

Also, there appears to be an adequate with of keratinized tissue along the entire buccal surface, with no significant gingival recession or mucal-gingival problems.

Four separate palatal incisions are made using disposable scalpel blades and an interproximal knife.
The first palatal incision is made with a

#15 scalpel. Beginning at the distal of the molar,

a scalloped, reverse bevel incision is continued anteriorally.

The blade is angled so that this incision is made parallel to the outer surface of the palatal tissue. This will insure that the palatal flap will have a thin cross-section, and so, will adapt well around the teeth.

midpalatal surface of each tooth is more apical than the incisions in the interproximal region.
The scalloped shape is accentuated so that the incision on the

This scalloping allows the apically positioned palatal flap to cover the interproximal tissues because the alveolus becomes wider as we proceed apically.

The incision is continued forward to include the premolars with accentuation of the scalloping of the palatal gingival margin.

A second vertical incision is placed on the mesial of the first premolar and is angled anteriorally to maximize the blood supply to the flap.
The scalpel is now used to reflect the flap beginning with the vertical incision, and a split-thickness flap is obtained with the blade cutting outside the alveolar bone.

Then a periostial elevator reflects the tissue while the split-thickness flap is continued with a

#15 blade.

Complete reflection of this split-thickness flap is accomplished. The flap continues to have the thin cross-section that was begun with the initial palatal incision. Palatal tissue is reflected so that at least 3mm of periosteum covering the bone can be visualized.

#12-B scalpel is then used to make the third, or sulcular, incision on the palate. This

blade is used with an up-and-down motion that allows for precise cutting. The tip of the blade passes apically to the bony crest, and so frees up the cuff of the gingival tissue.

Cuts are made across each papilla, in order to separate the palatal papilla from the buccal papilla.

An Orban interproximal knife is used for the fourth incision. The blade is angled
to allow a horizontal cutting action and this interproximal knife is used to make the final palatal incision perpendicular to the tooth and at the same time incises the tissue at the alveolar bony crest. It is moved along the entire palatal surface with the tip passing through the interproximal tissue.

The

Kirkland chisel has one end that is a back-action chisel. The other end is a straight

chisel. The cuff of gingival tissue is now removed with the back-action hoe beginning at the posterior portion of the surgical area. This allows for exposure of the bone margin.

The same instrument is used to remove the thin tissue covering of the periosteum so that at least 3mm of the bone margin can be seen and will be accessible for any necessary osseous surgery.

A Prichard periosteal elevator is useful to hold back the palatal flap. Large
pieces of tissue are removed with a minimum of tissue trauma because the interproximal knife has made a clean cut of the gingival margin.

Buccal incisions are made so that a full-thickness flap can be reflected. A

#12-B blade is

used for the buccal incision.

A sulcular incision is made beginning at the posterior tooth and proceeds forward with the blade cutting with an up-and-down motion. The incision is for a full-thickness mucal-periostial flap and so the tip of the blade is contacting the alveolar bone margin. In contrast to the palatal flap, where the blade was outside the alveolar bone margin. Interproximal tissue is maintained by allowing the

#12-B blade to pass deep into the interdental space. The incision is terminated

just a short distance anterior to the line angle on the distal of the cuspid tooth.

A Gracey curette is the next instrument to be used to reflect the flap. This curette, of small dimension, is used to initiate the full-thickness flap. The tip of this instrument is passed through the buccal incision so that it contacts the bone and the periosteum elevation is begun.

The interdental papillae are carefully reflected using a minimum of trauma.

The

Goldman Fox periosteal elevator allows for atraumatic flap elevation.

This periosteal elevator, of narrow cross-section, is then applied to reflect the buccalmucoperiosteal flap. This instrument passes under the periosteum and moves laterally to reflect the flap.

The flap should be freed-up so that reflection of the periosteum is a minimum of 5mm apical to the mucal-gingival junction. This will allow the elasticity of the oral-mucosal part of the flap to give the flap mobility.

Degranulation is initiated with large scalers. The Ball scaler is a double-ended instrument which gives excellent interproximal access. The buccal interproximal tissues are removed in large pieces so that minimal time is taken to clean up the area and to expose the bone margin.

The palatal surface is treated in the same manner.

An ultrasonic scaler is now used to remove smaller pieces of granulation tissue along the bone margins. The tip of this instrument is applied directly to the bone and clumps of tissue are removed. The instrument moves throughout the entire surgical area and will allow direct visual access of all the root surfaces. Granulation tissue removal also exposes the depths of the bony defects. The same is done on the palatal surfaces.

Gracey curettes are used to refine the removal of the granulation tissue. All small tissue tags are removed and a clear view of the bone defects and the root surfaces is obtained so that a decision can be made on the extent of the osseous surgery that is needed.

One of the most important parts of periodontal surgery is root planing. Gracey curettes are first used on all accessible root surfaces.

Visualization of these surfaces gives a better opportunity to obtain optimal smoothness of the roots and all visible calculus is removed.

The ultrasonic scaler can be used in inaccessible surfaces such as furcations, and in areas where curettes have not removed all the calculus.

Use of a slow speed handpiece with

an ultrafine diamond bur is a valuable technique to

smooth root surfaces that are still rough or which have calculus. This bur can
reach into the depths of the bony crevices as well as hard-to-reach root surfaces.

The root surfaces are checked with explorers, and inspected visually to be certain that no obvious calculus is left. Special care is needed to be sure the roots are clean and smooth.

The next surgical step is

osseous surgery. A high speed handpiece with a rear air #8 round bur
is applied to those areas of the alveolar

exhaust is used for osseous surgery so that there is no risk of air being forced into the tissues and so causing an air embolism. A

process where the bone is thick and irregular. An osteoplasty procedure is first done to give a thin tapered bone margin on the palatal surfaces with accentuation of the interdental grooves. Interproximal craters are reduced by removing the palatal tip of bone. This palatal approach has the advantage of giving access to the interproximal surfaces and reduces the need to remove bone in the buccal furcations. Once the craters have been opened up and reduced, contouring of the bone on the palatal surface of each tooth is carried out so that a flowing, curved bone margin is obtained.

This is the straight end of the used in areas where it fits.

Kirkland chisel. The back action chisel on the other end is

The bone margin next to the tooth areas is removed with minimal effect on the root surface. In interproximal regions, the straight end also refines the bone margin next to the tooth.

A similar approach is used on the buccal, beginning with an osteoplasty using the round bur. This is used to thin the alveolus and to develop a tapered bone margin next to the teeth.

The interdental grooves are emphasized. Bone is removed slowly with a minimum of pressure in order to keep the temperature gradient as low as possible. Copious amounts of coolant are essential. Minimal bone height is removed interproximally in the areas where craters exist.

The two ends of the Kirkland chisel are then passed along the bone margins to give a more controlled finish to the final contour of the bone and to round off any sharp edges.

A disposable plastic syringe filled with surgical area of any remaining debris.

sterile saline is able to wash and cleanse the

continuous sling suture with palatal mattress sutures will be used. A 15cm Crile-Wood needle holder holds the needle. Flaps are sutured with a 3-0 silk suture attached to a X-1 end cutting needle.
A

A mattress suture is begun on the palatal and the palatal flap is sutured with a continuous sling suture.

The needle is passed around the tooth one time before the next mattress suture is placed. This

anchoring of the suture insures the palatal flap is held in an apical position. The
suture is passed through the last palatal papilla and then continued to the buccal.

simple sling suture with anchors placed around the tooth to hold the buccal tissue
The buccal flap suturing begins from the distal portion forward with a at its correct position. Care is taken to position the flap close to the bone margin and to get the best possible flap adaption interproximally. The needle penetrates each papilla in keratinized tissue at least 3-4mm away from the flap margin.

Each interproximal tissue is positioned and the continuous suture moves forward.

The two flaps are tied with a knot in the anterior portion of the surgery.

Pressure is applied to the flaps with saline moistened gauze for 2-3 minutes to insure close flap adaption and to promote hemostasis.

The surgical dressing is mixed and placed in sterile saline. When the dressing is set enough not to stick to the gloves, a roll is applied to the palatal, and then another roll is applied to the buccal. The dressing is pushed interproximally.

Cotton pliers are used to lock the dressing in the embrasures. This will join the buccal and palatal rolls.
The area is checked to make sure there is no excess dressing in the vestibule and on the occlusal surface. Hemostasis is essential. For the first week the patient has been given appropriate analgesic tablets and instructed not to brush or floss in the area of the dressing. The dressing is gently removed. The dressing has protected the surgical sites from mechanical trauma to the flaps.

You can see that the palatal tissues have healed well and are well-adapted around the teeth. The buccal tissues also show good tissue adaption and normal healing.

The area is lightly cleansed with saline and the sutures are removed. The patient will be given oral hygiene instruction and seen again in 1 week.

3-0 BLACK SILK SUTURES WITH X-1 NEEDLE

Comparable to Eithicon Silk - 632G

PST-CP-632S 3-0 Silk Black Braided with X-1 Needle - 18 Inches / 45cm $27.00

X-1 Needle Information

1/2 Circle 23.0 mm

PST-MY-SK632 3-0 Silk Black Braided with X-1 Needle - 18 Inches / 45cm $15.00

15C

15

12D

CRILEWOOD NEED HOLDER

MOSQUITO ARTERY FORCEP

IRIS FORCEP

ADSON FORCEP

DENTAL COLLEGE FORCEP

KELNER NEEDLE HOLDER

B/P No 3 Handle - will hold scalpel blades Number 10, 15, 11

Halstead single use, curved, Mosquito Artery Forceps.

12cm length with curved grooved contact plates 2cm length with curved grooved contact plates

These curved Halstead Artery Forceps are also known as 'Mosquitos' (mosquito Forceps) and as a 'Haemostatic Clamp' Also available as Straight blade mosquito forceps. (See Halstead Artery Forceps 12cm straight)

CHEEK RETRACTORS

BONE CURRETES

MATHEW NEEDLE HOLDER

MAYO

GUM SCISSORS