Surgical Considerations

• Minimum implant distance: 3 mm
• Mesio – distal space for 2 implants: 14 mm
• Twist drill speed: 800 – 1500 rpm (2mm drill)
• Piezosurgery: Invented by Vercellotti, developed by Mectron

Biological Considerations

• Peri – implant biological width: 4 – 4.5 mm (epithelial attachment + supracrestal CT)
• Maximum bone loss: First 6 – 24 months post – extraction

Blade Angulation Protocols

Scaling & Root Planing

• Angulation: 45-90 degrees to tooth surface
• Purpose: Effective calculus removal and root surface debridement

Gingival Curettage

• Angulation: >90 degrees
• Technique: Removal of infected soft tissue from pocket wall

Curette Sharpening

• Optimal Angle: 100-110 degrees
• Maintenance: Critical for effective instrumentation

Curette Design

Gracey Curettes

• Offset Angle: 60 degrees
• Specificity: Area-specific design for different tooth surfaces

Universal Curettes

• Angle: 90 degrees
• Application: Suitable for all tooth surfaces

After-Five Curettes

• Modification: Terminal shank extended by 3mm
• Purpose: Access to deep pockets (>5mm)

Probing Systems

CPITN Probe

• Tip Diameter: 0.5mm
• Markings: 3.5, 5.5, 8.5, 11.5mm
• Use: Community periodontal index assessment

Florida Probe

• Tip Diameter: 0.4mm (more precise)
• Technology: Computerized probing system

Implant Probing

• Maximum Force: 25N
• Probe Type: Plastic probes recommended to prevent implant surface damage

• Scaling in 2 appointments within 24 hours
• Tongue brushing with 1% chlorhexidine gel
• 0.2% chlorhexidine rinse
• 1% chlorhexidine pocket irrigation

Oral Hygiene Tools

Toothbrush Bristle Diameter:

• Soft: 0.007" (0.2 mm)
• Medium: 0.012" (0.3 mm)
• Hard: 0.014" (0.4 mm)

Brushing Techniques:

• Roll: Modified Stillman
• Circular: Fones
• Vertical: Leonard
• Horizontal: Scrub

Scaling Instruments

• Gracey curettes: Only outer cutting edge
• Universal curettes: Both edges cutting
• Langer curettes: Gracey shank + Universal blade
• Best grasp: Modified pen grasp (tripod effect)
• Scaling angle: 45 – 90°

Ultrasonic Scaling

• Vibration frequency: 18,000 – 50,000 cycles/sec

Stroke Types

• Exploratory: Light feeling (with probes)
• Scaling: Short powerful pull
• Root planing: Moderate to light pull

Electrosurgery

• Frequency: 1.5 – 7.5 million cycles/sec

Flap Incisions & Blades

• Internal bevel: #15 blade
• Crevicular: #12 blade
• Interdental: Orban's knife

Suturing Techniques

• Horizontal mattress: For diastema/wide spaces
• Anchor suture: For flap closure mesial/distal to tooth

Specific Procedures

• Modified Widman flap: Does not reduce pocket depth
• Apically displaced flap: Increases attached gingiva width

Osseous Surgery Sequence

1. Osteoplasty: Vertical grooving, radicular blending
2. Ostectomy: Flattening interproximal bone, gradualizing marginal bone

Bone Grafts

• FDBA: Osteoconductive
• DFDBA: Osteoinductive
• Hydroxyapatite: Ca:P ratio 1.67
• Beta – TCP: Ca:P ratio 1.5

Furcation Treatment

• Grade 2: "Cul – de – sac" defect
• Most common hemisection: Distobuccal root of maxillary 1st molar

Root Coverage Procedures

• Laterally displaced pedicle: Grupe & Warren technique
• Subepithelial connective tissue graft: Langer & Langer technique
• Papilla preservation flap: First choice for maxillary anterior (esthetics)

Healing Timeline

Scaling & Curettage

• Epithelialization: 2 – 7 days
• Immature collagen: 21 days

Gingivectomy

• Surface epithelialization: 5 – 14 days
• Complete repair: 1 month

Flap Surgery

• Epithelial attachment: 1 week

Drug – Induced Enlargement

• Phenytoin: Fibrotic nature
• Cyclosporine: Vascular nature

Pregnancy Gingivitis

• Angiogranuloma: Appears after 3rd month
• Raspberry appearance: Characteristic finding
• Peak severity: 8th month, decreases in 9th month
• Cause: Increased progesterone levels

Children vs Adults

• Children: T – lymphocyte dominated response

Desquamative Gingivitis

• 75% have dermatological origin
• 50% localized to gingiva only