General principles of Periodontal surgery

HKES S.N. Dental college

General Principles of Periodontal

Surgery

Dr. Jignesh Patel,MDS, Periodontology.


O Main objective of periodontal surgery is to contribute to the long-term preservation of the periodontium by facilitating plaque removal and plaque control

- Jan LindheO Patient preparation is an important

aspect of the intervention


Indicated in...

O Impaired access for scaling and root planing

O Presence of root fissures, root concavities, furcations and defective margins of restorations in the subgingival area

O Correction of gross gingival aberrations

O Impaired access for the self-performed plaque control

O To facilitate proper restorative therapy


Contraindicated in...

O Poor patient cooperation

O Cardiovascular diseases

O Pt. With bleeding disorders

O Hormonal and metabolic disorders

O Smoking habit


Out patient surgery

1. Patient preparation• Re-

evaluation after phase I therapy• Premedicatio

n• Informed

consent

2. Check for emergency euipment

3. Measures to prevent transmission of infection


4. Sedation and AnaesthesiaO Most reliable means of painless surgery is- L.A.

O Patient’s medical history & history of allergy should be assessed before L.A. Administration

O lidocaine HCl without epinephrine the maximum individual dose should not exceed 4.5 mg/kg of body weight, and in general it is recommended that the maximum total dose does not exceed 300 mg. (max. Volume is 15ml= 7 cartridges)

O with epinephrine should not exceed 7 mg/kg of body weight, and in general it is recommended that the maximum total dose not exceed 500 mg. (max. Volume is 25ml= 12cartridges)


O Apprehensive & neurotic patients require sedatives and hypnotics

O I.V. Benzodiazepins can be used to achieve greater level of sedation in patients with severe level of anxiety but with caution !!!

Alprazolam 0.25-0.5 mgDiazepam 2-10 mgLorazepam 1-4 mgTriazolam 0.125- 0.5 mg


O Operate gently and carefullyO Thoroughness is essential but roughness must

be avoided

O Observe the patient at all timesO facial expressions, pallor and perspiration are

distinct signs that may indicate that patient is experiencing pain

O Be certain the instruments are sharpO Dull instruments inflict unnecessary trauma

5. Tissue management


O All exposed root surfaces should be carefully explored and planed.

O In areas of difficult access, such as furcations or deep pockets often have rough areas or calculus undetected during phase-I.

O The assistant who is retracting the tissue should also check for presence of calculus and smoothness of root from a different angle

6. Debridement


O Importance of hemostasis:

1. Accurate visualization of the extent of the disease, pattern of bone destruction, anatomy and condition of roots

2. Provides clear view for debridement

3. Prevents excess loss of blood from the body

7. Hemostasis


O Periodontal surgeries can produce profuse bleeding during initial incisions and flap reflection and upon removal of granulation tissue, bleeding is considerably reduced

•Intraoperative bleeding can be managed with continuous aspiration/suctioning•Application of pressure with gauze can control the site specific bleeding


O Fortunately, the laceration of the large or medium vessels is less because incisions near highly vascular areas such as posterior mandiblular (inferior alvelolar and lingual) and mid palatal regions are avoided in incision and flap design.

O If a medium or large vessel is lacerated, a suture around the bleeding end is necessary for the hemostasis.


Methods to control bleeding from capillariesO Application of cold pressure to the site

with moist gauze (soaked in a sterile ice water)

O Use of local anaesthetic with the vasoconstrictor

O Absorbable gelatin sponge

O Oxidized cellulose

O Oxidized regenerated cellulose

O Microfibriller collagen hemostats

O thrombin


O In general, dressings have no curative properties; they assist healing by protecting

the tissue rather than providing healing factorsO Benefits of periodontal dressing:

1. Minimizes post operative infection and hemorrhage

2. Prevents surface trauma during mastication

3. Protects against pain induced by contact of wound with food or the tounge

8. Periodontal dressings


Ideal Properties Periodontal dressing

1. The dressing should be soft, but still have enough plasticity and flexibility to facilitate its placement in the operated area and to allow proper adaptation.

2. The dressing should harden within a reasonable time.

3. After setting, the dressing should be sufficiently rigid to prevent fracture and dislocation.


O The dressing should have a smooth

surface after setting to prevent irritation

to the cheeks and lips.

O The dressing should preferably have

bactericidal properties to prevent

excessive plaque formation.

O The dressing must not detrimentally

interfere with healing.


Zinc oxide eugenol packs• Developed by Ward in

1923• Supplied as liquid and

powder• eugenol may induce an

allergic reaction and burning pain in some patients

Noneugenol packs• Metallic oxide and

fatty acids (Coe-Pak)• Cyanoacrylates

(Barricade)• Tissue conditioners


Composition of Coe-PakO Pink Paste tube (Accelerator)

O Zinc oxide

O Oil (for plasticity)

O A gum (for cohesiveness)

O Lorothidol (fungicide)

O Liquid paste tube (pale yellow)

O Liquid coconut fatty acids thickened with Rosin

O Chlorothymol (bacteriostatic agent)


Studies related to antibacterial properties of

PacksO Baer et al. And frailgh et al. Studied Bacitracin and

neomysin incorporated packs in clinical trials, but all produced hypersensitivity reactions

O In a study of Romanov et al., the emergence of resistant organisms and opportunitic infection has been reported

O But, Carranza suggests incorporation of tetracyclin powder in Coe-Pak is recommended, when long and traumatic surgeries are performed


Preparation and application of periodontal dressing

Equal length of the two paste placed on a paper pad

Mixed with a wooden tongue depressor for 2-3 minutes until paste loses its tackiness


O Paste is placed in a paper cup of water at room temperature

O With lubricated fingers rolled into cylinders and placed on the surgical wound


O Strip of pack is hooked

around last molar and

pressed in to place anteriorly

O Lingual pack is joined to

facial strip at the distal

surface of last molar and

fitted into place anteriorly

O Gentle pressure on the facial

and lingual surfaces join the

pack interproximally


O A study by Curtis et al. (J periodontal 1985) on 304 consecutive periodntal interventions revealed that 51.3% of patients reported minimal or no post operative pain and only 4.6% reported severe pain. Of these 20.1% took five or more dose of analgesic.

O A common source of post operative pain is over extension of pack

O Second reason is prolonged exposure and dryness of bone

9. Management of postoperative pain


O According to Carranza, a preoperative dose of ibuprofen (600-800 mg.) followed by one tablet 400mg every eight hours for 24-48 hours is very

effective for post operative pain reduction.

O When severe pain is present, the patient should be seen at the office on an emergency basis.

O Post operative pain related to infection should be treated with systemic antibiotics


Postoperative instructions

O Instruct the patient to take two paracetamol/ibuprofen tabs. Every 8 hours

for first 24 hours (do not take aspirin)

O Don't brush over the pack

O Rinse with 0.12% CHX gluconate twice daily until normal plaque control technique can

be resumed


O Avoid hot foods during first 24 hours

O Try to chew on the non-operated side of the mouth (semisolid foods are suggested)

O avoid alcohol, citrus fruits or juices, spiced foods

(food supplements or vitamins are generally not necessary)

O Don't smoke


O Swelling is normal, particularly in areas that required extensive surgical procedures

O During the first day, apply ice intermittently on the face over operated area (or to suck ice cubes

intermittently)

O Occasionally, blood may be seen in the saliva for the first 4 to 5 hours, this is not unusual and will

correct itself

O Pack should remain in place until it is removed in the office at the next appointment


Post operative evaluation

Findings at Pack removalO In case of Gingivectomy,

O Cut surface is covered with a friable meshwork of new epithelium, which shouldn't be disturbed

O If calculus has not been completely removed, red, beadlike protuberances of granulation tissue will persist


O In case of flap surgery:O Facial and lingual mucosa may be covered with

grayish yellow or granular whitish layer of food debris that has seeped under the pack

O This is easily removed with a moist cotton pellet

O areas corresponding to the incisions are epithelialized but may bleed readily when touched

O Pockets shouldn't be probed


Evaluation of tooth mobilityO According to the study by Burch et al.

Tooth mobility is increased immediately after surgery

O But, it diminishes below the pre-treatment level by the fourth week- (Majewski et al.)


Mouth care between proceduresO This measure should begin after the pack is removed from

the first surgery

O Patient should be reinstructed at this time

1. No vigorous brushing during the first week after the pack

is removed (gentle use of soft brushes and light water

irrigation)

2. Rinsing with chlorhexidine mouthwash or topical gel

application

3. Brushing is permitted when healing of the tissue permits


Principles for Hospital Periodontal Surgery

O Treating the full mouth at one surgery in a hospital

operating room under general anaesthesia

O Principles are:

1. Premedication

2. Anaesthesia

3. Positioning and periodontal dressing

4. Post operative instruction


Why is it Indicated?1. Patient apprehension

O Procedures in one session rather than in repeated visits is an added comfort to the patient

2. Patient convenienceO One time surgery is less stress for the patient and less

time involved in post operative care

3. Patient protectionO Some patients have systemic conditions that require

special precautions best provided in a hospital setting


Premedication

O A sedative (benzodiazepins) should be given a night before the surgery

O Premedication for patients with systemic problems (e.g. H/O rheumetic fever, valvular and cardiovascular diseases)


AnaesthesiaO Local anaesthesia is the method of choice,

except for especially apprehensive patients

O When GA is indicated, it is administered by an anaesthesiologist

O the judicious use of LA to regional nerve blocks allows the GA to be lighter (wide margin of safety is ensured)


Patient positioning

O Surgery is performed on the operating table with the patient lying down and the table either positioned flat or with head inclined up to 30 degrees


Periodontal dressing

O When GA is used, delay the placement of periodontal dressing until the patient has recovered sufficiently to have a demonstrable cough reflex


Post operative instructionO After a full recovery from general anaesthesia,

most patient can be discharged

O The effect of GA and sedatives make the

patient drowsy for hours, so adult supervision

at home for up to 24 hours is recommended

O Patient is scheduled for a post operative visit in

1 week


General considerations for Instruments used in periodontal surgery

O Incision and excision (periodontal knives)O Deflection and readaptation of mucosal flaps

(periosteal elevators)O Removal of adherent fibrous and granulomatous

tissue (soft tissue rongeurs and tissue scissors)O Scaling and root planing (scalers and curettes)O Removal of bone tissue (bone rongeurs, chisels and

files)O Root sectioning (burs)O Suturing (sutures and needle holders, suture scissors)O Application of wound dressing (plastic instruments)

HKES S.N. Dental collegeO Set of instruments used for periodontal

surgery and included in a standard tray.


O Additional equipment may include:

• Syringe for local anesthesia

• Syringe for irrigation

• Aspirator tip

• Physiologic saline

• Drapings for the patient

• Surgical gloves and surgical mask


Goals of surgery O To Gain access for root preparation when

nonsurgical methods are ineffective

O To Establish favourable gingival contours

O Facilitate self performed oral hygiene

O Lengthen the clinical crown to facilitating adequate restorative procedures; and

O To Regain lost periodontium using regenerative approaches

*Wang & Greenwell (PERIODONTOLOGY 2000)


ConclusionO Periodontal therapy is directed at disease

prevention,

O slowing or arresting disease progression,

O regenerating lost periodontium, and

O maintaining achieved therapeutic objectives.


For proper healing principles to be followed

Wang & Greenwell (PERIODONTOLOGY 2000)


References: 1. Fermin A. Carranza, Jr., Michael G.

Newman,Textbook of Clinical periodontology.,1oth ed., WB saunders &Co.,2008

2. Jan Lindhe, Thorkild Karring . Niklaus P. Lang, Textbook of Clinical Periodontology and Implant Dentistry, 4th ed. by Blackwell Munksgaard, a Blackwell, Publishing Company, 2003.

3. Hom-laywang & Henry Greenwell, Surgical periodontal therapy, Periodontology 2000, Vol. 25, 2001, 89–99.

4. H. A. Sachs, A. Farnoush, L. Checchi and C. E. Joseph, Current Status of Periodontal Dressings, J. Periodontol. December, 1984


Thank you

General principles of Periodontal surgery

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