Bsics of Periodontal Surgery

1. General Principles of
Periodontal Surgery
Dr. Jignesh Patel,
MDS, Periodontology.HKES S.N. Dental college

2. 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 Lindhe
O Patient preparation is an important aspect of
the intervention
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3. 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
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4. Contraindicated in...
O Poor patient cooperation
O Cardiovascular diseases
O Pt. With bleeding disorders
O Hormonal and metabolic disorders
O Smoking habit
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5. Out patient surgery
1. Patient
preparation
•Re-evaluation
after phase I
therapy
•Premedication
•Informed
consent
2. Check for
emergency
euipment
3. Measures to
prevent
transmission
of infection
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6. 4. Sedation and Anaesthesia
O 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)
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7. 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 mg
Diazepam 2-10 mg
Lorazepam 1-4 mg
Triazolam 0.125- 0.5 mg
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8. O Operate gently and carefully
O Thoroughness is essential but roughness must be
avoided
O Observe the patient at all times
O facial expressions, pallor and perspiration are distinct
signs that may indicate that patient is experiencing pain
O Be certain the instruments are sharp
O Dull instruments inflict unnecessary trauma
5. Tissue management
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9. 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
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10. 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
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11. 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
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12. 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.
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13. Methods to control bleeding from capillaries
O 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 thrombinHKES S.N. Dental college

14. O In general, dressings have no curative properties;
they assist healing by protecting the tissue rather
than providing healing factors
O 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
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15. 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.
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16. 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.
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17. 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
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18. Composition of Coe-Pak
O 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)HKES S.N. Dental college

19. Studies related to antibacterial
properties of Packs
O 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
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20. 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
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21. 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
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22. 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 interproximallyHKES S.N. Dental college

23. 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
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24. 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
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25. 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
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26. 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
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27. 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 appointmentHKES S.N. Dental college

28. Post operative evaluation
Findings at Pack removal
O 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
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29. 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
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30. Evaluation of tooth mobility
O 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.)
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31. Mouth care between procedures
O 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 permitsHKES S.N. Dental college

32. 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 instructionHKES S.N. Dental college

33. 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 convenience
O One time surgery is less stress for the patient and less
time involved in post operative care
3. Patient protection
O Some patients have systemic conditions that require
special precautions best provided in a hospital settingHKES S.N. Dental college

34. 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)
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35. Anaesthesia
O 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)
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36. 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
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37. 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
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38. Post operative instruction
O 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
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39. 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 college

40. O Set of instruments used for periodontal
surgery and included in a standard tray.HKES S.N. Dental college

41. 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
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42. 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)
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43. Conclusion
O Periodontal therapy is directed at disease
prevention,
O slowing or arresting disease progression,
O regenerating lost periodontium, and
O maintaining achieved therapeutic objectives.
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44. For proper healing principles to be followed
7. Proper suturing and dressing
6. Preventing unnecessary contamination
5. Short operating time
4. Minimal, atraumatic tissue handling
3. Sharp instrumentation
2. Surface disinfection
1. Adequate anesthesia
Wang & Greenwell (PERIODONTOLOGY 2000)
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45. 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, 1984HKES S.N. Dental college

46. HKES S.N. Dental college