basic principles of periodontal surgery
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Basic principles of periodontal surgery
Dr. Sapna S. Rao
CONTENTS Introduction
Surgical goals, objectives, indications,
contraindications
General surgical principles
- Medical history and physical status
- Diagnosis and treatment plan
- Aseptic surgical technique
- Anesthesia and pain control
Tissue management (Flap management)-Incisions-Flap preparation-Flap design-Flap retraction-Open flap debridement-Flap position Hemostasis Suturing Wound management – periodontal dressings - postoperative
instructions Conclusion References
Introduction
Treatment of periodontal diseases encompasses a vast array of non surgical techniques aimed at elimination of infection and inflammation to establish a healthy periodontium
Periodontal surgery is an irreplaceable therapeutic modality that must be mastered to effectively treat the dental health problems that many patients have.
Objectives
Access to roots and alveolar bone - Enhance visibility- Increase scaling and root planing- Less tissue trauma
Modification of osseous defects- Establish physiologic architecture of hard tissues
through regeneration and resection- Augment ridge defects
Repair or regeneration of the periodontium
Pocket reduction- Enhance maintenance by patient and therapist
- Improve long term stability
Provide acceptable soft tissue contours- Enhance plaque control and maintenance
- Improve esthetics
INDICATIONS
Accessibility for proper scaling and root planing
Establishment of a morphology of the dento gingival area conductive to plaque control
Pocket depth reduction
Correction of gross gingival aberrations
Shift of the gingival margin to a position apical to plaque- retaining restorations
Facilitate proper restorative therapy
Contraindications Uncontrolled medical conditions such as- Unstable angina- Uncontrolled hypertension- Uncontrolled diabetes- Myocardial infarction or stroke within 6 months Poor plaque control High caries rate Unrealistic patient Expectations or desires
HOSPITAL PERIODONTAL SURGERY
Purpose of hospitalization is to protect patients against anticipating their special needs, not to perform periodontal surgery when it is contraindicated by patients general condition
Indicated in apprehensive patients
Patient convenience
The length of hospital stay is 48 hours
Patient admitted early in the afternoon preceding the day of operation
Physical examination, hemogram laboratory procedures, medical consultations
Premedication and anesthesia
Operation
Post operative instructions at the hospital
First post operative office visit
General Principles of periodontal surgery
Medical history and physical status
Thorough comprehensive medical history is a proactive step in identifying potential health problems before they occur suddenly without warning
Relevant aspects of medical history*
In addition to patient history a general assessments of patients physical characteristics for abnormalities in gait, body movements, body symmetry, posture , weight, skin, eyes, speech, and ability to think clearly should be included
Diagnosis and treatment plan
Periodontal surgery must be integrated into a well thought out and organized sequence of treatment that is based on previously determined etiologic factors, diagnosis, prognosis, and patient desire and expectations
Aseptic surgical treatment
A unique aspect of periodontal surgery
Surgical team must follow an aseptic surgical technique to ensure the incidence of post operative infection remains as low as possible
Surgical caps, surgical masks , surgical gloves
Patient draped with sterile towels
Use of sterile saline or water irrigation including irrigation through ultrasonic hand pieces
Surgical instruments should be properly sterilized
Sterile coverings over light handles
Patient preparation*
Pre surgical rinse with 0.12% chlorhexidine for 30sec will provide significant reduction in intraoral bacterial load
Prophylactic antibiotic ?
Anesthesia and pain control Control of physiologic mechanisms of pain is the function
of local anesthetics
Where as, control over psychological factors that influence the interpretation of stimuli as painful is a function of conscious sedation
Pharmacological and physical properties of the anesthetic agent determine the effectiveness and duration of action of the anesthetic
Potency, onset of action, duration of action are the properties of local anesthetics imp to dental practitioner
Important aspect of pain control is providing long lasting anesthesia during the immediate post operative period
Instruments used in periodontal surgery
Surgical procedures used in periodontal therapy often involve the following measures
(instruments)
- Incision and excision (periodontal knives)
- Deflection and readaptation of mucosal flaps (periosteal elevators)
- Removal of adherent fibrous and granulomatous tissue (soft tissue rongeurs and tissue scissors)
- Scaling and root planing (scalers and curettes)
- Removal of bone tissue (bone rongeurs, chisels and files)
- Root sectioning (burs)
- Suturing (sutures and needle holders, suture scissors)
- Application of wound dressing (plastic instruments)
Set of instruments should have simple design
As a general rule number and varieties of instruments should be minimum
Instruments to be stored in sterile “ready to use’’ packs or trays
Instruments should be in good working condition
The instrument tray Mouth mirrors Graduated periodontal probe/ explorer Handles for disposable surgical blades( eg Bard parker
handle) Mucoperiosteal elevator and tissue retractor Scalers and curettes Cotton pliers Tissue pliers Tissue scissors Needle holder Plastic instrument Hemostat Burs
Additional equipment may include
Syringe for local anesthesia Syringe for irrigation Aspirator tip Physiologic saline Drapings for the patient Surgical gloves, surgical mask, surgeons hood
Tissue management
Flap management Surgical access to various components of the
periodontium begins with well thought out INCISIONS
Different surgical techniques involve a variety of incision designs
Regardless the type of incision used the surgeon must- Use sharp cutting instrument- Definite and smooth movement- Minimal drag to tissue
External bevel
incision
Coronally directed
Gingivectomy gingival overgrowth, crown lengthening, gingivolplasty
Kirklands knife , orbans knife, scalpel blades # 11D, #15 (360-knife handle)laser
Internal bevel
incision (reverse bevel,inverse bevel
incision)
Apically directed, placed at the crest of the gingival margin or stepped back from margin 0.5- 2.0 mm
Excisional new attachment procedures ,
modified widman flap,
flap and curretage ,
crown lengthening,
gingival enlargement
Scalpel blades #11, #12 or 12b #15 or 15c
sulcular incision
(crevicular incision)
Apically directed placed in the gingival crevice and directed toward the alveolar crest
When preservation of gingival is critical, as in esthetic areas of minimal keratinized tissue, GTR procedures
Scalpel blades #11, #12,#15 or #15 c
Releasing incision (vertical incision)
Perpendicular to gingival margins at line angles of teeth
To increase access, to allow apical or coronal positioning of flap
Scalpels #11,#15,
Thinning incision
Internal or undermining incisions extending from gingival margin towards the base of the flap to decrease bulk of connective tissue on the underside of the flap
Palatal flaps, distal wedge procedures, internal bevel gingivectomy bulky papillae
Scalpel blades #12 or #12b, #15 or #15c
Cutback incision
Small incision made at the apical aspect of a releasing incision and
directed towards the base of the
flap
Pedicle flaps that are laterally positioned
Scalpels #11,#15c
Periosteal releasing incision
Incision at the base of the flap severing the underlying periosteum
To release flap tension allow coronal advancement of flap
Scalpels #15 or #15c
EXTERNAL BEVEL INCISION
RIGHT ANGLE INCISION
SULCULAR INCISION
INTERNAL BEVEL INCISION
Flap preparation
Surgical flap is defined as the separation of a section of tissue from surrounding tissues except at its base
Full thickness or mucoperiosteal flap*
Partial thickness*
Based on the principle of maintaining an optimal blood supply to the tissue
2 basic flap designs
– those with vertical releasing incisions
- without vertical releasing incisions
Flap design
Alterations in gingival circulation resulting from various periodontal flap designs were studied in humans, the major blood supply to flap was found to exist at its base traveling in apical coronal direction
Also determined greater the ratio of flap length to flap base greater vascular compromise at flap margins
Flap reflection
Full thickness flap is elevated using sharp periosteal elevator directed beneath the periosteum always kept against the bone
Papilla are reflected first
Followed by marginal gingiva working across the anterior posterior direction of the incisions until flap margin has been freed from teeth, alveolar bone or both using gentle force
Inadequate flap reflection results in greater tissue trauma decreased treatment efficiency
Flap retraction Once flap reflected adequately retraction should be
passive without any force
Edge of the retractor always kept on the bone
Trapping of flap between retractor and bone cause tissue ischemia lead to post operative flap necrosis
Avoid continuous flap retraction for long period of time
When flap retracted surgical field should be frequently irrigated with sterile saline to keep tissues moistened, to reduce contamination, improve visibility
Flap debridement
The rationale for this basic surgical approach is same as all flap surgery
Direct visualization increse effectiveness of of scaling and root planing and allow debridement of granulomatous tissue from osseous defects
Roots are planed, defects are degranulated, and flaps are closed either at or apical to their original position
Flap positioning The final step location is usually determined by the goals
of therapy and the specific periodontal surgical technique performed
A repositioned flap used when surgical access for debridement of the root is
primary goal Used in periodontal regeneration procedures
Apically positioned flap Pocket elimination procedures
Coronally positioned flap
Mucogingival surgery (cover either root , connective tissue graft or barrier membrane)
Laterally positioned flaps ( positioning of flap adjacent or contiguous site for purpose of increasing the width of keratinized tissue or covering of an exposed root)
Hemostasis
Surgical Hemostasis – intra operative
- post operative control of bleeding
1977 studies by Baab and colleagues reported blood loss in the range of 16 – 592 ml with mean of 134 ml
Causes for intra operative bleeding- Oozing from capillaries, small arterioles within flap- Nutrient channels and marrow spaces in the bone
Control of bleeding – direct pressure moist gauze 2-5min
If source of bleeding a small artery direct pressure ineffective vessel ligation using a resorbable suture
In cases of flap and harvest of free tissue auto graft from palate full thickness suture at the base of the flap in an attempt to compress the tissues against the vessels is used
Bleeding of bone burnishing the bone area of bleed with molt , elevator, curette when ineffective bone wax in area of the bleed
Variety of topical Hemostatic agents
Absorbable oxidized
regenerated cellulose
SURGICEL
Loosely woven or knitted fiber strips
SURGICEL
Fibrillar in form of cotton wisps
SURGICEL NUKNIT
Thicker denser woven fabric
Apply dry – acts as scaffold for platelet aggregation and clot stability ;quickly loses integrity in blood and saliva; bactericidal
not recc.for implantation in bone defects unless removed before flap closure
Stops bleedind in 2-8 min
Absorbed in 7-14 days
Absorbable gelatin sponge
Absorbable collagen
Gelform ; purified porcine skin
Instat : lyophilized bovine dermal collagen (sponge pad)
Collatape collacote colla plug
Use dry or hydrated in saline scaffold for platelet aggregation ,clot stability
Apply dry or hydrated with saline : hemostasis 2-5 min scaffold to platelet aggregation clot stability
Topical
Ferric sulphate
Bone wax
Thrombostat
Monsel’s solution 20% ferric subsulfate
Bone wax, semisynthetic bees wax and isopropyl palmiate
Liquid or powder;
absorbable collagen or sponge
Astringent and protein precipitate sealing blood vessels ; irratating to wound
Pressed into nutient canal mechanical plug
Post operative bleeding – direct pressure on the flaps for 5 min , if bleeding persists use of hemostatic agents
Suturing materials and techniques
A suture is a strand of material used to ligate blood vessels and to approximate tissues together
Properties of a suture material – Adequate strength
Low tissue irritation and reaction Low capillarity
Good handling and knotting properties Sterilization without deterioration in properties
Suture materials can be broadly divided into
Absorbable Non – absorbable
Monofilamentous Multifilamentous
Natural Synthetic
Absorbable suture
GUT oldest known absorbable suture material
Derived – sheep intestinal mucosa or bovine intestinal serosa
Gut- most variable suture material in tensile strength and absorbability
Organic material highly susceptible to enzymatic degradation
Packaged in isopropyl alcohol ( acts as a preservative) which also serves to condition or soften it
Suture absorbs alcohol causing it to swell
Alcohol irritating to tissues should be removed by quick rinse to saline prior to use
Chromic gut
Plain gut tanned with a solution of chromium salts prior to being spun, ground and polished
Chromium salts act as a cross linking agent and increase the tensile strength of the material and its resistance to absorption by the body
May remain for a span of 80 days when implanted
Collagen
Synthetic absorbable suture material
Polyglycolic acid & polyglactin 910
Polyglycolic acid hydrolytic acid heat & a catalyst converted into HMW linear chain polymer
Suture material is prepared by orienting these filaments by means of stretching and braiding
Polyglactin 910 copolymer of glycolide and lactide
These 2 materials when braided are the strongest of the absorbable materials
Studies
Adv- quickens dissolution when implanted
Disadv- difficulty in tying knot
Non- absorbable suture materials
Silk- organic substance undergoes slow proteolysis when implanted
Most popular suture material
Braided has excellent handling characteristics
Produce a moderate tissue response
Does not irritate adjacent membrane
Herman (1971) - silk has lowest strength among suture materials, ranking
just above gut and collagen
- In terms of knot holding ability it ranks the lowest of all commonly used suture materials, therefore atleast 3 ties should be used for each knot
Nylon Braided or monofilament forms
In monofilament form it is the most popular skin suture material
Studies – have shown anti bacterial activity. Breakdown products of nylon , adipic acid & 1,b hexanediamine, cause a marked reduction in counts of staph. aureus
Possess the property of ‘ memory’ when tied, the suture tends to ‘remember’ that it was originally a straight fiber & knots slip and untie, so surgeons say that they tie 1 knot for everyday so that the suture remains in place
Couz of its stiffness large knot is required, & tendency to tear through non keratinized tissue, nylon not frequently used intraorally
Cotton & linen Strength similar to silk
Handling characteristics inferior
Metal Stainless steel (monofilament or braided)
Strongest and produce most secure knot
Metallic material may undergo degradation, resulting in transfer of ions from surface of tissue
Suture material produces tissue reaction produce damage and increased susceptibility to infection
Dacron polyester, polypropylene, polyethylene, teflon coated or impregnated dacron polyester
silicon coated dacron polyester
Braided suture materials
Exhibit greatest tensile strength& knot holding ability
Minimal tissue reaction
Disadv- expensive
Suture material Non absorbable
1) Surgical silk
2) expanded polytetra- fluoroethylene
Absorbable
Catgut:-
1) Surgical gut (plain)
2) Surgical gut (chromic)
Synthetic fiber:-
1) Polyglactin 910 (coated vicryl)
2) Polyglecaprone (monocryl)
Indication Generalized purpose used in keratinized tissue
GTR
General purpose (gingiva and mucosa)
Several filaments ,twisted Single strand of material
or braided together
Increased strength and
flexibility Passes smoothly into
tissues
Increased incidence of
infection causing invasion
of bacteria into braided Less chance of infection
crevices
Also cause increased friction
against tissues
Multi filament versus monofilament
Biological response of the body to suture material
Surgical needles have 3 basic components- The eye- The body- The point
The eye- Closed or swaged- Shape of the eye round, oblong or square- Eyed needles traumatic needles- Swaged suture Atraumatic needles
The body Widest point of the needle and is referred to as grasping
area Cross – sectional configuration of the body may be
round, oval, side flattened rectangular, triangular or trapezoidal
Point Or the tip can be conventional or reverse cutting The tip can be cutting, round or blunt They are triangular in cross- section
Suturing
Selection of the type of suture material and needle is dependent on tissue type and thickness location in the mouth ease of handling, cost, and planned time of suture removal
Technique selection is determined by final flap positioning
Goals of suturing
1) Maintains Hemostasis
2) Permits healing by primary intention
3) Reduces postoperative pain
4) Permits proper flap position
5) Prevents bone exposure resulting in delayed healing and unnecessary resorption
Principles of suturing
Suture techniques 1) Interrupted
2) Sling
3) Continuous sling
Closure of vertical releasing incisions and interproximal areas replaced and coronally positioned flap closure
Allows separate facial or lingual flap positioning in isolated areas
Single suture to closure to close sextant or quadrant, allows facial and lingual flaps to be closed in
4) Double continuous sling
5) External mattress
Apically positioned flap closure, allows facial and lingual flaps to be closed independently
Reduces amount of suture under the flap, allows papilla closure over osseous grafts without the suture running through the graft , enhances positioning of papilla
6) Vertical
7) Horizontal
8)Internal mattress
Narrower interdental spaces
Wider interdental spaces
Ant. Interdental areas, knot may be tied on the lingual or palate to improve esthetics, edentulous areas in combination with interrupted sutures to reduce tension on incision line
10) Suspensory
11) Anchoring
12) Laurel loop
Coronally advanced flaps, useful for root coverage techniques
GTR
Used in GTR to close over an interproximal barrier membrane
Surgical knots
Square knot- wrapping the suture around needle holder once in opposite directions between the ties. At least 3 ties are recommended
Surgeon’s knot- 2 throws of suture around the needle holder on the 1st tie and 1throw in the opposite direction in the 2nd tie
Granny’s knot- tie in one direction followed by a tie in the same direction 3rd tie in the opposite direction to square knot and hold it permanently
Wound management
Crucial aspect of periodontal surgical therapy
Post operative wound stability is a paramount for desired surgical outcome to be achieved
Periodontal dressing or Pack is a protective material applied over a wound created by periodontal surgical procedures
Uses1) To protect wound post surgically
2) To obtain and maintain a close adaptation of the mucosal flaps to the underlying bone (especially when a flap has been apical repositioned)
3) For comfort of patient
Properties of periodontal dressings
The dressings should be soft, but still have enough plasticity and flexibility to facilitate its replacement in operated area and to allow proper adaptation
Harden within reasonable time
After setting, the dressing should be sufficiently rigid to prevent fracture and dislocation
Smooth surface after setting to prevent excessive plaque formation
The dressing should preferably have bactericidal properties to prevent excessive plaque formation
Must not detrimentally interfere with healing
Types of periodontal dressings
1) Zinc oxide eugenol packs
- Based on reaction of zinc oxide and eugenol
- Developed by ward in 1923 (Wondr- Pak)
- COMPOSITION- zinc oxide, eugenol - zinc acetate (accelerator) - asbestos (binder, filler)
- Asbestos – induce lung disease- Tannic acid – liver damage
2) NON EUGENOL PACKS
- Based on the reaction between a metallic oxide and fatty acids
- COMPOSITION- supplied in 2 tubes ( coe pak)- Zinc oxide- Oil( plasticity)- Gum ( cohesiveness)- Liquid coconut fatty acids - Rosin and chlorothymol (bacteriostatic)- Cyanoacrylates and methyl acrylic gel
(eg of other noneugenol packs)
Preparation and application of periodontal dressings
- Zinc oxide packs mixed with eugenol or non eugenol liquids on wax paper pad with wooden spatula or tongue depressor. Powder is gradually incorporated into liquid, until thick paste formed
- Coe pack : prepared by mixing equal lengths of pastes from accelerator and base until a paste with uniform color formed
- A capsule of tetracycline powder can be added at this time
- Pack than placed in water at room temperature
- 2-3 min paste looses tackiness, 3-5 min can be handled and molded. Remains workable 15-30 min
The mix than rolled into 2 straight strips
End of 1 strip is rolled and bent to hook shaped to fit around the distal surface remainder brought over facial surface and nicely adapted to gingival margin area and interproximal area
Next strip placed lingually
2 strips joined with gentle force interproximally
Area can be covered with tin foil to protect sutures
Bleeding must be controlled before placement of pack and the area dried
Pack should not cover more than apical 3rd of tooth surfaces
Over extention should be avoided- causes irritation, tends to break off, after asking patient to make all functional and forcible movements pack which interferes with occlusion should be removed
As a general rule pack placed for 1 week after surgery
Instruction to patients after placement of periodontal dressings
Imp of pack should be explained
If pack breaks leaving sharp edges, report to office
Do not brush over pack
Use chlorhexidine mouth wash
Come back after 7 days for pack removal
Findings at pack removal
If gingivectomy performed, cut surface covered with friable meshwork of new epithelium which should not be disturbed
If calculus not been completely removed red bead like protuberances of granulation tissue will persist. This granulation tissue must be removed with curette
After flap operation , areas corresponding to incision are epithelialized but may bleed readily when touched, they should not be disturbed, pockets should not be probed
The facial and lingual mucosa may be covered with greyish yellow or white granular layer of food debris that has seeped under the pack. Easily removed with moist cotton pellet. Root surfaces may be sensitive to a probe or thermal changes.
Fragments of calculus delay healing. Each root surface to be rechecked visually to be certain no calculus is present.
Repacking
Advisable for additional week for patients with
1) Low pain threshold (who are uncomfortable when pack removed)
2) Unusually extensive periodontal involvement
3) Slow healing
Application of periodontal dressings?
Instructions for the patient after surgery
Complications during surgery Syncope Hemorrhage
Complications in 1st post operative week Persistent bleeding after surgery Sensitivity to percussion Swelling Feeling of weakness Post operative pain Sensitive roots / root hyperensitivity
Conclusion Knowledge of Basic surgical principles allow a surgeon
to perform safe and effective periodontal surgery. Every surgical procedures must have an end point in mind before the initiation of treatment. With the current emphasis on evidence based periodontal therapy, scientific knowledge when available should become primary driving force in therapeutic and surgical making decisions.
References Carranza’s Clinical periodontology 8th 9th 10th edition Jan lindhe – Text book of Clinical Periodontology and
implant dentistry 4th edition Louis F. rose -Periodontics surgery Sigusch BW, Pfitzner A, Nietzsch T, Glockmann E.
Periodontal dressing (Vocopac®) influences outcomes in a two-step treatment procedure. J Clin Periodontol 2005; 32: 401–4
Veksler A, Kayrouz GA, Newman MG:reduction of salivary bacteria by preprocedural rinses with chlorhexidine 0.12% J periodontol 62;649- 651 1991
Essentials of medical pharmacology- KD tripathi
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