general principles of periodontal surgery

7/21/2019 General Principles of Periodontal Surgery

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General Principles of Periodontal Surgery.

Classification of periodontal surgery

A. Pocket reduction surgery:

•Resective: Gingivectomy, apically displaced flap andundisplaced flap with or without osseous resection.

•Regenerative: Flaps with grafts and memranes.!. "orrection of anatomic#morphologic defects:

•Plastic surgery techni$ues to widen attached gingiva:

% &pithelial grafts

% "onnective tissue grafts •&sthetic surgery:

% Root coverage

% Recreation of gingival papillae •Preprosthetic surgery techni$ues:

% "rown lengthening % Ridge augmentation % 'estiular deepening

•Placement of dental implants:

% (ith G!R % )inus grafts



Objectives of surgical phase of periodontal surgery

•Regeneration of lost periodontal attachment.

•*mprovement of the prognosis of teeth and their replacements.

•*mprovement of esthetics.

PREOPERAT!E "#OR$ATO"

Case %istory

Medical history

+he operator should determine if specific preoperative modifications are indicated ecause of

patients medical history, well efore scheduling any surgical procedure. -rug allergy, patients

medication or systemic disease dictate alterations in the type of anesthetic agent, analgesics, prophylactic antiiotic and even surgical procedure.

ndications for Periodontal Surgery

i. "orrection of gross gingival aerrations.

ii. Persistent inflammation in areas with moderate to deep pockets.iii. Areas with irregularly ony contours, deep craters.

iv. (hen removal of root irritant is not possile due to deep pockets especially in molars and premolars.

v. Furcation lesions.

vi. *nfraony pockets on the distal areas of last molars, complicated y mucogingival prolems.

Contraindications for Periodontal Surgery

i. ncooperative patient

ii. ncontrolled systemic diseases#hormonal disordersa. ncontrolled diaetes mellitus

. Adrenal dysfunction

iii. !lood disorders

iv. )moking

v. "ardiovascular diseases

a. /ypertension . 0yocardial infarction

c. Angina pectoris

d. Anticoagulant therapy

e. Rheumatic fever

vi. 1rgan transplantation

vii. 2eurological disorders

a. 0ultiple sclerosis . Parkinsons disease

Consent

Patient should e fully informed verally and in writing aout the details of the procedure and

possile complications. Patient should e given agreement for the procedure oth with an oral

statement and y signing a consent form.



Pre&edications

Premedication should e given when indicated. +h chemotherapeutic agents used for premedications are:

i. Anxiolytics: Apprehensive and neurotic patients are given antian3iety, sedative, hypnotic

agents, tran$uili4ers or ariturates im or iv prior to surgical therapy.ii. Antibiotics: Given to only medically compromised patients such as infective endocarditis or

patients who re$uire prophylactic antiiotics regimen 5valvular heart disease6. Antiiotics should

e given one hour efore surgery to attain ade$uate levels so as to prevent acteremia.

iii. Antiseptics: 1ral rinse with 7.89 "/; gluconate mouthwash.

iv. Nonsteroidal Anti-inflammatory drugs (NSAIDs): *uprofen can e given as premedication

efore surgery.

Patients on anticoagulant therapy#aspirin shouldstop such medicines < to 8= days efore surgeryand > to = days afterwards with physicians approval.

"TRAOPERAT!E CO"S'ERATO"S

$onitoring Presurgical 'ata+he data necessary to select the surgical procedure includes periapical radiographs, study casts

and proing charts.

Anesthesia

Periodontal surgery should e performed painlessly, the entire area of the dentition scheduled for

surgery, the teeth as well as periodontal tissues should e anestheti4ed y proper anesthesia.?ocal infiltration and lock anesthesia are the methods of choice. After the initial administration

of local anesthesia, in@ect a drop of anesthetic solution directly into interdental papilla. *t makes

the gingiva firmer and easier to incise and has a hemostatic effect ecause of the vasoconstrictor

present in the solution. *n general, most periodontal surgical procedures are done under localanesthesia. /owever, in apprehensive patients or patients suffering from neurological disorders,

surgery is done under general anesthesia.

Tissue $anage&ent

Flap Preparation

)urgical flap is defined as the separation of a section of tissue from the surrounding tissues

e3cept at its ase. Flap can e full thickness or partial thickness.

Flap Design

Flap design should e ased on the principle of maintaining an optimal lood supply to the

tissue. +he recommended flap length 5height6 to ase ratio should e no greater than 9:8 (#ig. )*.

+he greater the ratio of the flap length to flap ase, the greater the vascular compromise at theflap margins.



Fig. 1: Flap height-to base ratio (Ratio should not exceed 2:1

Flap Reflection

A full thickness flap is elevated using a sharp periosteaelevator directed eneath the periosteum

keeping against the one. Papillae are reflected first, followed y the marginal gingiva, working

across the anterior#posterior e3tent of the incisions until the flap margin has een freed from theteeth or alveolar crest or oth. 1nce the flap margin has een completely released, the

periostealelevator is directed in oth hori4ontal and vertical plane until ade$uate access isachieved.

Flap Retraction

)urgical retractors are used to hold the flap ack from the teeth and one. Retraction should e

passive without any tension. "ontinuous flap retraction for long period is not advised. (hen theflap is retracted, the surgical field should e irrigated with the sterile saline to keep the tissues

moist, to reduce contamination and to improve visiility.

Flap Repositioning

)urgical flaps may e repositioned, apically positione coronally positioned or laterally

positioned. +he final flap location is determined y the goal of therapy and the specific

periodontal surgical techni$ue performed. +hus in general, tissue should e handled carefullywith minimum surgical trauma.

•se suction during surgery to avoid compression of tissues with dry sponge. "otton fiers of

dry sponge# gau4e could e left ehind and may e source of future irritation and infection.

•)terile saline solution should e used. •-o not low air into the surgical site as it may induce cervicofacial emphysema which can e

fatal.

•)lowspeed sharp surgical ur and ade$uate cooling should e used for one removal. Avoidundue drying of the one and do not heat the one aove =<B" otherwise it will cause necrosis of

one surface.

•Avoid heavy pressure against soft tissues#one.

Scaling and Root Planing

)caling and root planing in con@unction with periodont surgery is done on e3posed root surfaces

with the help of curettes.

%e&ostasis

)teps to minimi4e postsurgical leeding:

8.!efore appro3imation of flaps, all areas should e rinsed free of clots and the surgical site

should e checked again for leeding.9.Pressure should e applied to the flap to encourage minimal clot thickness.

>.Good closure with suturing discourages postsurgical hemorrhage.

=.-istal wedge and edentulous ridge sites should e well appro3imated carefully with attention ecause these areas are good source of postoperative leeding.

+ound Closure

+he various techni$ues of wound closure are sutures, skin clips#staples, skin tapes and woundadhesive CAutologous firin glue, firin fironectin sealing system 5+issucol6, "yanoacrylate,

0ussel adhesive proteinD.

+he various intraoral anchoring structures useful in securing movale tissues are:

i. Teeth: +hese teeth are easiest and most secure of all intraoral anchors.

ii. ound do!n tissue: Gingiva affi3ed to one via periosteum, is the second most reliale

anchor .



iii. "eriosteum.

iv. #oose connecti$e tissue: *t is the least secure anchoring structure in the mouth. "onnective

tissue in the vestiule and fatty tissue in the retromolar area are the e3amples of loose connectivetissue anchor source.

Suture and Suturing Techni,ues

)election of the type of suture material and needle is dependent on tissue type and thickness,location in them mouth, ease of handling, cost and the planned time of suture removal.

Parts of Surgical Needle

i. Point % *t is the working end of needle.

ii. !ody % *t refers to the grasping area which forms the ma@ority of length of needle. *t starts

where the point of needle ends and ends where the contour change, marking the eginning of

swage of the needle.

iii. &ye#)wage % *t is the segment at which needle and suture material are @oined.!pes of Needles

A. 1n the asis of shape:

i. )traight

ii. "urved: 8#=, >#E, 8#9, #E (#ig-

%ig& ' Suture needles Needles are described by their arc as *+, *' or .*+th of a circle

. 1n the asis of eye:

i. /yed : )uture material is tied to the needle and is designed to reuse.

ii. /yeless*s!aged : +he suture material is inserted into hollow end during manufacturing and

metal is compressed around it. 2eedle is not reusale.

C. 1n the asis of function:

i. Tapered : sed for closing mesenchymal layers such as muscle#fascia that are soft and easily

penetrale.

ii. 0utting : sed for keratini4ed mucosa and skin.a. "onventional cutting (#ig. /A*

. Reverse cutting (#ig. /



#ig/0 A. "onventional cutting needle and . Reverse cutting needle

!pes of Suture "aterials

A. !ased on the numer of filaments:

a. 0onofilament, e.g. steel, nylon

b. 0ultifilament, e.g. silk, cotton.

. ased on suture diameter y ) Pharmacopoeia in descending order from , =, >, 9, 87 till

887 si4e. 87 eing the largest diameter and 887 the smallest one.C. !ased on resoraility of suture material:

a. Asorale

b. 2on asorale

'. !ased on the source:

a. 2atural:

• Absorbable % Plain gut, chromic gut, fast asoring gut, plain collagen, chromic collagen. • Nonabsorbable % )ilk, cotton, linen.

b. )ynthetic:

• Absorbable % Polyglactin, Polyglyconate, Polyglycolic, Polydio3anone. • Nonabsorbable % 2ylon, Polyutester, Polyester, -ecron, Polypropylene, 2urolone.

"ethod of Prescription of Suture*t should contain the name of the suture, its si4e, length and atraumatic, the type of needle, si4eof the needle and numer of foils re$uired, e.g. prolene 97, <7 cms with atraumatic reverse

cutting needle 5>#E circle = mm6 % 8 foil.

#b$ecti%es of Suturing

i. +o staili4e the tissueii. +o secure tissues in the desired locations

iii. +o maintain hemostasis

iv. +o permit healing y primary intentionv. As a tool to retract flap for photography or toretrieve free gingiva#connective tissue autografts.

Principles of Suturing

i. 2eedle holder should grasp the needle appro3imately th of the distance from point.ii. 2eedle should enter the tissue perpendicular to the surface.

iii. 2eedle should e passed through the tissue following curvature of the needle.

iv. )uture should e placed at an e$ual distance 59 to

>mm6 from incision on oth sides and at an e$ual depth.v. 2eedle should e passed from free to fi3ed side.

vi. 2eedle should e passed from thinner to the thicker side.



vii. *f one tissue plane is deeper than the other, needle should e passed from deeper to

superficial side.

viii. +he distance that the needle is passed into tissue should e greater than the distance from thetissue edge.

i3. +he tissue should not e closed under tension, it will either tear or necrose.

3. )uture should e tied so that tissue is merely appro3imated, not lanched.3i. )uture should not e placed over the incision line.

3ii. )uture should e placed appro3imately >= mm apart.

&arious !pes of Suturing

A. *nterrupted sutures:

a. "ircumferential: -irect#loop

. Figure of eight

c. 0attress: 'ertical and hori4ontal

. "ontinuous sutures:

a. *ndependent sling suture

. 0attress: 'ertical and hori4ontal

c. "ontinuous lockingC. )imple sling suture

'. Periosteal sutures

'irect12oop suture0 +he needle penetrates the outersurface of the first flap. +he undersurface of

the opposite flap is engaged and the suture is rought ack to the initial side where the knot is

tied (#igs 3A to '*. +hese sutures are used where one grafts are placed and when closedapposition of scalloped incision is re$uired.

Figs ' to D: Direct loop suture



#igure of eight0 +he needle penetrates the outer surface of the first flap and the outer surface of

the opposite flap.+he suture is rought ack to the first flap and the knot is tied (#igs 4A to '*. +hese sutures are

placed when flaps are not in close apposition ecause of apical flap position or nonscalloped

incisions.

Figs ) to D: Figure of eight suture

Si&ple sling suture0 +he needle engages the outer surface of the flap and encircles the tooth.

+he outer surface of the same flap of the ad@acent interdental area is engaged. +he suture isreturned to the initial site and

the knot tied (#igs. 5A to '*. *t is used primarily with apically positioned flap and in

repositioning the flap.+he sling#suspensory suture is used primarily when

the surgical procedure is of limited e3tent and involves only the tissue of the uccal or lingual

aspect of the teeth.



Figs * to D: Sling suture

*t is also the suture of choice when the uccal and lingual flaps are repositioned at different

levels and to place arrier memrane onto the tooth surface.

$attress sutures0 0attress means that the suture passes through the flap twice. +he material

does not pass under the incision line, thus minimi4ing wicking.

a. 1ertical mattress: +he needle penetrates the outer# epitheli4ed surface of the flap E to 87 mmapical to the tip of the papilla. *t is passed through the under surface of the flap, emerging again

from the outer surface of the same flap 9 to > mm from the tip of papilla. +hus, a vertical ite of

H to < mm is taken with the needle.

+he needle is passed through the emrasure, where the techni$ue is again repeated with theopposite# second flap. +he suture is tied on the first flap (#igs 6A to '*. *t is used in areas with

long and narrow papillae. *t is of two types % everting and inverting. . 2ori3ontal mattress: +he

needle penetrate the outer surfaces of flap < to E mm apical and to one side of the midline of papilla emerging again = to mm through the outer surface on the opposite side of the midline

papilla.



+ to D: &ertical ,attress suture

+hus, hori4ontal ite of = to mm is taken with the needle. +he needle is passed the emrasure,

where the techni$ue is again

repeated with the opposite#second flap. +he suture is tied on the first flap (#igs 7 and 8*. *t isused in interpro3imal areas of diastema with short and wide papillae.

Fig to : /ori0ontal ,attress suture



Fig. : ontinuous hori0ontal ,attress sutures

"riss "ross suture: +he use of a criss cross as the suture passes through the interpro3imal areas

provides good control of the flap papilla and keeps the suture out of the healing interpro3imal

sulcus area. +hus, crisscross single hori4ontal mattress is good for holding osseous grafts in papilla preservation flap (#ig )9*.

Fig. 1: riss cross hori0ontal ,attress suture

Circu&ferential suturing0 *t is indicated for suturing grafts.

Continuous suture0 +he suturing procedure is started at the mesial#distal aspect of the uccal

flap y passing the needle through the flap and across the interdental area. +he suture is laidaround the lingual surface of the tooth and returned to the uccal side through the ne3t

interdental space. +he procedure is repeated tooth y tooth until the distal#mesial end of the flapis reached.

+hereafter, the needle is passed through the lingual flap, with the suture laid around the uccal

aspect of each tooth and through each interpro3imal space.(hen the suturing of the lingual flap is completed and the needle has een rought ack to the

first interdental area, the positions of

the flaps are ad@usted and secured in their proper positions y closing the suture (#igs ))A and

*. +hus, only one knot is needed (#ig. )-*. +he continuous suture is commonly used when flaps

involving several teeth are to e apically repositioned. (hen flaps have een elevatedon oth

sides of the teeth, one flap at a time is secured in its correct position.

Figs 11 and 3: ontinuous sutures



Fig. 12: ontinuous sutures

Periosteal sutures0 *t is indicated in apically positioned partial thickness flap (#ig. )/*.

Fig. 14: Periosteal suture

Sutured 4nots



+he components of sutured knots are loop, knot and ears. Inot is composed of a numer of tight,

throws, each throw represents a weave of the two strands and ears that are the cut ends of the

suture. Inots should e tied as small as possile. "ompleted knots should e firm to reduceslippage. +ie knots on facial aspect for access in removal leaving 9 to > mm suture tail.

Types of :nots0

i. S5uare 6not : +wo single tie in opposite direction.ii. 7ranny 6not : +wo or three tie in same direction.

iii. Surgeon8s 6not '-: 8st tie is doule and 9nd tie is single in opposite direction.

iv. Surgeon8s 6not '-': 8st tie is doule and 9nd tie is also doule in opposite direction.

Principles of suture re&oval0

i. Areas should e swaed with hydrogen pero3ide for removal of encrusted necrotic deris,

lood and serum from suture.

ii. A sharp suture scissor should e used to cut the loops of suture, close to the epithelial surfaceas possile. *n this way, a minimal amount of portion of sutures that was e3posed to the outside

environment and has ecome laden with deris and acteria will e dragged through the tissue.

iii. A cotton plier is then used to remove the sutures. +he location of knots should e noted so

that they can e removed first, which will prevent unnecessary entrapment of the flap.Periodontal 'ressings

Periodontal dressings were first introduced in 8J9> when -r A( (ard advocated the rules anduse of packing material around the teeth following gingival surgery.

+his material was called (onder pack, which consisted of 4inc o3ide eugenol mi3ed with

alcohol, pine oil and asestos fiers.

Purpose

Periodontal dressings are used for the following reasons:

a. Protect the wound area from irritants such as hot# spicy food.

. &nhances patient comfort.c. /elps to maintain the position of repositioned soft tissues and act as a template to prevent

formation of e3cessive granulation tissue.

d. Also protects newly e3posed root surfaces from temperature changes, staili4es moile teethand protect sutures.

Properties

a. -ressing should e soft, ut with enough plasticityand fle3iility.

. -ressing should set within a reasonale time.

c. -ressing should have sufficient rigidity to prevent fracture and dislocation.

d. -ressing should have a smooth surface after settingto prevent irritation to the cheeks and lips.

e. -ressing should e dimensionally stale to prevent salivary leakage and accumulation of

pla$ue deris.f. -ressing should preferaly have actericidal properties to prevent e3cessive pla$ue formation.

g. -ressing should not induce allergic reactions.

h. -ressing should have an acceptale taste.i. -ressing must not detrimentally interfere with healing.

lassification of Periodontal Dressing :

i. Kinc o3ide eugenol

ii. Kinc o3ide noneugenol: "oepak, periocare, periopac,



perioputty and vocopac

iii. 1thers: Photocuring periodontal dressing 5!arricaid6,collagen dressings, methacrylic gel and

cyanoacrylate. Kinc o3ide eugenol dressings:i. "o!der and li5uid form (4ir6land pac6): Powder is composed of 4inc o3ide, tannic acid, rosin,

kaolin, 4inc % steorate, asestos. ?i$uid contains eugenol, peanut oil, rosin. (hen the

components of 4inc o3ide eugenol dressings are mi3ed, setting occurs as a result of chemicalinteraction etween 4inc o3ide and eugenol forming 4inc eugenolate.

ii. "aste form +ue 8 % !ase 4inc o3ide E<, fi3ed vegetale#mineral oil 8>L +ue 9 %

Accelerator oil of clove 89, gum#polymeri4ed rosin.Kinc o3ide noneugenol dressings:

i. 0oepa6 : *t is the most common and widely used non % eugenol dressing (#ig. )3

Fig. 1': #5 P6: Periodontal dressing

Kinc o3ide : 0ain ingredient

'egetale oil : For plasticity

Gum : For cohesiveness?orothidol : Fungicide

?i$uid coconut : Fatty acids

"hlorothymol : !acteriostatic agent"olophony resin

ii. "eriocare: Paste contain 4inc o3ide, 0g1, "a51/69 vegetale oils. Gel contain resins, fatty

acids, ethylcellulose, lanolin, "a51/69. +he setting of periocare occurs y chemical reaction.

iii. "eriopac: *t is premi3ed Kn1 noneugenol dressing containing "a>5P1=69, Kn1, acrylate,

organic solvents, flavoring and coloring agents. (hen this material is e3posed to air or moisture,

it sets y the loss of organic solvents.

iv. 1ocopac: *t is a new formulated product for use as periodontal dressing. *t contains J7 gm ase and J7 gm catalyst. *t contains neither eugenol nor coumarin and causes no gingival

irritation, it retains its tough elastic $ualities throughout its life in the patients mouth, and does

not ecome rittle. *t adheres e3cellently to the teeth and promotes healing. 0i3ing time is aout97>7 seconds and its working time is appro3imately 878 minutes.

v. "erioputty: *t is a noneugenol dressing which contains methyl and propylparaens for their

effective acteriocidal and fungicide properties and en4ocaine as a topical anesthetic.

vi. arricaid $isible light cure periodontal dressing : +his single component of periodontal

dressing eliminates messy, time consuming mi3ing of paste. *t is availale in a syringe for the

direct application or dispensing on a mi3ing pad and placement intraorally. "uring of thematerial is then accomplished with a visile light curing unit to form a nonrittle, ut firm,



protective elastic covering. +he principle ingredients of this material are polyether urethane

dimethacrylate resin, silica, visile light cure 5'?"6 photoinitiator, accelerator and staili4er. *t

contains polymerisale monomers which may cause skin sensiti4ation 5allergic contactdermatitis6 in susceptile persons. &ye protection should e worn, while curing with a visile

light unit.

vii. 0ollagen dressings: An e3ample of collagen dressing is collocate. "ollagen dressing is in theform of collagen sponge which is a type * collagen derived from ovine Achilles tendon. *t is

completely resorale dressing that is used to cover and protect palatal graft sitesL the sponge is

appro3imately > mm thick and can e cut to fit the graft site. *t stops leeding and can asor >7=7 times its weight in fluid, without swelling.

viii. Methacrylate gel dressings: +hey have elastic consistency that is soft and resilient and will

flow under pressure. +hey adapt closely to the tissues and are very comfortale with wound site.

+he ma@or advantage of this material is its aility tocarry and release medicaments to the soft tissues.

i;. 0yanoacrylate: *n 8JH= tissue adhesives were introduced to dentistry. -r )2 !haskar

conceive the idea of their potential use in periodontics and conducted the ulk of the laoratory

and clinical research. +he asic formula of "yanoacrylate is "/M " 5"26 % "11R. +he utyland isoutyl formsare ideal as periodontal dressings. +he use of cyanoacrylate is an alternative to

suturing and as a surface adhesive and periodontal dressing. +his material has the uni$ue ailityto cement together

moist, living tissue surfaces. "yanoacrylate is either applied in drops or sprayed on the tissues.

+he material is much less ulky than other dressings.1ther advantages include lack of apparent side effects, easy adherence to living tissues,

immediate hemostasis, lack of evidence of systemic to3icity# sensitivity, precise placement of

flaps, decreased suturing time, ease of application and patient preference over ulky dressings. *t

is most useful in flap control in concave 4ones such as furcal area fluting. "yanoacrylate has een used for surface application onlyL adhesives that ecome trapped under soft tissue flap will

delay wound healing.

Antibacterial properties of pac6s: !acitracins,13ytetracycline 5+erramycin6, 2eomycin and 2itrofura3one have een tried, ut all may produce

hypersensitivity reactions. *ncorporation of tetracycline powder in "oe % Pak is generally

recommended, particularly when long and traumatic surgeries are performed.

Preparation and pplication of Periodontal Dressings

Kinc o3ide packs are mi3ed with eugenol or non % eugenol li$uids on a wa3 paper pad with a

wooden tongue depressor. +he powder is gradually incorporated with the li$uid until a thick

paste is formed. "oePak is prepared y mi3ing e$ual lengths of paste from tues containing theaccelerator and the ase until the resulting paste is of uniform color. +he pack is thenplaced in a

cup of water at room temperature, in 9> min the paste looses its tackiness and can e molded,

and it remains workale for 897 min. +he pack is then rolledinto two strips of appro3imately the length of the treated area. +he end of one strip is end into a

hook shape and fitted around the distal surface of the last tooth, approaching it from the distal

surface. +he remainder of the strip is rought forward along the facial surface tothe midline. +he second strip is applied from the lingual surface. *t is @oined to the pack at the

distal surface of the last tooth, and then rought forward along the gingival margin to the

midline. +he strips are @oined interpro3imally y applying gentle pressure on the facial and

lingual surfaces of the pack (#ig. )4*.



Fig. 1): Periodontal pac7 place,ent

'o "ots

NPeriodontal dressing should not e3tend onto uninvolved mucosa.

N)hould not e3tend over occlusal surfaces of teeth.

N)hould not interfere with occlusion. Place,ent of Periodontal Dressings

Periodontal dressings are retained mechanically y interlocking in interdental spaces of teeth and

@oining the lingual and facial portions of the pack. *n case of edentulous areas, the periodontaldressing is retained with the help of splints, hawley appliance and stents. *n case of isolated

teeth, tie dental floss or gau4e loosely around the teeth and over which pack is

applied.Periodontal dressing may entrap sutures eneath the dressing and may displace flap.

POSTOPERAT!E "STR<CTO"S A"' CARE

Appropriate postoperative instructions should e given oth verally and in written to the patient

including an e3planation concerning:

8.-iscomfort and potential complicationsL9.All medications, especially analgesics and antiioticsL

>.-iet modification

nstructions to the Patient after Surgery

Do8s

+ake 9 talets of acetaminophen every H hours on first day.

"hew on the nonoperated side+ake semisolid food

Apply ice, intermittently for alternating 97 minutes on and 97 minutes off, on the face over the

operated side on the first day

se chlorhe3idine mouthwash*f the leeding does not stop, take piece of gauge and form it into shape and hold it in thum

and inde3 finger, apply it to oth sides of the pack, and hold it there under pressure for 97

minutes)welling is usual in e3tensive surgical procedure. *t susides in > or = days. Apply moist heat if it

persists

*f any other prolem arises do call the doctor .

Do Not8s

NAvoid hot food

N-o not smoke or take alcohol



NAvoid citrus, highly spicy food

N-o not rush over the pack

NAvoid e3ertion N-o not try to stop leeding y rinsing.

Postsurgical Care

-ay 8: Analgesics, cold packs, moist gau4e locally as needed, total avoidance of wounddisturance After day 8: Pain, swelling, leeding should diminish or disappear. !egin light

activity, warm packs as needed and chemical pla$ue control are recommended. After to 87

days: Remove dressing and sutures after < days: Professionally depla$ue supragingivally. !eginlight oral hygiene.

After = to H weekly: !iweekly visits for professional depla$ing and oral hygiene instructions.

+he dentogingival @unction should not e proed or instrumented for H to E weeks following

surgery. )oft toothrush should e used gently for the first few postoperative weeks. +he patientshould follow "harters method avoiding vigorous toothrushing.

POSTS<RGCA2 CO$P2CATO"S

*f postoperative complications occur, they should e managed y prompt and appropriate

treatment, which may include control of leeding, ade$uate analgesics or antiiotics.Co&plications associated =ith periodontal surgery are0

•/emorrhage •Postoperative pain

•*nfection

•)welling •Reaction to medications

•1ther potential risks include root sensitivity, flap sloughing, root resorption or ankylosis, some

loss of alveolar crest, flap perforation, ascess formation and irregular gingival contours.

%e&orrhage

Primary postoperative hemorrhage starts at the time of surgery. *ntermediate hemorrhage starts

soon after the surgery, after having stopped temporarily following surgery. *t is usually due to the

reakdown of an incomplete clot, such as is associated with loss of the vasoconstrictor effect ofanesthesia. )econdary hemorrhage starts from 9= hours to 87 days postoperatively.

Steps to control postsurgical bleeding0

8.First step to control leeding is to identify the source of leeding. )uction is done carefullyand local pressure with gau4e sponges is applied.

9.Oudicious in@ection of vasoconstrictor comined with continuous application of pressure

encourages clot

formation.>.Artificial clot may e induced y use of an o3idi4ed cellulose microfirillar collagen product.

=.&lectrocoagulation can e effective for capillary leeding sites and small arterioles.

.?arge arteriole leeding sites can e controlled y placing sutures in the soft tissue. Inot isdrawn tight to occlude vessel y compression from the surrounding tissue (#ig. )5*.

H.*f leeding is from intraosseous site then it can e controlled y one wa3 5eeswa3 and

salicylic acid6 which occlude ony canals.<.&3cessive leeding from interpro3imal and infraony lesions results from inade$uate

degranulation. Residual granulomatous tissue is a common source of hemorrhage, since it is

composed largely of capillaries.



Fig. 1*: Diagra, sho9ing co,pression suture to control bleeding

The various topical he&ostatic

agents are

gent "ain

constituent

Avitene"ollagen

"ollacote"ollagen

"ollatape"ollagen

"ollaplug"ollagen

+hrominar +hromin

+hromogen+hromin

+hromostat+hromin

GelfoamGelatin

!eriplastFirin

)urgicel"ellulose

Postoperative Pain

+he severity of postoperative pain varies depending on the patient threshold level, location,duration, e3tent of surgery and skill with which the soft and osseous tissue are handled during

surgery. Postoperative pain and discomfort for the patient can e minimi4ed y the surgical

handling of the soft and osseous tissues atraumatically. •+he one should e kept moist as dryness of one induces severe pain. +here should e

complete soft tissu e coverage of the one during suturing. +hus one e3posure should not e

e3tensive. •+he periodontal dressing should not over e3tend eyond the mucogingival @unction, or onto

frenum and palate.

•Patient should e instructed to avoid chewing from the operated site.

•+wo acetoaminophen talets every H hours for the first 9= hours is prescried for little pain ordiscomfort. !ut if pain persists then acetoaminophen plus codeine talets can e prescried.

•*f the postoperative pain is related to infection which usually start after = days following

surgery 5locali4ed



lymphadenopathy and fever6, then it should e treated with systemic antiiotics along with

analgesics.

S=elling

)welling after surgery is est prevented y the use of ice packs. After swelling develops, hot

moist packs and fre$uent lavage with warm saline solution are preferred.*t generally susides y

the =th postoperative day. *f swelling persists and ecomes worse, then amo3icillin 677mg5should e taken every E hours for 8 week. 2o all postoperative swelling is caused y

inflammationL some may e caused y leeding into tissues. +his may occur after flap operations

and are accompanied y discoloration under cheek, chin or eye.

+O<"' %EA2"G

+o ensure proper healing, atraumatic surgical principles should e followed including: 586

ade$uate anesthesiaL 596 surface disinfectionL 5>6 sharp instrumentationL 5=6 minimal, atraumatic

tissue handlingL 56 short operating timeL 5H6 preventing unnecessary contaminationL and 5<6 proper suturing and dressing, if indicated. /ealing is a phase of the inflammatory response that

leads to a new physiological and anatomical relationship among the disrupted ody elements.

/ealing of periodontal tissue can e in the form of repair, new attachment and regeneration.

%ealing rates of various periodontal tissues

issue t!pe /ealing rate

(pproxi,atel!

Ounctional epitheliumdays

)ulcular epithelium<87days

Gingival surface epithelium878=days

"onnective tissue989Edays

Alveolar one=Hweeks

Gingival wounds heal much more rapidly with much less scar formation when compared to skin.

+he reason for this reduced scar formation are:a. Gingival firolasts unlike the firolasts of other connective tissue produce more 00P8>than 00P8. 00P8> has a road sustantivity and is capale of reak down#turnover of a

numer of e3tracellular matri3 proteins. 00P8 on the other hand has a iological activity that is

restricted to collagen *. +he greater presence of 00P8> in the wound area is thought to producea greater turnover and therey, prevent scar formation.

. +here is a greater presence of myofirolasts in thegingiva when compared to skin.

Firolasts can differentiate to form the more synthetic myofirolasts under the influence of+GF. +he presence of +GF in the wound area enhances the already greater presence of

myofirolasts therey leading to lesser wound contraction and scarring.

2A"'$AR> ST<'ES RE2ATE' 2indhe ?@ Socrans:y SS@ "y&an S@ et al. Critical

probing depths in periodontal therapy. ?ournal of Clinical Periodontology )87-80/-/B/5.+hey reported that scaling and root planing procedures induce loss of attachment if performed in

pockets shallower than 9.J mm, whereas gain of attachment occurs in deeper pockets. +he

modified (idman flap induces loss of attachment if done in pockets shallower than =.9 mm utresults in a greater gain of attachment than root planing in pockets deeper than =.9 mm. +he

critical proing depth at which the



attachment level was unchanged after treatment was 9.J mm for root planing and =.9 mm for

surgery. *t was concluded that molars responded etter to surgery than to root planing aove =.

mm. Poor pla$ue control y patients in the maintena

PO"TS TO PO"'ER

"auses of e3cessive leeding during surgery include laceration of large lood vessels,

incomplete removal of granulation tissue, hypertensive patient, leeding disorder patient and patient on anticoagulant therapy.

*f the surrounding tissue lanches, however, the suture is too tight, which may cause necrosis

ecause of poor vasculari4ation./emostasis should e achieved efore, and not y, the application of a dressing. +he only clear

indication for a dressing is to achieve tissue stasis, such as with a free mucosal graft, or to protect

a clot over one in the interdental denudation techni$ue. Application of dressing is a matter of

individual preference.+he possile outcomes of surgical periodontal therapy are: Regeneration, new attachment, long

@unctional epithelium, root resorption#ankylosis and recurrence of pocket

general principles of periodontal surgery

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