Generalprinciplesofperiodontalsurgery

DR JEBIN,MDS.,D.ICOI

Introduction

Allsurgicalproceduresshouldbecarefully planned. Thepatientshouldbeadequatelyprepared medically,psychologically,andpracticallyfor allaspectsofintervention.

OBJECTIVES OF PERIODONTAL SURGERY

To establish drainage of gingival & periodontal abscess

To improve esthetic appearance of tissue overgrowth or recession of gingiva

To prepare for restorative dentistry

Aberrant frenum

Gingival recession

Minimal keratinized gingiva

For osseous regenerative & guided tissue regeneration.

For surgical pocket elimination by removal of soft tissue, to correct gingival contours that interferes with oral hygiene.

INDICATIONS OF PERIODONTAL SURGERY

Areas with irregular bony contours and craters

Infra bony pockets in the distal areas of last molars

Persistent inflammation in areas with moderate to deep pockets

In cases of grade II or grade III furcation involvement

CONTRAINDICATIONS
HAEMORRHAGIC DISORDERS

Haemophilia Thrombocytopenic purpura, Followinganticoagulant therapy Duringfirsttwodaysof menstrualperiod

Neutropenia Uncontrolleddiabetes, Prolongedcortisone therapy.

SPECIFIC CONTRAINDICATIONS
HANDICAPPED

POOR ORAL HYGIENE

Specificcontraindications

TIMING FOR PERIODONTAL SURGERY

Timing for periodontal surgery Except for emergency, all periodontal surgery should be at least one month after completion of phase I therapy. The need for mucogingival surgery cannot be assessed properly at the time of the initial examination.

 Temporary splinting and/or occlusal adjustments procedures should be completed prior to the periodontal surgery

PRE OPERATIVE EVALUATION

Medical and dental history should be reviewed. The patients ability to remove plaque should be evaluated. Tooth sensitivity should be noted and measures taken to control it. In case of anxiety or history of syncope, premedication should be considered.

PREOPERATIVE EVALUATION

No specific nutritional regime is indicated before periodontal surgery. The need for adequate fluid intake should always be emphasized. Advise to quit smoking Informed consent

Emergencyequipment

Theoperator,allassistantsandoffice personnelshouldbetrainedtohandleall emergencies. Drugsandequipmentforemergencyuse shouldbereadilyavailableatalltimes. Mostcommonemergencyissyncope

SYNCOPE

Syncope

Transientlossofconsciousnesscausedby reductionincerebralbloodflow. Commoncausefearandanxiety. Syncopeusuallyprecededby 1. Malaise 2. Pallor 3. Sweating 4. Coldnessoftheextremities 5. Dizziness,Tachycardia 6. Slowingofthepulse.

 Patientshould beplaced inthesupine Syncope management positionwithlegselevated.

 Tightclothesshouldbeloosenedandwide openairway isensured. Syncope management Administrationofoxygenisalsouseful

MATERIALS & METHODS FOR PERIODONTAL SURGERY

INSTRUMENTS

Allinstrumentsprepackedandpresterilized Inspectedcarefullyandsharpenedwhen indicated. Additionalinstruments,sterilizedinsealed paperbags,availableifneeded Prepackednewdisposablesyringeneedles, scalpelblades,sutures&materialsshouldbe used.

SURGICAL ASSISTANT

SURGICAL ASSISTANT

Theassistantisanactiveparticipantinall surgicalprocedures, servingasasecondpair ofhands. Theroleofanassistantistomakeiteasierfor thesurgeontoadministertreatmentsmoothly andefficiently.

Duties of an assistant

BEFORE SURGERY

DURING SURGERY

Aftersurgery

Willprovideaninstructionsheet,gauze,and atemporaryicepack. Theassistantdeliversandexplains prescriptionsandpostsurgicalcare

Principlesofatraumaticsurgery

Anaesthesia Sharpinstrumentsandminimumforceless trauma Atraumatictissuemanagement Suturing.

Tissuemanagement Flapsandgraftsshouldbehandledgently, Elevatorsortissueretractorsshouldbeusedinsuchaway thattheydonottearorcompresssofttissues. Usesuctionduringperiodontalsurgeryratherthanto compressthetissueswithadryspongeinordertogain bettervision. Theuseofspongesalsomayresultincottonfibersbeingleft inthewound,whichmaybe asourceoffutureirritation.

Avoiddryingofbone,whichwillcausenecrosisofsurfacebone.

Donotblowairintothefieldofsurgery,asitmayinduceemphysema, orevenairemboli,whichcanbefatal.

Hemostasis Intraoperativebleeding isbestcontrolledwith pressureusingmoist gauzefor2to5minutes. Resorbablesutureto controlthearterial bleeding. Bleedingfrombonecan bestoppedbyburnishing theboneintheareaof thebleedwithamolt, elevator,orcurette. Ifthisisineffective,bone waxcanbecompressed intotheareaofthe bleed.

AccordingtoEdwardSCohen, Asurgicalsutureisonethatapproximatestheadjacent cutsurfacesorcompressesbloodvessels

PURPOSEOFSUTURING Theprimaryobjectiveistoposition&securesurgicalflapsto promoteoptimalhealing(Primaryhealing) Hastensthewoundhealingtime Reducespostoperativepain&increasesPatientcomfort Preventionofinfectiontothedeepertissueslikebone Permitproperflapposition

Thesuturing needlesare madeof SUTURING NEEDLE eitherstainlesssteelorcarbonsteel Theneedleconsists of3parts Needlepoint Body Eyed/Swagedend

Suturingneedlesareofdifferenttypes Dependingonthecurvature,theycanbeclassifiedas

circle

3/8 th circle

circle

th circle

Straight with curved end

Straight

Dependingontheshapeoftheneedlebody,theycanbe classifiedas Tapered / round body

Cutting

Conventional cutting Reverse cutting

Tapered/roundbody Intheseneedles,thebodyiscircularincrosssection&tapers graduallytotheneedlepoint.

Cuttingneedles Triangularincrosssection.Theanglesofthetriangle representtheblades. Conventionalcuttingcuttingedgesalongtheinnercurvature oftheneedle.

cutting edge on inner curvature Of the needle

Reversecutting doesnthaveanycuttingedgealongitsinner curvature&hasflatinternalsurface

Flat internal surface

SELECTIONCRITERIAOFNEEDLEINPERIODONTALSURGERY DEPENDINGUPONTHETYPEOFNEEDLEBODY

Thetaperedneedle isgenerallyusedforsoft,non keratinized,easilypenetratabletissues. Usedforthinmucoperiostealflaps&closureofreleasing incisionsextendingontothealveolarmucosa

In periodontal surgeries-always use Reverse cutting needles. This prevents the suture material tearing through the papillae or surgical flap edges , referred to as cut-out, which most commonly happens while using conventional cutting needles

Dependingtheattachment ofsuturematerialtothe needleclassifiedas

Eyed/Traumatic

Swaged/Atraumatic

Frencheye(splitorspring)

Eyed/Traumaticneedles Itconsistsofahole/eye Eyeoftheneedlelargerthanthediameterofthesuture producelargerholeinthetissuethanthediameteroftheir own

Swaged/Atraumaticneedles Insertedintothehollowendduringmanufacture&themetalis compressedaroundit. Thisdoesntcauseinjurytothetissuescomparedtoeyed needleAtraumaticneedles.

NEEDLE HOLDERS
Types Locking: Thelockonasutureforcepsisa convenientmeansforparking theneedleandpassingittothe surgeon.

Nonlocking

Castroviejo needleholdersarefine,flathandleneedle holders.

Itcanbeusedwhereoperationsiteislimited.

Scissors

Heldsimilartotheneedleholder

Theyhaverelativelylonghandles

andthumb/fingerrings.

Shortcuttingedges.bladesmay

SUTUREMATERIAL/SUTURE THREAD IDEALREQUISITESOFSUTUREMATERIAL Adequatetensilestrength Goodhandlingproperties Easetotietheknot,withoutslips Biocompatiblewithminimaltissuereaction Sterilizable Favorableabsorptionprofile Resistanttoinfection

DependingonthemicrostructureoftheSuturematerial,they canbeclassifiedas Monofilamentsuture

Braidedsuture

Monofilamentsuture Structurallyitisasolidstring.Thewholediameterofthe sutureismadeupofasingleblockofmaterial.

Braidedsuture Itconsistsofmanythinnerfilaments,twistedtogetherto formastringofdesireddiameter.

MonofilamentsutureisadvantageousovertheBraidedsuture as,theBraidedsuturedoeshavethewickingeffect . i.e, itpullsthebacteria&fluidintothewoundsite.

HenceMonofilamentsuturearemoresterilethan thebraidedsuture.

TYPESOFSUTUREMATERIAL

SUTURINGTHEPERIODONTIUM PRINCIPLESOFSUTURING: Theneedleholdershouldgrasptheneedleatapproximately 3/4thofthedistancefromtheneedlepoint

Theneedleshouldenterthetissueperpendiculartothesurface

Sutures should be located below the imaginary line that forms the base of the triangle of the interdental papillae.

Thesutureshouldbeplacedatanequaldistance[2 3mm] onbothsidesoftheincision

Sutureshouldbealwaysinsertedthroughthemoremobile flapfirst. Thesutureshouldbetiedsothetissueismerely approximated&notblanched. Theknotshouldntbeplacedontheincisionline.

PERIODONTALSUTURINGTECHNIQUES

SIMPLELOOPSUTURE Mostcommonlyusedsuturebecauseofitssimplicity. Sutureformsasimplecircularloopunitingthetwoedgesof thesurgicalincision.

FIGURE 8SUTURE Asthenametells,thissutureformsaloopwithafigureof eight,withthecrisscrosslimbsofeightplacedbetweenthe twoflapedges.

PeriostealSutures

Usedtoholdapicallydisplacedflapsinplace Mainlyconsistsof2sutures 1. Holdingsutures

2.Closingsutures

SuturedKnotComponents

KNOTTYING Theknotmaybetiedin2techniques INSTRUMENTTIE Usingneedleholder ONE HANDED&TWOHANDEDTIE Usingfingers Asperiodontalsurgeriesinstrumenttieisthemost appropriate&extensivelyusedtechnique.

PrinciplesofKnot tyingEthicon1985.
1. 2. 3. Knotmustbefirm.noslippage. Knotshouldnotbeplacedonincisionlines..avoidwicking. Avoidexcessivetension..crimpingofsuture.

5.Knotendsmustbe23mm. 6.Anaddedthrowdoesnotincreasethestrengthoftheknot. 8.Finaltensionorfinalthrowshouldbeasnearlyhorizontal aspossible.

TYPESOFKNOTS SQUAREKNOT SURGEONSKNOT GRANNYSKNOT

SQUAREKNOT Thisknotappearssquarish beforetighteningtheknot. Technique: Itisformedbytying2ties. Thefirstoneinone direction&thesecondtie bythrowingthesuturein oppositedirection

SURGEONSKNOT Itisthemostcommonlyusedknot asitreducesslippageofthefirst tie,whilethe2ndtieisplaced. Technique: Itisformedbytying2ties. Thefirsttieisformedby2throws inonedirection&the2ndtiein oppositedirection.

GRANNYSKNOT Sameknotisusedafter completionofsewingthecloth. Technique: Itinvolvesafirsttieinone directionfollowedbyasecondtie inthesamedirectionasfirst. Laterathirdtieismadetohold theknotpermanently.

SUTUREREMOVAL
Whentodoit AsaruleIntraoralsuturesareremoved 57days afterthesuturing. Naturalnonresorbablesutures,likesilkareremoved after1week ofsuturing.

ComplicationsfollowingSuturing
Theknotslipsgivesriseto90%ofthecomplications followingsuturing,leadingtodehiscenceofwound. Ifthenonresorbablesutureslikesilk,areleftinplace forlongerdurationtheleadtoabcessformation.Here termedasStichAbcess

ComplicationsfollowingSuturing
Incaseofbraidedsutures,becauseofthewickingeffect there canbespreadofinfectionallalongthesutureline Ifthesuturematerialisleftinsituforlongerperiodsthan3weeks, theepithelialcellsmigratedownthesuturepathwayleadingto

Epithelialinclusioncysts

Railroadtrackscar

Periodontaldressing

Periodontaldressingswerefirstintroducedin 1923byA.W.Wardfollowinggingivalsurgery. ThismaterialwascalledWonderpakwhich consistedofzincoxideeugenolmixedwith alcohol,pineoilandasbestosfibres.

Uses of periodontal dressing

Usesofperiodontal dressing

Protection of the wound area. Enhancement of the patient comfort Maintainence of a debris free area Helps to control bleeding Helps to maintain the position of repositioned soft tissues Periodontal dressings also protect newly exposed root surfaces from temperature changes, stabilize mobile teeth protect suture. Act as a template to prevent formation of excessive granulation tissue Protects the surgical healing areas from irritants such as hot and spicy foods.

Thetwomostwidelyusedtypeofdressing
materials: Zincoxide eugenol zincoxide noneugenoldressings. Inaddition, Cyanoacrylates, Tissueconditioners, Periodontaldressingthatcontainantimicrobial agents, photocuringperiodontaldressingmaterialsarealso available.

Thevariouszincoxidenon eugenoldressings availableare CoePak, Peripac, Vocopac,Periocare, Collagendressings, Barricaid, Cyanoacrylates Tissueconditioners.

Coepakcomposition Base Rosin, Cellulose, Naturalgumsandwaxes, fattyacids, Chlorothymol, Zincacetate, Alcohol. Accelerator: Zincoxide, Vegetableoil, Cholrothymol, Magnesiumoxide, Silica,syntheticresin, Coumarin Lorothiodol[a fungicide].

Retentionofpacks

Periodontaldressingsareusuallykeptinplace mechanicallybyinterlockingininterdental spacesandbyjoiningthelingualandfacial portionsofthepack. Aroundisolatedteethorseveralmissingteeth ,splintsandstentsareusedforretention purpose.

Cyanoacrylate: UseofCyanoacrylatesisanalternativeto suturingandasasurfaceadhesiveand periodontaldressing. Cyanoacrylatesiseitherappliedindropsor sprayedonthetissue.

Postoperativeinstructions
Avoidbrushinginthat areaforaboutaweek. Adviceagoodmouth rinsetominimize plaquedeposits. Advicetoavoidsolid foodfor24hours. Ifpatientsfeels excessivepainhe shouldreturntoclinic. Ifthereisbleeding, shouldseethedentist. Ifatallperiodontal dressingfallsoffwithin threedays,should cometoclinicfornew dressing. Giveanalgesics. Advisabletouseanti inflammatoryanalgesic whensofttissue surgeryiscarriedout.

Firstpostoperativeweek

Ifproperlyperformed noseriouspost operativeproblems. Patientadvisedtorinsewith0.12%chlorhexidin immediatelyafterthesurgicalprocedureand twicedailythereafteruntilnormalplaque controltechniquecanberesumed

Complicationsthatmayariseinthefirstpostoperative week

1. 2. 3. 4.

Persistentbleedingaftersurgery Sensitivitytopercussion Swelling Feelingofweakness

Feelingofweakness

Occasionally,patientsreporthaving experiencedawashedout,weakenedfeeling forabout24hrsaftersurgery. Transientbacteremiainducedbythe procedure. Avoidedbypremedicationwithamoxicillin 500mgevery8hrs,beginning24hrsbefore thenextprocedureandcontinuingfor5days postoperatively.

Removalofpack&returnvisit

Oneweekaftersurgerypackisremoved. gentlelateralpressure. packretainedinterproximally andadheringto thetoothsurfaceareremovedwithscalers.

Afterflapoperation

maybleedreadilywhentouched;theyshould notdisturbed. Pocketsshouldnotbeprobed. Grayishyelloworwhitegranularlayeroffood debristhathasseepedunderthepackshould beremovedwithmoistcottonpellet.

Postoperativepain

Analgesicsareusedforreliefofpain

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