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ParOdontology
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General principles of periodontal surgery
DR JEBIN,MDS.,D.ICOI
Introduction
• All surgical procedures should be carefully planned .
• The patient should be adequately prepared medically, psychologically, and practically for all aspects of intervention.
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,
• Following anticoagulant therapy
• During first two days of menstrual period
• Neutropenia
• Uncontrolled diabetes,
• Prolonged cortisone therapy.
HANDICAPPED
POOR ORAL HYGIENE
SPECIFIC CONTRAINDICATIONS
Specific contraindications
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 occlusaladjustments procedures should be completed prior to the periodontal surgery
PRE OPERATIVE EVALUATION
Medical and dental history should be reviewed.
The patient’s 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
Emergency equipment
• The operator, all assistants and office personnel should be trained to handle all emergencies.
• Drugs and equipment for emergency use should be readily available at all times.
• Most common emergency is syncope
SYNCOPE
Syncope
Transient loss of consciousness caused by reduction in cerebral blood flow.Common cause fear and anxiety.
Syncope usually preceded by1. Malaise 2. Pallor3. Sweating4. Coldness of the extremities5. Dizziness ,Tachycardia6. Slowing of the pulse.
Syncope management• Patient should be placed in the supine position with legs elevated.
Syncope management• Tight clothes should be loosened and wide –open airway is ensured.
• Administration of oxygen is also useful
MATERIALS & METHODS FOR PERIODONTAL SURGERY
INSTRUMENTS
• All instruments prepacked and presterilized
• Inspected carefully and sharpened when indicated.
• Additional instruments, sterilized in sealed paper bags, available if needed
• Prepacked new disposable syringe needles, scalpel blades, sutures & materials should be used.
SURGICAL ASSISTANT
SURGICAL ASSISTANT
• The assistant is an active participant in all surgical procedures, serving as a second pair of hands.
• The role of an assistant is to make it easier for the surgeon to administer treatment smoothly and efficiently.
Duties of an assistant
BEFORE SURGERY
DURING SURGERY
After surgery
• Will provide an instruction sheet, gauze, and a temporary ice pack.
• The assistant delivers and explains prescriptions and postsurgical care
Principles of atraumatic surgery
• Anaesthesia
• Sharp instruments and minimum force‐less trauma
• Atraumatic tissue management
• Suturing.
Tissue management
Flaps and grafts should be handled gently,Elevators or tissue retractors should be used in such a way that they do not tear or compress soft tissues.
Use suction during periodontal surgery rather than to compress the tissues with a dry sponge in order to gain better vision.
The use of sponges also may result in cotton fibers being left in the wound, which may be a source of future irritation.
Avoid drying of bone, which will cause necrosis of surface bone.
Do not blow air into the field of surgery, as it may induce emphysema, or even air emboli, which can be fatal.
Hemostasis
Intra operative bleeding is best controlled with pressure using moist gauze for 2 to 5 minutes.
Resorbable suture to control the arterial bleeding.
Bleeding from bone can be stopped by burnishing the bone in the area of the bleed with a molt, elevator, or curette.
If this is ineffective, bone wax can be compressed into the area of the bleed.
According to Edward S Cohen,
“ A surgical suture is one that approximates the adjacent cut surfaces or compresses blood vessels”
PURPOSE OF SUTURING
The primary objective is to position & secure surgical flaps to promote optimal healing ( Primary healing )
Hastens the wound healing time
Reduces post operative pain & increases ‐Patient comfort
Prevention of infection to the deeper tissues like bone
Permit proper flap position
SUTURING NEEDLEThe suturing needles are made of either stainless steel or carbon steel
The needle consists of 3 parts
• Needle point
• Body
• Eyed / Swaged end
Suturing needles are of different types
Depending on the curvature , they can be classified as
Straight
Straight with curved end
¼ circle 3/8 th circle ½ circle
¾ th circle
Depending on the shape of the needle body, they can be classified as
• Tapered / round body
• Cutting Conventional cuttingReverse cutting
Tapered / round body
In these needles , the body is circular in cross‐section & tapers gradually to the needle point.
Cutting needles
Triangular in cross‐section. The angles of the triangle represent the blades .
Conventional cutting ‐cutting edges along the inner curvature of the needle.
cutting edge on inner curvature Of the needle
Reverse cutting‐ doesn’t have any cutting edge along its inner curvature & has flat internal surface
Flat internal surface
SELECTION CRITERIA OF NEEDLE IN PERIODONTAL SURGERY
DEPENDING UPON THE TYPE OF NEEDLE BODYThe tapered needle is generally used for soft , non‐keratinized , easily penetratable tissues.
Used for thin mucoperiosteal flaps & closure of releasing incisions extending on to the alveolar mucosa
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
Depending the attachment of suture material to the
needle classified as
– Eyed / Traumatic
– Swaged / Atraumatic
– French eye(split or spring )
Eyed / Traumatic needles
It consists of a hole / eye
Eye of the needle‐larger than the diameter of the suture ‐produce larger hole in the tissue than the diameter of their own
Swaged / Atraumatic needles
Inserted into the hollow end during manufacture& the metal is compressed around it.
This doesn’t cause injury to the tissues compared to eyed needle ‐Atraumatic needles.
Types
• Locking:The lock on a suture forceps is a convenient means for parking the needle and passing it to the surgeon.
• Non‐locking
NEEDLE HOLDERS
Castroviejo needle holders are fine, flat handle needle holders.
It can be used where operation site is limited.
• Held similar to the needle holder
• They have relatively long handles
and thumb/ finger rings.
• Short cutting edges….blades may
Scissors
SUTURE MATERIAL / SUTURE THREAD
IDEAL REQUISITES OF SUTURE MATERIAL
Adequate tensile strength
Good handling properties
Ease to tie the knot , without slips
Biocompatible with minimal tissue reactionSterilizable
Favorable absorption profile
Resistant to infection
Depending on the microstructure of the Suture material, they can be classified as
– Monofilament suture
– Braided suture
Monofilament suture
Structurally it is a solid string. The whole diameter of the suture is made up of a single block of material.
Braided suture
It consists of many thinner filaments , twisted together to form a string of desired diameter.
Monofilament suture is advantageous over the Braided suture as, the Braided suture does have the “ wicking effect ” . ” i.e, it pulls the bacteria & fluid into the wound site .
Hence Monofilament suture are more sterile than the braided suture.
TYPES OF SUTURE MATERIAL
SUTURING THE PERIODONTIUMPRINCIPLES OF SUTURING:
The needle holder should grasp the needle at approximately 3/4th of the distance from the needle point
The needle should enter the tissue perpendicular to the surface
Sutures should be located below the imaginary line that forms the base of the triangle
of the interdental papillae.
The suture should be placed at an equal distance [ 2‐ 3 mm ] on both sides of the incision
• Suture should be always inserted through the more mobile flap first.
• The suture should be tied so the tissue is merely approximated & not blanched.
• The knot shouldn’t be placed on the incision line.
PERIODONTAL SUTURING TECHNIQUES
SIMPLE LOOP SUTURE
Most commonly used suture because of its simplicity.
Suture forms a simple circular loop uniting the two edges of the surgical incision.
FIGURE – 8 SUTURE
As the name tells, this suture forms a loop with a figure of eight, with the criss‐cross limbs of eight placed between the two flap edges.
Periosteal Sutures
Used to hold apically displaced flaps in place
Mainly consists of 2 sutures
1. Holding sutures
2. Closing sutures
Sutured Knot Components
KNOT TYING
The knot may be tied in 2 techniques
INSTRUMENT TIE Using needle holder
ONE‐ HANDED & TWO‐HANDED TIE Using fingers
As periodontal surgeries instrument tie is the most appropriate & extensively used technique.
Principles of Knot tying…Ethicon 1985.
1. Knot must be firm ….no slippage.
2. Knot should not be placed on incision lines ..avoid wicking.
3. Avoid excessive tension…..crimping of suture.
5. Knot ends must be 2‐3mm.
6. An added throw does not increase the strength of the knot.
8. Final tension or final throw should be as nearly horizontal
as possible.
TYPES OF KNOTS
SQUARE KNOT
SURGEON’S KNOT
GRANNY’S KNOT
SQUARE KNOT
This knot appears squarish before tightening the knot.
Technique:It is formed by tying 2 ties.
The first one in one direction & the second tie by throwing the suture in opposite direction
SURGEON’S KNOT
It is the most commonly used knot as it reduces slippage of the first tie, while the 2nd tie is placed.
Technique:
It is formed by tying 2 ties.
The first tie is formed by 2 throws in one direction & the 2nd tie in opposite direction.
GRANNY’S KNOTSame knot is used after completion of sewing the cloth.
Technique:
It involves a first tie in one direction followed by a second tie in the same direction as first.
Later a third tie is made to hold the knot permanently.
SUTURE REMOVAL
When to do it
As a rule Intra oral sutures are removed 5‐7 days after the suturing.
Natural non‐resorbable sutures, like silk are removed after 1 week of suturing.
Complications following Suturing
The knot slips gives rise to 90% of the complications following suturing, leading to dehiscence of wound.
If the non‐resorbable sutures like silk, are left in place for longer duration the lead to abcess formation. Here termed as “ Stich Abcess ”
Complications following Suturing
In case of braided sutures,because of the“ wicking‐effect” there can be spread of infection all along the suture line
If the suture material is left in‐situ for longer periods than 3 weeks, the epithelial cells migrate down the suture pathway leading to
Epithelial inclusion cysts
“ Railroad track ” scar
Periodontal dressing
• Periodontal dressings were first introduced in 1923 by A.W. Ward following gingival surgery.
• This material was called Wonder pak which consisted of zinc oxide eugenol mixed with alcohol, pine oil and asbestos fibres.
Uses of periodontal 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.
Uses of periodontal dressing
The two most widely used type of dressing materials :
Zinc oxide‐ eugenol
zinc oxide‐ noneugenol dressings.
In addition,
Cyanoacrylates,
Tissue conditioners,
Periodontal dressing that contain anti microbial agents,
photo curing periodontal dressing materials are also available.
The various zinc oxide non‐ eugenol dressings available are
• Coe‐Pak,
• Peripac,
• Vocopac, Perio care,
• Collagen dressings,
• Barric aid,
• Cyanoacrylates
• Tissue conditioners.
Coe‐pak composition
Base
• Rosin,
• Cellulose,
• Natural gums and waxes, fatty acids,
• Chlorothymol,
• Zinc acetate,
• Alcohol.
Accelerator:
• Zinc oxide,
• Vegetable oil,
• Cholrothymol,
• Magnesium oxide,
• Silica, synthetic resin,
• Coumarin
• Lorothiodol [a fungicide].
Retention of packs
• Periodontal dressings are usually kept in place mechanically by interlocking in interdental spaces and by joining the lingual and facial portions of the pack.
• Around isolated teeth or several missing teeth , splints and stents are used for retention purpose.
Cyanoacrylate:
• Use of Cyanoacrylates is an alternative to suturing and as a surface adhesive and periodontal dressing.
• Cyanoacrylates is either applied in drops or sprayed on the tissue.
Post operative instructions
Avoid brushing in that area for about a week.
Advice a good mouth rinse to minimize plaque deposits.
Advice to avoid solid food for 24 hours.
If patients feels excessive pain he should return to clinic.
If there is bleeding, should see the dentist.
If at all periodontal dressing falls off within three days, should come to clinic for new dressing.
Give analgesics.
Advisable to use anti‐inflammatory analgesic when soft tissue surgery is carried out.
First post operative week
• If properly performed ‐ no serious post operative problems.
• Patient advised to rinse with 0.12% chlorhexidin immediately after the surgical procedure and twice daily thereafter until normal plaque control technique can be resumed
Complications that may arise in the first post operative week
1. Persistent bleeding after surgery
2. Sensitivity to percussion
3. Swelling
4. Feeling of weakness
Feeling of weakness
• Occasionally, patients report having experienced a washed out , weakened feeling for about 24hrs after surgery.
• Transient bacteremia induced by the procedure.
• Avoided by premedication with amoxicillin 500mg every 8 hrs, beginning 24 hrs before the next procedure and continuing for 5 days post operatively.
Removal of pack & return visit
• One week after surgery pack is removed.
• gentle lateral pressure.
pack retained interproximally and adhering to the tooth surface are removed with scalers.
After flap operation
• may bleed readily when touched; they should not disturbed.
• Pockets should not be probed.
• Grayish yellow or white granular layer of food debris that has seeped under the pack should be removed with moist cotton pellet.
Post operative pain
• Analgesics are used for relief of pain
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