ENERAL

RINCIPLES
F PERIODONTAL
URGERY
Rikko Hudyono
Unsoed-2015

OUTLINE

Outpatient surgery
Hospital Periodontal
Surgery

OUTPATIENT SURGERY
1. Patient Preparation
2. Emergency Equipment
3. Measures to prevent transmission
of infection
4. Sedation and anaesthesia
5. Tissue management
6. Scaling and Root Planning
7. Hemostasis
8. Periodontal Dressing
9. Post-operative procedures

1. PATIENT PREPARATION

KNOW
YOUR
PATIENT
KNOW
YOUR

PATIENT

1. PATIENT PREPARATION
Patient overall health status
Know your operation site.
Re-evaluation after phase I Therapy
Premedication
Smoking
Informed Consent

Patient Overall Health

Status
General assessment of the
patient's physical characteristics
for abnormalities in gait, body
movements, body symmetry,
posture, weight, skin, eyes,
speech, and ability to think
clearly.
Patient's cardiovascular and
respiratory functions

Whenever there is some question a

medical consultation is
recommended

1. PATIENT
PREPARATION

Know your operation site

Surgical site anatomical
structure
Anatomical spaces
Innervation of nerves
Arterial branches

Whenever there is some question a

medical consultation is
recommended

1. PATIENT
PREPARATION

Reevaluation after phase

1 Therapy
Eliminate some lesions entirely
Render tissues more fi rm and
consistent
Acquaint the patient with
dental offi ce
Re-probing and re-examination all
findings that previously indicated the
need for surgery

1. PATIENT
PREPARATION

1. PATIENT
PREPARATION

Premedication
Reduce anxiety see Sedation
Prophylactic antibiotic
Especially for patient with medically
compromised patient
It is supposed to have greater
success rate for the new attachment
or any tissue engineering procedure

Although the rationale for prophylactic

antibiotic uses seem logical, no research
evidence is available to support it

1. PATIENT
PREPARATION

Premedication

NSAIDs (Ibuprofen,
Methampyron & Diazepam,
Mefenamic acid)

Corticosteroid
(Dexamethasone, Methyl
Prednisolon)

Mouthwashes (Chlorhexidine,
Chlorine Dioxine, Hyaluronic
Acid, Aloe Vera, warm brine)
1. PATIENT
PREPARATION

Smoking
The deleterious eff ects of
smoking had been well
documented
Patient should be informed of
this fact and asked to quit
smoking 3-4 weeks after the
procedure

1. PATIENT
PREPARATION

Smoking

1. PATIENT
PREPARATION

Informed Consent
Patient should be informed at
the initial visit about the
diagnosis, prognosis, and
diff erent possible treatment,
with their expected results,
and all pros and contras of
each approach.

1. PATIENT
PREPARATION

2. EMERGENCY
EQUIPMENTS
The operator, all assistants, and offi ce personnel
should be trained to handle all the possible
emergencies that may arise. Drugs and equipment for
emergency use should be readily available at all
times.
BASIC LIFE SUPPORT

Respiratory Equipments

The most important

Circulatory Equipments

2.
EMERGENCY
EQUIPMENTS

Medicaments
Ephinephrine
Glucocorticoids (Prednisone)
Morphine or its derivatives
Infusion solutions
Inhaled short-action beta-2
mimetic
Nitroglycerin
etc

2.
EMERGENCY
EQUIPMENTS

3. MEASURES TO PREVENT
TRANSMISSION OF
INFECTION
Universal Precaution
Sterilization
Disposal

4. SEDATION &
ANESTHESIA

Utk mengurangi kecemasan perlu diberi

obat penenang atau obat sedasi utk
mengurangi rasa takut dan kecemasan.
Dpt diberikan secara inhalasi, oral,
intramuskular, dan intravenous. Contoh :
benzodiazepine.

Utk mengurangi rasa sakit saat operasi

maka perlu pemberian anastesi lokal
sebelumnya

SEDATION

Safe and quite

effective

4. SEDATION
&
ANESTHESIA

5. TISSUE
MANAGEMENT
1. Operate gently and carefully .
2. Observe the patient at all times .
3. Be certain the instruments are

sharp .

6. SCALING & ROOT PLANING

All exposed root surface should be carefully explored and

planned as needed as part of the surgical procedure

7. HEMOSTASIS
Clear visualization of the surgical site
is HALF WAY of success
Be sure no bleeding disorders. It is
imperative to recognize that excessive
bleeding may be caused by systemic
disorders
Be familiar with your surgical site
Good aspiration with continuous suctioning
Ice-moist sterile gauze
Absorbable gelatin sponge

8. PERIODONTAL DRESSINGS

Zinc Oxide Eugenol

Developed by Ward in 1923
Based on reaction of eugenol and zinc oxide.

Noneugenol Packs
Based on reaction of fatty acid and metallic oxide
Other non eugenol packs include cyanocrylates, tissue
conditioners (methacrylate gel), zinc oxide and glycol
alcohol

Kegunaan Periodontal
Pack
Melindungi luka dari gesekan
sehingga dapat membantu
penyembuhan
Mengurangi perdarahan dengan
menjaga bekuan darah tetap di
tempatnya
Mengurangi kegoyangan gigi
Menjaga posisi fl ap secara
mekanis
Memberi bentuk pada jaringan
baru

8.
PERIODONTAL
DRESSINGS

CHARACTERICS OF PERIODONTAL
PACK
Nontoxic or nonirritating to the
tissue
Conveniently prepared, placed and
removed with minimal discomfort to
patient
Should maintain adhesion to itself
and to the teeth, kept in place
mechanically by interlocking in
interdental spaces

8.
PERIODONTAL
DRESSINGS

Zinc Eugenol Pack

Didasarkan pada reaksi dr zinc
oxide eugenol.
Bahan tambahan lainnya adalah
asbestos sbg bahan pelekat dan
pengisi serta tanic acid.
Asbestos dpt menyebabkan
penyakit paru dan karsinogenik
serta tanic acid menyebabkan
kerusakan hati
Eugenol dapat meningkatkan
reaksi allargi yg mengakibatkan
warna kemerahan pd daerah yg
dikenai dan rasa nyeri seperti
terbakar pada beberapa

8.
PERIODONTAL
DRESSINGS

Retention of Packs
Mechanical interlocking of interdental spaces

Antibacterial properties
May be enhanced by incorporating
antibiotics in pack

Allergy
So far, contact allergy with eugenol and
resin had been reported

8.
PERIODONTAL
DRESSINGS

PERIODONTAL
DRESSINGS

COE PACK the most widely

used periodontal dressings
8.
PERIODONTAL
DRESSINGS

The clinical eff ects of a periodontal

dressing after modifi ed Widman fl ap surgery
were studied. A total of thirty surgical sites in
13 patients were included in the study. Half of
the sites were not covered by a periodontal
dressing while the other half were. All
patients were instructed in oral hygiene
procedures and received rubber cup
prophylaxes and fl ossing at 1 week, 2 weeks,
1 month and 2 months postoperatively.
At the conclusion of the study, a questionnaire
was administered to each patient. No
signifi cant diff erences were found between
dressed and undressed segments regarding
changes in clinical attachment levels, pocket
depth, or gingival infl ammation. The omission
of a dressing did not result in a greater
incidence of discomfort. More patients stated
preference for no dressing.
Comparison of results following modified Widman flap surgery with and without s
urgical
dressing.
(eng) By: Allen DR, Caffesse RG, Journal Of Periodontology [J Periodontol], ISSN:
0022-3492, 1983 Aug; Vol. 54 (8), pp. 470-5; PMID: 6352896;

8.
PERIODONTAL
DRESSINGS

Wound dressing has a positive eff ect

on clinical long-term results using a
two-step non-surgical procedure.
Moreover, removing the dressing
after 78 days leads to clearly better
results than removing it earlier.

Sigusch BW, Pfitzner A, Nietzsch T, Glockmann E.

Periodontal dressing (Vocopacs) influences outcomes
in a two-step treatment procedure. J Clin Periodontol
2005; 32: 401405.

8.
PERIODONTAL
DRESSINGS

HOW TO PREPARE COEPACK

2-3
8.
PERIODONTAL
DRESSINGS

HOW TO APPLY COE-PACK

Supposed to be kept for 1 week

8.
PERIODONTAL
DRESSINGS

9. POST OPERATIVE
PROCEDURES

Clear and brief instruction and

explanation shall be given to the
patient after the pack is placed

FIRST POST OPERATIVE WEEK

If a gingivectomy has been performed,
the cut surface is covered with a friable
meshwork of new epithelium, which
should not be disturbed.
After a fl ap operation, the areas
corresponding to the incisions 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 a grayish yellow or white
granular layer of food debris that has
seeped under the pack.

Fragments of calculus delay healing .

9. POST- OP
PROCEDURES

FINDINGS ON PACK
(after 1 week)
If a gingivectomy has been performed,
the cut surface is covered with a friable
meshwork of new epithelium, which
should not be disturbed.
After a fl ap operation, the areas
corresponding to the incisions 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 a grayish yellow or white
granular layer of food debris that has
seeped under the pack.

Fragments of calculus delay healing .

9. POST- OP
PROCEDURES

Mouthcare
Patient is advised to keep area clean, as
plaque and food accumulation may
impair healing
Soft toothbrushes and light water
irrigation are advised. Rinsing with
chlorhexidine
Bleeding is normal, and will subside as
healing progresses

9. POST- OP
PROCEDURES

Management of Post-op
Pain
Minor pain and discomfort are normal
following periodontal surgery
Common source of post operative pain
is overextension of periodontal pack
For healthy patient, NSAIDs prescribed
is eff ective to reduce post operative
pain
Antibiotics may be prescribed if postoperative pain is related to infection,
which is usually accompanied by
lymphadenopathy, and slight elevation
of body temperature

9. POST- OP
PROCEDURES

Treatment of
Hypersensitivity
At home
Dentrifi ces containing strontium
chloride, potassium nitrate, and sodium
citrate
In offi ce
These products and treatments aim to
decrease hypersensitivity by blocking
dentinal tubules with either a crystalline
salt precipitation or an applied coating
(varnish or bonding agent) on the root
surface

9. POST- OP
PROCEDURES

HOSPITAL PERIODONTAL
SURGERY
Ordinarily, periodontal surgery is an offi ce
procedure performed in quadrants or sextants,
usually at biweekly or longer intervals.
Indications for hospital periodontal surgery
include
optimal control and management of
apprehension
convenience for individuals who cannot
endure multiple visits to complete surgical
treatment
patient protection.

SURGICAL INSTRUMENT
1 Excisional and incisional instruments
2 Surgical curettes and sickles
3 Periosteal elevators
4 Surgical chisels
5 Surgical files
6 Scissors
7 Hemostats and tissue forceps

EXCISIONAL AND INCISIONAL

INSTRUMENTS

SURGICAL CURETTES AND SICKLES

PERIOSTEAL ELEVATORS

SURGICAL CHISELS

SURGICAL FILES

SCISSORS AND NIPPERS

HEMOSTATS AND TISSUE FORCEPS