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 plaqueretaining 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 (360knife 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

Apically directed placed in the sulcular gingival incision crevice and (crevicular directed incision) 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)

Perpendicula r to gingival margins at line angles of teeth

To increase Scalpels access, to #11,#15, allow apical or coronal positioning of flap

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

Incision at the base of the flap severing the Periosteal underlying periosteum

To release Scalpels #15 flap tension or #15c allow coronal advancement of flap

releasing incision

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*

Flap design
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

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 g 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

g g

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 g direct pressure ineffective g vessel ligation using a resorbable suture In cases of flap and harvest of free tissue auto graft from palate g full thickness suture at the base of the flap in an attempt to compress the tissues against the vessels is used Bleeding of bone g burnishing the bone area of bleed with molt , elevator, curette when ineffective bone wax in area of the bleed

Variety of topical Hemostatic agents

SURGICEL Loosely woven or knitted fiber strips Absorbable oxidized regenerated cellulose 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

Gelform ; purified porcine skin

Use dry or hydrated in saline scaffold for platelet aggregation ,clot stability

Absorbable collagen

Instat : lyophilized bovine dermal collagen (sponge pad) Collatape collacote colla plug

Apply dry or hydrated with saline : hemostasis 2-5 min scaffold to platelet aggregation clot stability

Topical

Thrombostat

Liquid or powder; absorbable collagen or sponge Astringent and protein precipitate sealing blood vessels ; irratating to wound

Monsels solution Ferric sulphate 20% ferric subsulfate

Bone wax

Bone wax, Pressed into semisynthetic nutient canal bees wax and mechanical plug isopropyl palmiate

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 g highly susceptible to enzymatic degradation

Packaged in isopropyl alcohol ( acts as a preservative) which also serves to condition or soften it

Suture g absorbs alcohol g causing it to swell

Alcohol irritating to tissues g 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 g hydrolytic acid g heat & a catalyst g converted into g HMW linear chain polymer

Suture material is prepared by orienting these filaments by means of stretching and braiding

Polyglactin 910 g 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) g 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 polytetrafluoroethylene 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)

Multi filament versus monofilament

Several filaments ,twisted or braided together Increased strength and flexibility Increased incidence of infection causing invasion of bacteria into braided crevices Also cause increased friction against tissues Single strand of material

Passes smoothly into tissues

Less chance of infection

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 g traumatic needles Swaged suture g 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) 2) 3) 4)

5)

Maintains Hemostasis Permits healing by primary intention Reduces postoperative pain Permits proper flap position Prevents bone exposure resulting in delayed healing and unnecessary resorption

Principles of suturing

Suture techniques
1) Interrupted 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

2) Sling

3) Continuous sling

4) Double continuous sling

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

5) External mattress

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

Coronally advanced flaps, useful for root coverage techniques GTR Used in GTR to close over an interproximal barrier membrane

11) Anchoring

12) Laurel loop

Surgical knots

Square knot- wrapping the suture around needle holder once in opposite directions between the ties. At least 3 ties are recommended Surgeons knot- 2 throws of suture around the needle holder on the 1st tie and 1throw in the opposite direction in the 2nd tie Grannys 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

Uses
1)

2)

3)

To protect wound post surgically To obtain and maintain a close adaptation of the mucosal flaps to the underlying bone (especially when a flap has been apical repositioned) 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
1) 2) 3)

Advisable for additional week for patients with Low pain threshold (who are uncomfortable when pack removed) Unusually extensive periodontal involvement 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

Carranzas 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: 4014 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