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 plaque-

retaining 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 Coronally Gingivectomy Kirklands
bevel directed gingival knife , orbans
incision overgrowth, knife, scalpel
crown blades # 11D,
lengthening, #15 (360-
gingivolplasty knife
handle)laser
 Apically Excisional Scalpel
directed, new blades #11,
placed at the attachment #12 or 12b
Internal crest of the procedures , #15 or 15c
bevel gingival modified
incision margin or widman flap,
(reverse stepped back flap and
from margin
bevel, 0.5- 2.0 mm
curretage ,
inverse crown
lengthening,
bevel
gingival
incision)
enlargement
 Apically When Scalpel
directed preservation blades #11,
placed in the of gingival is #12,#15 or
sulcular gingival critical, as in #15 c
incision crevice and esthetic
(crevicular directed areas of
incision) toward the minimal
alveolar crest keratinized
tissue, GTR
procedures
 Perpendicula To increase Scalpels
r to gingival access, to #11,#15,
margins at allow apical
Releasing line angles of or coronal
incision teeth positioning of
(vertical flap
incision)
 Internal or Palatal flaps, Scalpel
undermining distal wedge blades #12 or
incisions procedures, #12b, #15 or
Thinning extending internal bevel #15c
incision from gingival gingivectomy
margin bulky papillae
towards the
base of the
flap to
decrease
bulk of
connective
tissue on the
underside of
the flap
 Small incision Pedicle flaps Scalpels
made at the that are #11,#15c
apical aspect laterally
of a releasing positioned
Cutback incision and
directed
incision
towards the
base of the
flap
 Incision at To release Scalpels #15
the base of flap tension or #15c
the flap allow coronal
severing the advancement
Periosteal underlying of flap
periosteum
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
 The final step location is usually determined by the goals
of therapy and the specific periodontal surgical technique
performed
 A repositioned flap used
g when surgical access for debridement of the root is
primary goal
g Used in periodontal regeneration procedures

Apically positioned flap

g Pocket elimination procedures
 Coronally positioned flap

g Mucogingival surgery (cover either root , connective

tissue graft or barrier membrane)

g 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 Apply dry – acts as
scaffold for platelet
knitted fiber strips aggregation and clot
stability ;quickly loses
integrity in blood and
Absorbable SURGICEL
saliva; bactericidal
oxidized Fibrillar in form of not recc.for
regenerated cotton wisps implantation in bone
cellulose defects unless
removed before flap
SURGICEL closure
NUKNIT Stops bleedind in 2-8
Thicker denser min
woven fabric Absorbed in 7-14 days
Absorbable Gelform ; purified Use dry or
gelatin sponge porcine skin hydrated in saline
scaffold for platelet
aggregation ,clot
stability

Absorbable Instat : lyophilized

collagen bovine dermal Apply dry or
collagen (sponge hydrated with
pad) saline :
hemostasis 2-5
Collatape min scaffold to
collacote colla platelet
plug aggregation clot
stability
Topical Thrombostat Liquid or powder;
absorbable
collagen or
sponge

Monsel’s solution
Ferric sulphate 20% ferric Astringent and
subsulfate protein precipitate
sealing blood
vessels ; irratating
to wound

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 Indication
Non absorbable Generalized purpose used in
1) Surgical silk keratinized tissue
2) expanded polytetra-
fluoroethylene GTR
Absorbable
Catgut:-
1) Surgical gut (plain)
2) Surgical gut (chromic) General purpose (gingiva
Synthetic fiber:- and mucosa)
1) Polyglactin 910 (coated
vicryl)
2) Polyglecaprone
(monocryl)
 Multi filament versus monofilament
Several filaments ,twisted Single strand of material
or braided together

Increased strength and

flexibility Passes smoothly into
tissues
Increased incidence of
infection causing invasion
of bacteria into braided Less chance of infection
crevices

Also cause increased friction

against tissues
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) Maintains Hemostasis
2) Permits healing by primary intention
3) Reduces postoperative pain
4) Permits proper flap position
5) 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

2) Sling
Allows separate facial or
lingual flap positioning in
isolated areas

Single suture to closure to

3) Continuous sling close sextant or quadrant,
allows facial and lingual
flaps to be closed in
4) Double continuous sling Apically positioned flap
closure, allows facial and
lingual flaps to be closed
independently

5) External mattress
Reduces amount of suture
under the flap, allows papilla
closure over osseous grafts
without the suture running
through the graft , enhances
positioning of papilla
6) Vertical Narrower interdental spaces

7) Horizontal Wider interdental spaces

8)Internal mattress 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

11) Anchoring GTR

12) Laurel loop Used in GTR to close over

an interproximal barrier
membrane
 Surgical knots

 Square knot- wrapping the suture around needle holder

once in opposite directions between the ties. At least 3
ties are recommended

 Surgeon’s knot- 2 throws of suture around the needle

holder on the 1st tie and 1throw in the opposite direction
in the 2nd tie

 Granny’s 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) To protect wound post surgically
2) To obtain and maintain a close adaptation of the
mucosal flaps to the underlying bone (especially when
a flap has been apical repositioned)
3) 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
 Advisable for additional week for patients with
1) Low pain threshold (who are uncomfortable when pack removed)
2) Unusually extensive periodontal involvement
3) 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
 Carranza’s 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: 401–4
 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