General principles of periodontal surgery

1. General Principles Of
Periodontal
Surgery
KVG Dental college and Dr. MD Abdul
Haleem

2. CONTENTS1. Introduction
2. Objectives
3. Indications
4. Contraindications
5. Outpatient surgery
A. Patient preparation
B. Emergency equipment
C. Measures to prevent transmission of
infection
D. Sedation and anesthesia
E. Tissue management
F. Scaling and root planning
G. Hemostasis
H. Periodontal dressings
I. Post operative instructions
J. Removal of pack and return visit
K. Mouth care between procedures
L. Management of postoperative pain

3. CONTENTS
6. Hospital periodontal surgery
A. Indication
B. Patient preparation
C. Postoperative instructions
7. Surgical instruction
A. Excisional and incisional instruments
B. Surgical curettes and Sickles
C. Periosteal elevator
D. Surgical chisels
E. Tissue forceps
F. Scissors and nippers
G. Needle holders
8. Reference

4. INTRODUCTION
• All surgical procedures
should be carefully planned .
• The patient should be
adequately prepared
medically, psychologically,
and practically for all aspects
of intervention.

5. • Main objective of periodontal
surgery is to contribute to the
long-term preservation of the
periodontium by facilitating
plaque removal and its control -
Jan Lindhe
• Patient preparation is an
important aspect of the
intervention

6. INDICATED IN...
• Impaired access for SRP
• Root fissures
• Root concavities
• Furcation's
• Defective margins of restorations
in the subgingival area
• Gross gingival Deformities
• To facilitate proper restorative therapy

7. APPARENT
CONTRAINDICATION...
• Poor patient cooperation
• Cardiovascular diseases
• Pt. With bleeding disorders
• Hormonal and metabolic disorders
• Smoking

8. OUT PATIENT SURGERY
1. Patient preparation
•Re-evaluation after
phase I therapy
•Premedication
•Smoking
•Informed consent
2. Check for
emergency
equipment
3. Measures to
prevent
transmission
of infection

9. 4. SEDATION AND
ANAESTHESIA
• Most reliable means of painless
surgery is- L.A.
• Patient’s medical history &
history of allergy should be
assessed before L.A.
Administration

10. 4. SEDATION AND
ANAESTHESIA
• lidocaine HCl without epinephrine the
maximum individual dose should not exceed 4.5
mg/kg of body weight, and in general it is
recommended that the maximum total dose
does not exceed 300 mg. (max. Volume is 15ml=
7 cartridges)

11. 4. SEDATION AND ANAESTHESIA
• With epinephrine it should not
exceed 7 mg/kg of body weight,
and in general it is
recommended that the
maximum total dose not
exceed 500 mg. (max. Volume
is 25ml= 12cartridges)

12. • Apprehensive & neurotic patients require
sedatives and hypnotics
• I.V. Benzodiazepins can be used to achieve
greater level of sedation in patients with
severe level of anxiety but with caution !!!
Alprazolam 0.25-0.5 mg
Diazepam 2-10 mg
Lorazepam 1-4 mg
Triazolam 0.125- 0.5 mg

13. • Operate gently and carefully
• Thoroughness is essential but roughness
must be avoided
5. Tissue management
• Observe the patient at all times
• facial expressions, pallor and
perspiration are distinct signs that may
indicate that patient is experiencing
pain
• Be certain the instruments are sharp
• Dull instruments inflict unnecessary
trauma

14. • All exposed root surfaces should be
carefully explored and planed.
• In areas of difficult access, such as
furcations or deep pockets often have
rough areas or calculus undetected
during phase-I.
• The assistant who is retracting the
tissue should also check for presence of
calculus and smoothness of root from a
different angle
6. Scaling and Root Planning - Debridement

15. Importance of haemostasis:
1. Accurate visualization of the
extent of the disease, pattern
of bone destruction, anatomy
and condition of roots
2. Provides clear view for
debridement
3. Prevents excess loss of blood
from the body
7. Hemostasis

16. • Periodontal surgeries can produce
profuse bleeding during initial
incisions and flap reflection and
upon removal of granulation tissue,
bleeding is considerably reduced
•Intraoperative bleeding can be
managed with continuous
aspiration/suctioning
•Application of pressure with gauze can
control the site specific bleeding

17. • Fortunately, the laceration of the
large or medium vessels is less
because incisions near highly
vascular areas such as posterior
mandibular (inferior alveolar and
lingual) and mid palatal regions
are avoided in incision and flap
design.
• If a medium or large vessel is lacerated, a
suture around the bleeding end is
necessary for the hemostasis.

18. METHODS TO CONTROL BLEEDING
FROM CAPILLARIES
• Application of cold pressure to the
site with moist gauze (soaked in a
sterile ice water)
• Use of local anaesthetic with the
vasoconstrictor
• Absorbable gelatine sponge
• Oxidized cellulose
• Oxidized regenerated cellulose
• Microfibriller collagen haemostats
• Thrombin

19. •Benefits of periodontal dressing:
1. Minimizes post operative
infection and haemorrhage
2. Prevents surface trauma during mastication
3. Protects against pain induced by contact of wound with
food or the tongue
8. Periodontal dressings
In general, dressings have no curative properties;
they assist healing by protecting the tissue rather
than providing healing factors

20. IDEAL PROPERTIES
PERIODONTAL DRESSING
1. The dressing should be soft, but still have
enough plasticity and flexibility to
facilitate its placement in the operated
area and to allow proper adaptation.
2. The dressing should harden within a reasonable time.
3. After setting, the dressing should be sufficiently rigid to
prevent fracture and dislocation.

21. • The dressing should have
a smooth surface after setting
to prevent irritation to the
cheeks and lips.
• The dressing should preferably have bactericidal
properties to prevent excessive plaque formation.
• The dressing must not detrimentally interfere with
healing.

22. Zinc oxide eugenol
packs
•Developed by Ward in
1923 (Wondr-Pak)
•Supplied as liquid and
powder
• eugenol may induce an
allergic reaction and
burning pain in some
patients
Noneugenol packs
•Metallic oxide and fatty
acids (Coe-Pak)
•Cyanoacrylates
(Barricade)
•Tissue conditioners

23. COMPOSITION OF COE-PAK
• Pink Paste tube (Accelerator)
• Zinc oxide
• Oil (for plasticity)
• A gum (for cohesiveness)
• Lorothidol (fungicide)
• Liquid paste tube (pale yellow)
• Liquid coconut fatty acids thickened
with Rosin
• Chlorothymol (bacteriostatic agent)

24. STUDIES RELATED TO
ANTIBACTERIAL PROPERTIES OF
PACKS
• Baer et al. And frailgh et al. Studied Bacitracin and
neomysin incorporated packs in clinical trials, but all
produced hypersensitivity reactions
• In a study of Romanov et al., the emergence of resistant
organisms and opportunistic infection has been reported
• But, Carranza suggests incorporation of tetracycline
powder in Coe-Pak is recommended, when long and
traumatic surgeries are performed

25. PREPARATION AND APPLICATION
OF PERIODONTAL DRESSING
Equal length of the
two paste placed on a
paper pad
Mixed with a wooden
tongue depressor for 2-3
minutes until paste loses
its tackiness

26. • Paste is placed in a paper cup of
water at room temperature
• With lubricated fingers rolled
into cylinders and placed on the
surgical wound

27. • Strip of pack is hooked around last
molar and pressed in to place
anteriorly
• Lingual pack is joined to facial
strip at the distal surface of last
molar and fitted into place
anteriorly
• Gentle pressure on the facial and
lingual surfaces join the pack
interproximally

28. • A study by Curtis et al. (J periodontal 1985) on 304
consecutive periodontal interventions revealed that
51.3% of patients reported minimal or no post operative
pain and only 4.6% reported severe pain. Of these 20.1%
took five or more dose of analgesic.
9. Management of postoperative pain
• A common source of post operative pain
is over extension of pack
• Second reason is prolonged exposure
and dryness of bone

29. • According to Carranza, a preoperative
dose of ibuprofen (600-800 mg.) followed
by one tablet 400mg every eight hours
for 1 or 2 days is very effective for post
operative pain reduction.
• When severe pain is present, the
patient should be seen at the office on
an emergency basis.
• Post operative pain related to infection
should be treated with systemic
antibiotics

30. POSTOPERATIVE INSTRUCTIONS
• Instruct the patient to take two
paracetamol/ibuprofen tabs. Every 8 hours
for first 24 hours (do not take aspirin)
• Don't brush over the pack
• Rinse with 0.12% CHX gluconate twice daily
until normal plaque control technique can be
resumed

31. • Avoid hot foods during first 24 hours
• Try to chew on the non-operated side
of the mouth (semisolid foods are
suggested)
• avoid alcohol, citrus fruits or juices,
spiced foods
(food supplements or vitamins are
generally not necessary)
• Don't smoke

32. • Swelling is normal, particularly in areas that
required extensive surgical procedures
• During the first day, apply ice intermittently
on the face over operated area (or to suck ice
cubes intermittently)
• Occasionally, blood may be seen in the saliva
for the first 4 to 5 hours, this is not unusual
and will correct itself
• Pack should remain in place until it is
removed in the office at the next
appointment

33. POST OPERATIVE EVALUATION
• In case of Gingivectomy:
• Cut surface is covered with a friable
meshwork of new epithelium, which
shouldn't be disturbed
• If calculus has not been completely
removed, red, beadlike protuberances
of granulation tissue will persist.
Findings at Pack removal

34. In case of flap surgery:
• Facial and lingual mucosa may be covered
with greyish yellow or granular whitish
layer of food debris that has seeped under
the pack
• This is easily removed with a moist cotton
pellet
• areas corresponding to the incisions are
epithelialized but may bleed readily when
touched
• “POCKETS SHOULDN'T BE

35. • According to the study by
Burch et al. Tooth mobility
is increased immediately
after surgery
• But, it diminishes below
the pre-treatment level
by the fourth week
- (Majewski et al.)
Evaluation of tooth mobility

36. MOUTH CARE BETWEEN
PROCEDURES
• This measure should begin after the pack
is removed from the first surgery
1. No vigorous brushing during the first
week after the pack is removed (gentle
use of soft brushes and light water
irrigation)
2. Rinsing with chlorhexidine mouthwash
or topical gel application

37. PRINCIPLES FOR HOSPITAL
PERIODONTAL SURGERY
•Treating the full mouth at one surgery in a
hospital operating room under general
anaesthesia
•Principles are:
1. Premedication
2. Anaesthesia
3. Positioning and periodontal dressing
4. Post operative instruction

38. WHY IS IT INDICATED?
1. Patient apprehension
Procedures in one session rather than in repeated visits
is an added comfort to the patient
2. Patient convenience
One time surgery is less stress for the patient and less
time involved in post operative care
3. Patient protection
Some patients have systemic conditions that require
special precautions best provided in a hospital setting

39. PREMEDICATION
• A sedative
(benzodiazepins) should be
given a night before the
surgery
• Premedication for patients
with systemic problems
(e.g. H/O rheumatic fever,
valvular and
cardiovascular diseases)

40. ANAESTHESIA
• Local anaesthesia is the method of
choice, except for especially
apprehensive patients
• When GA is indicated, it is
administered by an
anaesthesiologist
• the judicious use of LA to regional
nerve blocks allows the GA to be
lighter (wide margin of safety is
ensured)

41. PATIENT POSITIONING
• Surgery is performed on
the operating table with
the patient lying down and
the table either positioned
flat or with head inclined
up to 30 degrees

42. PERIODONTAL DRESSING
• When GA is used, delay the placement of periodontal
dressing until the patient has recovered sufficiently to
have a demonstrable cough reflex

43. POST OPERATIVE INSTRUCTION
• After a full recovery from general
anaesthesia, most patient can be
discharged
• The effect of GA and sedatives make
the patient drowsy for hours, so
adult supervision at home for up to
24 hours is recommended
• Patient is scheduled for a post
operative visit in 1st week.

44. GENERAL CONSIDERATIONS FOR
INSTRUMENTS USED IN
PERIODONTAL SURGERY
• 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)

45. Set of instruments used for periodontal surgery and
included in a standard tray.

46. • Additional equipment may include:
• Syringe for local anaesthesia
• Syringe for irrigation
• Aspirator tip
• Physiologic saline
• Drapings for the patient
• Surgical gloves and surgical mask

47. COMPLICATIONS IN PERIODONTAL
SURGERY
The most significant complication or emergency occur in
PERIODONTAL THERAPY are:
1. SHOCK & SYNCOPE
2. HEMORRHAGE
3. PAIN
4. SWELLING and HEMATOMA
5. DELAYED HEALING
6. ALLERGIC REACTIONS TO DRESSING
7. SENSITIVITY OF THE TEETH

48. SHOCK
• The most serious of all complication is anaphylactic shock
to an administered drug
• It is life threatening state, which require immediate
attention.

49. CLINICAL MANIFESTATIONS
• It usually develops within few minutes
following administration of drug.
• The patient feels uneasy, difficulty in
breathing, nausea, becomes pall, then
cyanotic, perspire heavily and collapse.
• The blood pressure becomes very low
and the pulse fast and weak or it may
not be felt at all. Respiration becomes
asthmatic.

50. MANAGEMENT
• The assistant should be
introduced to call emergency
service whenever it is
suspected that the patient is
going into shock.
• Place the patient in trendelen
burg´s position, clear the air
passages and administer
oxygen.

51. MANAGEMENT
• If the blood pressure is very
low, give 0.5 ml. epinephrine
(1:1000 injectable form)
intramuscularly.
• It may be given in any large
muscle.

52. MANAGEMENT
• Do not inject epinephrine
subcutaneouly, it is absorbed very
slowly.
• If the patient`s heart has stopped
completely, emergency external
heart massage should be
introduced, if the breathing has
also stopped, artificial respiration
should be given until emergency
help arrives.

53. MANAGEMENT
• Cardiopulmonary resuscitation (CPR) .
• If the patient shows signs of agitation and chest pain,
oxygen should be administered and the emergency service
called, since these symptoms may indicate a heart attack.
Administration of epinephrine would be contraindicated for
such patient.

54. MANAGEMENT
• OTHER CAUSES Of shock like symptoms may be
hypoglycemia of insulin shock in diabetes.
• Individual with hypoglycemia may require a sugar
containing beverage prior to and during periodontal
surgery.
• Shock may also be the result of loss of blood. Internal
hemorrhage or cardiovascular accidents.
• The most important action in any shock like reaction is to
administer supportive emergency therapy.

55. SYNCOPE
• The most common cause of loss of consciousness in
the dental chair is simple syncope.
• The situation is unpleasant and embracing to the
patient and disruptive to the treatment procedures.

56. SYNCOPE
MANAGEMENT
• If the patient starts to become abnormally
pale perspire heavily and is restless, place
the chair in horizontal position with the
head below the level of the body.
• If the pulse become noticeable weaker than
normal, record the blood pressure.
• Aromatic ammonia may help to prevent
syncope.
• If the patient is in deep syncope and making
slow recovery, oxygen should be
administered.

57. MANAGEMENT
• While the patient is regaining consciousness,
he should be kept in horizontal position and
should not be allowed to sit up until his
normal color has returned and is fully
recovered from a feeling of dizziness and
nausea.
PRECAUTION
• The patient fears through psychological and
pharmacological preparation before the
surgery.
• Instruments and blood should be kept outside
the patient`s field of vision.

58. HEMORRHAGE
• Because periodontal surgery ordinarily involves only small
blood vessels, significant hemorrhage is not a frequent
complication of periodontal surgery when local anesthetics and
vasoconstrictor drugs are used
• Average amount of blood loss during one session of periodontal
surgery has been reported to be 37ml.

59. HEMORRHAGE
CAUSES
• Bleeding disorders.
• Heavy intake of aspirin or the other
drugs.
• Abnormal bleeding may be related to
unexpected on set of menstrual period.
• There may also be accidental severing
of large blood vessels during surgery
provoking extensive bleeding.

60. PRIMARY: Primary postoperative hemorrhage starts at the time
of surgery.
INTERMEDIATE: Intermediate hemorrhage starts soon after
the surgery, after having stopped temporarily following surgery.
It is due to break down of incomplete clot, such as associated
with loss of vasoconstrictor effect of anesthesia.
SECONDARY: The secondary type post surgical hemorrhage
may starts from 24 hours to 10 days postoperatively. The patient
should be instructed to contact the dentist, who did the surgery
immediately if intermediate or secondary hemorrhage occurs.
Hemorrhage: Primary, Intermediate &
Secondary

61. MANAGEMENT :
First to reassure the Patient and control the
patient’s emotional concern about the bleeding.
A mild oozing type of bleeding can usually be
controlled by a pressure pack , using gauze
moistened in sterile saline solution and held
firmly in position for 2-3 minutes . Injection of
LA along with 1:50,000 vasoconstrictor drug
may also be helpful in controlling bleeding.
Hemorrhage: Primary, Intermediate &
Secondary

62. • If the bleeding is arterial spouting of light red
blood as may be seen with encroachment on the
palatal anterior , one may try to crush the cut
artery with a hemostat. Hold the hemostat in
position for several minutes and remove it
carefully .
• If there is not enough soft tissue to grasp the
hemostat one may attempt to seal the vessel by
crushing the bone of nutrient bone channel . If
the cut are surface is in soft tissue, cautery may
be tried either by a hot instrument or a ball
electrode from an electrosurgical machine.
Hemorrhage: Primary, Intermediate &
Secondary

63. • If the bleeding is severe, it may have to be
stopped by tying a suture around the
bleeding vessel.
• A slow , oozing , venous bleeding (dark
blood) may be stopped by the use of
Gelfom or oxygel.
• These preparation are somewhat irritating
and definitely have to be removed before a
periodontal dressing is placed over the
wound.

64. • The patient should never be allowed to leave the dentist
office until all gross hemorrhaging has stopped.
• If intermediate or secondary hemorrhage occurs ,
administration of local anesthetic with vasoconstrictor
centrally to the wound is recommended .

65. PAIN
• During the first 24 hours following the periodontal surgery ,
there should be only minimal pain and discomfort if the basic
principles of atraumatic surgery were absorbed carefully.
CAUSES
• Mechanical trauma during surgery.
• Drying the bone
• Traumatic bone surgery or incorrectly placed periodontal dressing
• A very common source of post operative pain is impingement from the post
surgical dressing .

66. PAIN
Management
• The surgical area should be anesthetized , the
dressing removed and the cause of pain is
identified.
• When the cause has been eliminated a new
carefully fitted dressing should be placed in to
the position.
• After the dressing has been changed the
patient may be given pain relieving
medication, however medication usually for
few days.

67. INFECTION
• INFECTION Usually does not start until
2-4 days following surgery.
• Such pain is usually accompanied by
lymphadenopathy and there may be slight
elevation in temperature
• place a topical antibiotic ointment (eg. 3%
achromycin) over the wound and apply a
new dressing .

68. INFECTION
• The patient should be placed on systemic
antibiotic therapy.
• Fever and soreness of the teeth to percussion may
indicate a developing osteomyelitis and the patient
should be treated with large doses of antibiotics,
preferably PENICILLIN .
• Doubling the normal dosage for at least 10- 14
days is recommended for osteomyelitis.

69. REACTION TO PERIODONTAL DRESSING
• Allergic reaction to periodontal dressing some times occur
especially in patient who have been wearing dressing over a
prolonged period of time due to multiple episodes of surgery or
delayed healing.
• The sensitivity reaction is usually provoked by the eugenol in
zinc oxide eugenol type of dressing.

70. REACTION TO PERIODONTAL DRESSING
• It has been observed , although very rarely with noneugenol
containing dressing.
• First symptom of a sensitivity reaction to periodontal dressing
is a burning sensation in the buccal mucosa and on the surface
of the tongue where contact with dressing occur.

71. REACTION TO PERIODONTAL DRESSING
• The patient should be told at time of the surgery of the
possibility of such symptom occurring and instructed to
contact the dentist on experiencing them.
• If the dressing is not removed ,
the reaction progress from
erythema to vesicle formation
and edema ( which is especially
in relation to the tongue ) may
be serious complication, since
epiglottal edema interfere with
air passage.

72. REACTION TO PERIODONTAL DRESSING
• If the patient is not treated a generalized allergic reaction
may develop , including a dermatitis.
• It is therefore very important that the surgical dressing be
removed completely as soon as any of the initial symptoms
of allergic reaction appear .
• If a new dressing is needed a non eugenol- containing type
of dressing, such as coe-pack or peripak may be used .

73. • The patient should also be given systemic
antihistamines for at least 4-5 days in order to intercept
the allergic reaction.
• With severe allergic reaction, the patient may have to be
hospitalized and given cortisone therapy.

74. SENSITIVITY OF THE TEETH
The root surface of the teeth that have been exposed to the
oral environment as a result of periodontal surgery
sometimes become extremely sensitive to heat and cold , as
well as to mechanical and chemical stimuli.

75. SENSITIVITY OF THE TEETH
MANAGEMENT
• Tooth paste for reduction of sensitivity provide
varying degrees of relief for long term sensitivity.
• Topical fluoride application are often used .
• Combining fluorides and electrical has been
claimed to reduce sensitivity , but the reduction
apparently is not dependent on the use of
electric current.

76. SENSITIVITY OF THE TEETH
Vigorous plaque control in the most significant factor in long
term reduction of sensitivity , unless the sensitivity is related
to occlusal dysfunction , which requires the oral therapy

77. GOALS OF SURGERY
• To Gain access for root preparation when nonsurgical
methods are ineffective
• To Establish favourable gingival contours
• Facilitate self performed oral hygiene
• Lengthen the clinical crown to facilitating adequate
restorative procedures; and
• To Regain lost periodontium using regenerative approaches
*Wang & Greenwell (PERIODONTOLOGY 2000)

78. CONCLUSION
• Periodontal therapy is directed at disease
prevention, slowing or arresting disease progression,
regenerating lost periodontium and maintaining
achieved therapeutic objectives.

79. FOR PROPER HEALING PRINCIPLES TO
BE FOLLOWED
7. Proper suturing and dressing
6. Preventing unnecessary contamination
5. Short operating time
4. Minimal, atraumatic tissue handling
3. Sharp instrumentation
2. Surface disinfection
1. Adequate anaesthesia
Wang & Greenwell (PERIODONTOLOGY 2000)

80. REFERENCES:
1. Fermin A. Carranza, Jr., Michael G. Newman,Textbook of
Clinical periodontology.,1oth ed., WB saunders &Co.,2008
2. Jan Lindhe, Thorkild Karring . Niklaus P. Lang, Textbook
of Clinical Periodontology and Implant Dentistry, 4th ed. by
Blackwell Munksgaard, a Blackwell, Publishing Company,
2003.
3. Hom-laywang & Henry Greenwell, Surgical periodontal
therapy, Periodontology 2000, Vol. 25, 2001, 89–99.
4. H. A. Sachs, A. Farnoush, L. Checchi and C. E. Joseph,
Current Status of Periodontal Dressings, J. Periodontol.
December, 1984

81. Thank you 