The main objective of periodontal surgery is to achieve health and integrity of the periodontium by plaque removal and plaque control. Patient preparation is an important aspect of the intervention. The presentation mentions certain principles of periodontal surgery which are crucial for effective treatment of the patient.

1. GENERAL
PRINCIPLES OF
PERIODONTAL
SURGERY
-DR.SHRADDHA KODE

2. All surgical procedures must be carefully
planned
The patient should be adequately
prepared medically, psychologically and
practically for all aspects of the intervention
2

3. OUTPATIENT SURGERY
REEVALUATION AFTER PHASE I THERAPY
3
Purpose of scaling and root planing:
1. Eliminate some lesions entirely
2. Render the tissues more firm and consistent
thereby allowing for a more accurate and delicate
surgery
3. Acquaint the patient with the clinic, the operator
and the assistants thus reducing apprehension and
fear
The reevaluation phase consists of reprobing and
reexamining all of the findings and persistence of
them confirms the indication for surgery

4. “
4
PREMEDICATION
The prophylactic use of antibiotics before periodontal surgery
show reduced postoperative complications, reduced pain and
swelling
For patients who are not medically compromised the value of
administering antibiotics routinely for periodontal surgery has not
been clearly recommended
Other pre-surgical medications involve – NSAIDS 1hour before
the procedure and the use of 0.12% chlorhexidine gluconate

5. 5
SMOKING
Patient should be asked to quit smoking completely or
atleast stop smoking for a minimum of 3-4 weeks
after the procedure
INFORMED CONSENT
The patient should be informed about the diagnosis,
prognosis and the different possible treatments, the
expected results and the pros and cons in verbally and
in writing

6. 6
EMERGENCY EQUIPMENT
The operator, the assistants and the office personnel should be trained
to handle all the possible emergencies that may arise
TREATMENT OF SENSITIVE ROOTS
Root hypersensitivity may occur spontaneously when the root
becomes exposed as a result of gingival recession or pocket
formation
Mechanism of action by which the desensitising agents work is
by occlusion of the dentinal tubules or by nerve desensitisation
The desensitising agents do not produce immediate relief and
must be used for several days or weeks to produce results

7. 7
2 MODES OF ADMINISTRATION OF
DESENSITISING AGENTS
AT HOME:
Tooth dentrifices and tooth pastes are over the counter
desensitising materials to be used with soft bristled toothbrush
Mouthwashes and chewing gums containing potassium nitrate
and fluoride reduce dentinal hypersensitivity
2-4 weeks after at home therapy, degree of DH shuld be
reinvestigated. If pain still exists dentist should start the
next phase – IN OFFICE THERAPY

8. 8
IN OFFICE THERAPY
FOR DENTINAL
HYPERSENSITIVITY

9. METHODS TO PREVENT
TRANSMISSION OF INFECTION
9
Universal precautions and barrier techniques are
recommended for each and every patient which include use
of disposable sterile gloves, surgical masks and protective
eyewear
All surfaces that may be possibly contaminated with blood
or saliva and that cannot be sterilised (eg. light handles,
unit syringes) must be covered with aluminium foil or plastic
wrap

10. “
10
The most reliable means of providing painless surgery is the
effective administration of local anesthesia by regional block and
local infiltration
Apprehensive and neurotic patients require special management
by anti-anxiety or sedative-hypnotic agents (which include
inhalation, oral, intramuscular and intravenous routes)
SEDATION AND ANESTHESIA

11. 11
TISSUE MANAGEMENT
Operate gently and carefully: Tissue manipulation should be precise,
deliberate and gentle. Roughness must be avoided because it
produces excessive tissue injury, causes postoperative discomfort
and delays healing
Observe the patient at all times: Facial expressions, pallor and
perspiration are distinct signs that may indicate that the patient is
experiencing pain, anxiety or fear
Be certain that the instruments are sharp: Instruments must be
sharp to be effective. Dull instruments inflict unnecessary trauma as
a result of poor cutting and excessive force applied to compensate
for their effectiveness

12. 12
SCALING AND ROOT PLANING
Although scaling and root planing have been performed previously as
a part of Phase I therapy, all exposed root surfaces should be carefully
explored and planed as a part of the surgical procedure
Also, areas of difficult access (eg. Furcations, deep pockets) should be
assessed
HEMOSTASIS
Good intraoperative control of bleeding permits an accurate
visualisation of the surgical site
Good hemostasis prevents the excessive loss of blood into the
mouth, oropharynx and stomach

13. 13
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
Fortunately, the laceration of the large or medium vessels is less
because incisions near highly vascular areas such as posterior
mandiblular (inferior alvelolar 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

14. 14

15. 15
ABSORBABLE HEMOSTATIC AGENTS

16. PERIODONTAL DRESSINGS
In general, dressings have no curative
properties; they assist healing by
protecting the tissue rather than
providing healing factors
ADVANTAGES:
◎ Minimizes post operative infection and
hemorrhage
◎ Prevents surface trauma during mastication
◎ Protects against pain induced by contact of
wound with food or the tounge
16

17. IDEAL PROPERTIES
OF PERIODONTAL
DRESSING
 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.
 The dressing should harden within a
reasonable time.
 After setting, the dressing should be
sufficiently rigid to prevent fracture and
dislocation.
 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.
17

18. 18
ZINC OXIDE EUGENOL PACKS
Reaction between zinc oxide and eugenol
Developed by Ward in 1923
Addition of accelerator like zinc oxide gives the
dressing a better working time
Disadvantage: Eugenol may cause an allergic
reaction that results in reddening of the area and
burning pain in some patients
NONEUGENOL PACKS
Reaction between a metallic oxide and fatty acids
Marketed as Coe-Pak
Supplied in two tubes – contents mixed to obtain a
uniform colour
Other noneugenol packs – cyanoacrylayes, tissue
conditioners (methacrylate gels)

19. 19
COMPOSITION OF COE-PAK

20. 20
PREPARATION OF DRESSING

21. 21
APPLICATION OF DRESSING

22. 22
Mechanically by interlocking in interdental spaces
In isolated teeth or when several teeth in the arch are
missing – reinforcements and splints and stents may be
used
RETENTION OF DRESSING
The incorporation of tetracycline powder into the dressing
is recommended in the case of long and traumatic surgeries
Improved healing and patient comfort with less odor and
taste is reported
ANTIBACTERIAL PROPERTIES OF DRESSING

23. 23
WAKE UP

24. 24
POST-OPERATIVE INSTRUCTIONS

25. FIRST POST-OPERATIVE WEEK
25
PERSISTENT BLEEDING AFTER SURGERY: The pack is removed, the
bleeding points are located, and the bleeding is stopped with pressure,
electrosurgery, or electrocautery. After the bleeding is stopped, the area
is repacked.
SENSITIVITY TO PERCUSSION: Extension of inflammation into the
periodontal ligament may cause sensitivity to percussion. The pack
should be removed and the gingiva checked for localized areas of
infection or irritation, which should be cleaned or incised to provide
drainage. Sensitivity to percussion may also be caused by excess pack,
which interferes with the occlusion. Removal of the excess usually
corrects the condition.

26. FIRST POST-OPERATIVE WEEK
26
SWELLING: During the first 2 postoperative days, some patients
may report a soft, painless swelling of the cheek in the surgical
area. Lymph node enlargement may occur, and the temperature
may be slightly elevated. This type of involvement results from a
localized inflammatory reaction to the procedure. It generally subsides
by the fourth postoperative day, without necessitating the removal
of the pack. If swelling persists, becomes worse, or is associated
with increased pain, amoxicillin (500 mg) should be taken
every 8 hours for 1 week, and the patient should also be
instructed to apply moist heat intermittently over the area.

27. FIRST POST-OPERATIVE WEEK
27
FEELING OF WEAKNESS: Occasionally, patients report having
experienced a “washed-out,” weakened feeling for about 24 hours
after surgery. This represents a systemic reaction to a transient
bacteremia induced by the procedure. This reaction is prevented
by premedication with amoxicillin (500 mg) every 8 hours,
beginning 24 hours before the next procedure and continuing
for 5 days postoperatively.

28. 28
SURGICAL INSTRUMENTS
For incision (surgical blades 11,12,15) and excision (periodontal knives)
For reflection of the flap (periosteal elevators)
For the removal of granulation tissue, fibrous interdental tissues, and tenacious
subgingival deposits (Surgical curettes and sickles)
For holding the flap during suturing and to position and displace the flap after the
flap has been reflected (Tissue forceps)
To remove tabs of tissue during gingivectomy, to trim the margins of flaps, to
enlarge incisions in periodontal abscesses, and to remove muscle attachments in
mucogingival surgery (Scissors and nippers)
To suture the flap at the desired position after the surgical procedure has been
completed (Needle holder)

29. HOSPITAL PERIODONTAL SURGERY
INDICATIONS:
Patient apprehension
Patient convenience
Patient protection
Ordinarily, periodontal surgery is an
office procedure that is performed
in quadrants or sextants, usually at
biweekly or longer intervals.
Under certain circumstances,
however, it is in the best interest of
the patient to treat the mouth with
only one surgery, with the patient in
a hospital operating room and
under general anesthesia.
29

30. POINTS TO REMEMBER
◎ The efficient, precise, and minimally
traumatic management of tissues is
the way to obtain the best clinical
outcomes.
◎ Patients should be given the
necessary pain-relieving medications
so that an effective level of analgesic
is present during the postsurgical
period
30

31. POINTS TO REMEMBER
◎ The use of longer-acting local
anesthesia agents and protective
periodontal dressings also helps to
reduce postsurgical pain.
◎ During the immediate postsurgical
weeks, plaque control and healing are
enhanced by the use of antimicrobial
mouthrinses such as chlorhexidine.
◎ Postsurgical root sensitivity is well
controlled by ensuring that plaque
control is optimal, and desensitizing
agents will be needed only
occasionally 31

32. EXERCISE
32

33. 33
What is the composition of coe pak?

34. 34
What are the three objectives of tissue
management?
Operate gently and carefully: Tissue manipulation should be precise,
deliberate and gentle. Roughness must be avoided because it
produces excessive tissue injury, causes postoperative discomfort
and delays healing
Observe the patient at all times: Facial expressions, pallor and
perspiration are distinct signs that may indicate that the patient is
experiencing pain, anxiety or fear
Be certain that the instruments are sharp: Instruments must be
sharp to be effective. Dull instruments inflict unnecessary trauma as
a result of poor cutting and excessive force applied to compensate
for their effectiveness

35. 35
How to treat post-operative dentinal
hypersensitivity?
IN OFFICE THERAPY
FOR DENTINAL
HYPERSENSITIVITY
AT HOME

36. 36
What are the indications of hospital
periodontal surgery?
INDICATIONS:
Patient apprehension
Patient convenience
Patient protection

37. CONCLUSION
For effective healing post periodontal
therapy the mentioned principles of
periodontal surgery should be followed37

38. 38