Principles of Periodontal Surgery

1. 🙢
General principles of
periodontal surgery

2. 🙢
Patient preparation
Emergency Equipment
Measures to Prevent Transmission of Infection
Sedation and Anesthesia
Tissue Management
Scaling and Root Planning
Hemostasis
Periodontal Dressings (Periodontal Packs)
Postoperative Instructions
Treatment of Sensitive Roots
Desensitizing agent
OUTLINE

3. 🙢
1- re-evaluation after phase 1 therapy
2-Premedication
3- smoking
4-Informed Consent
Patient preparation

4. 🙢
1- Re-evaluation after phase 1 therapy:
The patient should be re-evaluated after phase
1 therapy for the persistance of any findings
that would make surgical procedures
necessary.
e.g. pocket depth more than 5 mm that bleed on
probing, gingival enlargement, vertical bone
Patient preparation

5. 🙢
2-Premedication:
� Some studies have reported reduced
postoperative complications including reduced
pain and swelling when antibiotics are given
before periodontal surgery and continuing for 4
to 7 days after surgery.
� Other presurgical medications include
administration of a nonsteroidal,
antiinflammatory drug such as ibuprofen 1 hour

6. 🙢
3- smoking:
� Has effect on healing of periodontal
wounds.
� Patients should be clearly informed of this
fact and requested to stop smoking for a
minimum of 3 to 4 weeks after the
procedure.

7. 🙢
4-Informed Consent:
� The patient should be informed at the time of the initial
visit about the diagnosis, prognosis, the different
possible treatments with their expected results.
� At the time of surgery, the patient should again be
informed, verbally and in writing, of the procedure to be
performed, and he or she should indicate agreement by
signing the consent form.

8. 🙢
� The operator, all assistants, and office 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.
� The most common emergency is syncope or a
transient loss of consciousness due to a reduction in
cerebral blood flow.
Emergency Equipment

9. 🙢
� Universal precautions, including protective attire,
and barrier techniques are strongly recommended
and often required.
� They include the use of disposable sterile gloves,
surgical masks, and protective eyewear.
� All surfaces possibly contaminated with blood or
saliva that cannot be sterilized (such as light handles
and unit syringes) must be covered with aluminum
foil or plastic wrap.
Measures to Prevent Transmission of
Infection:

10. 🙢
� Aerosol-producing devices, such as the Cavitron,
should not be used on patients with suspected
infections.
� Special care should be taken when using and
disposing of sharp items such as needles and scalpel
blades.

11. 🙢
� Periodontal surgery should be performed painless
� The area to be treated should be anesthetized by
means of regional block and local infiltration
injections.
� Apprehensive and neurotic patients require special
management with antianxiety or sedative hypnotic
agents.
Sedation and Anesthesia:

12. 🙢
� the simplest, least invasive method to alleviate anxiety
in the dental office is nitrous oxide and oxygen
inhalation sedation
� For individuals with mild to moderate anxiety, oral
administration of a benzodiazepine can be effective in
decreasing anxiety and producing a level of relaxation.
(e.g. Alprazolam 0.5mg or Diazepam 5mg can be given 1
hour before the procedure).

13. 🙢
1. Operate gently and carefully:
� Tissue manipulation should be precise, and gentle.
� Thoroughness is essential, but roughness must be
avoided because it produces excessive tissue injury,
causes postoperative discomfort, and delays healing.
Tissue Management:

14. 🙢
2. Observe the patient at all times:
� It is essential to pay careful attention to the patient's
reactions.
� Facial expressions, pallor, and perspiration are some
distinct signs that may indicate the patient is
experiencing pain, anxiety, or fear.
� The doctor's responsiveness to these signs can be the
difference between success and failure.

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3. Be certain the instruments are sharp:
� Instruments must be sharp to be effective.
� Dull instruments inflict unnecessary trauma due to
poor cutting and excessive force applied to
compensate for their ineffectiveness.
� A sterile sharpening stone should be available on the
operating table at all times.

16. 🙢
� Although scaling and root planing has been
performed previously as part of Phase I therapy, all
exposed root surfaces should be carefully explored
and planed as needed as part of the surgical
procedure.
� In particular, areas of difficult access such as
furcations or deep pockets often have rough areas or
even calculus that was undetected during the phase
1 therapy.
Scaling and Root Planing:

17. 🙢
� good intraoperative control of bleeding permits an
accurate visualization of the extent of disease, pattern of
bone destruction, and anatomy and condition of the root
surfaces.
� Periodontal surgery can produce profuse bleeding,
especially during the initial incisions and flap reflection.
� After flap reflection and removal of granulation tissue,
bleeding disappears or is considerably reduced.
� Continuous suctioning of the surgical site with an
aspirator is indispensable for performing periodontal
Hemostasis:

18. 🙢
� Application of pressure to the surgical wound with moist gauze
can be a helpful adjunct to control site specific bleeding.
� Excessive hemorrhaging following initial incisions and flap
reflection may be due to laceration of venules, arterioles, or
larger vessels.
� Pressure should be applied through the tissue to determine the
location that will stop blood flow in the severed vessel. Then a
suture can be passed through the tissue and tied to restrict
blood flow.
� Minor areas of persistent bleeding from capillaries can be
stopped by applying cold pressure to the site with moist gauze
(soaked in sterile ice water) for several minutes.

19. 🙢
1. Absorbable gelatin sponge (Gelfoam)-from
pork skin
2. oxydized cellulose (Oxycel)- chemically
modified form of surgical gauze
3. oxidized regenerated cellulose (Surgicel)-
like a gauze.
4. Thrombin (Thrombostat): from bovin,
Some hemostatic agents:

20. 🙢
� In most cases, after the surgical periodontal
procedures are completed, the area is covered with a
surgical pack.
� Dressings have no curative properties; they assist
healing by protecting the tissue rather than
providing "healing factors."
Periodontal Dressings
(PeriodontalPacks):

21. 🙢
1. pack minimizes the likelihood of postoperative
infection and hemorrhage.
2. facilitates healing and protects against pain by
preventing surface trauma and contact of the
wound with food or the tongue during mastication.
Advantages of using a periodontal pack:

22. 🙢
1. Zinc Oxide-Eugenol Packs:
e.g. Wondr-Pak.
� Eugenol in this type of pack may induce an allergic
reaction that produces reddening of the area and
burning pain in some patients.
� Not used anymore.
Types of periodontal packs:

23. 🙢
2. Noneugenol Packs:
e.g. Coe-pak, cyanoacrylates, and tissue conditioners
(methacrylate gels) .
� Is the most widely used dressing.
� supplied in two tubes, the contents of which are mixed
immediately before use until a uniform color is
obtained.
� One tube contains zinc oxide , the other tube contains
liquid coconut fatty acids.
� The reaction between a metallic oxide and fatty acids is

24. 🙢
Preparation and Application of the Periodontal
Dressing:
• Take equal lengths of the two
pastes on a paper pad.
• Mix them with a wooden
tongue depressor for 2 or 3
minutes and place it in a cup
of water at room temperature
until the paste loses its
tackiness

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• With lubricated
fingers, roll it into
cylinders and then
place it on the
surgical wound

26. 🙢
� Trim away excess pack: it should not extend into the
vestibule or floor of the mouth.
� It should not interfere with occlusion.

27. 🙢
� The pack is usually kept on for 1 week after surgery.
� The pack is taken off by inserting a surgical hoe (or
sickle scaler) along the margin and exerting gentle
lateral pressure.
� The area is rinsed with saline to remove superficial
debris.

28. 🙢
The First Postoperative Week:
� Properly performed, periodontal surgery
presents no serious postoperative problems.
� Patients should be told to rinse with 0.12%
chlorhexidine gluconate immediately after
the surgical procedure and twice daily
thereafter until normal plaque control
technique can be resumed
Postoperative Instructions

29. 🙢
� Avoid hot, spicy food and drinks for the first 24 hours.
� Eat soft, semisolid or minced foods.
� Do not drink alcohol or smoke.
� Do not brush over the pack / healing area for at least a
week.
� On the first day, apply ice intermittently on the face over
the operated area.
� If there is any swelling 1-2 days after the surgery, apply
moist heat over the area and call your doctor if it become
worse

30. 🙢
1. 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.
Complications may arise in the first
postoperative week:

31. 🙢
2. Sensitivity to percussion:
� Sensitivity to percussion may be caused by the extension
of inflammation into the periodontal ligament. The
patient should be questioned regarding the progress of
the symptoms. Gradually diminishing severity is a
favorable sign.
� 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.

32. 🙢
� Particles of calculus that may have been overlooked
should be removed.
� Relieving the occlusion is usually helpful.
� Sensitivity to percussion may also be caused by
excess pack, which interferes with the occlusion.
Removal of the excess usually corrects the condition.

33. 🙢
3. Swelling:
� Sometimes within the first 2 postoperative days, patients
report a soft, painless swelling of the cheek in the area of
operation. Lymph node enlargement may occur, and the
temperature may be slightly elevated. The area of
operation itself is usually symptom free.
� This type of involvement results from a localized
inflammatory reaction to the operative procedure. It
generally subsides by the fourth postoperative day,

34. 🙢
� If swelling persists, becomes worse, or is associated
with increased pain, then amoxyicillin, 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.

35. 🙢
4. Feeling of weakness:
� Occasionally, patients report having experienced a
"washed-out," weakened feeling for about 24 hours after
the operation.
� This represents a systemic reaction to a transient
bacteremia induced by the operative procedure.
� It is prevented by premedication with amoxycillin, 500
mg every 8 hours, beginning
24 hours before the next operation and continuing
for a 5-day postoperative period.

36. 🙢
� When the patient returns after 1 week, the pack is
taken off by inserting a surgical hoe along the
margin and exerting gentle lateral pressure.
� Pieces of pack retained interproximally and particles
adhering to the tooth surfaces are removed with
scalers.
� The entire area is rinsed with saline / peroxide
to remove superficial debris.
Removal of the Periodontal Pack and Return
Visit Care:

37. 🙢
� Root hypersensitivity is a relatively common
problem in periodontal practice.
� It may occur spontaneously when the root
becomes exposed as a result of gingival
recession or pocket formation, or it may
appear after scaling and root planing and
surgical procedures.
Treatment of Sensitive Roots:

38. 🙢
� It is manifested as pain induced by cold or hot
temperature, more commonly cold; by citrus fruits or
sweets; or by contact with a toothbrush or a dental
instrument.
� Root sensitivity occurs more frequently in the cervical
area of the root, where the cementum is extremely thin.
� Scaling and root planing procedures remove this thin
cementum, inducing the hypersensitivity.

39. 🙢
� Transmission of stimuli from the surface of the
dentin to the nerve endings located in the dental
pulp results from a hydrodynamic mechanism
(displacement of dentinal fluid).

40. 🙢
hydrodynamic mechanism
The theory describes how the
fluid within the dental tubules
shift in the canals when the
tooth receives a stimuli of some
form, which then causes the
pulp to send out a signal to the
brain which it is interpreted as
pain.

41. 🙢
� They can be classified into:
1. Agents used by the Patient.
2. Agents used in the dental office.
DESENSITIZING AGENTS:

42. 🙢
� They are usually in the form of toothpaste,
mouthwashes and gels.
� Active ingredients for desensitization include
fluorides (Sodium/ stannous fluoride) in
combination with:
1. Strontium chloride: Sensodyne.
2. Potassium nitrate: crest sensitivity protection.
1. Agents used by the
Patient:

43. 🙢
� Desensitizing agents act via the precipitation of
crystalline salts on the dentin surface, which block
dentinal tubules.
� Patients must be aware that their use will not prove
to be effective unless used continuously for a period
of at least 2 weeks.

44. 🙢
� These products and treatments aim to decrease
hypersensitivity via blocking dentinal tubules with
either:
1. a crystalline salt precipitation or
2. an applied coating (varnish or bonding agent) on the
root surface.
2.Agents used in the dental office:

45. 🙢
� Fluoride solutions and pastes historically have been the
agents of choice.
� Currently, potassium oxalate (protect) and ferric oxalate
(sensodyne sealant) are the preferred agents. They form
insoluble calcium oxalate crystals that occlude the
dentinal tubules.
� Cavity varnishes or dentin bonding agents can be
applied to the root surface to occlude dentinal tubules

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� When cases do not respond to other treatments, the
dentist may choose to use a restorative material such as:
˃ GIC or
˃ Composite resins (with dentin bonding agents)
� Recently, attempts have been made to improve the
success and longevity of these treatments using lasers.
� Low-level laser "melting" of the dentin surface appears

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