The document outlines an introduction to periodontal surgery, detailing its rationale, indications, contraindications, and various surgical techniques. It emphasizes the objectives of surgery such as enhancing visibility, modifying osseous defects, and improving the periodontium's health, while also addressing patient factors and emphasizing the importance of aseptic techniques and proper wound management. Furthermore, it covers aspects related to anesthesia, hemostasis, and postoperative care, ensuring a comprehensive overview of surgical procedures within periodontology.

1. INTRODUCTION TO
PERIODONTAL SURGERY
Dr. Akama Gladys
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2. Outline
• Introduction
• Rationale for periodontal surgery
• Indications and contraindications
• Principles of Periodontal surgery
• Surgical techniques
• Wound management
• Post operative instructions and review
• Conclusion
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3. Introduction
• Periodontal therapy: Non-surgical and Surgical
• Nonsurgical- OHE, FMS, SRP
• Review- BoP, deep pockets
• Next step: surgical access –
• Aims :
- thorough root debridement
- establishment of an oral environment easier to maintain by both the patient
- aid in restoring periodontal health.
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4. Goals
The major goals of periodontal surgery are :
1. To create an oral environment that is conducive to maintaining the patient's dentition in a healthy,
comfortable, and functional esthetic state.
2. To regenerate and preserve the periodontal attachment.
Factors/Questions to consider:
- patient factors
-benefits of the surgery
- type of defect present
- best therapeutic approach
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5. Objectives of Periodontal Surgery
1. Access to roots and alveolar bone
• enhance visibility
• increase scaling and root planing effectiveness
• less tissue trauma
2. Modification of osseous defects
• establish physiologic architecture of hard tissues through regeneration or resection
• augment alveolar ridge defects
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6. Objectives of Periodontal Surgery
3. Repair or regeneration of the periodontium Pocket reduction
• enhance maintenance by patient and therapist
• improve long-term stability
4. Provide acceptable soft tissue contours
• enhance plaque control and maintenance
• improve esthetics
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7. Patient Factors • Patient factors include :
-medical
-Smoking
-psychological status
-patient desires and expected outcomes
-oral hygiene effectiveness
-gingival health.
• Systemic factors should be addressed and modified before
and during the commencement of initial therapy.
• Local factors are addressed during initial therapy to ensure
adequate plaque control is obtained and gingival
inflammation has been reduced sufficiently to allow
atraumatic surgical technique.
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8. Indications and
Contraindications
of Surgery
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9. Principles of Periodontal Surgery
• Know your patient and his or her medical status
• Develop a thorough and complete treatment plan
• Know anatomy of surgical sites
• Provide profound anesthesia
• Follow aseptic surgical technique
• Practice atraumatic tissue management
- sharp, smooth incisions
- careful flap reflection and retraction
-avoid flap tension
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10. Principles of Periodontal Surgery
• Attain hemostasis
• Use atraumatic suturing techniques
-smallest needle and suture that can be used in the area
- place sutures in keratinized tissue when possible
-take adequate bites of tissue
-minimum number of sutures to achieve closure
• Obliterate dead space between flap and bone Promote stable wound healing
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11. Patient Evaluation
• General assessment of the patient’s:
- physical characteristics for abnormalities in gait, body movements, body symmetry, posture, weight,
skin, eyes, speech, and ability to think.
- The patient's cardiovascular and respiratory functions-Blood pressure; rate, rhythm, and quality of
the pulse; and rate, depth, and pattern of respirations.
• Abnormal findings in any of the above assessments should be followed up with more focused
evaluation and appropriate medical referral if necessary.
• Once a complete patient evaluation has been performed, the patient's physical status may be
categorized according to the American Society of Anesthesiologists' (ASA) classification system
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12. Medical Consultation
• Whenever there is some question as to the physical status of a patient, the effect that their systemic
health may have on dental management, or the effect that dental treatment may have on their
systemic condition, a medical consultation is recommended.
• Generally, a consultation request should be made to the patient's primary physician.
• However, in cases where the patient does not have a primary physician, the consultation may be sent
to a physician of their choosing or by direct referral.
• It is preferable for the medical consultation to be written
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13. Medical Consultation: Components
Components of the medical consult should include the following:
• Patient name, age, sex, and race
• Current systemic condition based on the patient's own history
• Brief description of current dental condition
• Brief description of treatment as to duration
• Proposed drugs and anesthetic use
• Expected morbidity and alterations in patient's daily routine
• Specific questions relative to the patient's ability to safely tolerate the proposed
therapy and drugs to be administered
• Any suggested alterations in treatment plan
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14. Anatomic Considerations
Blood supply to oral cavity
• A, Lingual and facial arteries.
• B, Maxillary artery and branches
• C, Greater and lesser palatine
arteries. Ext Car, external carotid;
Fac, facial; GP, greater palatine
artery; IA, inferior alveolar; IC,
inferior coronary; IL, inferior labial;
IO, infraorbital; Ling, lingual; LP,
lesser palatine artery; MAX,
maxillary artery; Pal, palatine; PSA,
posterior superior alveolar; SC,
superior coronary; SL, sublingual;
SM, submental; SP, sphenopalatine.
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15. Anatomic Considerations
Gingival blood supply.
Supraperiosteal arterioles course
from the posterior to the anterior
part of the oral cavity in a horizontal
plane parallel to the mucogingival
junction.
Branches of these arterioles extend
vertically (apical to coronal) to
supply the interproximal gingiva and
papilla and the gingiva over molar
furcations.
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16. Wound Healing
• The basic events of wound healing are the same regardless of location in the body.
• The time required for the completion of healing depends on the size and volume of the wound and
the availability of adjacent tissue elements to contribute to its repair.
• The sequence of events can be divided into:
-an inflammatory phase
- a proliferative or granulation phase
- a remodeling or maturation phase
• A complex array of biological mediators and cellular interactions occur that act in a dynamic but
orderly process.
• For periodontal wounds this involves interaction between the epithelium, connective tissue, and
bone, as well as the cells of the periodontal ligament and root cementum.
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17. Wound Healing
• Three types of surgical wound healing are recognized. All three are related to the degree of wound
closure.
- Primary intention healing occurs when the wound margins are directly approximated—that is,
primary closure is obtained. This type of healing occurs rapidly compared to other types.
- Healing by secondary intention occurs when the wound margins are not approximated and remain
apart; granulation tissue must form to close the gap.
- Tertiary intention healing is usually associated with a disruption of secondary intention healing as
might occur if the wound is infected.
• Most periodontal surgical wounds heal by primary and secondary intention.
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18. Wound healing -Phases
• The inflammatory phase of healing is characterized clinically by the classic signs of redness
(erythema), heat, swelling (edema), and discomfort.
• These signs and symptoms are related to a multitude of events that occur at the cellular and
molecular level, which involve the vascular system, immune system, and tissue cells at the site of
injury.
• The redness, heat, and swelling are caused by vasodilation and increased vascular permeability and
blood flow, resulting in the buildup of exudate in the extracellular tissue environment.
• Discomfort is usually mediated by the release of histamine, serotonin, kinins, and the metabolites of
arachidonic acid, known as prostaglandins.
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19. Wound Healing
• Within hours of wounding: there is an increase in epithelial mitosis in the basal and spinous layers at the wound
margin.
• In 1 to 2 days: epithelium begins to migrate beneath a layer of polymorphonuclear leukocytes called the polyband,
which forms under the blood clot.
• Epithelial cells migrate at a rate of 0.5 to 1.0 mm per day toward the center of the wound.
• Once epithelium covers the entire wound surface, it takes an additional 28 to 42 days to achieve complete maturation.
• At approximately 3 to 4 days: fibroblasts begin formation of a new connective tissue matrix.
• Collagen formation peaks between 7 and 21 days.
• Maturation is complete by 21 to 28 days.
• Revascularization also begins around 3 to 4 days, with new blood vessels arising from proliferating endothelial cells.
• Vascular budding and sprouting of new vessels continues for 10 to 15 days.
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20. Bone Healing
• Injury to bone can occur simply with the reflection of a flap exposing the periosteum or bone proper.
• Osteoclastic activity to remove necrotic bone begins at around 3 to 4 days and involves either
endosteal (undermining resorption) or surface resorption.
• The resorptive process peaks at around 8 to 10 days but continues along with bone formation
between 14 and 21 days.
• Bone formation predominates between 21 and 28 days and remodeling may take up to 2 years.
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21. Anaesthetia and pain control
• Control of the physiologic mechanisms of pain is the function of local anesthetics, whereas control
over psychological factors that influence the interpretation of stimuli as painful is a function of
conscious sedation.
• Selection of an appropriate local anesthetic for periodontal surgical procedures should be based on
pharmacologic and physical properties of the anesthetic agent.
• These properties determine the effectiveness and duration of action of the anesthetic and potential
effects on patient safety.
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22. Aseptic Surgical Technique
• Surgical caps and surgical masks should be worn.
• The patient should be draped with sterile towels, including a sterile head wrap to cover the patient's
hair and eyes.
• Sterile surgical glove use is the standard of care
• The use of sterile saline or sterile water irrigation, including irrigation through ultrasonic instruments
and handpieces, should be a standard of care in surgical treatment rooms.
• All surgical instruments must be properly sterilized and sterile coverings over light handles are
required.
• A simple technique for covering light handles is to include aluminum foil in surgical kits before
sterilization.
• The sterile foil is then wrapped over the light handles.
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23. Aseptic Techniques
• The patient's oral hygiene should be at an acceptable level before surgery. An immediate
presurgical rinse with 0.12% chlorhexidine mouthrinse for 30 seconds will provide a
significant reduction
The use of prophylactic antibiotics in healthy immunocompetent patients is not necessary
or recommended for most periodontal surgical procedures.
• Infection rates after routine flap surgery are similar regardless of whether prophylactic
antibiotics are used
• A notable exception to this philosophy is the empirical use of antibiotics when guided
tissue regeneration or implant placement surgery is performed.
• Some clinicians will provide a 7- to 14- day course of antibiotics starting the day before or
the day of surgery.
• The stated rationale for use of antibiotics with these two types of surgical procedures is
to enhance the predictability of a favorable outcome
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24. Flap Management
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25. Hemostasis
• Surgical hemostasis is divided into intraoperative and postoperative control of bleeding.
• Intraoperative hemostasis is essential if visualization of the operative field is to be obtained.
• Although bleeding is to be expected when placing incisions and reflecting flaps, prevention of
excessive blood loss is initially guarded against by obtaining a thorough preoperative medical history
to rule out potential bleeding secondary to systemic disease or medications.
• The surgeon must develop a sound knowledge of surgical anatomy, achieve adequate tissue health
after initial therapy, and implement the principles of atraumatic flap management.
• Blood loss during periodontal flap surgery is highly variable.
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26. Hemostasis
• Intraoperative bleeding is usually in the form of oozing from capillaries and small arterioles within the
flap, or from nutrient canals and marrow spaces in the bone.
• If deemed excessive, this type of bleeding is best controlled with pressure using moist gauze for 2 to
5 minutes.
• Occasionally, a small artery may be the source of bleeding. If direct pressure is ineffective and the
vessel can be isolated, vessel ligation using a resorbable suture is the best way to control the arterial
bleeding.
• Another way to control bleeding from a flap is the use of a full-thickness suture at the base of the
flap in an attempt to compress the tissues against the vessels.
• This deep suture technique is also useful when bleeding occurs after the harvest of a free soft tissue
autograft from the palate.
• Placing a suture distal to the donor site will compress the greater palatine artery and provide
hemostasis in the area
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27. Hemostasis
• Bleeding from bone can usually be stopped by
-burnishing the bone in the area of the bleed with a molt, elevator, or curet.
- bone wax can be compressed into the area of the bleed. Once bleeding is controlled, excess bone wax
should be carefully removed to avoid possible delay of normal healing events.
• A variety of topical hemostatic agents are available to control surgical bleeding
- Oxidized regenerated cellulose,
- absorbable collagen and microfibrillar collagen hemostats
• They act primarily as a lattice to physically promote and stabilize the blood clot through platelet
aggregation.
• These agents usually come in the form of woven fabrics, porous sheets or cubes, or as fibrillar powder.
• Ferric sulfate acts as an astringent and protein precipitator capable of sealing small blood vessels
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28. Suturing
• As important as incision placement and atraumatic flap management are to the outcome of the
surgical procedure, flap adaptation and stabilization at the end of the procedure are equally
important.
• After any necessary final recontouring and thinning of gingival tissues, the flaps are placed passively
in position.
• The surgeon must not rely on sutures to pull the flap beyond its passive positioning, as tension is
created on the flap.
• Such tension potentially interferes with blood supply to the gingiva and increases the likelihood of
the sutures pulling through the tissues, thereby hindering wound stability.
• The result may be necrosis of the marginal portion of the flap and delayed healing.
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29. Advantages of sutures
• The value of placing periodontal dressings after surgery is controversial.
• Stated benefits include:
- improved flap adaptation to the underlying bone and root surface
- control of immediate postoperative bleeding
- wound protection and immobilization
- to help retain osseous graft materials, patient comfort, and temporary splinting of mobile teeth.
• Periodontal dressings still have a place in postoperative wound management for many therapists, but
the surgeon should focus on good surgical technique and thorough postoperative instructions to
provide stable flap adaptation, hemostasis, and patient comfort, rather than relying on surgical
dressings to produce the desired outcome.
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30. Suture Materials
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31. Suture Technique
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32. Periodontal Dressing
• At periodontal dressing or pack is a protective material applied over a wound created by periodontal
surgical procedures.
• It is most often used to assist in flap adaptation where there are postoperative variations in tissue
levels.
• Most periodontal dressings currently in use are eugenol-free and are either a two-paste chemical
cure material containing zinc oxide, mineral oils, rosin and bacteriostatic, or fungicidal agents (Coe-
Pak—GC America, Inc., Alsip, IL; PerioCare—Pulpdent Corp, Watertown, MA), or a visible light-cured
gel, composed of polyether urethane dimethacrylate resin and silanated silica
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33. Periodontal
Dressing
• A- Coe-Pak (GC America, Inc.; Alsip, IL) dressing is formed into a small roll, looped around
the terminal tooth, and gently pressed in place with lateral pressure. Engaging interdental
undercuts provides mechanical retention of the dressing. This can easily be accomplished by
using a moist cotton tip applicator or curets. B- Barricaid (Dentsply International; Milford, DE)
dressing is placed as a viscous gel and light cured. It provides a more esthetic dressing for
anterior areas.
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34. Post Operative Management
• Patient comfort, wound stability, and plaque control are the three most important considerations during the
postoperative phase.
• Patient comfort and wound stability are provided through a combination of good surgical and suturing techniques and
careful postoperative care of the surgical site.
• In addition, patient discomfort can be controlled with a variety of nonsteroidal or narcotic pain medications, or both.
• The patient is instructed not to chew or to use mechanical plaque control in the area of surgery until told otherwise.
• This is usually 10 to 14 days for most flap and gingivectomy procedures, with the exception of guided tissue
regeneration and hard or soft tissue grafting surgery.
• After such procedures, wound stability is important for at least 4 to 6 weeks.
• To reduce plaque formation during this crucial healing period, a 0.12% chlorhexidine mouthrinse used twice a day is
recommended and should be continued until mechanical plaque control is reinstituted in the surgical area.
• All areas away from the surgical site should be cleansed with normal brushing and interdental plaque control measures.
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35. Post-Op
• After surgery, rest and proper nutrition should be stressed to the patient.
• The diet should be restricted to soft foods and liquids for the first 24 to 48 hours.
• Chewing should be limited to the side of the mouth opposite the surgical site.
• Swelling in the area of surgery is to be expected but can be minimized with good surgical technique
and intermittent application of an ice pack for the first 8 to 10 hours after surgery.
• Although smoking is not an absolute contraindication to periodontal surgery, it is a detriment to
wound healing and a negative influence on the overall outcome of surgical therapy
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36. 1st Post Op Review
• The first postoperative visit is usually 7 to 10 days after surgery.
• Patient comfort, edema, and tissue healing are assessed.
• If used, the periodontal dressing is removed and the surgical site is debrided with an antimicrobial solution on a cotton tip
applicator.
• A combination of 0.12% chlorhexidine and 3% peroxide diluted in half with water is useful for mechanical and chemical
debridement of the area.
• If sutures are no longer providing stabilization of the gingival tissues, they are carefully removed at this first postoperative visit.
• If the sutures are still providing wound stability, they may be left in place and removed at the next postoperative appointment.
• Additional supragingival plaque removal is accomplished atraumatically with a curet or a rubber cup, or both.
• If the gingival tissues have been apically positioned at the time of surgery, mechanical plaque control can be instituted 10 to 14
days after surgery.
• If guided tissue regeneration procedures were performed, the patient should continue with chemical plaque control using a
0.12% chlorhexidine rinse until adequate mechanical plaque control can take place in 4 to 6 weeks.
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37. 2nd Post Op Review
• At the second postoperative visit (14 to 21 days after surgery), tissue healing and oral hygiene are
assessed.
• Supragingival prophylaxis is completed as needed.
• If thermal sensitivity or root caries is a concern, a fluoride gel should be prescribed for daily use.
• It should be noted that the above procedures are only guidelines. Postoperative care frequently
varies from patient to patient based on the type of surgery, wound healing, and the patient's ability
to achieve an acceptable level of oral hygiene.
• The postoperative phase usually lasts 1 to 6 months in most cases.
• Once wound healing is complete, the patient may enter maintenance therapy.
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38. Conclusion
• Knowledge of the patient's medical status, surgical anatomy, and basic surgical principles will allow
the surgeon to perform safe and effective periodontal surgery.
• Every surgical procedure must have an end-point in mind before the initiation of treatment.
• With experience, the mechanics required to reach that surgical end-point are relatively
straightforward.
• The true challenge facing the clinician is determining if the treatment approach selected will
predictably achieve the overall therapeutic goals of a healthy, stable, and maintainable dentition over
an extended period.
• With the current emphasis on evidence-based periodontal therapy, scientific knowledge, when
available, should become the primary driving force in therapeutic and surgical decision making.
• Clinical judgment, personal experience, and patient preferences are still valuable entities in this
decision-making process, but they must be integrated with sound science to improve the
predictability, quality, and efficiency of periodontal care.
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39. Learning outcome
DISCUSS THE RATIONALE, INDICATIONS
AND CONTRAINDICATIONS FOR
PERIODONTAL SURGERY
DESCRIBE THE PRINCIPLES OF
PERIODONTAL SURGERY
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