General guidelines for periodontal surgery: instruments, local anesthesia,

periodontal dressing, suturing.

Dr. Salar Zeinali Oct.2013

Objectives of the Surgical Phase

1. Improvement of the prognosis of teeth and their replacements.

Techniques performed for pocket therapy and for the correction of related morphologic problems, namely, mucogingival defects.

the purpose of surgical pocket therapy is to eliminate the pathologic changes in the pocket walls; to create a stable, easily maintainable state; and if possible, to promote periodontal regeneration. To fulfill these objectives, surgical techniques (1) increase accessibility to the root surface, making it possible to remove all irritants; (2) reduce or eliminate pocket depth, making it possible for the patient to maintain the root surfaces free of plaque; and (3) reshape soft and hard tissues to attain a harmonious topography. Pocket reduction surgery seeks to reduce pocket depth by either resective or regenerative means or often by a combination of both methods

2. Improvement of esthetics.

Pocket Reduction Surgery • Resective (gingivectomy, apically displaced flap, and undisplaced flap with or without osseous resection

• Regenerative (flaps with grafts, membranes, etc)

Correction of Anatomic/Morphologic Defects

• Plastic surgery techniques to widen attached gingiva (free gingival grafts, other techniques, etc)

• Esthetic surgery (root coverage, recreation of gingival papillae)

• Preprosthetic techniques (crown lengthening, ridge augmentation, and vestibular deepening)

• Placement of dental implants, including techniques for site development for implants (guided bone regeneration, sinus grafts)

General Principle• Patient Preparation: Almost every patient undergoes the so-called initial or preparatory phase of therapy,

which basically consists of thorough scaling and root planing and removing all irritants responsible for the periodontal inflammation.

• Premedication: The prophylactic use of antibiotics in patients who are otherwise healthy has been advocated for bone-grafting procedures and purported to enhance the chances of new attachment. Although the rationale for such use appears logical, no research evidence is available to support it Other pre-surgical medications include administration of a nonsteroidal antiinflammatory drug (NSAID) such as ibuprofen (Motrin) 1 hour before the procedure and an oral rinse with 0.12% chlorhexidine gluconate

• Smoking: The deleterious effect of smoking on healing of periodontal wounds has been amply documented. Patients should be clearly informed of this fact and asked to quit or stop smoking for a minimum of 3 to 4 weeks after the procedure. For patients who are unwilling to follow this advice, an alternate treatment plan that does not include more sophisticated techniques (e.g., regenerative, mucogingival, esthetic) should be considered.

• Informed Consent The patient should be informed at the initial visit about the diagnosis, prognosis, and different possible treatments, with their expected results and all pros and cons of each approach

Periodontal Dressings (Periodontal Packs)

In most cases, after the surgical periodontal procedures are completed, the area is covered with a surgical pack. In general, dressings have no curative properties; they assist healing by protecting the tissue rather than providing “healing factors.” The pack minimizes the likelihood of postoperative infection and hemorrhage, facilitates healing by preventing surface trauma during mastication, and protects against pain induced by contact of the wound with food or the tongue during mastication.

Zinc Oxide–Eugenol PacksZinc oxide–eugenol dressings are supplied as a liquid and powder that are mixed before use. Eugenol in this type of pack may induce an allergic reaction that produces reddening of the area and burning pain in some patients.

Noneugenol Packsthe most widely used dressing in the United States. This is supplied in two tubes, the contents of which are mixed immediately before use until a uniform color is obtained. One tube contains zinc oxide, an oil (for plasticity), a gum (for cohesiveness), and Lorothidol (a fungicide); the other tube contains liquid coconut fatty acids thickened with colophony resin (or rosin) and chlorothymol (a bacteriostatic agent). This dressing does not contain asbestos or eugenol, thereby avoiding the problems associated with these substances.

Antibacterial Properties of Packs

Improved healing and patient comfort with less odor and taste have been obtained by incorporating antibiotics in the pack, Incorporation of tetracycline powder in Coe-Pak is generally recommended, particularly when long and traumatic surgeries are performed

Preparation and Application of Dressing

Zinc oxide packs are mixed with eugenol or noneugenol liquids on a wax paper pad with a wooden tongue depressor. The powder is graduallyincorporated with the liquid until a thick paste is formed.

Coe-Pak is prepared by mixing equal lengths of paste from tubes containing the accelerator and the base until the resulting paste is a uniform color. A capsule of tetracycline powder can be added at this time. The pack is then placed in a cup of water at room temperature. In 2 to 3 minutes the paste loses its tackiness and can be handled and molded; it remains workable for 15 to 20 minutes. Working time can be shortened by adding a small amount of zinc oxide to the accelerator (pink paste) before spatulating.

The pack is then rolled into two strips approximately the length of the treated area. The end of one strip is bent into a hook shape and fitted around the distal surface of the last tooth, approaching it from the distal surface. The remainder of the strip is brought forward along the facial surface to the midline and gently pressed into place along the gingival margin and interproximally. The second strip is applied from the lingual surface. It is joined to the pack at the distal surface of the last tooth, then brought forward along the gingival margin to the midline. The strips are joined interproximally by applying gentle pressure on the facial and lingual surfaces of the pack

• Inserting the periodontal pack. A, Strip of pack is hooked around the last molar and pressed into place anteriorly. B, Lingual pack is joined to the facial strip at the distal surface of the last molar and fitted into place anteriorly. C, Gentle pressure on the facial and lingual surfaces joins the pack interproximally.

• Periodontal pack should not interfere with the occlusion.

Surgical instruments

1. Excisional and incisional instruments  2. Surgical curettes and sickles  3. Periosteal elevators  4. Surgical chisels  5. Surgical files  6. Scissors  7. Hemostats and tissue forceps

Excisional and incisional instruments

Periodontal Knives (Gingivectomy Knives)

Interdental Knives

Surgical Blades

Gingivectomy knives. A, Kirkland knife. B, Orban interdental knife. 

Surgical blades. Top to bottom, #15, #12D, and #15C. These blades are disposable. 

Surgical Curettes and Sickles

Larger and heavier curettes and sickles are often needed during surgery for the removal of granulation tissue, fibrous interdental tissues, and tenacious subgingival deposits

Prichard surgical curette. Curettes used in surgery have wider blades than those used for conventional scaling and root planing.  Woodson periosteal elevator. 

Periosteal Elevators

Surgical Chisels

 Back-action chisel. 

Ochsenbein chisels are paired, with the cutting edges in opposite directions. 

Tissue Forceps

DeBakey tissue forceps.

Scissors and NippersScissors and nippers are used in periodontal surgery to remove tabs of tissue during gingivectomy, trim the margins of flaps, enlarge incisions in periodontal abscesses, and remove muscle attachments in mucogingival surgery.

Goldman-Fox scissors. 

Needleholders

Conventional needleholder. B, Castroviejo needleholder.

Suturing

Almost all periodontal surgical wounds arc closed with sutures, and a wide variety of suturing techniques have been developed to aid the surgeon in achieving the surgical objectives. Successful suturing is an exercise in tissue control, and different surgical procedures will require different types of suture mate rials and suturing methods."

There are two general methods of suturing periodontal flaps: interrupted suturing and continuous suturing," With interrupted sutures, each interdental papilla is sutured separately from the others; with continuous sutures, several papillae arc sutured together with one knot. There arc several variations within these two categories.

Simple interrupted suture

The simple interrupted suture is the easiest suture to perform. It is used to rejoin a buccal interdental papilla and a lingual interdental papilla that have been separated by a flap. Beginning on the buccal aspect, the suture needle is passed through the interdental papilla . leaving approximately 2 cm of free suture material on the buccal aspect. Th is called the tag end of the suture. The needle is then passed, back end first so as no t to dull the point, through the same interdental space to the lingual aspect, where the lingual flap is engaged in a similar manner. Finally, the needle is once again passed through that interdental space, and a knot is tied on the buccal aspect. As a general rule , sutures are always tied with the knot on the facial or buccal surfaces of the teeth . This makes them easier to remove and protects the tongue from soreness or ulceration

Continues suture

As the name implies, continuous sutures are used to join two or more interdental papillae of the same flap. They are usually used when the buccal flap is sutured separately from the lingual flap or when no lingual flap is performed. In a continuous suture, the suture needle is first passed through an interdental papilla on the buccal aspect of a flap. The needle is then passed through the interdental space to the lingual aspect , where it does not engage the lingual tissue. Instead, the needle is passed around the tooth, either mesially or distally, and through the adjacent inerdental space back to the buccal aspect . Here the buccal flap is again engaged. The needle is once again passed through the interdental space and back around the tooth, to emerge, At the position from which the suture began. The suture is tied at this point. Continuous sutures are very useful in a variety of different clinical situations. For example, they may be used to suture a barrier membrane over the buccal surface of a tooth, The overlying flap may then he sutured coronally with a separate continuous (or interrupted) suture.

Mattress suture

In this type of suture, the needle enters the flap through the papilla and exits under the free margin of the flap. These flaps cannot be sutured coronally, apically, or laterally because they are hound down at the mucogingival junction, limiting their movement. flaps that involve dissection beyond the mucogingival junction (either split- or full thickness flaps) require the use of a mattress suture. This suture enters the flap at or near the mucogingival junction and exits the flap through the interdental papilla. In this way, much more of the suture lies on to p of the flap, and it is able to hold the full extent of the flap in close contact with the underlying bone or periosteum . This aids in healing and flap reattachment and reduces the chance of postoperative bleeding. If the surgeon merely relies on the periodontal dressing or a primary blood clot to hold the flap in contact with the bone or periosteum, postoperative complications, such as bleeding under the flap, flap detachment, or flap necrosis, may occur.

Cross (Criss-Cross) Suture

This is a useful variation of a continuous mattress suture. Here, the mattress sutures are placed horizontally, not vertically. For example, at an edentulous space with buccal and lingual flaps, the suture needle enters the buccal flap at the distobuccall line angle and exits the buccal flap at the mesiobuccal line angle. The same maneuver is duplicated on the lingual or palatal aspect; the needle enters the flap at the distobuccal Iine angle and exits through the mesiobuccal line angle. The knot is then tied and will form a cross on top of the flap

Knots

There are three types of knots that are useful to the periodontal surgeon: the square knot, the surgeon's knot, and the slip or "granny" knot.

Square knot

This is a simple knot to tie and consists of two overhand knots, each done in opposite directions. The first overhand knot is made by making a loop over the jaws of the needle holder, grabbing the tag end of the suture material, and pulling the knot snugly to the flap . A second overhand knot is then made by making a loop under the jaws of the needle holder again , grabbing the tag end of the suture, and pulling the two ends of the suture (the one held by the needle holder and the one held in the surgeon's hand) tight.

Surgeon’s knot

The surgeon's knot is a modified square knot with (two overhand knots, each done in opposite directions. The first knot, however, is a double overhand knot , and the second one is a single. This doubling of the first overhand knot prevents slipping and loosening, especially if the flaps are under tension. This is probably the most commonly used knot in periodontal surgery. It is quick and simple to tie and can hold flaps securely, even if they are under slight or moderate tension.

Slip knot

This extremely useful knot is sometimes called the granny knot. It too is a variation of the square knot made with two single overhand knots; with the slip knot, however, both overhand knots arc made in the same direction. The first overhand knot is made by making a loop over the needle holder, grabbing the free end of the suture, and pulling the ends tight . The second overhand knot is made the same way, so that the loop again goes over the needle holder. The great advantage of the slip knot is that, once it is tied, it can he tightened further. Once it is tightened to the desired extent , it can be locked into place by another overhand knot, made in the opposite direction of the first two.