Introduction to Principles of Periodontal Surgery.pptx

Periodontal Surgery

1. INTRODUCTION TO PERIODONTAL SURGERY Dr. Akama Gladys 30/04/2024 12:31 1

2. Outline Introduction Rationale for periodontal surgery Indications and contraindications Principles of Periodontal surgery Surgical techniques Wound management Post operative instructions and review Conclusion 30/04/2024 12:31 2

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. 30/04/2024 12:31 3

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 30/04/2024 12:31 4

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 30/04/2024 13:57 5

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 30/04/2024 13:58 6

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. 30/04/2024 12:31 7

8. Indications and Contraindications of Surgery 30/04/2024 12:31 8

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 30/04/2024 12:31 9

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 30/04/2024 12:31 10

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 30/04/2024 12:31 11

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 30/04/2024 12:31 12

13. Medical Consultation: Components 30/04/2024 12:31 13

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. 30/04/2024 12:31 14

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 . 30/04/2024 12:31 15

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. 30/04/2024 12:31 16

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. 30/04/2024 12:31 17

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. 30/04/2024 12:31 18

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. M aturation 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. 30/04/2024 12:31 19

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. 30/04/2024 12:31 20

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. 30/04/2024 12:31 21

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. 30/04/2024 12:31 22

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 30/04/2024 12:31 23

24. Flap Management 30/04/2024 12:31 24

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. 30/04/2024 12:31 25

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 30/04/2024 12:31 26

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 30/04/2024 12:31 27

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. 30/04/2024 12:31 28

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. 30/04/2024 12:31 29

30. Suture Materials 30/04/2024 12:31 30

31. Suture Technique 30/04/2024 12:31 31

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 30/04/2024 12:31 32

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. 30/04/2024 12:31 33

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. 30/04/2024 12:31 34

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 30/04/2024 12:31 35

36. 1 st 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. 30/04/2024 12:31 36

37. 2 nd 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. 30/04/2024 12:31 37

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. 30/04/2024 12:31 38

39. Learning outcome 30/04/2024 12:31 39