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    بريو دنتل سيرجري

    Uploaded by

    Yehya Alkhashab

    Copyright:

    © All Rights Reserved
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    \ex 1G Servo bYesvy > Introduction: « Assesment of Aacio-Surgets ” The decision about what type of periodontal surgery should be performed and how many sites should be included is usually made after the effect of initial cause- related measures has been evaluated. The time lapse between termination of the initial cause-related phase of therapy and this evaluation may vary from 1 to 6 months. The successful cause related therapy depends on: 1, Removal of calculus and bacterial plaque will eliminate or reduce the inflammatory cell infiltrate in the gingiva. 2. Reduction of gingival inflammation makes the soft tissues more fibrous and thus firmer, which facilitates surgical handling of the soft tissues, the bleeding is reduced, making inspection of the surgical field easier. 3. A proper assessment of the prognosis has been established by The effectiveness of the patient’s home care, Lack of effective self-performed infection control will often mean that the patient should be excluded from surgical treatment. Objectives of surgical treatment 1. Creating accessibility for proper professional scaling and root planit tates the patient's self- 2. Establishing a gingival morphology which faci performed infection control. 3. Regeneration of periodontal attachment lost due to destructive disease. 4, Reduction or climination of plaque retentive area especially periodontal pockets that have not responded to initial therapy. example exudates, hemorrhage, ” Eliminate inflamed periodontal tis suppuration that means to stop progression of disease process. 6. Correct mucogingival defect and improved periodontal esthetic. 7. Provide access to correct bony defect. Indications for surgical treatment 1. Impaired access for scaling and root planing due. to presence of certain impeding factors as a wide tooth surface, root fissures, root furrows & furcations involvement. These factors may make even a shallow. pocket demanding a surgical access gaining, 2. Impaired access for self performed plaque control such as gingival hyperplasia or crater, 3. Correction of gross gingival abnormalities (for esthetic reason). 4. Shifting of gingival margin apically to a plague retaining restoration. 5. To facilitate a proper restorative therapy. Contraindications for periodontal surgery 1. Uncooperative patient: Patient who don’t cooperate during cause related phase of therapy because we are going to do more destruction to the connective tissue than if leave the patient without operation. In few days after surgery, we have loss of attachment. If the patient left hout surgery he will have loss of attachment but within longer period of time in the patient with the poor oral hygiene. 2. Cardiovascular disease: Arte hypertension: Local anesthesia without adrenaline, and used aspirating syringe. pectoris: As above + Anticoagulant treatment: Aspirin and other non-steroidal _anti- inflammatory drugs should not be used for post-operative pain control since they increase bleeding tendency. Furthermore, tetracyclines are contraindicated in patients on anticoagulant drugs due to interference with prothrombin formation. “+Rheumatic endocarditis: Used prophylactic antibiotic regimen. 3. Organ transplantation: Medications are used to prevent transplant rejection. The drug of choice is cyclosporine. The adverse effects following cyclosporine include an increased risk for gingival enlargement and hypertension. Prophylactic antibiotics are recommended in transplant patients taking immunosuppressive drugs. In addition, antiseptic mouth rinsing (0.2% chlorhe: ) should precede the surgical treatment. 4. Blood disorders: Patients suffering from acute leuken a, agranulocytosis, and lymphogranulomatosis must not be subjected to periodontal surgery. Anemia in mild and compensated forms does not preclude surgical treatment. More severe and less compensated forms may entail lowered resistance to infection and increased propensity for blecdi . In such cases, periodontal surgery should ouly be performed after consultation with the patient’s physician, 5. Hormonal disorders: * Diabetes mellitus. % Adrenal function: may be impeded in patients receiving large doses of corticosteroids over an extended period. The doses of corticosteroid may have to be altered during the period of surg: . The patient's: phys should be consulted 6. Neurologic disorders: + Epilepsy: Is often treated with phenytoin that in 50% of cases, may mediate the formation of gingival enlargement. 7. Smoking: Although smoking has a negative affects on wound healing, it may not be considered as a contraindication for surgical periodontal treatment. The periodontist should be aware, however, that less resolution of probing pocket depth and smaller improvement in clinical attachment may be observed in smokers than in non-smokers. Instruments used periodontal surgery The instrument tray: te 2. Mouth mirrors and graduated periodon | probe/explorer. Handles for disposable surgical blades: le (ordinary handle). OQ Blacks handle with screw key (special handle). steal elevator and tissu Mucoperi Sealers and curettes. Cotton pliers and tissue pliers. Tissue scissors, suture scissors and Needle holder. Burs. Plastic instrument, Hemostat Additional equipment: 1. Syringe for local anesthesia and syringe for irrigation 2. Aspirator tip. 3. Physiologic saline. 4. Surgical gloves and mask, surgeon’s hood and Draping for the patient Je The characteristic oozing type of bleeding can be controlled by a pressure Pack (sterile gauze moistened with saline). Bleeding from small vessels can be stopped by a hemostat and resorbable sutures. Sterile physiologic saline is used for rinsing and moistening the field of operation d for ‘ooling when burs are employed. The application of saline to the wound by means of a sterile disposable plastic syringe and a needle with a blunt tip. * Visibility in the field of operation is secured by using effective suction. Surgical instruments: 1. Knives: a) Fixed blade: The advantage (can be given any desired shape and orientation in relation (o the handle), while disadvantage (needs resharpening). b) Replaceable blade: Vhe advantage (sharp and can be replaced rapidly) while disadvan' (cutti ge follows the long avis of handle which limit their use). Png Disposable blade when mounted a handles (Bard-Parker), they are used for releasing incisions in flap operations , mucogingival surgery and for reverse bevel incisions where access is obtainable, but when it mounted in Special handles make it possible to mount blades in any angulated positions, which facilitate the use of such knives for both: gingivectomy excisions and reverse bevel incisions. 2. Sealers and curettes: Scaling and root planing in conjunction with periodontal surgery take place on exposed root surfaces. Access to the root for debridement may be obtained with the use of comparatively sturdy instruments. Tungsten carbide curettes and scalers with durable cutting edges are often used when “access” is not a problem. 3. Surgical burs: The burs should operate at low speed and rinsing with sterile physiologic saline should ensure cooling and removal of tissue remnants. Rotating fine-grained diamond stones may be used within infrabony pockets, root concavities, and entrances to furcations. T 4Anstruments for bone removal: Sharp bone chisels or bone rongeurs cause the least tissue damage and should be employed whenever access permits. With reduced access, surgical burs or files may be used for bone recontouring. 5. Instruments for handling flaps: The proper healing of the periodontal wound is critical for the success of the operation. It is therefore important that the manipulations of flaps are performed with the minimum of tissue damage. Care should be exercised in the use of periosteal elevators when flaps are deflected and retracted for optimal visibility. Surgical pliers and tissue retractors that pierce the tissues should not be used in the marginal of the flaps Types of periodontal surgery 1. Gingivectomy & Gingivoplasty procedures: * The surgical approach as an alternative to subgingival scaling for pocket therapy was already recognized by Robicsek (1884). later defined by Grant et al. (1979) as “the excision of the soft tissue wall of a pathologic periodontal pocket’. The surgical procedure, which aimed at “pocket elimination”, was usually combined with recontouring of the diseased gingiva to restore physiologic form. While, the gingivoplasty is the minor alterations in the \ gingival morphology. - YT =r jt Robiesek and, later, Zentler {I h Mh 0 a A Aad ; A MAK, described the gingiveetomy al procedure in the following way. The line to which the gum is to / o ie straig! Phe scalloped he resceted is determined first, THe srtight ore incision technique incision technique (Robiesek 1884). (Zentler 1918). a Indications of gingivectomy : 1- The presence of deep supra-alveolar pockets. 2- Minor corrective procedure. 3- Idiopathic gingival fibromatosis 4- Reshape abnormal gingival contours such| as gingival craters and gingival hyperplasia Advantage: 1. Complete pocket elimination. 2. Restoration of a physiologic f gingival contour 3. Technically simple and good visual accesses. Contraindications of gingivectomy : 1. When the bottom of the probable pocket to be excised is located at or below the mucogingival junction. As an alternative in such a situation, an internal beveled gingivectomy may be performed. 2. Infrabony pocket. 3. Thickening of marginal alveolar marginal bone and the need for bone surgery. Disadvantage: L. Gross wound post operative pain. 2. Healing by secondary intention. 3. Danger of exposing bone. 4. ned gingiva. 1 esthetic problem in the anterior area rea of the tooth a) with sensitivity duc to exposure cervica : “Technique: It was described in 1951 by Goldman. When dentition in the area indicated for surgery has been properly anesthetized, the depths of the pathological pockets are identified with a conventional periodontal probe. At the level of the bottom of the pocket, the gingiva is pierced with the probe and a bleeding point is produced on the outer surface of the soft tissue. The series of bleeding points produced describes the depth of the pockets at several location points around each tooth in the area indicated for treatment and is used as a guideline for the incision. ci The primary incision, which may be made by a scalpel blade (No. 12B or 15) in either a Bard-Parker handle or an angulated handle (e.g. a Blake's handle), or a Kirk 1 knife No. 15/16, should be planned fo give a thin and properly festooned margin of the remai ing gingiva. Thus, in areas where the gingiva is bulky, the incision must be placed at a level more apical to the level of the bleeding points than in areas with a thin gingiva. In areas where the interdental pockets are deeper than the buceal or lingual pockets, additional amounts of buccal and/or lingual (palatal) gingiva must be removed in order to establish a “physiologic” The interproximal soft tissue is separated from the interdental periodontium by secondary incision using an Orban knife (No. 1 or 2) or a Waerhaug knife . The incised tissues are carefully removed by means of a curette or a scaler ,Pieces of gauze packs often have to be placed in the interdental areas to control bleeding. When the field of operation is properly prepared, the exposed root surfaces are carefully scaled and planned. ‘The detached gin; Waerhaug knife removed with a scaler "The gingival contour is checked and, if necessary, corrected by means of knives or rotating diamond burs. To protect the incised area during the period of healing, it must be covered by a periodontal dressing. The dressing should be closely adapted and not bulky, since this is not only uncomfortable for the patient, but also facilitates dislodgement of the dressing. The dressing should remain in position for 10-14 days. After removal of the dressing, the teeth must be cleaned and polished. 2. Flap procedures: Main objectives of the lap procedures: 1. Facilitate the debridement of the root surfaces , the removal of the pocket epithelium and the inflamed connective tissue. 2. Eliminate the deepened pockets(the original Widman and the Neumann flaps). 3. Cause a imal amount of trauma to the periodontal tissues and discomfort to the patient Advantages of flap operations include: s preserved. arginal alveolar bone is exposed where by the morphology of bony defects can be identified and the proper tr nt rel 3. Furcation areas are exposed, the degree of involvement and the “tooth-bone” relationship can be identified. A 4. The flap can be repositioned at its original level or shifted apically, thereby making it possible to adjust the gingival margin to the local conditions. 5. The flap procedure preserves the oral epithelium and often makes the use of surgical dressing additionally. 6. The post-operative period is usually less discomfort to the patient when compared to gingivectomy Flaps are divided into 2 types depend on thickness of flap: 1, Full thickness flap: flap includes: epithelia, connective tissue, periosteum, reflected from underneath bone (mucoperiosteal flap). 2. Partial thickness flap: flap includes| epithelia and connective tissue reflected form bone and periosteum (split flap). Other classification of flaps is: 1- The original Widman flap: ished one of the first detailed descriptions of the use In 1918 Leonard Widman pu of a mucoperiosteal flap design aimed at removing the pocket epithelium and the inflamed connective tissue, thereby facilitating optimal cleaning of the root surfaces. The advantages in comparison to the gingivectomy procedure: eee since healing occurred by primary intention. ss discomfort for the pat 2. It was possible to re-establish a proper contour of the alveolar bone in sites with 3 ir bony defects. 1S > Technique: Sectional releasing incisions were first made to demarcate the area indicated for surgery. These incisions were made from the mid-buccal gingival margins of the two peripheral teeth of the treatment area and were continued several millimeters out into the alveolar mucosa. The two releasing incisions were connected by 2 scalloped reverse bevel gingival incision, then separated the pocket epithelium and the inflamed connective tissue from the non-inflamed gingiva. Hsimitar reteasing and gingival incisions, if needed, were made on the lingual aspect of the teeth. A mucoperiosteal flap was elevated to expose at least 2-3 mm of the marginal alveolar bone. The collar of inflamed tissue around the neck of the teeth was removed and the exposed root surfaces were carefully scaled. Bone recontouring was recommended in order to achieve an ideal anatomic form of the underlying bone. “sg Bone recontouring the a \Acholes Following careful debridement of the teeth in the surgical area, the buccal and lingual flaps were placed at the alveolar bone crest and secured in this position with interproximal sutures. Widman pointed out the importance of placing the soft tissue margin at the level of the alveolar bone crest, so that no pockets would remain. The procedure resulted in the exposure of root surfaces and Often the interproximal areas were left without soft tissue coverage of the alveolar bone. 3- The apically repositioned flap: New surgical tech iques for the removal of soft and, when indicated, hard tissue periodontal pockets. The importance of maintaining an adequate zone of attached gingiva after surgery was emphasized. One of the first authors to describe a technique for the preservation of the gingiva following surgery was Nabers (1954). In 1962 Friedman proposed the term apically repositioned Map to describe more appropriately the surgical technique introduced by Nabers. Friedman emphasized the fact that, the entire complex of the gingiva and alveolar mucosa rather than the gingiva alone was displaced in an apical direction. This surgical technique was used on buceal surfaces in upper and lower jaws and on lingual su in the lower jaw, while an excisional technique had to be used on the palatal aspect of maxillary teeth where the lack of alveolar mucosa made it impossible to reposition the fap in direction. 1. 2. -Advanitages of the apically repositioned flap procedure: Minimum pocket depth post-operatively. If optimal soft tissue coverage of the alveolar bone is obtained, the post- surgical bone loss is minimal. The post-operative position of the gingival margin may be controlled and the entire mucogingival complex may be maintained. Disadvantages of the apically repositioned flap procedure: 1 2. 3. Contraindications of the apically repos’ 1. XA Rew May cause esthetic problems due to root exposure. May cause hypersensitivity. May increase the risk of root caries. ned flap procedure: Periodontal pockets in severe periodontal disease Periodontal pockets in areas where esthetics is critical Deep intrabony defects Patient at high risk for caries Severe hypersensitivity Tooth with marked mobility and severe attachment loss Tooth with unfavorable clinical crown/root ratio Technique: According to Friedman (1962) : A reverse bevel incision is made using a scalpel with a Bard-Parker blade (No. 12B or No. 15). How far from the buceal/lingual gingival margin the incision should be made is dependent on the pocket depth as well as the thickness and the width of the gingiva. If pre-operatively the gingiva is thin and only a narrow zone of keratinized tissue is present, the incision should be made close to the tooth. The beveling incision should be given a scalloped outline, to ensure maximal interproximal coverage of the alveolar bone when the flap subsequently is repositioned. +Rollowing a vertical releasing incision, The reverse bevel incision is made through the gingiva and the periosteum to separate the inflamed tissue adjacent to the tooth from the flap. A full-thickness flap is raised by means of a mucoperiosteal elevator. The flap has to be elevated beyond the mucogingival line in order to be able later to reposition the soft tissue apically. The marginal collar of tissue, including pocket epithelium and granulation tissue, is removed with curettes, and the exposed root surfaces are carefully scaled and planed. The alveolar bone crest is recontoured with the objective of recapturing the normal form of the alveolar process but at a more apical level. The osseous surgery is performed using burs and/or bone chisels. od cy Fs ‘The buccaVlingual flap is repositioned in an apical direction to the level of the newly recontoured alveolar bone crest and secured in this position. A periodontal dressing should therefore be applied to protect the exposed bone and to retain the soft tissue at the level of the bone crest. To handle periodontal pockets on the palatal aspect of the maxillary teeth, Friedman described a modification of the “apically repositioned flap”, which he termed the beveled flap. In order to prepare the tissue at the gingival margin to follow the outline of the alveolar bone crest properly, A primary incision is made intracrevicularly through the bottom of the periodontal pocket and a conventional mucoperiosteal Nap is elevated. The tooth surfaces are debrided and osseous recontouring is performed, The palatal flap is subsequently replaced and the gingival margin is prepared by a secondary scalloped reverse bevel incision to adjust the length of the flap to the height of the remaining alveolar bone.. The flap is secured in this position with interproximal sutures. 4- The modified Widman flap: Ramfjord and Nissle (1974) described the modified Widman flap technique that is also recognized as the open flap curettage technique. It should be noted that, while the original Widman flap technique included both apical displacement of the flaps and osseous recontouring (elimi ion of bony defects) to obtain Proper pocket elimination, the modified Widman flap technique is not intended to meet these objectives. The main advantages: 1. The possibility of obtaining a close adaptation of the soft tissues to the root surfaces. 2. The minimum of trauma to which the alveolar bone and the soft connective issues are exposed. 3. Less exposure of the root surfaces, this from an esthetic point of view is an advantage in the treatment of anterior segments of the dentition. oS . Technique: The initial incision, which may be performed with a Bard-Parker knife (No.11), should be parallel to the long axis of the tooth and placed approximately 1 mm from the buccal gingival margin in order to properly separate the pocket . epithelium from the flap. If tle pockets on the buccal aspects of the teeth are less than 2 mm deep or if esthetic considerations are important, an intracrevicular incision may be made. Furthermore, the scalloped incision should be extended as far as possible in between the teeth, to allow maximum amounts of the interdental palatal aspect. Vertical releasing incisions are not usually required. Buccal and palatal full-thickness flaps are carefully elevated with a mucoperiosteal elevator. The flap elevation should be limited and allow only a few millimeters of the alveolar bone crest to become exposed. To facilitate the gentle separation of the collar of pocket epithelium and granulation tissue from the root intracrevicular incision is made around the teeth (second incision) to ision made in a horizontal direction and in a position close to the surface of the alveolar bone crest separates the soft tissue collar of the root surfaces from the alveolar bone The pocket epithelium and the granulation tissues are removed by means of curettes. The exposed roots are carefully scaled and planed, except for a narrow area close to the alveolar bone crest in which remnants of attachment fibers may be preserved. Angular bony defects are carefully curetted. The flaps are complete coverage of the interproximal bone. If adaptation cannot be achieved by soft tissue recontouring, some bone may be removed from the outer aspects of the alveolar process in order to facilitate the all-important flap adaptation. The flaps are sutured together with individual interproximal sutures. Surgical dressing placed over the area to close adaptation of the flaps. The dressing, as well as om the sutures, is removed after | week. A. Osteoplasty: The leveling of interproximal craters and the elimination (or reduction) of bony walls of circumferential osseous defects are often referred to as “osteoplasty” since usually no resection of supporting bone is required. It was introduced by Friedman in 1955 Examples of osteoplasty are the thinning of thick osseous ledges and the establishment of a scalloped contour of the buccal (lingual and palatal) bone crests. It may be required to gain access for intrabony root surface debridement. ‘B: Ostectomy: This means removal of large amounts of supporting bone. (a) A combined one- and two-wall osseous defect on the distal aspect of a mandibular premolar has been exposed following reflection of mucoperiosteal flaps. Since esthetics is not a critical factor to consider in the posterior tooth region of the mandible, the bone walls are reduced (o a level close to the base of the defect using rotating round burs under continuous saline irrigation. (b) The osseous recontouring completed. Note that some supporting bone has to be removed from the buccal and lingual aspect of both the second premolar and the first molar in order to provide a hard tissue topography which allows a close adaptation of the covering soft tissue flap. Treatment decisions for soft and hard tissue pockets in flap surgery: From a didactic point of view it seems more appropriate to discuss surgical therapy with re; rd to how to deal with (1) the soft tissue component and (2) the hard tissue component of the periodontal pocket at a specific tooth site. Periodontal leston Soft tisve Cotonaly repositioned fap? jomponent meee Apically repositioned flap? Eliminate? | taintain > —- Bone fi? | one gat? Hard tissue component —— | Regenerate tsue? | - Membrane barrier? Enamel matic proteins? There are a number of factors that affect on the treatment decision: 1. Esthetics, 2. Tooth/tooth site involved. 3. Defect morphology. 4. Amount of remaining periodontium. Since alveolar bone supports the soft tissue, an altered bone level through recontouring will result in recession of the soft tissue margin. For esthetic reasons one may therefore be restrictive in eliminating proximal bony defects in the anterior tooth region. For example, in the case of an approximal crater it may often be sufficient to reduce/elit inate the bone wall on the lingual side of the crater, while maintaining the bone support on the facial aspect. For esthetics one may even have to compromise the amount of bone removal and accept that some pocket depth will remain in certain situations. In addition to esthetics, the presence of furcations may limit the extent to which bone recontouring can be performed. Defect morphology is significance for repair/regeneration during healing. While two-and, especially, three-wall defects may show great potential for repair/regeneration, one-wall defects and approximal craters will rarely result in h good healing. Further, the removal of i rabony connective tissue/granulation tissue during a surgical procedure will always lead to crestal resorption of bone, especially in sites with thin bony walls without recontoured. This results in reduction of the vertical dimensions of the bone at the site. Nay 2 < Mag -6: Crown lengthening: It is increase in clinical crown length. It's performed by removing significant amounts of supporting bone and by recontouring. A “biologic width” of approximately 3 mm between the alveolar bone crest to be established and the anticipated restoration margin must be ensured for successful results. indicated in: 1. Subgingival caries, perforations. 2. Root fractures in the coronal third of the root. 3. Deep subgingivally located crown preparation margins; resulting in difficulty finishing margins and taking impressions. 4. Esthetic improvement of anterior teeth with short crowns and high lip line. 7. Mucogingival surgery (M.G.S): They are plastic surgical procedures designed to correct defects in the morphology, Position and am nt of the gingiva surrounding the teeth. It's indicated in: I. In areas where the change in the morphology of gingival margin will facilitate proper plaque control e.g. correction of high frenum attachment & deep narrow recession defect ly if it is extend to the level of vestibular fornix. with localized soft tissue recession that creates esthetic or root ity problems. 3. When we have a thin gingiva facial to a tooth planned for orthodonti movement when the final position of that tooth expected to result in an alveolar bone dehi Types of M.G.S: a- Vestibular extenuation procedures. b- Transplantation of gingiva & palatal mucosa: That may be either, free gingival graft or pedicle graft e.g. laterally repositioned flap. c- Frenectomy and Frenetomy: Frenectomy is complete removal of the frenum including its attachment to the underlying bone. While Frenetomy is the incision of frenum. They are indicated when the frenum is present with: 1. Significantly interferes with the patient's ability to maintain the area. 2. Compromises the labial flange of a maxillary denture. 3. Produces pull on the free gingival margin (that by history is causing progressive attachment loss). 4. Interferes with the orthodontic closure of a diastema. There are 2 techniques for the labial Frenectomy; 1, Dieffenbachia V-shape: *Hold frenum with hemostat *Surgical incision with #15 blade “Excise wedge of tissue *Dissect fibers from periosteum ‘Interrupted suture placed ‘2. Schuchardt Z-shape: The main advantage of this method over the V-shape method was minimal scar tissue formation. The method requires a skilled operator as it is tedious to perform. The technique is done to reduce loss of vestibular depth sometimes seen with linear incision. *Make elliptical incision *Excise fibrous tissue +Make 2 oblique incisions “Undermine pointed flaps “Rotate points to close vertical incision horizontall Suturin Sutures should not interfere with incision lines and not pass through the tissues near the flap margins or too close to a papilla, because this may result in tearing of the tissues. ting, nonresorbable, mono-filamentous materials is 2- The use of non recommended. These materials do not adhere to tissues therefore ‘easy to pull out and the phenomenon of bac! moving along or within multi-stranded suture materials, particularly silk, is also avoided. ure materi: 3- The dimensions usually preferred are 4/0 to 5/0, but even finer (6/0 or 7/0) may be used, particularly in conjunction with periodontal micro- and plastic su +€ al procedures. ed or straight non-traumatic needles, with a small diameter, should be used. ble as rounded (noncutting) or with different cutting edges Such needles are av such as reverse cutting. 5-Sutures are removed after 7=14 days. Ee Suturing technique: 1. Interrupted interdental suture: It provides a close interdental adaptation between the buccal and lingual flaps with equal tension on both units. not recommended when the buccal and lingual flaps are repositioned at different levels. In this technique the needle is passed through the buccal flap from the external surface, across the interdental area and through the lingual flap from the internal surface, or vice versa. b is. $8.4 Suuning. fnerrupted tnterdental suture. Modified interrupted interdental suture can be used if the flaps have not been elevated beyond the mucogingival line in order to avoid having the suture material between the mucosa and the alveolar bone in the interdental area. In this technique the curved needle is passed through the attached tissue on the buccal aspect of the proximal site, the suture brought to the lingual side through the proximal sites, and anchored in the attached tissue on the lingual side, The suture is then brought back to the starting point and tied. Hence, the suture will be lying on the surface of the interdental tissue, keeping the soft tissue Maps in close contact with the underlying bone. In‘ regenerative procedures, which require a coronal advancement of the flap, a modified mattress suture may be used to secure close flap adaptation. The needle is passed through the buccal flap from the external surface, across the interdental area and through the lingual flap from the internal surface. The suture is run back to the buccal side by passing the needle through the lingual and buccal flaps. Thereafter, the suture is brought through the approximal site coronally to the tissue, passed through the loop of the suture on the lingual aspect, then brought back to the starting point on the buccal side and tied. 2. Suspensory suture: It used when the surgical procedure involves only the tissue of the buccal or lingual aspect of the teeth and when the buccal and lingual flaps are repositioned at different levels. The needle is passed through the buccal flap from its external surface at the mesial side of the tooth, the suture is placed around the lingual surface of the tooth and the needle is passed through the buccal flap on the distal side of the tooth. The suture is brought back to the starting point via the lingual surface of the tooth and tied. If a lingual flap has been elevated as well, this is secured in the intended position using the same technique. 3. The continuous suture: Its used when flaps involving several teeth are to be repositioned apically. When flaps have been elevated on both sides of the teeth, one flap at a time is secured in its correct position. It is started at the mesial/distal aspect of the buccal flap by passing the needle through the flap and across the interdental area, The suture is laid around the lingual surface of the tooth and returned to the buccal side through the next interdental space. The procedure is repeated tooth by tooth until the distal/mesial end of the flap is reached. Thereafter, the needle is passed through the lingual flap, with the suture laid around the buccal aspect of each tooth and through each interproximal space. When the suturing of the lingual flap is completed and the needle has been brought back to the first interdental area, the positions of the flaps are adjusted and secured in their proper positions by closing the suture. Thus, only one knot is needed. Periodontal dressings: Are used 1. To protect the wound post-surgically. To maintain close adaptation of the flap to the underlying bone. For the comfort of the patient & To prevent post-operative bleeding. a YN To prevent the formation of excessive granulation tissue. Periodontal dressings should have the following properties: 1. Soft, but have enough flexibility to facilitate its placement and adaptation. 2. The dressing should harden within a reasonable time. 3. After setting, the dressing should be sufficiently rigid to prevent fracture and dislocation from operated area. 4. The dressing should have a smooth surface after setting (o prevent irritation to the cheeks and lips. They have bactericidal properties to prevent plaque formation. 6 The dressing must not inter ith healing am | ‘Types of periodontal dressing: | L Coc-PakTM: in two tubes. One tube contains oxides of various metals which is suppli (mainly zinc oxide) and lorothidol (a fungicide). The second tube contains nonionizing carboxylic acids and chlorothymol (a bacteriostatic agent). Equal parts from both tubes are mixed together immediately prior to insertion. Spedding a retarder can prolong the setting time of the dressing. 2. A light-cured dressing, e.g. Barricaid TM : which is useful in the anterior region, because it has a esthetic appearance and it can be applied without dislocating the soft tissue. However, it is not the choice of dressing for situations where the flap has to be retained apically, due to its soft state before curing, :as liquid or sprayed over the wound surface. Application technique: sure that bleeding from the operated tissues has stopped ,dry teeth and soft tissue before the application for optimal adherence of the dressing. gloves to avoid the ail sticking to the finge! 3a When using the Coe-PakTM dressing, the interproximal areas are filled first. Thin rolls of the dressing, adjusted in length to cover the entire field of operation: are then placed against the buccal and lingual surfaces of the teeth. It is forced int the interproiimal areas. It is important to ensure that dressing material is never introduced between the flap and the underlying bone or root surface. Excess material is removed with a suitable instrument. The dressing should nui cover more than the apical third of the tooth surfaces. Furthermore, interference of the dressing with mucogingival structures (e.g. vestibular fold, frenula) should be carcfully :hecked to avoid displacement of the dressing during normal function. The light-cured dressing is preferably applied with the supplizd sy adjusted anc: then cured by light.. Excess can be removed following curing with knife or finishing burs in a low-speed handpiece. s s 1 Post-operative pain contro In order to minii ize post-operative pain and discorafort for the patieni, surgical handling of the tissues should be without trauma, Care should be taken during surgery to ayoid tearing of the flaps, to keep the bone moistened, and to secure compete soft tissue coverage of the alveolar bone at suturing. The pain experience is limited to the first days following surgery and controlled ith used drugs for pain control. However, it is important to recognize that pain threshold level is subjective and may vary between individuals. It is also importaust to give the patient information about the post-surgical sequence further, during the early phase of healing; the patient should be instructed t» avoid chewing in the surgical ares.. So i \ POst-cp,.: ' ' 1 Surgical care i Post-operative plaque control is determining the long-term result of periodontal surgery. It is often associated with pain and djscomfort.during the immediate post-surgical phase, regularly performed professional tooth eleaning is a more effeetive means of mechanical infection control following periodonta! surgery. ! In he immediate post-surgical period self performed rising with antiplaque ing with 0.1-0.2% ehlorhestine olution is agent, | recacende i Maintaining good post-surgical wound stability is impottant factor affecting the outcome of some types of flap surgery. The measures to stabilize the healing wound include (e.g, adequate suturing technique, protection from mechanical trauma to the marginal tissues during the initial healing phase). ' i ad i { {f a mucoperiosteal flap is replaced rather than repositioned apically, eari. apical migravion of gingival epithelial cells will occur as a ednsequence of a break between root surface and healing connective tissue. Hence, maintenance of a tight adaptation of the flap to the root surface is essential and one may therefor: consider kee the sutures in place for longer than tHe 7-10 days usuali, prescribed following standard flap surgery. Following suture' removal, tlie surgical area is irrigated with a dental spray and the teeth are careful y polishec!. If the healing is satisfactory, the patient is instructed in gentle brushing of the operated area using a soft toothbrush, Toothpicks are prescribed for cleaning the interdental erea. Following surgical treatment the use of interdental brushes is abandoned due to the risk of traumatizing the interdental ti Vis.ts aré scheduled for supportive care at 2-week intervals to monitor ti: patient’s plaque control. At the end of treatment, the following objectives should be met: 1. No sub- cr supragingival dental deposits. No pathologic pockets (no bleeding on probing to the bottom of the pockets). No plaque-retaining aberrations of gingival morphology. Pe No plaque-retaining parts of restorations in relation to the gingival margin. Bz \ec \F ep PERIODONTICS RR Pi PI FAL PY’ ical phase}; “he time laps between the termination of the cause related phase af periodontal therapy and the evaluation {patient cooperation & tissue resoonse might vary frora one to six months. and according to this valuation the need for periodantal surgery. nny be decided. The corrective phase may include periodontal urgery, osseous surgery & mucozinaival surgery. The objectives of periodontal surgical intervention are: “Surgical ellmination of peciadontal pocket. 2-Aecess creation for proper SRP. Establishing gingival morphology that facilitate s the self performed plaque control measures. “May aim at the regeneration of periodontal attachment loss due to P.D.D. deneral indications of periodontal surgery: = Impaired access foASRP Aue to presence of certain impeding-factors as @ wide tooth suctace. root Issures, root furrows & furcation involvement. These factors may make even a shallow pocket ‘emanding a surgical access gaining. JeImpaired access for self performed plaque control measures such as gingival hyperplasia or crater that complicates such procedures. 3-Correction of gross gingival abnazmalities (for esthetic reason). Shifting of gingival margin apically to a plaque retaining restaration. 5-To facilisate a proper estorative therapy = shallow suprabony pocket " ” : Surettage, gingivoplasty. gingivectomy. flaps, osseous surgery & mucogingival surgery. Curettage: {th jval allot dontal pock 1 soft ti Paquiation tissue contains areas of chronic inflammation and may so have pleces of dislodged calculus and bacterial calanies. These olonies may have the pathologic features of the tissue and impair ealing. This inflamed granulation tissue is lined by epithelium and exp strands of epithelium penetrate Into the tissue. The presence of iis epithelium is considered as a barrier to the attachment of new bers in the area. When the root is thoroughly planed, the major source of bacteria disappears, and the athological changes in the tissues adjacent to the pocket resolve with no need to eliminate the inflamed ranulation tissue by curettage. (ndications ; 1 In moderately deep intrabony pockets Located in accessible areas in which a Non flap type of “closed” surgery is Indicated. 2. When aggressive surgical techniques (eg.. Flaps are contraindicated in patients because of their age, systemic Problems, psychological problems, or other factors. 3. Maintenance treatment for areas of recurrent Inflammation & pocket depth. Pre : Curentage should always be preceded by SRP .Giving local anaesthesia ta the selected area. The instrument Is inserted to engage the inner lining of the pocket wall and is carried along the soft tissue, usually in @ horizontal stroke .The pocket wall may be supported by gentle finger pressure on the external surface, The curette cutting edge is applied the inner lining of the pocket wall to remove it with a scooping motion of the curette to the tooth surface .The area is flushed to remove debris, and the tissue is partly adapted to the tooth by gentle finger pressure. In some cases. suturing of separated papillae and application Periodontal pack may’ be indicated, L-Excisional New Anachment Procedure (ENAP). 2-Litrasonic Curettage. 3-Caustic Drugs. New NAP): I- Its a definitive subgingival curettage’ procedure performed by doing internat bevel incision 2oremave the excised tissue with curette & Preserve the connective tissue. S-approximate the wound edge GINGIVOPLASTY ds. a reshaping of the gingiva Yo creare physiologic gingival contours. ms (1) Gingival clefis and craters. (2) Crater like interdental papillae caused by NUG. (3) Gingival enlargements. Gingivoplosty may be accomplished with: * A periodontal knife, “A scalpel *Rotary coarse diamond stones. * Electrodes. Swelcal Technique : Resembles that of festooning of a artificial denture: ( 1-)Tapering the gingival margin. (2-)Creating a scalloped marginal outline. (3-)Thinning the attached gingival. (4-)Creating vertical inter-dental grooves. (5-)Shaping the interdental papillae. AGINGIVECTOMY Excision of she ginaiva. By removing the pocket Wall, provides visibilin: and accessibility for ete calculus removal and thorough smoothing of the roots creatine a favorable environment ‘or gingival heating "Gingival enlargement or overgrowth (caused by medicaments.or hormonally) 2 Idiopathic fibrosis - — 3- Suprabony pockets and abscesses in areas with limited access Qnuraingications : i = Narrow or absent attached gingiva 2- Infrabony pockets 3- Thickening of marginal alveolar bone ‘Esthetic consideration. Advantages E "Technically simple: good visuagccess 2- Complete pocket elimination 3- good morghologic results. Disadvantane: 'sV ery limited indichhion 2- Gross wound; postoperative pain 3- Healing is by secondary intention. '- Danger of expasing bone 5- Sacrifice of attached gingiva _6- Exposes cervical area af ‘noth sensitivity, esthetics, caries) 7 Phonetic and estheric problems in anterior area surgical gingivectonyy 2-gingivectomn by chemosurgen’ 3- ‘ingivectomy by elsztrosurgery —4-ginglvectome: by creasurgery “gingivectomy by las iurgi in Gineit Rocker marking forceps idtsed exclusively in the G3 /GP Procedure ‘«dicating the TZONOIHS the base of the pocket. Gingivectomy knives :(Kirkland:),single bend- Papilta knife (Orban) Sugea &subgingwal scaler (d=) Curettes LyThe pockets on each surface are explored with a PD probe and uarked with a(pocket marker ¢: make bleeding points “2-)Continuous incision at 45 ° angle toward the base of the pocket ‘lth Periodontal knaje just.apical to bleeding points ,tauure to bev! te incision will eave a'eroag fibrous Platean. (3-)Sharp dissecron 1 tissues in the interdental areas (4~ )Smroothing of the incislgn edge: (Kirkland;), & (Orban) | §=)Scaling and root planing (MOST IMPORTANT STEP) (6- )Contouring of the gingival surface (GP) 7-) Wound coverage (perlodontal dressing; tissue adhesive) Formation of a protective surface bload clgt. The underlxing tissue Becomes acutely inflamed with Aécrosjt. The clot is then replaced by Granulation tissue. ~The hlghle. vascular gre=lation tissue ‘grows OronalD, creating a new Foe gingival. margin. and suicys, Vasodilation and vascularity Begin to detrease ayter the fourth dav of Healing and appear to be almast.normal bx the sixteenth day.-During the NST 4 weeks after gingivectomr, keratin!-ation.ts less than Iéwas before surgery Complete epithelial repair takes about 1 month complete repair of the conpective issue takes about 7 weeks, ‘2Electrosurgers; Finds its primary function ja, the gingwoptasty-srocedure, wérece it is useful for ass Contotirine soft tisgyie, for Mbpillectomy; for smocthing out Bbrupt tissue cctees sand for the’ m@zgins of.“restorations. Electrosurgery not Recommerided for expansive einglvoolasty because of the possibility at Injury ‘Yo the tooth root, parlésteum, bone or the toath.pulp. For contouring the gingival surjace GP), fine electrosurgical tips are Indicated. Electrosurgery is also indicated for minor procedures such as Exposing the margin of a tooth preparation Vit before taking an impression, or Before seating a restoration. Because electro- ii surgery exerts a certain ‘Hemostatic effect} i: may be used to advantage for excision of highly Vascular, edematous soft tissues. aus 3-Gingivectomy bvichemosurgery Agent use: 25%phenol with 75% camphor —_S%eparaphormaldehyde in ZNO eugenol pack J- no analgesia or anesthesia is required for this procedure 2- procedure ts easy to perform é&required less instruments UStain the tissue! 2-Medicated area discolored. 3-Don't have antibacterial or bacteriostatic effect 4 ecgingivectorn: be crcasurgerv: Temperature’ S04d -6pc is apply 10 the gingiva by swaeans of a probe. - cryosurgery unit Advantage: The procedure does not causepaityot bleeding. S-Gingivectorm, zr) The use of lasers for periodontal treatment becomes more complex Because the perlodontium consists of both hard and soft tissués, high-power Lasers, such as CO2, Nd:¥4G, and diode lasers. can be uséd in periodontics. Because of their excellen soft tissue ablation and hemasiatic Characteristics, the use of thesé Tasers has beén approved for soft tissue management in periodontal-end-oral-surgery. when applied to the root surface or alveolar bone, carbonization and major fuermal damage nave Been reported on the target and adjacent tissues. Therefore the use of these Lasers is fintte®to eingivectomy. ftenecioms, and similar sof, “issue procedures including the removal of melanin pigmentation ahd ‘msfat catroos of the gingiva. he advanta: f laser i su (1+) *Great hemostasis (Less bleeding during the procedure). ( 2- )*Surgical site sterilization(bacteriocidal effect). _¢ 3-) "Less post-operative swelling and pain(minimal wound contraction. (4-)*More effective bone cleaning & Faster completion of Me operation. _(5-)*No rotary tool vibrations (patient comfort). Disadvantages of | Strong thermal energy, _ 2- Melting, cracking, simple warming. coagulation, or excision and incision ough tissue vaporization. 3-Carbonization of hard tissues. 4~ Size of laser device (large). * Limiting Factors must i du 2 re 1 Conservation of keratinized gingival (2) Minimal gingival tissue loss to maintain esthetics. GuAdeauate access to the osseous defects for definitive defect correction. (4) Minimal postsurgical discomfort and bleeding by attempting surgical procedures that will allow primary closure, PERIODONTAL DRESSING AND TISSUE ADHESIVES The gingivectomy wound must be covered with o dressing. it is generally left in situ for 7-10 days. A second dressing may be indicated if Healing Is inadequate Thev are used for the following purposes: 1. Protection of the wound. 2, Close adaptation of the flap to the underlving bone. 3 More copsfostabletothepatient. 4. Prevgnt post operative bleeding. — . Prevent formation of-excessive granulation tissues, :s of periodontal dressing:

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