General Principles of Periodontal

Surgery

Dr.Essam Dhaifullah
Ch 54(pages 525-534)
 Objective

• covers the preparation of the patient and the general considerations

common to all periodontal surgical techniques

• Complications that may occur during or after surgery are also

discussed

• review of common surgical instruments and its uses

 INTRODUCTION

Satisfactory result requires careful approach to patient

preparation

All patient should be adequately prepared medical,

psychologically and practically for all aspects of

intervention
 PATIENT PREPARATION
 Satisfactory result requires careful approach to patient preparation
Reevaluation after Phase I Therapy
 Premedication
 Smoking
 Informed Consent
 MEDICAL HISTORY AND PHYSICAL STATUS
MEDICAL HISTORY SHOULD INCLUDE :
1. Review of patient past and current history with emphasis on review of the major
organ system
2. Past hospitalization
3. History of any recent surgery
4. Current medications,
5. Any known allergies especially to drugs and latex
6. Past and current history of tobacco, alcohol, or substance used or abuse
7. Family history of illness.
 PREMEDICATION
For patients who are not medically compromised, the value of administering antibiotics normally for
periodontal surgery has not been clearly demonstrated,

although some studies have reported reduced postoperative complications including reduced pain and
swelling when antibiotics are given before periodontal surgery and continuing for 4 to 7 days after
surgery.

The prophylactic use of antibiotics in patients who are otherwise healthy has been advocated for bone-
grafting procedures and has been claimed to enhance the chances of new attachment.

Other presurgical medications include administration of a nonsteroidal, anti-inflammatory drug 1 hour

before the procedure and an oral rinse with 0.12% chlorhexidine gluconate (Peridex or PerioGard).
 SMOKING
The deleterious effect of smoking on healing of periodontal wounds has been amply
documented.

Patients should be clearly informed of this fact and requested 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 not
including highly sophisticated techniques such as regenerative procedures and
mucogingival and esthetic techniques should be considered.
 INFORMED CONSENT

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

At the time of surgery, the patient should again be informed, verbally and in writing, of the procedure
to be performed, and he or she should indicate agreement by signing the consent form.
 EMERGENCY EQUIPMENT

The operator, all assistants, and office personnel should be trained to handle all the possible
emergencies that may arise.

Drugs and equipment for emergency use should be readily available at all times.

The most common emergency is syncope

A history of previous syncope attacks during dental appointments should be explored before
treatment is begun, and, if these are reported, extra efforts to relieve the patient’s fear and
anxiety should be made.
 Syncope

Transient loss of consciousness proceeded with weakness, pallor, sweating, & coldness. It
due to the reduction of cerebral blood flow.
Management:
Supine position
Ensured airways & O2 administration
Avoid through history taking
 MEASURES TO PREVENT
TRANSMISSION OF INFECTION

1. Using of disposable sterile gloves, surgical masks, and

protective eyewear.

2. All surfaces possibly contaminated with blood or saliva that

cannot be sterilized (e.g., light handles, unit syringes) must be
covered with aluminum foil or plastic wrap.

3. Aerosol producing devices (e.g., Cavitron) should not be used

on patients with suspected infections, and their use should be
kept to a minimum in all other patients
 SEDATION AND ANESTHESIA

Periodontal surgery should be performed painlessly.

 Most effective administration of anesthesia through:

Local block & infiltration,& interdental papilla injections with adrenaline.
Sedation to the apprehensive pt through:
-Diazepam (valium) 10 mg orally (for mild to moderate) IV (for moderate to sever anxiety)
-Nitrous oxide-O2 inhelatiofor mild anixity (Rapid recovery & quick onset).
Responsible adult.
 TISSUE MANAGEMENT
DURING SURGERY

1. Operate gently and carefully.

o Thoroughness is essential, but roughness must be avoided

2. Observe the patient at all times.

o Facial expression, pain & pallor are warning signs for anxiety

3. Be certain the instruments are sharp

Dull instrument will cause unnecessary trauma (sterile sharpening stone).
 Haemostasis

Importance of haemostasis:
 an accurate visualization of the extent of disease,

pattern of bone anatomy and condition of roots

 Provides clear view for debridement

 Prevents excess loss of blood form the body

 Methods to control bleeding from
capillaries

 Application of cold pressure to the site with

moist gauze (soaked in a sterile ice water)

 Use of local anaesthetic with the

vasoconstrictor

 Absorbable gelatin sponge

 Oxidized regenerated cellulose

 Microfibriller collagen hemostats

 PERIODONTAL DRESSING
In general, dressings have no healing properties;

They assist healing by protecting the tissue rather than

providing healing factors

Benefits of the periodontal dressing:

1. Minimizes post operative infection and hemorrhage

2. Prevents surface trauma during mastication

3. Protects against pain induces by contact of wound with food or

tongue
Types
Periodontal pack should not interfere with the occlusion
 Instruction for pt after perio surgery

• Discomfort  2 acetaminophen every 6h for the 1st 24h. Avoid Aspirn

• Perio pack (it s importance)
• Don’t smoke
• Don’t brush over the pack -
• Rinse with 0.12% CHX gluconate twice daily
• Cold application (to the operated area in the 1st day).
• Bleeding (during the 1st 4-5 h is normal & will correct it self)
• Problematic call
 MANAGEMENT OF
POSTOPERATIVE PAIN

Pack bordersfunctional but if overextended  edema.

Ibuprofen 600-800mg before surgery

Paracetamol 500 mg every 6 hours one day (after surgery).

3
 1 ST POST OPERATIVE WEEK
During this week the following complications may occur (but its not a rule):

1-persistant bleeding after surgery the pack is removed & bleeding controlled with pressure,
electrosurgery… then repacks.

2-Sensitivity to percussion may be due to extension of inflammation into PDL or excess pack
interferes with occlusion.

3-Swellingespecially with bone removal .it usually subsides spontaneously.

4-feeling of weaknesstransient bacterimia which can be prevented by amoxicillin 500mg every 8h

for 1day before operation & continuing for a 5 day postoperative.
 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)

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

 EXCISIONAL AND INCISIONAL INSTRUMENTS:

B
These blades are disposable

Surgical blades
• A: #15, is used for thinning flaps and general purposes

• B: #12D, with cutting edges on both sides, allowing the operator to engage narrow, limited areas with both pushing and
pulling cutting motions.

• C: #15C. For scalloping-type incision

•
 Surgical curettes and sickles

Prichard surgical curette. Curettes used in surgery

have wider blades than those used for conventional
scaling and root planing.
 PERIOSTEAL ELEVATORS

Woodson periosteal elevator

It is used to reflect and move the flap after the incision has been made for flap surgery.
 SURGICAL CHISELS

Ochsenbein chisels are paired, with the cutting edges in opposite directions
a push motion
 TISSUE FORCEPS

The tissue forceps is used to hold the flap during suturing

 It is also used to position and displace the flap after the flap has been reflected.
 SCISSORS AND NIPPERS

used to remove tabs of tissue during gingivectomy

trim the margins of flaps,
enlarge incisions in periodontal abscesses,
remove muscle attachments in mucogingival surgery

Goldman-Fox scissors.
NEEDLE HOLDERS
 SUMMERY
All surgical procedures should be carefully planned

Proper tissue management is most important , as it can cause postoperative

discomfort an delayed wound healing

Excessive hemorrhage following surgery should be of great concern to the operator

and should be handled carefully

 ANY QUESTIONS??

Thank you