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SARANRAJ JPS PUBLICATION DR. SYED WALi PEERAI

Bl. IAITHIIEYAI IAMAL/lliAM
Essentials of
PERIODONTICS &
ORAL IMPLANTOLOGY

DR. SYED WALi PEERAN

DR. KARTHIKEYAN RAMALINGAM
Essentials Of
PERIODONTICS & ORAL IMPLANTOLOGY
Published by Dr. Syed Wali Peeran and Dr. Karthikeyan Ramalingam @
Saranraj JPS Publication,
Tamil Nadu, India

© Dr. Syed Wali Peeran &

Dr. Karthikeyan Ramalingam
1st Edition 2021
ISBN: 978-81-950475-4-3
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording or any information storage and retrieval system without the permission in writing from the
publisher.
Note: As new information becomes available, changes become necessary. The editors/author/contributors and the publishers have,
as far as it is possible, taken care to ensure that the information given in this book is accurate and up to date. In veiw of the possibility
of human error or advances in medical science neither the editor nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete. Readers
are strongly advised to conirm. This book is for sale in India only and cannot be exported without the permission of the publisher in
writing. Any disputes and legal matters to be settled under Chennai jurisdiction only.

Published in India
 Dr. Syed Wali Peeran is Professor of Periodontology and Oral lmplantology.
He finished his postgraduation in Periodontology in 2008 and has a doctoral degree.
He has a postgraduate certificate in advanced oral implantology and a
fellowship from international congress of oral implantologists.
He is the Editor in Chief and the founding editor for the journals-
Dentistry & Medical Research and Case Reports in Odontology.
He has over 63 national and international publications to his credit.
He has attended various national and international conferences and workshops.
He has also authored "Perio-Quest- MCQs in Periodontics with Self-Assessment
Picture Test" published by EMMESS publishers. He has been a reviewer for Libyan
Journal of Medicine,Journal of Nature, Biology and Medicine and various other
journals. He is a Life member of Indian Academy of Osseo Integration,
Indian Society of Periodontology, Indian immunological Society,
Indian Society of Oral lmplantologists and Indian Dental association.

Dr. Syed Wali Peeran, B.D.S, M.D.S (Peria), Ph.D. FICO/., PGCOI.
Professor, Department of Periodontics & Oral lmplantology,Faculty of Dentistry, Sebha
University, Sebha, Libya.

Dr. Karthikeyan Ramalingam is a Professor of Oral Pathology and Microbiology.

He finished his graduation and post graduation from Saveetha Dental College,
Chennai. He was the College topper in Part I and Part II postgraduate University
examinations.
He had secured the Gold medal in Pathology & Microbiology and Community
Dentistry in University examinations.He has guided postgraduates in oral pathology for
their seminars, research studies, journal discussions, library dissertations, thesis
preparation and in submitting articles for publication in various national and
international journals. He has also handled lectures and practical demonstrations
for undergraduates in oral histology,dental anatomy, forensic odontology, oral
pathology and microbiology. He has 65 international and national publications to his
credit. He is the Co-author of Textbook of Prosthodontics by Jaypee Brothers Medical
Publishers (P) Ltd. He has also contributed multiple choice questions and clinical
pictures to Perio-Quest- MCQs in Periodontics with Self-Assessment Picture Test by
EMMESS publishers. He is the Editor for Journals - Dentistry and Medical Research &
Case reports in Odontology.He is also the Reviewer for Journal of Oral and
Maxillofacial Pathology and North American Journal of Medical Sciences
(Indexed with PUBMED) and Journal of Cranio-Maxillary diseases.
He is a member of International Association of Oral Pathologists since 2016.
He is a Life member of Tamilnadu Dental Council since 2001, Life member of
Indian Association of Oral and Maxillofacial Pathologists since 2006 and a Life
member of Saveetha Dental College Old Students Association since 2001.
Dr. Karthikeyan Ramalingam, B.D.S, M.D.S
Professor, Department of Oral Pathology & Microbiology,Faculty of Dentistry, Sebha University,
Sebha,Libya
 Dr. ABDULNASIR MAQBOOL AHMED.
MSc, FICOI (U.S.A), Private Practice,
U.A.E.
Dr. Abhilash.
P.R. M.D.S
(Oral Pathology and Microbiology),
Reader, Department of Oral Pathology
and Microbiology,
Oxford Dental College & Hospitals,
Bangalore, Karnataka, India.
Dr. Ahmed Taher El-Hassan.
M.Sc (Oral Sciences-Periodontics),
Diplomate of American Board of
Periodontics, NOBE, WREB.
Assistant Professor, Benghazi University,
Benghazi, Libya.
Dr. Aisha Ahmed.
MB.ChB
ECFMG Certified Physician.
Department of Medicine, Faculty of
Medicine, Sebha University, Sebha,
Libya.
Dr. Bandar M.A. AL-Makramani.
BOS, HOD, MDSc, Ph.D
Assistant Professor, Fixed Prosthodontics,
Department of Prosthodontics, College
of Dentistry, Jazan University, Kingdom
of Saudi Arabia.
Dr. Fatma Mojtaba Al Said.
BOS., MPH (USA),
Faculty of Dentistry, Sebha University,
Sebha, Libya.
Dr. Franciso AL.
College of Dentistry, Jizan University,
KSA
Dr. Fuad Al Sanabani.
MSc, PhD
Department of Oral and Maxillofacial
Prosthodontics, Jazan University, Jazan,
Kingdom of Saudi Arabia
Dr. Ismail Abbas Darout.
DDS, Ph.D. (Dr .odont),
Postdoc Peria, Associate Professor
and Head, Department of Preventive
Dental Sciences, College of Dentistry,
Jazan University, Kingdom of Saudi
Arabia.
Dr. Khaled Awidat Abdalla.
B.D.S., C.E.S., DuODF (France),
Assistant Professor, Department of
Oral Biology and Orthodontics,
Sebha University, Sebha, Libya.
Dr. Manohar Murugan
M.Sc. (Microbiology), Ph.D.,
Assistant Professor, Department of
Medical Microbiology, Faculty
of Medicine, Sebha University, Sebha,
Libya.
Powered by TCPDF (www.tcpdf.org)
Dr. MOHAMMAD NAZISH ALAM.
BOS., MOS.
Asst. Prof, Department of Periodontics,
College of Dentistry, Jazan university
Dr. Nagabushan.
B.D.S., M.D.S
(Oral Medicine and Radiology),
Department of Oral Medicine and Radiology,
India.
Dr. Neha.
MOS.,
Department Of Periodontics and lmplantology,
Surendera Dental College and Research Institute,
Sriganganagar, Rajasthan.
Dr. R. Ganesh.
B.D.S., M.D.S. (Pedodontics)
Reader, Department of Pediatric and
Preventive dentistry, SRM University,
Tamil Nadu, India.
Dr. Rashmi Rai.
BOS., MOS.
Senior lecturer, public health dentistry,lndex
institute of dental sciences, Indore
Dr. Santosh Kumar.BB
BOS, MOS (Peria), M.Perio RCSEd (U.K),
MICOI (U.S.A) ), Specialist Periodontist and
lmplantologist, Kuwait.
Dr. Salhya Selhuraman.
B.D.S, M.A, PG0CA,
Surendra Dental College and Research
Institute, Sriganganagar, Rajasthan. India.
Dr. Shaesta Begum.
BOS, MOS (Periodontics),
Reader, Depatment of Periodontics, Farooqia
Dental College & Hospital, Mysore, Karnataka.
India.
Dr. Shamimul Hasan.
BOS, MOS
Assistant Professor, Department of Oral
Medicine and Radiology, Faculty of Dentistry,
Jamia Milia lslamia, New Delhi.India
Dr. Soumya K Nair.
B.D.S., MOS.,
Private practitioner, Mysore, India.
Dr. Suchelra N. Malleshi.
B.D.S., M.D.S (Oral Medicine and Radiology),
Department of Oral Medicine and Radiology,
J.S.S Dental College, Karnataka, India.
Dr. Supriya Ebenezer.
BOS., MOS.
Reader, Department of Periodontics,
Mathrusri Ramabai Ambedkar Dental
College and Hospital, Bangalore, India.
Dr. Syed Ali Peeran.
M.D.S. (Prostho)., MBA(HA), M.Phil (H.A),
Department of Prosthodontics, Assistant
Professor, Jazan University, Jazan, KSA.
Dr. Syed Kuduruthullah. S.K
M.0.S.(Oral Path)
Lecturer, Ajman University,
Ajman, U.A.E.
Dr. Syed Nahid Basheer.
BOS., MOS.
Assistant Professor, Department of Restorative
Dental Science, College of Dentistry, Jazan
University, Gizan, Kingdom of Saudi Arabia.
Dr. Syeda Nikhat Mohammadi.
BOS., MOS.
Senior lecturer, public health dentistry,
Pravara institute of dental sciences, Loni.
Maharashtra.
Dr. Tazeen.D
B.D.S., M.D.S (Peria).
Assistant Professor, Department of Periodontics,
Jazan University, Jazan, KSA.
Prof. Dr. Abdul Hafeez Khan
M.Sc., Ph.D.
Chairman, Department of Parasitology, Faculty
of Medicine, Sebha University, Sebha, Libya.
Prof. Dr. Abdul Hafeez Khan
M.Sc., Ph.D.
Chairman, Department of Parasitology, Faculty
of Medicine, Sebha University, Sebha, Libya.
Prof. Dr. Madhumala Thiruneervannan
BOS., M.D.S (Peria),
Head, Department of Periodontics, Vinayaka
Mission's Sankarachariyar Dental College,
Salem, India.
Prof. Dr. Marei Hamad Al Mugrabi.
B.D.S., M.Dent.Sc. (Periodontics-Dublin),Ph.D.
Head, Department of Periodontics, Benghazi
University, Libya.
Prof. Dr. Nurgul KOMERIK.
DDS., Ph.D.
Post Doc. Biruni University, Dental School,
Dept. of Oral Surgery, Istanbul, TURKEY
Prof. Dr. P.G. Naveen Kumar.
B.D.S., M.D.S., (Community Dentistry),
Head, Department of Community and
Preventive dentistry, College of Dental
Sciences, Davangere, Karnataka, India.
Prof. Dr. PC Anila Namboodiripad.
BDS, MDS., Department of Oral and M axillofacial
Pathology, India
Prof. Dr. R Thiruneervannan
BDS., MDS.
Principal, Vinayaka Mission's Sankarachariyar Dental
College, Salem, Tamil Nadu, India.
Prof. Dr. Syed Khalid Alla!.
MDS.
Associate Fellow AAID, Department of oral
mplantology, Vivekenanda dental college,
TN, India
Prof. Dr. V.Gopinalh.
M.D.S.
Professor, Department of Periodontology and
lmplantology, Chhattisgarh dental college
and research institute, Rajnandgaon, India
Prof. DR.V.HARIKRISHNA.
M.D.S.
Department of Orthodontics and Dentofacial
Orthopaedics. Chhattisgarh Dental college
and research institute, Rajnandgaon, India.
Chapter 2 Gingiva

SECTION - VIII
Surgical Methodology

Periodontics & Oral Implantology 7

Chapter 43 General consideration in Periodontal Surgery
CHAPTER

47 General Consideration in
Periodontal Surgery

Syed Wali Peeran &

Karthikeyan Ramalingam

Chapter Outline:
• Instructions to patients after periodontal surgery. • Suturing techniques.
• Hemostatic agents. • Periodontal pack.
• Dental Surgical Procedures in patients undergoing o Types of periodontal pack.
anticoagulation therapy. • Healing after flap surgery.
• Suturing in periodontics. o Stages of wound healing.
• Complications of periodontal surgery.
o Needles.
• Review Questions.
o Guidelines and Techniques for suturing in
• Principal Sources and Suggested Further Reading.
periodontal surgery. • Incisions in Periodontal surgery.
The principles of periodontal surgery are as same as another
surgical procedure. The prime aim of the periodontal
INSTRUCTIONS TO PATIENTS AFTER
surgery is to enhance the long-term preservation of the PERIODONTAL SURGERY
periodontium by aiding in plaque removal and plaque
1. Care about anaesthesia:
control.
• Care must be taken not to damage the tongue,
The periodontal surgery can serve the following purposes
cheek, lip and the treated area until numbness
1. Create access for scaling and root planing. does not wear off.
2. To reduce, modify or eliminate plaque retentive areas • Patient must be asked not to sleep during that
– thus facilitating plaque control. time, as they may bite the anesthetized tissues
3. To re-establish physiological morphology of the unknowingly.
periodontium. • In case of discomfort take paracetamol, avoid
4. Enhance periodontal regeneration. aspirin.

5. Enhance the aesthetics of even otherwise 2. Use of antiseptics:

physiologically normal gingiva. • Patient is asked to hold 10ml of 0.2% chlorhexidine
However, periodontal surgical procedures are financially mouthwash in the operated area for 1 minute, at
costly, time-consuming and technically demanding. least once daily.
(Trombelli) Hence the clinical decision-making process 3. Postoperativehaemorrhage:
should be based on evidence-based information.
• Occasional presence of blood stains in the saliva.
It is common for 4 to 5 hrs after surgery.
Periodontics & Oral Implantology 1
Non-Surgical Methodology Section - VIII

• In case of considerable bleeding, the patient is 7. Habits:

asked to apply gentle but firm pressure to the area • Eating habits: Avoid eating citrus fruits, fruit juices,
for 20 minutes using gauze or a clean handkerchief. aerated beverages, spicy foodstuffs, and alcohol.
Tea bag contains tannic acid, which is an astringent. Use of such items may cause pain.
Hence, it can be used as a home remedy, and the
patient can bite on the tea bag to arrest bleeding. • For the first day, avoid hot foods.
• The patient should never try to stop bleeding by • Soft diet is preferred. It decreases the chances of
rinsing. trauma and injury.
• The dentist should be contacted if bleeding does • The patient should be encouraged to return to a
not stop. regular eating schedule as soon as possible.
4. Swelling and inflammation: • Dehydration may impede recovery. Hence the
patient should be educated about the importance
• The patient is asked to suck ice or place ice pack of keeping well hydrated.
over the area of surgery for the first 24 hours.
This keeps the tissue cool, reduces inflammation • Use of tobacco in any form is to be avoided.
and swelling. Nicotine present in tobacco interferes with
normal wound healing.
• Swelling is not unusual. It may be seen by 1-2 days
after surgery and subsides gradually by 3-4 days. If • Use of betel nut, pan with slake lime is to be
swelling occurs, apply moist heat over the area. avoided.
5. Periodontal dressing and sutures: 8. General instructions;
• Care must be taken to avoid dislodgment of the • Patient should be asked to minimize physical
periodontal dressing. activity, to avoid exertion.
• In case the pack gets dislodged or damaged, it can HEMOSTATIC AGENTS
be removed, and the area can be repacked.
• Hot food is to be avoided for first 3 hours to allow DEFINITIONS AND TERMINOLOGY:
the pack to harden. Haemostaticis an agent used to reduce or arrest bleeding
• Do not chew the food on the pack or on the side from minute vessels by hastening the clotting of blood or
of surgery. Patient is advised to chew on the non- by the formation of an artificial clot.
operated side. Haemorrhage (an escape of blood) is the loss of blood due
• In case a (suture) stitch gets loosened, the patient injury or damage to the blood vessel.
is advised not to tease or pull it.They must report Haemostasis: Arrest of haemorrhage. (Glossary of
to the dentist immediately. Periodontal Terms, 2001)
6. Plaque control measures: Haemostat:Any agent, apparatus, or instrument that may be
• The patient is advised to keep his/her teeth clean employed to arrest haemorrhage. (Glossary of Periodontal
using the usual method of brushing or flossing Terms, 2001)
except the areas which underwent surgical
LIGATE: To tie or bind, usually in the therapeutic sense,
procedure.
for the purpose of stopping bleeding or immobilizing a
• High degree of oral hygiene maintenance is a must structure. (Glossary of Periodontal Terms, 2001)
for uneventful healing and better results.
Astringents produce haemostasis by causing tissue
contraction followed by coagulation of blood in the vessels
in the local area.

2 Periodontics & Oral Implantology

Chapter 47 General consideration in Periodontal Surgery

Styptics may be considered as a concentrated form of an

astringent.
STASIS: The arrest or cessation of flow of any body fluid,
especially blood. (Glossary of Periodontal Terms, 2001)
Requirements of a haemostatic agent for use in oral
cavity:
♦ Must possess native clotting mechanisms that do not
pass through the salvage filtration systems.
♦ Must be inexpensive,
♦ Must be easy to apply and require minimal
supervision.
♦ Must be long lasting with low risk.
♦ Must be able to accomplish haemostasis within the
necessary time.
♦ Does not cause allergic reactions.
♦ Must not stain the oral tissue.
♦ Must have no adverse effect on the biomaterials used
in the oral cavity for therapy such as composite.
♦ Must not have bad taste and smell.
♦ There are various types of haemostatic agents and
respective configurations available. Each of these
agents have their own advantages and limitations.

Fig. 47.2 Hemostatic Agents/Methods to attain Haemostasis

that could be used in Periodontal Surgery

Fig. 47.1 Haemostasis and Periodontal surgery

Periodontics & Oral Implantology 3

 Non-Surgical Methodology Section - VIII

Table 47.1: Hemostatic Agents/Methods to Attain Haemostasis that Could be used in Periodontal Surgery
Agent/Methods Features Advantages, Disadvantages, and limitations
Ligation of Blood In case, a medium vessel or a large This will prevent further bleeding. It can be used when
Vessels vessel is lacerated. A suture could be a vessel gets severed while procuring, for example, a
passed through the tissue around the palatal soft tissue graft but bleeding from capillaries
vessel and sutured. and inflamed granulation tissue in periodontal pockets
cannot be managed.
Pressure applica- The bleeding area is compressed with It is the most prevalent and most common in practice.
tion gauze with ice. It helps in arrest of bleeding from the capillaries.
Electrocautery It cauterizes the bleeding capillaries. It is used when haemostasis is not achieved by pressure
application.
Epinephrine It may be applied topically as a local It is most effective in the control of superficial capil-
(1:100,000) haemostatic agent. lary bleeding but will not control bleeding from larger
vessels. Not advised for usage in patients with cardio-
vascular problems.
Gelatin (Bovine It is derived from denatured collagen. It is useful for most patients taking an anti-thrombotic
origin) It is commerciallyavailable in different agent.
forms and shapes. It is an absorbable
haemostatic agent and is available as
powder or porous sheet. Its haemo-
static properties can be improved by
soaking in thrombin / gel foam. It can
be sutured into a desired area.
Collagen (Bovine It is a compound present in the It controls mild-to-moderate bleeding in 2-5 min. It is
origin) extracellular matrix of animal cells. It expensive.
is used as an absorbable haemostatic
dressing. It is available in various
forms and shapes for application as
haemostatic agents. The collagen
fibrils attract platelets and triggers ag-
gregation in fibrous mass resulting in
primary hemostasis. It can be cut or
shaped. Adheres to bleeding surfaces
when wet, but does not stick to
instruments, gloves, or gauze sponges.
Oxidized Cellulose Oxidized cellulose is surgical gauze It is useful to control bleeding when other agents inef-
(Plant Origin) that has been treated with nitrogen fective. It is absorbed slowly if it contains a great deal of
dioxide. It is a physical haemostatic blood, may retard wound healing.
agent i.e. it exerts pressure. It ad-
heres to the tissues and absorbs
approximately 50 times its weight in
blood. Within a day of its placement,
it becomes gelatinous and can be
removed.

4 Periodontics & Oral Implantology

Chapter 47 General consideration in Periodontal Surgery

Topical thrombin. It is a blood-clotting factor- a pro- It can be used in moderate to severe bleeding. It is only
(bovine origin) teolytic enzyme, directly converts of topical use. If injected it leads to widespread intravas-
fibrinogen to fibrin speeds up the cular clotting and death.
disruption of platelets, and activates
factor V. It is available as powder or
liquid.
Chitosan (Crusta- It is a polysaccharide-deacetylated Can be used as a carrier membrane and as a haemo-
cean Origin) form of chitin, derived from the static agent.
exoskeletons of crustaceans. It is
nontoxic and enzymatically degrad-
able. It aids in haemostasis by platelet
adsorption and erythrocyte aggrega-
tion.
Tranexamic Acid It is a competitive inhibitor of plasmi-It is useful in short-term for upto a week as a mouth
nogen activation. rinse for preventing hemorrhage following dental
extractions. It has a superficial effect on the clot and
hence may be of limited use in case of bleeding from
inflamed tissues.
Fibrin/ Tissue Glue It converts fibrinogen to fibrin. It is technically difficult to handle and manipulate,
expensive and the risk of viral disease transmission.
Ferric Subsulfate It is an astringent and a haemostatic It causes temporary yellow-brown to black staining
Solution/ Monsel’s agent. and discolouration of the gingival tissues due to its iron
Solution content and disrupts the setting reaction of polyvinyl
siloxanes. It has limited use in periodontics and is used
in dentistry for gingival displacement.
Tannic Acid It is an astringent and has mild hemo- It is found in tea and is perhaps best used as a home
static action. remedy to temporarily control bleeding by biting on a
tea bag.
Cyanoacrylate They are biodegradable and N-butyl-2-cyanoacrylate is of common use as a surgical
glues (Synthetic) bacteriostatic agents formed from tissue adhesive tissue adhesive and haemostatic agent.
the chemi-cal reaction between
formaldehyde and a cyanoacetate
ester. They are available in short- and
long-chain derivatives.
Major blood vessels are not likely to be encountered yet osseous defect, number of involved teeth, presence of
local haemostasis in periodontal surgery is not simple as in granulation tissue, presence of proliferated capillaries
the case of dental extraction due to the following reasons: and various other periodontal disease factors.
♦ Inflammation: Periodontal disease is inflammatory. ♦ Dynamics of the oral cavity: Chewing, eating, speaking
Inflamed tissue complicates haemostasis and hence all could lead to the disturbance of the periodontal
through debridement to reduce inflammation is wound and hence haemostasis.
necessary before planning a periodontal surgical ♦ Incomplete removal of inflamed granulation tissue:
procedure. After elevation of the flap in periodontal surgery
♦ Complicated outline: Periodontal wound outline profuse bleeding is seen due to the presence of
depends on the presence of tooth roots, shape of the granulation tissue in the pocket walls. Generally, it

Periodontics & Oral Implantology 5

 Non-Surgical Methodology Section - VIII

disappears after the removal of the granulation tissue.

application of ethylene-diamine tetra acetic acid (EDTA)
Incomplete removal of inflamed granulation tissue by
followed by a water spray restored the bond strength of a
naïve surgeon may also lead to residual bleeding from
self-etching adhesive to dentin; use of phosphoric acid for
the surgical site. 15 seconds followed by a water spray also was an effective
Dental Surgical Procedures in patients undergoing cleaning method.
anticoagulation therapy: SUTURING IN PERIODONTICS
Review of the scientific literature by Beirne and recently
SUTURE: Material used in closing a surgical or traumatic
by Wahl et al have confirmed the findings that there is
wound with stitches. (Glossary of Periodontal Terms,
an exceedingly low risk (0.6%) of bleeding complications
2001)
requiring more than local hemostatic measures in
continuously anticoagulated patients, with no cases of SUTURE: The act or process of uniting a wound, either
permanent morbidity or fatality. surgical or accidental, through suturing. (Glossary of
Periodontal Terms, 2001)
On the other hand, there is a similarly low (0.8%) but highly
Objectives: The sutures
significant risk of serious embolic complications in patients
whose anticoagulation is reduced or withdrawn for dental ♦ Secure the soft tissues (flaps) in the desired position.
procedures. In some cases, these embolic complications ♦ Prevent bleeding.
resulted in permanent morbidity and even fatality. ♦ Stabilize the clot.
The evidence reviewed indicates that therapeutic ♦ Protect the wound against trauma.
anticoagulation with warfarin should not be interrupted ♦ Promote optimal healing.
for most dental surgery. Potential bleeding complications ♦ Prevent bone exposure.
in anticoagulated patients undergoing dental surgery
must be weighed against possible embolic complications Properties of suture material:
when anticoagulation is withdrawn or reduced for dental ♦ It should be non-allergenic.
surgery. ♦ It should be easy to handle.
The risk of postoperative bleeding complications in patients ♦ It should not dissolve in the oral environment.
whose anticoagulation is continued for dental surgery ♦ It should not be conducive to plaque accumulation.
is exceedingly small and is outweighed by the small risk
♦ It should be of small diameter.
of serious and sometimes fatal embolic complications in
patients whose anticoagulation is interrupted for dental ♦ It should be able to hold the knot and have minimal
surgery. Scaling can be safely performed in patients knot slippage.
on warfarin (Internationalized Normalized Ratio) ♦ It should have adequate tensile strength.
less than 4.0 and/or antiplatelet therapy. Curettage ♦ It should not elicit exaggerated tissue reactions.
and periodontal surgery can be performed in
♦ It should be sterilizable.
patients with Internationalized Normalized
Ratio less than 3.0 with proper local haemostatic ♦ It should be economical.
procedures. Suture materials:
Haemostatic agents and dental tissues: 1. Non-absorbable
Bernades et al cautioned the rampant use of a. Surgical Silk: Braided silk suture was the most
hemostatic agents as its use may induce changes in the commonly used suture material in the past.
dentin surface morphology and in bonding performed Advantages:
on dentin and enamel. Adhesive procedures may be • It is easy to use.
affected adversely when performed on dentin and • It has a fair tensile strength.
enamel contaminated by hemostatic agents. The
• It is economical.
authors found that a 60-second
6 Periodontics & Oral Implantology
Chapter 47
Disadvantages:
• It should be removed. So it needs a second
appointment.
• It has the phenomenon of “wicking” as it is a
multifilament material; it retains bacteria and
can act as a source of secondary infection.
• It elicits extensive inflammatory tissue
response.
b. Expanded poly tetra fluoroethylene (ePTFE)
(GORE-TEX by Gore medical products):The
expanded polytetrafluoroethylene synthetic
monofilament is an excellent non-resorbable
suture used today. It is ideal for use in implant
surgery, bone grafting, and guided tissue
regeneration procedures.
Advantages:
• It has good tensile strength.
• It has good knot security.
2. Absorbable (Resorbable):
• It elicits minimal tissue reaction when compared
to surgical silk.
Disadvantages:
• It is not as easy to handle as surgical silk.
• It is expensive when compared to other
materials.
c. Polyester (ethibond/mersilene by Ethicon): It
consists of polyethylene polymer multifilament
braided into a single strand.
Advantages:
• They have good tensile strength.
• They retain their strength in tissues
indefinitely.
• They are easy to use.
• Produce minimal tissue reaction.
Disadvantages:
• It should be removed. Therefore, it needs a
second appointment.
d. Nylon (ethilon by Ethicon):
Periodontics & Oral Implantology
General consideration in Periodontal Surgery
Advantages:
• Minimal tissue reaction.
Disadvantages:
• Nylon sutures may annoy the patient sometimes
by scratching the tongue, cheek, and lips.
e. Polypropylene (Prolene by Ethicon): it is
composed of an isostatic crystalline stereoisomer
of polypropylene or synthetic linear polyolefin.
Advantages:
• It has adequate strength.
• It is easy to handle.
• It is easy to place secure knots.
• It causes low tissue drag.
Disadvantages:
• In theoralenvironment, the knots may become
slippery.
a. Surgical gut: The 2nd-century Roman physician
Galenhas been credited as the first to describe
gut sutures, or alternatively the 10th-century
Andalusian surgeon Al-Zahrawi.They are derived
from the intestines of the sheep/beef. They have
a fair ease of handling, poor tensile strength, tend
to harden, moderate tissue reaction and a short
half-life of upto 14 days. They are commonly used
resorbable sutures.
i. Plain surgical gut: It has shorter absorption
period.
ii. Chromic surgical gut: It is treated with chromic
salt solution to resist the body enzymes and
hence has slower absorption rates. It should
not be used in persons allergic to chromium.
b. Polyglactin (Vicryl by Ethicon): It consists of
synthetic fibres made of copolymers of glycolide
and L-lactide.They are difficult to handle.They are
difficult to place a knot. They take longer times to
resorb.
c. Polyglecaprone /PGCL (Monocryl by Ethicon): It is
composed of glycolide and epsilon-caprolactone
copolymer. It has low immunogenicity and high
tensile strength.
7
 Non-Surgical Methodology Section - VIII

3. Cyanoacrylates: They are tissue adhesive materials.
The cyanoacrylate materials have a chemical formula
H2C=C(CN)COOR. N-butyl cyanoacrylate is a
biocompatible tissue adhesive hence used for closure
of wounds.
The suture threads material range from 1 to 10 in diameter.
The higher number corresponds to the thinner delicate
thread. The larger the number, the smaller is the diameter.
The diameter of the suture material is selected according to
the need. The following are the commonly used diameters
of suture materials in periodontal surgical procedures.
Table 47.2: Suture material used in Periodontics:
Diameter of Suture
Procedure
Material
Periodontal flap procedure 4-0
Periodontal plastic surgery 5-0
Periodontal microsurgery 7 to 10
♦ Suture needles are either conventional cutting (A) or
reverse cutting (B).
1. A conventional suture needle due to its sharpened
inside concave curvature may cause the tearing
through the flap which is often described as “cut
out”.
2. By contrast, a reverse cutting needle has a smooth
inner curvature with a third cutting edge located
on its convex (outer) edge. In periodontal surgery,
reverse cutting suture needles are used to prevent
the suture material from tearing through the
papillae or surgical flap edges.
Anatomy of the suture:
Ears: Cut ends of the suture beyond the knot.
Loops: It is created by the knot.The suture passing through
the tissues is part of the loop.
Knot: It consists of throws. It keeps the suture in place.

Implant dentistry 3-0,4-0 Knots: The most commonly used knots in

periodontal surgery are the square knot, the granny
knot, and the surgeon’s knot.
NEEDLES:
♦ The surgical needle consists of the needle point, the
needle body, and the eyeless/ swaged (press-fit) end
or the eye.
♦ Suture needles usually are classified according to
their curvature, radius, and shape.
♦ The 3/8 and 1/2 circle needles are used most
commonly. Needles are described as what portion
of a circle that needle would occupy. So a 3/8 needle
will be straighter then a 1/2 needle which with its Fig. 47.3 Square (Reef) knot
greater curve will when placed through the tissue
turn back on itself as it passes through the tissue.The
3/8 needle makes it possible to rotate the needle on
a central axis and pass from the buccal surface to the
lingual surface in one motion.
♦ By contrast, the 1/2 needle traditionally is used
in more restricted areas, such as the buccal of the
maxillary molars and the facial aspect of the maxillary
and mandibular incisors. The ½ circle needle also is
used routinely for periosteal and mucogingival surgery
especially when there is narrow space.
Fig. 47.4 Granny knot
8 Periodontics & Oral Implantology
Chapter 47 General consideration in Periodontal Surgery

SUTURING TECHNIQUES:
Interrupted sutures: They are the most commonly
used suture type. They are used when both the buccal and
lingual flaps are at similar level and require same amount
of tension.
a. Direct/loop/circumferential suture: It is the
commonly used technique.

Fig. 47.5 Surgeons knot (2-1)

Guidelines and Techniques for suturing in
periodontal surgery:
♦ Suturing is started from the most distal part of the
flap and continued mesially.
♦ The suturing is first inserted through the mobile
tissue flap.
♦ The needle is held with a needle holder.
♦ The needle is entered into the tissue at right angles
(30° to 45°).
♦ The suture is placed no less than 2 to 3 mm from the
flap edge. This will prevent tearing through the flap
during post-operative swelling.
♦ The needle is then passed through the tissue, in a
circular pattern following the needle’s curvature.
♦ The knot should be small, the ears of the knot be just
2 to 3 mm and not be placed over the incision.
♦ The suturing should not limit the blood supply to the
flap i.e. the flap should not blanch when sutured.
♦ The interdental papilla should not be damaged while
suturing. When suturing interdental tissue, the suture
should pass below an imaginary plane that forms the
base of the interdental papilla.
♦ Sutures of any kind placed in the interdental papillae
should enter and exit the tissue at a point located
below the imaginary line that forms the base of the
triangle of the interdental papilla.
Fig. 47.6 Direct circumferential loop
Advantages:
• Simple and easy to perform.
• Better approximation surgical flaps/interdental
papilla.
• No interposing suture material between the tissue
flaps.
Disadvantages:
• It cannot allow resistance of tension from muscle
pull.
b. Figure of eight: This technique is used in very
restricted areas (e.g., lingual second molar). The
second needle penetration is through the outer
surface of the lingual flap, on the inner surface, as
is the case with the simple loop interrupted suture
technique.The suture needle and material are passed
back under the contact point, and the knot is tied on
the buccal aspect of the buccal flap.

Fig. 47.7 Figure of eight

Periodontics & Oral Implantology 9
 Non-Surgical Methodology Section - VIII

Advantages:
• It is simpler and easier to perform.
Disadvantages:
• Suture thread passes between the flaps.
Mattress Suture:
a. Horizontal mattress suture: A horizontal mattress
suture begins with needle penetration at the mesial
buccal, apical to the mucogingival junction, and
Fig. 47.9
crossed under the flap to exit at the mesial lingual.
The suture penetrates the tissue at the distal lingual c. External mattress suture: It is used in an attempt
and crosses under the flap again to exit at the distal to keep minimal amount of the suture material
lingual, apical to the mucogingival junction. At that within the flap. It is used along with regenerative
point, the suture at the distal buccal is tied to the techniques
free end at the mesial buccal.
Uses:
• Bone regeneration.
• Wide interdental spaces.

Fig. 47.10 Vertical maltress suture (Internal)

Fig. 47.8 Horizontal mattress suture (External)

b. Vertical mattress suture: It is similar to the horizontal
mattress suture except that its orientation is in the
vertical direction.
Advantages: It is used in
• Bone regeneration.
• Narrow interdental spaces.
Fig. 43.11 Horizontal mattress suture (Internal)

10 Periodontics & Oral Implantology

Chapter 47 General consideration in Periodontal Surgery

Uses:
♦ It is used when flap is raised on one only side of the
tooth.
♦ It is used to position one side of the flap
independent of the other side.
♦ It is used to position lateral positioned/rotated
pedicle grafts.
Continuous sling suture: They are used for multiple
teeth, especially when an entire quadrant is to be sutured.
Fig. 47.12 Vertical mattress suture (External) The suturing is startedat the facial surface at the papilla
d. Internal mattress suture: The bulk of the suture nearest the midline.
material remains within the flap. It is aesthetically Advantages:
superior hence used in anterior areas. It also everts
It is simple and easy to place. It can involve multiple teeth,
the papilla and positions it upright in the embrasure
thus decreases the number of knots to be placed and time
space.
for suturing. The buccal and lingual flaps can be positioned
e. Laurel loop/vertical sling mattress suture: It is independently. The teeth are employed to anchor the
a modification of internal mattress suture wherein flaps.
the suture thread passes through the loop created
on the lingual side before the knot is placed. It is used
with guided tissue membrane and bone regeneration
techniques.

Fig. 47.14 Sling suture for a single tooth.

Fig. 47.13 Laurel loop suture
Sling suture:
Independent sling suture/Interrupted suspensory suture:
It involves two interdental spaces i.e. a papilla mesial and
distal to a tooth. The needle is passed through the distal
papilla of the buccal flap, is carried lingually around the neck
of the tooth or implant to penetrate the mesial papilla and
exits on the buccal side. The suture is carried back around
the same tooth lingually and tied with the free end on
the buccal surface of distal papilla. The knot is positioned
buccally.
Disadvantages: In case the knot slips/unties or the
suture breaks at even a point the entire suture will lose its
integrity.
Anchor suture: The anchor suture is a suturing technique
to close a flap located in an edentulous area mesial or
distal to a tooth. It is best used in mesial or distal wedge
procedures.
Advantages:
♦ This suture closes the facial and lingual flaps and
adapts them tightly against the tooth
♦ It is thought to provide better periodontal healing
adjacent to the second molars after third molar
surgery.
♦ It is used with periodontal regenerative techniques.

Periodontics & Oral Implantology 11

Non-Surgical Methodology Section - VIII

Fig. 47.15 Single, interrupted suture

Fig. 43.17 Continuous independent sling suture

Closed anchor suture: A direct suture is tied on the
edentulous area adjacent to a tooth. One of the threads
is then passed around the tooth and tied. It is similar but
more secure than anchor suture.

Fig. 47.18 Anchor suture

Fig. 47.16 Continuous independent sling suture with

mattress sutures

Fig. 47.19 Closed anchor suture

Periosteal suture: They are of two types, holding suture
and closing sutures. Holding sutures are placed at the
base of the flap. They help in positioning the displaced flap.
Closing sutures close the margins of the flap and hold them
to the periosteum.
Uses:
♦ To position apically displaced flaps.

12 Periodontics & Oral Implantology

Chapter 47 General consideration in Periodontal Surgery

Advantages: ** It maintains the position of apically repositioned

♦ Precise Flap placement. flap by preventing its coronal displacement.

♦ Better Stabilization. ♦ Splinting:

Disadvantages: ** It acts as a temporary splint of the teeth during

♦ Technique sensitive.
Disadvantages:
Periosteal sutures
Fig. 47.20: Periosteal suture - cross section
PERIODONTAL PACK
PERIODONTAL DRESSING (Pack): A protective
material applied over the wound created by periodontal
surgical procedures.(Glossary of Periodontal Terms, 2001)
Is, a surgical dressing applied to the necks of teeth and the
adjacent tissue to cover and protect the surgical wound
Advantages:
♦ Protection:
** It protects the surgical wound from trauma.
** It protects the stability of the clot.
** Improves the post-surgical patient comfort.
♦ Stability:
** It improves the adaptation of the flap.
the initial post-surgical healing phase.
♦ Root sensitivity:
** It covers the neck of the teeth and hence decreases
post-surgical root sensitivity.
♦ Haemostasis: It decreases the chances of post-surgical
haemorrhage by protecting the wound against physical
trauma and by acting as a pressure pack.
♦ Harmful effects of some of the Periodontal pack
components:
** Cytotoxicity:
** Tannic acid: liver damage.
** Asbestos: Asbestosis, lung cancer, and
mesothelioma.
** Eugenol is cytotoxic at higher concentrations,
can cause oral mucosal irritation, induce allergic
reactions-reddening of the area and burning pain
in some patients and may cause tissue necrosis.
♦ Plaque retention: Any addition to the tooth surface
may lead to an increase in plaque accumulation and
so does the Periodontal dressing.
♦ Allergic reaction to some components.
♦ No Antibacterial effects:The periodontal dressings, in
general, afford no antibacterial protection.
♦ No curative or healing properties.

Periodontics & Oral Implantology 13

 Non-Surgical Methodology Section - VIII

TYPES OF PERIODONTAL PACK:

Fig. 47.21: Eugenol Dressings

NON EUGENOL DRESSINGS:

Fig. 47.22: Dressings containing zinc-oxide Fig. 47.23: Dressings with neither zinc-
but without eugenol. oxide nor eugenol.

14 Periodontics & Oral Implantology

Chapter 47
Eugenol works as an obtundant and was hence initially used
in the periodontal dressings. However due to its ability to
elicit allergic reaction in some and due to burning taste
sensation non-eugenol periodontal dressings came into
being.
Coe-pak:
It is a commonly used non-eugenol periodontal dressing
materialwhichworkson the basis of a metallic oxide and
fatty acids reaction. It is available in two paste system.
♦ The two pastes are to be mixed thoroughly using
a wooden spatula or tongue depressor. On proper Retention of the pack;
mixing, an even colour is obtained. It is then rolled
into pencil shaped strips and applied on the surgical
area
♦ One tube-Base paste
** Oil – plasticity.
** A gum-for cohesiveness.
** Lorithidol- a fungicide.
♦ Second tube contains;
** Liquid - coconut fatty acids.
** Thickening agent-colophony resin (resin).
** A bacteriostatic agent-Chlorothymol.
Fig. 47.24 PeriGuard-light cure dressing in place
(courtesy Dr. El-Hassan.)
Periodontics & Oral Implantology
General consideration in Periodontal Surgery
Fig. 47.25: A commercially available periodontal pack
♦ Periodontal dressings are kept in place by mechanical
retention.(interlocking)
♦ In case of missing teeth - splints, stents can be used.
♦ Placement of dental floss tied loosely around the
teeth enhances retention of the pack.
Antibacterial properties of the pack;
♦ Bacitracin, oxytetracycline (Terramycin), neomycin
and nitrofurazone have been used but may produce
hypersensitivity reactions.
♦ Incorporation of tetracycline powder in coe-pakis
generally recommended.
Healing after flap surgery
Healing: “A complex dynamic process that results in the
restoration of anatomic continuity and function.” (Wound
Healing Society)
HEALING: The process of repair or regeneration of
injured, lost, or surgically treated tissue. (Glossary of
Periodontal Terms, 2001)
Wound Healing is a fascinating biologic event essential for
human survival. It is a physiologic process involving a series
of sequential overlapping steps. Healing is the restoration
of the normal structure and function of tissue. The various
events taking place are divided into following stages
haemostasis, inflammation, proliferation or granulation
and remodelling or maturation. In the process of wound
healing, a variety of biologic mechanisms work together
in an organized manner. In periodontium wound healing is
the result of interaction between the cells of the various
tissues i.e. the gingiva, alveolar bone, periodontal ligament
and the cementum.
15
 Non-Surgical Methodology Section - VIII

Types of Wound Healing: Secondary intention healing occurs with large wounds in
Healing by First intention: Primary union of a wound in which the tissues either cannot be approximated or remain
which the incised tissue edges are approximated and apart. The healing process in such wounds is extended and
held until union occurs.(Glossary of Periodontal terms, is determined by the amount of new connective tissue
2001) and epithelium required for their closure. The epithelium
migrates from the margins of the wound towards the centre.
Primary intention healing occurs after a clean injury e.g. in case of gingivectomy (external bevel gingivectomy).
e.g. with surgical incision when the wound margins are Healing in majority of periodontal surgical wounds is by
approximated. The healing occurs quickly. E.g.: in case of primary and secondary intention.
periodontal flap surgery.
Tertiary intention/Delayed primary intention: is usually
Healing by second intention: Wound closure wherein associated with infected or dehisced surgical wounds.
the edges remain separated, and the wound heals from
the base and sides via the formation of granulation
tissue. (Glossary of Periodontal Terms, 2001)

STAGES OF WOUND HEALING:

Fig. 47.26 Stages of wound healing

Stage I: Haemostasis: Bleeding occurs immediately at the time of injury. A mean amount of 134 ml of blood loss with
a wide range of 16 to 592ml has been reported with periodontal flap surgery. Injury also triggers the clotting cascade and
haemostasis follows. This stage usually completes with the initial few hours. Once the flap is sutured, blood clot appears
between the tooth-bone surface and the flap. It forms the provisional matrix or scaffold and is critical for successful
healing.
Stage II: Inflammation:
It is the second stage of healing. Classical signs of inflammation can be noticed i.e. redness, heat, swelling, pain and
discomfort. The inflammatory is triggered by a number of mediators released from the injured cells and capillaries,
activated platelets and their cytokines, and the by-products of haemostasis. Neutrophils are the first cell to
arrive within minutes of injury. They form a layer beneath the blood clot, and this layer is called as Polyband. An
exudate or a transudate leaks from the injury.
Stage III: Proliferation or granulation or repair:
Neovascularisation starts by 3 to 4 days. Epithelial cells migrate from the wound margins to the centre of the wound
at the rate of 0.5mm to 1. 0 mm per day beneath the polyband. Junctional epithelium formation is complete by a week
after surgery. Granulation tissue replaces the blood clot at about one week after the surgery. Fibroblasts migrate and

16 Periodontics & Oral Implantology

Chapter 47
start synthesizing collagen. Immature collagen fibres are
seen parallel to the tooth surface after 2 weeks of surgery.
In case of osteoplasty, resorption removes the necrosed
bone and bone repair completes by 3 to 4 weeks.
Stage IV: Remodelling or maturation (after 3
weeks):
It is the final stage of wound healing. The wound gains
much of its strength in this phase. This stage takes months
or years to complete. Extracellular matrix and Collagen
remodelling is carried out by the fibroblasts. In case of
osteoplasty, osseous remodelling continues for up to 2
years, and it decides the final shape of the osseous crest.
Complications of periodontal surgery:
Most of the complications are common to any dental
surgical procedure.
♦ Haemorrhage: A certain amount of blood loss
happens during periodontal surgical procedure. The
initial bleeding during the surgery reduces following
the removal of the granulation tissue. A blood loss
of more than 500 ml can lead to hypotension. Any
excessive bleeding should be immediately controlled.
** (A hematoma is defined as the collection of
blood within soft tissues from haemorrhage
leading to tissue enlargement). Postoperatively,
direct pressure on the surgical site helps insure
close adaptation of the mucoperiosteum to bone,
thereby, reducing the incidence of hematoma
formation.
♦ Syncope: It is also known as fainting or
vasodepressor syncope. It is a sudden, transient loss
of consciousness. It is the most common medical
emergency encountered in dental clinic.
It can be caused by,
• Decreased cerebral function due to impaired
circulation or altered metabolism
• Psychogenic factors like anxiety and fear
• Non-psychogenic causes like hypoglycaemia,
position change, heat,etc
Three stages of syncope include,
• Pre-syncope – feeling light-headed, weak,
nauseated, tingling in fingers and toes. It can be
avoided if the patient is placed in Trendelenburg
Periodontics & Oral Implantology
General consideration in Periodontal Surgery
position.
• Syncope – flaccid muscles, loss of consciousness.
The client may become pale with weak pulse
and shallow breathing. Its duration is less than 5
minutes
• Post-syncope – patient awakens, blood pressure
and pulse rate returns to normal but may feel
weak and disoriented. The patient should remain
in supine position to prevent another episode.
Management of syncope includes:
• Patient should be placed in supine/ Trendelenburg
position, and dental treatment should be
discontinued.
• Assess the patient airway and keep the patient
warm.
• Usually, the patient regains consciousness in
5 minutes after an episode of syncope. If not,
immediate medical follow-up is mandatory.
♦ Soft tissue shrinkage: Periodontal surgery
invariably leads to soft tissue shrinkage and at times
gingival recession. The recession may cause root
hypersensitivity, aesthetic problems especially in the
anterior segments and increased incidence of root
caries.
♦ Swelling: Within the first 2 post-operative days,
some patients may have a soft, painless swelling in
cheek. Some may have lymph node enlargement and
slightly elevated temperature. This is due to localized
inflammatory reaction to the procedure. It usually
subsided by the 4th day. If swelling persists or worsens,
antibiotics should be initiated. Patient can also apply
moist heat intermittently over the area.
♦ Feeling of weakness: The patient has a washed-out,
weakened feeling for about 24 hours after surgery. It
could be a systemic reaction to transient bacteremia
induced by the procedure. It can be prevented by
premedication with amoxicillin every 8 hours atleast
24 hours before the procedure and continuing it for
5 days postoperatively.
17
 Non-Surgical Methodology
Fig 47-27: Possible complications of conventional periodontal surgery
Review Questions:
Essay questions:
1. A patient has undergone a periodontal flap
procedure. Explain the instructions to patients that
you will give after periodontal surgery.
2. Describe in detail the suturing techniques used in
periodontal surgeries.
3. Describe the wound healing after flap surgery.
Short notes:
4. Write briefly about the dental surgical procedures in
patients undergoing anticoagulation therapy?
5. Write briefly about the possible complications of
periodontal surgery.
6. Classify Periodontal packs.Write in detail about non-
eugenol periodontal packs.
Principal Sources and Suggested Further
Reading:
♦ Baab DA, Ammons WF Jr, Selipsky H. Blood loss
during periodontal flap surgery. J Periodontol. 1977;
48:693-698.
♦ Behrens AM, Sikorski MJ, Kofinas P. 2013. Hemostatic
strategies for traumatic and surgical bleeding. J Biomed
Mater Res Part A 2013
18 Periodontics & Oral Implantology
Section - VIII
♦ Beirne OR. Evidence to continue oral anticoagulant
therapy for ambulatory oral surgery. J Oral Maxillofac
Surg 2005; 63(4):540-5.
♦ Chambrone L, Faggion CM Jr, Pannuti CM, Chambrone
LA. Evidence-based periodontal plastic surgery: an
assessment of quality of systematic reviews in the
treatment of recession-type defects. J ClinPeriodontol
2010; doi: 10.1111/j.1600-051X.2010.01634.x.
♦ Darby ML. Mosby’s Comprehensive Review of Dental
Hygiene. Seventh edition. 2012. Elsevier. Missouri.
♦ de Oliveira Bernades K, Hilgert LA, Ribeiro AP, Garcia
FC, Pereira PN. The influence of hemostatic agents
on dentin and enamel surfaces and dental bonding: A
systematic review. J Am Dent Assoc. 2014 Nov; 145
(11):1120-8. doi: 10.14219/jada.2014.84.
♦ Fouad A. Al-Belasy, Maged Z. Amer. Hemostatic
Effect of n-Butyl-2-Cyanoacrylate (Histoacryl)
Glue in Warfarin-Treated Patients Undergoing Oral
Surgery. J Oral MaxillofacSurg 61:1405-1409, 2003.
doi:10.1016/j.joms.2002.12.001
♦ Gaspar R, Brenner B, Ardekian L, et al: Use of
tranexamic acid mouthwash to prevent postoperative
bleeding in oral surgery patients on oral anticoagulant
medication. Quintessence Int 28:375, 1997
Chapter 47
♦ Hardean E. Achneck, BantayehuSileshi, Ryan M.
Jamiolkowski, David M. Albala, MD, Mark L. Shapiro,
Jeffrey H. Lawson,A Comprehensive Review of Topical
Hemostatic Agents-Efficacy and Recommendations
for Use. Ann Surg 2010;251: 217–228.
♦ James W. Little, DMD, MS,a Craig S. Miller, DMD,
MS,b Robert G. Henry, DMD, MPH,c Bruce A.
McIntosh, PharmD,d Naples, Fla, and Lexington, Ky.
Antithrombotic agents: Implications in dentistry. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2002;
93:544-51 doi:10.1067/moe.2002.121391.
♦ Lau BY, Johnston BD, Fritz PC, Ward WE. Dietary
strategies to optimize wound healing after periodontal
and dental implant surgery: an evidence-based review.
Open Dent J. 2013; 5; 7:36-46.
♦ Lazarus GS, Cooper DM, Knighton DR, et al.
Definitions and guidelines for assessment of wounds
and evaluation of healing. Arch Dermatol 130:489–
493, 1994
♦ Lee H. Silverstein, Gregori M. Kurtzman, Peter C.
Shatz.Surgical Soft Tissue Management.Alpha Omegan
• Volume 100 • Number 3, 148-155.
♦ Leslie P. Felpel,A review of pharmacotherapeutics
for prosthetic dentistry: Part I, J Prosthet Dent 1997;
77:285-92.
♦ Mantzikos K, Segelnick SL, Schoor R. Hematoma
Following Periodontal Surgery with a Torus
Reduction: A Case Report. J Contemp Dent Pract
2007 March;(8)3:072-080
♦ Mercy HP, Sukari AH, Abdul RH, chitosan-derivatives
as hemostatic agents: their role in tissue regeneration.
Regenerative research 1(1) 2012 38-46
♦ Newman, Takei, Fermin A Carranza. Clinical
Periodontology, 9thedn, WB Saunders Co, 2002.
♦ Rose F.L,Mealey BL,Genco RJ,Cohen DW,Periodontics:
Medicine, Surgery and Implants, Mosby,Inc. 2004.
Periodontics & Oral Implantology
General consideration in Periodontal Surgery
♦ Siervo S. Suturing Techniques in Oral Surgery.
QuintessenzaEdizioniS.r.l.
♦ Silverstein LH. Principles of dental suturing: the
complete guide to surgical closure. Mahwah, NJ:
Montage Media, 1999.
♦ Siniša M. Mirkoviã, LjubišaD. Dÿambas, SreãkoÐ.
Selakoviã, Influence of Different Types of Surgical
Suture Material on The Intensity of Tissue Reaction
in Oral Cavity. Proc. Nat. Sci, MaticaSrpska Novi Sad,
115, 91—99, 2008.
♦ Strodtbeck F. Physiology of Wound Healing. Newborn
and Infant Nursing Reviews; 2001:1(1): 43–52
♦ Tarighi P, Khoroushi M.A review on common chemical
hemostatic agents in restorative dentistry. Dent Res
J 2014;11:423-8.
♦ Trombelli L. Which reconstructive procedures are
effective for treating the periodontal intraosseous
defect? Periodontology 2000 2005; 37, 88–105.
♦ Vandersall DC, Concise Encyclopedia of
Periodontology. 2007. Blackwell Munksgaard.
♦ Wahl MJ, Pinto A, Kilham J, Lalla RV, Dental surgery in
anticoagulated patients – stop the interruption, Oral
Surgery, Oral Medicine, Oral Pathology and Oral
Radiology (2014), doi: 10.1016/j.oooo.2014.10.011.
♦ Wedmore I, McManus JG, Pusateri AE, Holcomb JB.
A special report on the chitosan-based hemostatic
dressing: experience in current combat operations. J
Trauma. 2006; 60: 655–658.
♦ Yoshinari Morimoto, Hitoshi Niwa, Kazuo Minematsu.
Hemostatic management for periodontal treatments
in patients on oral antithrombotic therapy: A
retrospective study. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2009; 108:889-896.
♦ Ziada H, Irwin C, Mullally B, Byrne PJ, Allen E.
Periodontics: 4. Surgical Management of Gingival and
Periodontal Diseases. Dent Update 2007; 34:39-396.
19
Chapter 1 Incision in Periodontal Surgery
CHAPTER

47a Incisions in Periodontal

Surgery

Syed Wali Peeran

Chapter Outline:
• Incision.
• Preconditions for selection of the appropriate
incision technique.
• Incisions used in Periodontics

INCISION: A cut or surgical wound made by a knife, electrosurgical scalpel, laser, or other such instrument. (Glossary
of Periodontal terms,2001)
Preconditions for selection of the appropriate incision technique:

Periodontics & Oral Implantology 1

 Table 47a.1: Incisions used in periodontics

2
External Bevel Internal Bevwel Inci- Sulcular Inci- Releasing Thinning Cut Back Periosteal
Incision (EBI) sion (IBI) sion Incision Incision Incision Incision
Synonyms Gingivectomy Reverse bevel(its bevel Intra-Sulcular/ Vertical Internal/ Periosteal
incision is in areverse position Crevicular incision under-mining Releasing
of EBI), inverted incision incision Incision
bevel or inverse bevel
incision. It is the
most common type
of incision used in
periodontics.
Incision in Periodontal Surgery

Descrip- Reduces the Reduces the thickness The surgical Made to Extendsfrom Placed in Incision at the
tion thickness of the of the mucogingival scalpel is enhance the gingival the alveolar base of the
mucogingival complex from the inserted into mobility of a margin mucosa at flap severing
complex from the sulcular side.(Glossary the crevice/ periodontal toward the apical the underlying
outside surface, as of Periodontal terms, pocket and flap. the base of aspect of periosteum.
in a gingivectomy. 2001)It is apically carried apically (Glossary of the flap to a releasing
(Glossary of directed, placed at the beyond its Periodontal decrease incision and
Periodontal terms, crest of the gingival base. It is terms, 2001) the bulk of directed
2001) margin or stepped commonly It is placed connective toward the
It is a coronally back, an acute angle is followed perpen- tissue on the base of the
directed incision;an formed between the by the dicular to underside of flap.
obtuse angle is tooth crown and the elevation of the gingival the flap.
formedbetween scalpel.It is a horizontal full thickness margin at the
the tooth crown incision. flap. It is a line angles

Periodontics & Oral Implantology

and the scalpel. It horizontal of teeth
is totally contained incision. and extend
within the gingiva. through the
It is a horizontal muco gingival
incision. junction.
Indications Gingival Excisional new Access surgery To increase Palatal flaps, Pedicle To release
enlargement- attachment procedure. for GTR access to distal wedge flaps: flap tension
Gingival Basic incision for Narrow allow apical procedures, laterally allowing
hyperplasia: flap procedures. (esp. keratinized or coronal internal positioned, coronal
External bevel Modified Widman Flap) gingiva positioning bevel rotational advancement
gingivectomy. ≤ 3 mm. of flap. gingivectomy, flap. Etc. of the flap.
Crown lengthening. bulky
Gingivoplasty. Aesthetically
Gingival enlargement. papillae
Section - VIII

Crown lengthening. relevant areas.

 External Bevel Internal Bevel Inci- Sulcular Inci- Releasing Thinning Cut Back Periosteal
Incision (EBI) sion (IBI) sion Incision Incision Incision Incision
Contra- When access to Inadequate attached For certain
Chapter 47a

indications underlying bone is gingiva. anatomic

a necessity. reasons
Unfavourable e.g.to
anatomic prevent
conditions trauma-
such as shallow tization of
palatal vault or the mental
a pronounced nerve-in
external oblique Mandi-bular
ridge. canine
High caries index. premolar
region, the
Pre-existing branches of
thermal sensitivity. the palatine
artery and
palatine vein-
in maxillary
second
molar area.
Radicular
promi-nence
and the

Periodontics & Oral Implantology

middle of the
papilla.
Advan- Simple and easy to Removal of pocket wall. Simplest It relaxes Relieves the
tages perform. Conserves the incision. the flap and flap tension
relatively uninvolved increases and enable
outer gingival surface access to the flap to
hence provides direct underlying rotate on a
apposition of healthy structures. pivot more
connective tissue to freely.
the root surface.
Produces a thin
adaptable flap margin.

3
Incision in Periodontal Surgery
 Incision in Periodontal Surgery Section - VIII

♦ Crescent incision: A paramarginal internal bevel

Periosteal

Parkerblade blades no; 15.

incision (IBI), which is used in cases of crown

Bard-parker
Incision

lengthening, restricted to the buccal crown

surface and does not involve the
interdental gingiva.
♦ Crestal incision: An incision directed towards
the crest of the alveolar process.
Cut Back
Incision

11 or 15
♦ Extra sulcular incision: An incision placed

Bard-
between the gingival margin and
the mucogingival junction, dictated by the
depth of the pocket, width of the attached

Bard-parker
Thinning
Incision

gingiva and the volume of the gingiva.

blade 12,
♦ Marginal incision: An IBI that is made on the top

12B.
of the gingival margin. It is difficult to perform in
thin gingival biotypes.
♦ Parapapillary incision: An incision that is taken
Bard-Parker
blade no: 11
Releasing
Incision

not into the interdental space but past it to

the next tooth (line angle to line angle) and thus
&12.

completely retaining the interdental gingiva.

♦ Paramarginal incision: A scalloped IBI placed at a
Sulcular Inci-

distance from the gingival margin creates an

Bard-Parker
blade no: 11

apposition of healthy gingival tissue to the teeth

sion

and a new interdental papilla. Used in flap

&12.

procedures for pocket reduction and crown

lengthening. It is contraindicated in cases of
inadequate keratinized gingiva and when
Internal Bevel Inci-

Bard-Parker blade no

aesthetics is critical.
Loss of keratinized

♦ Sub marginal incision: IBI placed towards the

sion (IBI)

bony crest away from the gingival margin.

11, 12 & 15.

♦ Interdental incision:The third incision in flap

procedures, is used to dislodge the
tissue.

triangular tissue created by the IBI and sulcular

incision. The incision is submarginal and is
placed by the interdental knife.
mentation Orban’s knife, Bard
antages heals by secondary

and post-operative

Entails a great loss

Disadv- Broad wound that
External Bevel

not in use except

Incision (EBI)

of tissue hence is

♦ The papilla base incision consisted of a

Parker blade 11
Intra-operative

Post-operative

Kirkland knife,
enlargements,

shallow first incision at the base of the papilla

in treatment
discomfort.

and a second incision directed to the crestal

of gingival
intention.

bleeding.

bone, creating a split thickness flap in the area

&15.

of the papilla base.

♦ Semilunar incision: A crest shaped incision used
in periodontal plastic surgery to coronally
Instru-

displace the flap.

4 Periodontics & Oral Implantology