Principles of periodontal surgery

When to perform them

Indication for periodontal surgery

• Correction of gross gingival abnormalities

• Persestent inflammation in areas with moderated to deep pockets
• Areas with regularly bony contours
• Furcation lesions
• Infrabony pockets on the distal areas of molar
 When NOT to perform them
Contraindication for periodontal surgery

• Uncooperative patients
• Uncontrolled systemic disease
• Bleeding disorder
• Smoking
• Cardiac disease
• Organ transplantation
• Neurological disorders
 Tissue management during surgery
Tissue should be handled carefully to reduce complications

• Using suction during surgery and avoid compression of tissue with dry sponge or gauze .
• Do not blow air into the surgical site as it may cause cervicofacial emphysema
• Low-speed bur and coolant should be used when removing bone , do not heat the bone above
47c
• Avoid heavy pressure against soft tissue
 Access opening
Selection of the appropriate incision technique is crucial for a uninterrupted healing process

• General principles
• - minimum traumatization
• - inflammation free tissue
• - maximum exsanguination ( releasing blood )
• - shortest possible duration of surgery
 Horizontal incision
Horizontal incisions serve to detach the soft tissue from the root surface,

• External horizontal ( coronally directed ) incision :

• - Form a large angle between the scalpel and the tooth surface
• - Resulting in a very great loss of tissue
• - Typically used in gingivectomy
 Horizontal incision
Horizontal incisions serve to detach the soft tissue from the root surface,

• Internal horizontal ( apically directed ) incision

• - Form an acute angle between the crown and the scalpel
• - Much less tissue lost
• - Typically used in flap surgery
• - According to the site of incision , can be classified into
• sucular / marginal / paramarginal
 Sulcular incision

• The scalpel is introduced into the sulcus or the pocket

• Stick as close to the teeth in the interdental space
• The deepest point of the incision is on the alveolar crest
• Come with the least loss of soft tissue.
• Pocket epithelium and granulation tissue are partially retained
 Parapapillary incision
( Line angel to line angle )

• Aim for retaining the interdental gingival

• Taking the incision not into the interdental space but past it to the next tooth
• Indicated if treatment can be confined to the oral or to the buccal surfaces
 Marginal incision

• Incision made on the top of the gingival margin

• The scalpel is guided at an acute angle to the tooth crown, though without following it
• The deepest point of the incision should be on the alveolar crest
• Its rarely indicated but could be useful in removal of pocket epithelium
 Paramarginal incision

• Moving the scalpel at an acute angle to the surface of the crown without touching it
• The distance from the gingival margin is approximately half the pocket depth
• Resulting in reduction of sulcus depth
• Indicated for pockets ≥ 5 mm in esthetically irrelevant areas and for crown lengthening.
 Vertical incision
Releasing incisions. Offering increased flap mobility

• They are absolutely essential if the flap must be moved into another than the presurgical
position.
• If vertical incisions are not performed, tension and even tearing may occur upon mobilization
of the flap at the end of horizontal incisions
• In ideal cases, the flap base is slightly wider than the flap margin to ensure that the blood
supply to the flap is maintained,
 Flap preparation
Provide access to the underlying tissue and enhance healing afterwards

• Separating section of tissue from the surrounding tissue except at its base , it can either be full
thickness or partial thickness .
• The flap should be proper designed, adjusting either size , site of incision , thickness and
preserving or removal specific layers of tissue for a designated purpose ,
 Wound closure

• The surgical wound might be closed with sutures , skin clips , staples , skin tapes , and wound
adhesive
 Post surgical care

• Avoid hot food

• No smoke or alcohol
• Avoid citrus
• Do not brush over the pack
• Do not try to stop bleeding by rising
 Wound healing
Importants elements for proper healing

• Adequate anesthesia
• Surface disinfection
• Sharp instrumentation
• Atraumatic tissue handling
• Short operating time
• Preventing contamination
• Proper suturing and dressing
Average healing rate
 Resective osseous surgery
Reestablish the marginal bone morphology

• Osteoblasty : creating a physiologic form of alveolar bone without removing any supporting
bone
• Osteotomy : reshape deformities of bone involving removal of supporting bone
 Regenerative osseous surgery
Guided regenerating of bone to restore the anatomical structure

• Guided tissue regeneration : procedures attempting to regenerate lost periodontal structures through
removal and excluding oral epithelium and gingival corium from the root surface ,
• Root biomodification : treating the root planed dentin with acid to exposing collagen fibrils , thus
enhancing new attachment between teeth and bone
• Bone grafting :
• autogenous — grafts transferred from the same individual
• allogenic — grafts transferred between genetically dissimilar members of the same species
• xenogeneic — graft from donor of another species
• alloplastic — synthetic or inorganic implant materials used as substitutes for bone graft