General Principles of Periodontal Surgery .



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Classification of periodontal surgery

A. Pocket reduction surgery:
• Resective: Gingivectomy, apically displaced flap and
undisplaced flap with or without osseous resection.
• Regenerative: Flaps with grafts and membranes.
B. Correction of anatomic/morphologic defects:
• Plastic surgery techniques to widen attached gingiva:
– Epithelial grafts
– Connective tissue grafts
• Esthetic surgery:
– Root coverage
– Recreation of gingival papillae
• Preprosthetic surgery techniques:
– Crown lengthening
– Ridge augmentation
– Vestibular deepening
• Placement of dental implants:
– With GBR
– Sinus grafts


Objectives of surgical phase of periodontal surgery
• Regeneration of lost periodontal attachment.
• Improvement of the prognosis of teeth and their replacements.
• Improvement of esthetics.

PREOPERATIVE INFORMATION
Case History
Medical history
The operator should determine if specific preoperative modifications are indicated because of patient’s medical history, well before scheduling any surgical procedure. Drug allergy, patient’s medication or systemic disease dictate alterations in the type of anesthetic agent, analgesics, prophylactic antibiotic and even surgical procedure.
Indications for Periodontal Surgery
i. Correction of gross gingival aberrations.
ii. Persistent inflammation in areas with moderate to deep pockets.
iii. Areas with irregularly bony contours, deep craters.
iv. When removal of root irritant is not possible due to deep pockets especially in molars and premolars.
v. Furcation lesions.
vi. Infrabony pockets on the distal areas of last molars, complicated by mucogingival problems.

Contraindications for Periodontal Surgery
i. Uncooperative patient
ii. Uncontrolled systemic diseases/hormonal disorders
a. Uncontrolled diabetes mellitus
b. Adrenal dysfunction
iii. Blood disorders
iv. Smoking
v. Cardiovascular diseases
a. Hypertension
b. Myocardial infarction
c. Angina pectoris
d. Anticoagulant therapy
e. Rheumatic fever
vi. Organ transplantation
vii. Neurological disorders
a. Multiple sclerosis
b. Parkinson’s disease

Consent
Patient should be fully informed verbally and in writing about the details of the procedure and possible complications. Patient should be given agreement for the procedure both with an oral statement and by signing a consent form.

Premedications
Premedication should be given when indicated. Th chemotherapeutic agents used for premedications are:
i. Anxiolytics: Apprehensive and neurotic patients are given antianxiety, sedative, hypnotic agents, tranquilizers or barbiturates im or iv prior to surgical therapy.
ii. Antibiotics: Given to only medically compromised patients such as infective endocarditis or patients who require prophylactic antibiotics regimen (valvular heart disease). Antibiotics should be given one hour before surgery to attain adequate levels so as to prevent bacteremia.
iii. Antiseptics: Oral rinse with 0.12% CHX gluconate mouthwash.
iv. Nonsteroidal Anti-inflammatory drugs (NSAIDs): Ibuprofen can be given as premedication before surgery.
Patients on anticoagulant therapy/aspirin shouldstop such medicines 7 to 14 days before surgery and 3 to 4 days afterwards with physician’s approval.

INTRAOPERATIVE CONSIDERATIONS
Monitoring Presurgical Data
The data necessary to select the surgical procedure includes periapical radiographs, study casts and probing charts.
Anesthesia
Periodontal surgery should be performed painlessly, the entire area of the dentition scheduled for surgery, the teeth as well as periodontal tissues should be anesthetized by proper anesthesia. Local infiltration and block anesthesia are the methods of choice. After the initial administration of local anesthesia, inject a drop of anesthetic solution directly into interdental papilla. It makes the gingiva firmer and easier to incise and has a hemostatic effect because of the vasoconstrictor present in the solution. In general, most periodontal surgical procedures are done under local anesthesia. However, in apprehensive patients or patients suffering from neurological disorders, surgery is done under general anesthesia.
Tissue Management
Flap Preparation
Surgical flap is defined as the separation of a section of tissue from the surrounding tissues except at its base. Flap can be full thickness or partial thickness.
Flap Design
Flap design should be based on the principle of maintaining an optimal blood supply to the tissue. The recommended flap length (height) to base ratio should be no greater than 2:1 (Fig. 1). The greater the ratio of the flap length to flap base, the greater the vascular compromise at the flap margins.
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Fig. 1: Flap height-to base ratio (Ratio should not exceed 2:1

Flap Reflection
A full thickness flap is elevated using a sharp periosteaelevator directed beneath the periosteum keeping against the bone. Papillae are reflected first, followed by the marginal gingiva, working across the anterior/posterior extent of the incisions until the flap margin has been freed from the teeth or alveolar crest or both. Once the flap margin has been completely released, the periostealelevator is directed in both horizontal and vertical plane until adequate access is achieved.
Flap Retraction
Surgical retractors are used to hold the flap back from the teeth and bone. Retraction should be passive without any tension. Continuous flap retraction for long period is not advised. When the flap is retracted, the surgical field should be irrigated with the sterile saline to keep the tissues moist, to reduce contamination and to improve visibility.
Flap Repositioning
Surgical flaps may be repositioned, apically positione coronally positioned or laterally positioned. The final flap location is determined by the goal of therapy and the specific periodontal surgical technique performed. Thus in general, tissue should be handled carefully with minimum surgical trauma.
• Use suction during surgery to avoid compression of tissues with dry sponge. Cotton fibers of dry sponge/ gauze could be left behind and may be source of future irritation and infection.
• Sterile saline solution should be used.
• Do not blow air into the surgical site as it may induce cervicofacial emphysema which can be fatal.
• Slow-speed sharp surgical bur and adequate cooling should be used for bone removal. Avoid undue drying of the bone and do not heat the bone above 47°C otherwise it will cause necrosis of bone surface.
• Avoid heavy pressure against soft tissues/bone.
Scaling and Root Planing
Scaling and root planing in conjunction with periodont surgery is done on exposed root surfaces with the help of curettes.
Hemostasis
Steps to minimize postsurgical bleeding:
1. Before approximation of flaps, all areas should be rinsed free of clots and the surgical site should be checked again for bleeding.
2. Pressure should be applied to the flap to encourage minimal clot thickness.
3. Good closure with suturing discourages postsurgical hemorrhage.
4. Distal wedge and edentulous ridge sites should be well approximated carefully with attention because these areas are good source of postoperative bleeding.
Wound Closure
The various techniques of wound closure are sutures, skin clips/staples, skin tapes and wound adhesive [Autologous fibrin glue, fibrin fibronectin sealing system (Tissucol), Cyanoacrylate, Mussel adhesive protein].
The various intraoral anchoring structures useful in securing movable tissues are:
i. Teeth: These teeth are easiest and most secure of all intraoral anchors.
ii. Bound down tissue: Gingiva affixed to bone via periosteum, is the second most reliable anchor.
iii. Periosteum.
iv. Loose connective tissue: It is the least secure anchoring structure in the mouth. Connective tissue in the vestibule and fatty tissue in the retromolar area are the examples of loose connective tissue anchor source.
Suture and Suturing Techniques
Selection of the type of suture material and needle is dependent on tissue type and thickness, location in them mouth, ease of handling, cost and the planned time of suture removal.
Parts of Surgical Needle
i. Point – It is the working end of needle.
ii. Body – It refers to the grasping area which forms the majority of length of needle. It starts where the point of needle ends and ends where the contour change, marking the beginning of swage of the needle.
iii. Eye/Swage – It is the segment at which needle and suture material are joined.
Types of Needles
A. On the basis of shape:
i. Straight
ii. Curved: 1/4, 3/8, 1/2, 5/8 (Fig2


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Fig. 2: Suture needles: Needles are described by their arc as 3/8, 1/2 or 5/8th of a circle
B. On the basis of eye:
i. Eyed: Suture material is tied to the needle and is designed to reuse.
ii. Eyeless/swaged: The suture material is inserted into hollow end during manufacturing and metal is compressed around it. Needle is not reusable.
C. On the basis of function:
i. Tapered: Used for closing mesenchymal layers such as muscle/fascia that are soft and easily penetrable.
ii. Cutting: Used for keratinized mucosa and skin.
a. Conventional cutting (Fig. 3A)
b. Reverse cutting (Fig. 3B


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Fig3: A. Conventional cutting needle and B. Reverse cutting needle

Types of Suture Materials
A. Based on the number of filaments:
a. Monofilament, e.g. steel, nylon
b. Multifilament, e.g. silk, cotton.
B. Based on suture diameter by US Pharmacopoeia in descending order from 5, 4, 3, 2, 1-0 till 11-0 size. 1-0 being the largest diameter and 11-0 the smallest one.
C. Based on resorbability of suture material:
a. Absorbable
b. Non absorbable
D. Based on the source:
a. Natural:
Absorbable– Plain gut, chromic gut, fast absorbing gut, plain collagen, chromic collagen.
Nonabsorbable– Silk, cotton, linen.
b. Synthetic:
Absorbable– Polyglactin, Polyglyconate, Polyglycolic, Polydioxanone.
Nonabsorbable– Nylon, Polybutester, Polyester, Decron, Polypropylene, Nurolone.
Method of Prescription of Suture
It should contain the name of the suture, its size, length and atraumatic, the type of needle, size of the needle and number of foils required, e.g. prolene 2-0, 70 cms with atraumatic reverse cutting needle (3/8 circle 45 mm) – 1 foil.
Objectives of Suturing
i. To stabilize the tissue
ii. To secure tissues in the desired locations
iii. To maintain hemostasis
iv. To permit healing by primary intention
v. As a tool to retract flap for photography or toretrieve free gingiva/connective tissue autografts.
Principles of Suturing
i. Needle holder should grasp the needle approximately ¾th of the distance from point.
ii. Needle should enter the tissue perpendicular to the surface.
iii. Needle should be passed through the tissue following curvature of the needle.
iv. Suture should be placed at an equal distance (2 to
3 mm) from incision on both sides and at an equal depth.
v. Needle should be passed from free to fixed side.
vi. Needle should be passed from thinner to the thicker side.
vii. If one tissue plane is deeper than the other, needle should be passed from deeper to superficial side.
viii. The distance that the needle is passed into tissue should be greater than the distance from the tissue edge.
ix. The tissue should not be closed under tension, it will either tear or necrose.
x. Suture should be tied so that tissue is merely approximated, not blanched.
xi. Suture should not be placed over the incision line.
xii. Suture should be placed approximately 3-4 mm apart.
Various Types of Suturing
A. Interrupted sutures:
a. Circumferential: Direct/loop
b. Figure of eight
c. Mattress: Vertical and horizontal
B. Continuous sutures:
a. Independent sling suture
b. Mattress: Vertical and horizontal
c. Continuous locking
C. Simple sling suture
D. Periosteal sutures
Direct/Loop suture: The needle penetrates the outersurface of the first flap. The undersurface of the opposite flap is engaged and the suture is brought back to the initial side where the knot is tied (Figs 4A to D). These sutures are used where bone grafts are placed and when closed apposition of scalloped incision is required.


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Figs 4A to D: Direct loop suture

Figure of eight: The needle penetrates the outer surface of the first flap and the outer surface of the opposite flap.
The suture is brought back to the first flap and the knot is tied (Figs 5A to D). These sutures are placed when flaps are not in close apposition because of apical flap position or nonscalloped incisions.

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Figs 5A to D: Figure of eight suture

Simple sling suture: The needle engages the outer surface of the flap and encircles the tooth. The outer surface of the same flap of the adjacent interdental area is engaged. The suture is returned to the initial site and
the knot tied (Figs. 6A to D). It is used primarily with apically positioned flap and in repositioning the flap.
The sling/suspensory suture is used primarily when
the surgical procedure is of limited extent and involves only the tissue of the buccal or lingual aspect of the teeth.

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Figs 6A to D: Sling suture


It is also the suture of choice when the buccal and lingual flaps are repositioned at different levels and to place barrier membrane onto the tooth surface.
Mattress sutures: Mattress means that the suture passes through the flap twice. The material does not pass under the incision line, thus minimizing wicking.
a. Vertical mattress: The needle penetrates the outer/ epithelized surface of the flap 8 to 10 mm apical to the tip of the papilla. It is passed through the under surface of the flap, emerging again from the outer surface of the same flap 2 to 3 mm from the tip of papilla. Thus, a vertical bite of 6 to 7 mm is taken with the needle.
The needle is passed through the embrasure, where the technique is again repeated with the opposite/ second flap. The suture is tied on the first flap (Figs 7A to D). It is used in areas with long and narrow papillae. It is of two types – everting and inverting. b. Horizontal mattress: The needle penetrate the outer surfaces of flap 7 to 8 mm apical and to one side of the midline of papilla emerging again 4 to 5 mm through the outer surface on the opposite side of the midline papilla.

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7A to D: Vertical mattress suture

Thus, horizontal bite of 4 to mm is taken with the needle. The needle is passed the embrasure, where the technique is again
repeated with the opposite/second flap. The suture is tied on the first flap (Figs 8 and 9). It is used in interproximal areas of diastema with short and wide papillae.


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Fig 8A to C: Horizontal mattress suture

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Fig. 9: Continuous horizontal mattress sutures

Criss Cross suture: The use of a criss- cross as the suture passes through the interproximal areas provides good control of the flap papilla and keeps the suture out of the healing interproximal sulcus area. Thus, criss-cross single horizontal mattress is good for holding osseous grafts in papilla preservation flap (Fig 10).

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Fig. 10: Criss cross horizontal mattress suture


Circumferential suturing: It is indicated for suturing grafts.
Continuous suture: The suturing procedure 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 (Figs 11A and B). Thus, only one knot is needed (Fig. 12). The continuous suture is commonly used when flaps involving several teeth are to be apically repositioned. When flaps have been elevatedon both sides of the teeth, one flap at a time is secured in its correct position.

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Figs 11A and B: Continuous sutures
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Fig. 12: Continuous sutures


Periosteal sutures: It is indicated in apically positioned partial thickness flap (Fig. 13).
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Fig. 13: Periosteal suture


Sutured Knots
The components of sutured knots are loop, knot and ears. Knot is composed of a number of tight, throws, each throw represents a weave of the two strands and ears that are the cut ends of the suture. Knots should be tied as small as possible. Completed knots should be firm to reduce slippage. Tie knots on facial aspect for access in removal leaving 2 to 3 mm suture tail.
Types of knots:
i. Square knot: Two single tie in opposite direction.
ii. Granny knot: Two or three tie in same direction.
iii. Surgeon’s knot 2-1: 1st tie is double and 2nd tie is single in opposite direction.
iv. Surgeon’s knot 2-2: 1st tie is double and 2nd tie is also double in opposite direction.
Principles of suture removal:
i. Areas should be swabbed with hydrogen peroxide for removal of encrusted necrotic debris, blood and serum from suture.
ii. A sharp suture scissor should be used to cut the loops of suture, close to the epithelial surface as possible. In this way, a minimal amount of portion of sutures that was exposed to the outside environment and has become laden with debris and bacteria will be dragged through the tissue.
iii. A cotton plier is then used to remove the sutures. The location of knots should be noted so that they can be removed first, which will prevent unnecessary entrapment of the flap.
Periodontal Dressings
Periodontal dressings were first introduced in 1923 when Dr AW Ward advocated the rules and use of packing material around the teeth following gingival surgery.
This material was called Wonder pack, which consisted of zinc oxide eugenol mixed with alcohol, pine oil and asbestos fibers.
Purpose
Periodontal dressings are used for the following reasons:
a. Protect the wound area from irritants such as hot/ spicy food.
b. Enhances patient comfort.
c. Helps to maintain the position of repositioned soft tissues and act as a template to prevent formation of excessive granulation tissue.
d. Also protects newly exposed root surfaces from temperature changes, stabilizes mobile teeth and protect sutures.
Properties
a. Dressing should be soft, but with enough plasticity
and flexibility.
b. Dressing should set within a reasonable time.
c. Dressing should have sufficient rigidity to prevent fracture and dislocation.
d. Dressing should have a smooth surface after setting
to prevent irritation to the cheeks and lips.
e. Dressing should be dimensionally stable to prevent salivary leakage and accumulation of plaque debris.
f. Dressing should preferably have bactericidal properties to prevent excessive plaque formation.
g. Dressing should not induce allergic reactions.
h. Dressing should have an acceptable taste.
i. Dressing must not detrimentally interfere with healing.
Classification of Periodontal Dressing:
i. Zinc oxide eugenol
ii. Zinc oxide noneugenol: Coepak, periocare, periopac,
perioputty and vocopac
iii. Others: Photocuring periodontal dressing (Barricaid),collagen dressings, methacrylic gel and cyanoacrylate. Zinc oxide eugenol dressings:
i. Powder and liquid form (Kirkland pack): Powder is composed of zinc oxide, tannic acid, rosin, kaolin, zinc – steorate, asbestos. Liquid contains eugenol, peanut oil, rosin. When the components of zinc oxide eugenol dressings are mixed, setting occurs as a result of chemical interaction between zinc oxide and eugenol forming zinc eugenolate.
ii. Paste form - Tube 1 – Base zinc oxide 87%, fixed vegetable/mineral oil 13%; Tube 2 – Accelerator oil of clove 12%, gum/polymerized rosin.
Zinc oxide non-eugenol dressings:
i. Coepak: It is the most common and widely used non – eugenol dressing (Fig. 14


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Fig. 14: COE PAK: Periodontal dressing

Zinc oxide : Main ingredient
Vegetable oil : For plasticity
Gum : For cohesiveness
Lorothidol : Fungicide
Liquid coconut : Fatty acids
Chlorothymol : Bacteriostatic agent
Colophony resin
ii. Periocare: Paste contain zinc oxide, MgO, Ca(OH)2 vegetable oils. Gel contain resins, fatty acids, ethylcellulose, lanolin, Ca(OH)2. The setting of periocare occurs by chemical reaction.
iii. Periopac: It is premixed ZnO noneugenol dressing containing Ca3(PO4)2, ZnO, acrylate, organic solvents, flavoring and coloring agents. When this material is exposed to air or moisture, it sets by the loss of organic solvents.
iv. Vocopac: It is a new formulated product for use as periodontal dressing. It contains 90 gm base and 90 gm catalyst. It contains neither eugenol nor coumarin and causes no gingival irritation, it retains its tough elastic qualities throughout its life in the patient’s mouth, and does not become brittle. It adheres excellently to the teeth and promotes healing. Mixing time is about 20-30 seconds and its working time is approximately 10-15 minutes.
v. Perioputty: It is a noneugenol dressing which contains methyl and propyl-parabens for their effective bacteriocidal and fungicide properties and benzocaine as a topical anesthetic.
vi. Barricaid visible light cure periodontal dressing: This single component of periodontal dressing eliminates messy, time consuming mixing of paste. It is available in a syringe for the direct application or dispensing on a mixing pad and placement intraorally. Curing of the material is then accomplished with a visible light curing unit to form a nonbrittle, but firm, protective elastic covering. The principle ingredients of this material are polyether urethane dimethacrylate resin, silica, visible light cure (VLC) photoinitiator, accelerator and stabilizer. It contains polymerisable monomers which may cause skin sensitization (allergic contact dermatitis) in susceptible persons. Eye protection should be worn, while curing with a visible light unit.
vii. Collagen dressings: An example of collagen dressing is collocate. Collagen dressing is in the form of collagen sponge which is a type I collagen derived from bovine Achilles tendon. It is completely resorbable dressing that is used to cover and protect palatal graft sites; the sponge is approximately 3 mm thick and can be cut to fit the graft site. It stops bleeding and can absorb 30-40 times its weight in fluid, without swelling.
viii. Methacrylate gel dressings: They have elastic consistency that is soft and resilient and will flow under pressure. They adapt closely to the tissues and are very comfortable with wound site. The major advantage of this material is its ability to
carry and release medicaments to the soft tissues.
ix. Cyanoacrylate: In 1964 tissue adhesives were introduced to dentistry. Dr SN Bhaskar conceive the idea of their potential use in periodontics and conducted the bulk of the laboratory and clinical research. The basic formula of Cyanoacrylate is CH= C (CN) – COOR. The butyl and isobutyl formsare ideal as periodontal dressings. The use of cyanoacrylate is an alternative to suturing and as a surface adhesive and periodontal dressing. This material has the unique ability to cement together
moist, living tissue surfaces. Cyanoacrylate is either applied in drops or sprayed on the tissues. The material is much less bulky than other dressings.
Other advantages include lack of apparent side effects, easy adherence to living tissues, immediate hemostasis, lack of evidence of systemic toxicity/ sensitivity, precise placement of flaps, decreased suturing time, ease of application and patient preference over bulky dressings. It is most useful in flap control in concave zones such as furcal area fluting. Cyanoacrylate has been used for surface application only; adhesives that become trapped under soft tissue flap will delay wound healing.
Antibacterial properties of packs: Bacitracins,
Oxytetracycline (Terramycin), Neomycin and Nitrofuraxone have been tried, but all may produce hypersensitivity reactions. Incorporation of tetracycline powder in Coe – Pak is generally recommended, particularly when long and traumatic surgeries are performed.
Preparation and Application of Periodontal Dressings
Zinc oxide packs are mixed with eugenol or non – eugenol liquids on a wax paper pad with a wooden tongue depressor. The powder is gradually incorporated with the liquid until a thick paste is formed. Coe-Pak is prepared by mixing equal lengths of paste from tubes containing the accelerator and the base until the resulting paste is of uniform color. The pack is thenplaced in a cup of water at room temperature, in 2-3 min the paste looses its tackiness and can be molded, and it remains workable for 15-20 min. The pack is then rolled
into two strips of approximately the length of the treated area. The end of one strip is bend into a hook shape and fitted around the distal surface of the last tooth, approaching it from the distal surface. The remainder of the strip is brought forward along the facial surface to
the midline. The second strip is applied from the lingual surface. It is joined to the pack at the distal surface of the last tooth, and then brought forward along the gingival margin to the midline. The strips are joined interproximally by applying gentle pressure on the facial and lingual surfaces of the pack (Fig. 15).

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Fig. 15: Periodontal pack placement


Do Nots
× Periodontal dressing should not extend onto uninvolved mucosa.
× Should not extend over occlusal surfaces of teeth.
× Should not interfere with occlusion.
Placement of Periodontal Dressings
Periodontal dressings are retained mechanically by interlocking in interdental spaces of teeth and joining the lingual and facial portions of the pack. In case of edentulous areas, the periodontal dressing is retained with the help of splints, hawley appliance and stents. In case of isolated teeth, tie dental floss or gauze loosely around the teeth and over which pack is applied.Periodontal dressing may entrap sutures beneath the dressing and may displace flap.
POSTOPERATIVE INSTRUCTIONS AND CARE
Appropriate postoperative instructions should be given both verbally and in written to the patient including an explanation concerning:
1. Discomfort and potential complications;
2. All medications, especially analgesics and antibiotics;
3. Diet modification
Instructions to the Patient after Surgery
Do’s
Take 2 tablets of acetaminophen every 6 hours on first day.
Chew on the nonoperated side
Take semisolid food
Apply ice, intermittently for alternating 20 minutes on and 20 minutes off, on the face over the operated side on the first day
Use chlorhexidine mouthwash
If the bleeding does not stop, take piece of gauge and form it into U-shape and hold it in thumb and index finger, apply it to both sides of the pack, and hold it there under pressure for 20 minutes
Swelling is usual in extensive surgical procedure. It subsides in 3 or 4 days. Apply moist heat if it persists
If any other problem arises do call the doctor.
Do Not’s
× Avoid hot food
× Do not smoke or take alcohol
× Avoid citrus, highly spicy food
× Do not brush over the pack
× Avoid exertion
× Do not try to stop bleeding by rinsing.
Postsurgical Care
Day 1: Analgesics, cold packs, moist gauze locally as needed, total avoidance of wound disturbance After day 1: Pain, swelling, bleeding should diminish or disappear. Begin light activity, warm packs as needed and chemical plaque control are recommended. After 5 to 10 days: Remove dressing and sutures after 7 days: Professionally de-plaque supragingivally. Begin light oral hygiene.
After 4 to 6 weekly: Biweekly visits for professional deplaqing and oral hygiene instructions. The dentogingival junction should not be probed or instrumented for 6 to 8 weeks following surgery. Soft toothbrush should be used gently for the first few postoperative weeks. The patient should follow Charter’s method avoiding vigorous toothbrushing.
POSTSURGICAL COMPLICATIONS
If postoperative complications occur, they should be managed by prompt and appropriate treatment, which may include control of bleeding, adequate analgesics or antibiotics.
Complications associated with periodontal surgery are:
• Hemorrhage
• Postoperative pain
• Infection
• Swelling
• Reaction to medications
• Other potential risks include root sensitivity, flap sloughing, root resorption or ankylosis, some loss of alveolar crest, flap perforation, abscess formation and irregular gingival contours.
Hemorrhage
Primary postoperative hemorrhage starts at the time of surgery. Intermediate hemorrhage starts soon after the surgery, after having stopped temporarily following surgery. It is usually due to the breakdown of an incomplete clot, such as is associated with loss of the vasoconstrictor effect of anesthesia. Secondary hemorrhage starts from 24 hours to 10 days postoperatively.
Steps to control postsurgical bleeding:
1. First step to control bleeding is to identify the source of bleeding. Suction is done carefully and local pressure with gauze sponges is applied.
2. Judicious injection of vasoconstrictor combined with continuous application of pressure encourages clot
formation.
3. Artificial clot may be induced by use of an oxidized cellulose microfibrillar collagen product.
4. Electrocoagulation can be effective for capillary bleeding sites and small arterioles.
5. Large arteriole bleeding sites can be controlled by placing sutures in the soft tissue. Knot is drawn tight to occlude vessel by compression from the surrounding tissue (Fig. 16).
6. If bleeding is from intraosseous site then it can be controlled by bone wax (beeswax and salicylic acid) which occlude bony canals.
7. Excessive bleeding from interproximal and infrabony lesions results from inadequate degranulation. Residual granulomatous tissue is a common source of hemorrhage, since it is composed largely of capillaries.

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Fig. 16: Diagram showing compression suture to control bleeding

 
The various topical hemostatic agents are
Agent Main constituent
Avitene Collagen
Collacote Collagen
Collatape Collagen
Collaplug Collagen
Thrombinar Thrombin
Thrombogen Thrombin
Thrombostat Thrombin
Gelfoam Gelatin
Beriplast Fibrin
Surgicel Cellulose


Postoperative Pain
The severity of postoperative pain varies depending on the patient threshold level, location, duration, extent of surgery and skill with which the soft and osseous tissue are handled during surgery. Postoperative pain and discomfort for the patient can be minimized by the surgical handling of the soft and osseous tissues atraumatically.
• The bone should be kept moist as dryness of bone induces severe pain. There should be complete soft tissu e coverage of the bone during suturing. Thus bone exposure should not be extensive.
• The periodontal dressing should not over extend beyond the mucogingival junction, or onto frenum and palate.
• Patient should be instructed to avoid chewing from the operated site.
• Two acetoaminophen tablets every 6 hours for the first 24 hours is prescribed for little pain or discomfort. But if pain persists then acetoaminophen plus codeine tablets can be prescribed.
• If the postoperative pain is related to infection which usually start after 4 days following surgery (localized
lymphadenopathy and fever), then it should be treated with systemic antibiotics along with analgesics.
Swelling
Swelling after surgery is best prevented by the use of ice packs. After swelling develops, hot moist packs and frequent lavage with warm saline solution are preferred.It generally subsides by the 4th postoperative day. If swelling persists and becomes worse, then amoxicillin
(500 mg) should be taken every 8 hours for 1 week. No all postoperative swelling is caused by inflammation; some may be caused by bleeding into tissues. This may occur after flap operations and are accompanied by discoloration under cheek, chin or eye.
WOUND HEALING
To ensure proper healing, atraumatic surgical principles should be followed including: (1) adequate anesthesia; (2) surface disinfection; (3) sharp instrumentation; (4) minimal, atraumatic tissue handling; (5) short operating time; (6) preventing unnecessary contamination; and (7) proper suturing and dressing, if indicated. Healing is a phase of the inflammatory response that leads to a new physiological and anatomical relationship among the disrupted body elements. Healing of periodontal tissue can be in the form of repair, new attachment and regeneration.

Healing rates of various periodontal tissues
Tissue type Healing rate (Approximately)
Junctional epithelium 5 days
Sulcular epithelium 7-10 days
Gingival surface epithelium 10-14 days
Connective tissue 21-28 days
Alveolar bone 4-6 weeks
Gingival wounds heal much more rapidly with much less scar formation when compared to skin. The reason for this reduced scar formation are:
a. Gingival fibroblasts unlike the fibroblasts of other connective tissue produce more MMP13 than MMP1. MMP13 has a broad substantivity and is capable of break down/turnover of a number of extracellular matrix proteins. MMP1 on the other hand has a biological activity that is restricted to collagen I. The greater presence of MMP13 in the wound area is thought to produce a greater turnover and thereby, prevent scar formation.
b. There is a greater presence of myofibroblasts in thegingiva when compared to skin. Fibroblasts can differentiate to form the more synthetic myofibroblasts under the influence of TGF-â. The presence of TGF-â in the wound area enhances the already greater presence of myofibroblasts thereby leading to lesser wound contraction and scarring.
LANDMARK STUDIES RELATED Lindhe J, Socransky SS, Nyman S, et al. Critical probing depths in periodontal therapy. Journal of Clinical Periodontology 1982;9:323-36.
They reported that scaling and root planing procedures induce loss of attachment if performed in pockets shallower than 2.9 mm, whereas gain of attachment occurs in deeper pockets. The modified Widman flap induces loss of attachment if done in pockets shallower than 4.2 mm but results in a greater gain of attachment than root planing in pockets deeper than 4.2 mm. The critical probing depth at which the
attachment level was unchanged after treatment was 2.9 mm for root planing and 4.2 mm for surgery. It was concluded that molars responded better to surgery than to root planing above 4.5 mm. Poor plaque control by patients in the maintena
POINTS TO PONDER
Causes of excessive bleeding during surgery include laceration of large blood vessels, incomplete removal of granulation tissue, hypertensive patient, bleeding disorder patient and patient on anticoagulant therapy.
If the surrounding tissue blanches, however, the suture is too tight, which may cause necrosis because of poor vascularization.
Hemostasis should be achieved before, and not by, the application of a dressing. The only clear indication for a dressing is to achieve tissue stasis, such as with a free mucosal graft, or to protect a clot over bone in the interdental denudation technique. Application of dressing is a matter of individual preference.
The possible outcomes of surgical periodontal therapy are: Regeneration, new attachment, long junctional epithelium, root resorption/ankylosis and recurrence of pocket.




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