#10 principles.pdf

Principles of PERIODONTAL SURGERY ((Where art meets science )) Dr.Jafar NaghshbandiD.D.S ; M.S , Diplomate of the American Board of Periodontology Special Thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon ...

Principles of PERIODONTAL SURGERY ((Where art meets science )) Dr.Jafar NaghshbandiD.D.S ; M.S , Diplomate of the American Board of Periodontology Special Thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon  INDICATIONS OF PERIODONTAL SURGERY 1.Areas with irregular bony contours, deep craters & others requiring a surgical approach. 2.Deep pockets where complete removal of root irritants is not possible, especially in inaccessible areas like molars & premolar areas. 3.In cases of Grade II & III furcation involvement, where apart from removing local irritants,necessary root resection or hemisection can be considered. 4.Infrabony pockets in non-accessible areas which are not responsive to non surgical methods. 5.Persistent inflammation in areas with moderate & deep pockets. 6.Correction of mucogingival problems.  CONTRAINDICATIONS OF PERIODONTAL SURGERY These may be oral or systemic: 1.In patients of advanced age where teeth may last for life without resorting to radical treatment (Procedures indicated in a person of 60 years of age may not be justified in someone of 70 years of age). 2.Patients with systemic diseases such as cardiovascular disease, malignancy, liver diseases, blood disorders , uncontrolled-diabetes, consultation with the patient’s physician is essential. 3.Where thorough subgingival scaling and good home care will remove or control the lesion. 4.Where patient motivation is inadequate. 5.In the presence of infection. 6.Where the prognosis is so poor that tooth loss is inevitable. GENERAL PRINCIPLES OF SURGERY  Preparation of the patient.  The general conditions that are common to all periodontal surgical techniques.  Complications that may occur during or after surgery.  PREPARATION OF THE PATIENT: Initial or preparatory phase of therapy scaling + root planning and removal of etiotropic elements) because it: I. Eliminates some lesions completely. II.Renders the tissues more firm and consistent, thus facilitating more accurate and delicate surgery. III. Acquaints the patients with the office and with the operator and assistants, thereby reducing the patient’s apprehension and fear. The re-evaluation phase consists of re-probing & re-examining all the findings that previously indicated the need for the surgical procedure. Persistence of thesefindings will confirm the indication for surgery. The number and dates of the surgical procedures, the outcome and the postoperative care that is needed are all decided before hand. Informed consent should be taken from the patient after explaining the details of surgical procedures, both verbally and in writing. General Conditions that are Common to All Procedures  Premedication For health patients their use is not clearly demonstrated. The prophylactic use of antibiotics has been advocated for both medically- compromised patients as well as patients undergoing, dental Implant placement and bone-grafting procedures. Emergency equipment should be readily available at all the times.  Preventing transmission of infections : The use of disposable gloves, surgical masks and protective eye wear. All surfaces that may be contaminated with blood or saliva and cannot be sterilized, must be covered with aluminum foil/plastic wrap. Use of Ultrasonic scaling is contraindicated in patients with infectious diseases, as it generates aerosols and special care should be taken while using it (Pre- procedural mouth rinsing).  Sedation and Anesthesia: In order to prevent pain during the surgery, the entire area to be treated should be thoroughly anesthetized by means of a regional block and local infiltration. Patients who are apprehensive and neurotic may require special management with agents like sedatives and anti-anxiety drugs.  Tissue Management 1. Operate gently and carefully: In addition to being most considerate to the patient, tissue manipulation should be gentle because it produces excessive tissue injury; causes postoperative discomfort and delays healing. 2. Observe the patient at all times. 3. Be certain the instruments are sharp: Dull instruments will cause unnecessary trauma because of excess force usually applied to compensate for their ineffectiveness.  Suturing Goals of suturing: 1.Maintains hemostasis 2.Permits healing by primary intention 3.Reduces postoperative pain 4.Permits proper flap position 5.Prevents bone exposure resulting in delayed healing and unnecessary resorption. Suturing techniques and materials: One of the cardinal rules in suturing is to avoid placing excessive tension on the tissues being sutured to the extent of inducing blanching. Such tension will result in necrosis of sutured area and subsequent loss of suture entirely. Various commercially-available periodontal dressings are: Coe pak Kirkland periopak Peridres Periocare Periodontal pack Perioputty Zone periodontal pak Types of Packs Zinc oxide eugenol packs. Non-eugenol packs. Eugenol may produce allergic reaction that may render the area erythematous combined with a burning sensation in some patients. Advantages of Periodontal Packs/Dressings are: 1. It minimizes the likelihood of postoperative infection and hemorrhage. 2. Facilitates healing by preventing surface trauma during mastication. 3. Protects against pain induced by contact of the wound with food or with tongue during mastication.  Coe pak (Non-eugenol) is prepared by mixing equal lengths of pastes, i.e. accelerator and base until it has a uniform color.  The paste is then placed in a cup of water at room temperature for 2 to 3minutes, when the pack loses its tackiness, it is ready to be placed on the surgical site.  The pack is then rolled into two strips approximately to the length of the treated area and placed on buccal surface from mesial-distal end and the remainder can be placed the same way on the lingual/palatal surfaces.  The strips are joined at the distal end by hooking it around the distal most tooth as well as interproximally by applying gentle pressure (with the help of a probe) to join facial and lingual surfaces of the pack. Any overextension onto uninvolved area should be avoided. It is usually kept on for 1 week after surgery.  If gingivectomy has been performed, the cut surface is covered with a meshwork of new epithelium. If calculus has not been removed completely, red bead- like protuberances of granulation tissue will persist,which should be removed with a curette.  After a flap operation, the incision areas are epithelialized but may bleed readily when probed, hence pockets should not be probed.  The facial and lingual mucosa may be covered with a grayish-yellow or white granular layer of food debris that has seeped under the pack and can be easily removed with a moist cotton pellet.  Instructions for the Patient after Surgery 1.Patients should take the advised medication. 2.The pack should remain in place until it is removed after one-week. 3.For the first three hours after the operation, avoid hot foods to permit the pack to harden, try to chew on the non-operated side of the mouth. Avoid citrus juices and spiced-food because it causes pain and burning. 4.Do not smoke. 5.Do not brush over the pack. 6.During the first day apply ice. 7.Follow your daily activities but avoid excessive exertion of any type. 8.Swelling is not unusual. COMPLICATIONS DURING SURGERY 1. Syncope or transient loss of consciousness owing to a reduction in cerebral blood flow. The most common cause is fear and anxiety. It is usually preceded by a feeling of weakness which is followed by pallor, sweating, coldness of the extremities, dizziness and slowing of the pulse. Management: Patient should be placed in a supine position with legs elevated, tight clothes should be loosened and an open airway ensured, administration of oxygen is also useful. History of previous syncopal attacks during dental appointments should be explored before treatment is begun. 2. Hemorrhage: Periodontal surgery produces profuse bleeding in its initial incisional steps. However, after the granulation tissue is removed, bleeding will disappear or reduce considerably. Excessive hemorrhage after the initial steps may be due to lacerated capillaries and arterioles or damage to larger vessels due to surgical invasion of anatomic areas. Treatment: Pressure pack, cotton pellet dipped in ferric subsulphate powder. Thrombin, hastens the process of blood clotting, oxidized cellulose and Gelfoam are most commonly used to control the hemorrhage. 1. Persistent bleeding after surgery 2. Sensitivity to percussion may be due to extension of inflammation into periodontal ligament. 3. Swelling 4. Feeling of weakness: Patients may experience a “washed out”, weakened feeling for about 24 hours after the surgery. This represents a systemic reaction to a transient bacteremia-induced by operative procedure. It can be prevented by prescribing prophylactic antibiotics. 5. Sensitive Roots/Root hypersensitivity 6.Postoperative pain Common sources of postoperative pain are: a. Over-extension of pack beyond mucogingival junction. b. Extensive and excessively prolonged exposure and dryness of bone can also induce severe pain. When severe postoperative pain is present, the patient should be treated on an emergency basis. The wound should be examined (under local anesthesia). This type of pain is related to infection accompanied by localized lymphadenopathy and a slight elevation in temperature. Treatment: Antibiotics and analgesics should be prescribed.  Usually, periodontal surgery is performed in dental clinics,either sextant or quadrant wise at weekly or longer intervals. Under certain circumstances, the full mouth periodontal surgery may have to be done in a hospital operating room under general anesthesia The purpose of hospitalization is to protect patients by anticipating their special needs, but not to perform surgery when it is contraindicated by the patient’s general condition.  Indications for hospital surgery include: To control and manage the apprehensive patient. Convenience for individuals who cannot endure multiple visits to complete surgical treatment. Patient protection—some patients who are suffering from systemic conditions that are not severe enough to contraindicate surgery but at the same time require special precautions that best provided in a hospital setting. Example: patients with cardiovascular disease, abnormal bleeding tendencies, prolonged steroid therapy and others.