#11 Principles of Periodontal Surgery Suturing .pdf

Principles of Periodontal Surgery Suturing Jafar Naghshbandi D.D.S; M.S, Ph.D Diplomate of American Board of Periodontology INDICATIONS OF PERIODONTAL SURGERY 1. Areas with irregular bony contours, deep craters and others requiring a surgical approach. 2. Deep pockets where complete remova...

Principles of Periodontal Surgery Suturing Jafar Naghshbandi D.D.S; M.S, Ph.D Diplomate of American Board of Periodontology INDICATIONS OF PERIODONTAL SURGERY 1. Areas with irregular bony contours, deep craters and others requiring a surgical approach. 2. Deep pockets where complete removal of root irritants is not possible, especially in inaccessible areas like molars and premolar areas. 3. In cases of Grade II and 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 and deep pockets. 6. Correction of mucogingival problems.  CONTRAINDICATIONS OF PERIODONTAL SURGERY It can be A. Oral B. systemic 1. In patients of advanced age where teeth may last for life without resorting to radical treatment Example: 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. CONTRAINDICATIONS OF PERIODONTAL SURGERY 3. Where thorough subgingival scaling and good home care will remove or control the lesion 4. Inadequate patient motivation 5. In the presence of infection 6. Poor prognosis GENERAL PRINCIPLES OF SURGERY a. Preparation of the patient b. The general conditions that are common to all periodontal surgical techniques an c. Complications that may occur during or after surgery.  PREPARATION OF THE PATIENT Completion of the initial or preparatory phase of therapy. (scaling + root planning and removal of contributing factors) because it: I. Eliminates some lesions completely. II. Helps to have the tissues more firm and consistent, thus facilitating more accurate and delicate surgery III. Familiarizes the patients with the office and with the operator and assistants, thereby reducing the patient’s apprehension and fear. PREPARATION OF THE PATIENT The re-evaluation phase consists of re-probing and re-examining all the findings that previously indicated the need for the surgical procedure. Informed consent should be taken from the patient after explaining the details of surgical procedures, both verbally and in writing.  General Conditions Common to All Procedures Premedication Prophylactic use of antibiotics has been advocated for both medically-compromised patients as well as patients undergoing bone-grafting procedures Emergency equipment should be readily available at all the times Following Infection Control protocol Ultrasonic scaling is contraindicated in patients with infectious diseases, as it generates aerosols and special care should be taken while Use of Pre-procedural mouth rinsing  General Conditions Common to All Procedures Anesthesia and Sedation Tissue Management 1. Operate gently and carefully 2. Observe the patient at all times 3. Be certain the instruments are sharp: Dull instruments will cause unnecessary trauma  Suturing The primary objective is to position and secure surgical flaps to promote optimal healing. When performed properly, healing by primary intention occurs. Performed intra- and extra-orally o Achieve functional and esthetic results o Decreasing the potential for postoperative infections occurance  Suturing Suturing materials are classified as: Non-absorbable or absorbable Non-absorbable Natural: example—braided-silk Synthetic: example—Dacron-coated and impregnated with Teflon. Absorbable Natural: example—Surgical gut Synthetic: example—Polyglycolic acid derivatives like vicryl.  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  Parts of surgical needles 1. Eye 2. Body: Widest point of the needle and is referred to as the “grasping area” 3. Point: or the tip can be conventional or reverse cutting  surgical needle A surgical needle has 3 parts: the needle point, the needle body, and the swaged (press-fit) end The most commonly used are the 3/8 and ½ circle needles. The common shapes: Round Less traumatic than the other two, requires more force Reverse cutting: The sharp TIP is DOWNWARD. More safe when working in delicate tissue Cutting Sharp TIP is UPWARD. Extra sharp tip in is more likely to tear the tissue  Knots and Knot typing Have three components: 1. The loop created by the knot 2. The knot itself 3. Ears—cut ends of the suture.  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.  Suturing Techniques Interrupted Suture a. Direct or loop suture b. Figure eight c. Horizontal mattress d. Vertical mattress e. Distal wedge or Anchor suture f. Periosteal suturing a. Direct or loop suture b. Figure eight c. Horizontal mattress d. Vertical mattress e. Distal wedge or Anchor suture f. Periosteal suturing  Continuous Suture a. Papillary sling b. Horizontal mattress c. Vertical mattress  Periodontal dressing Various commercially-available periodontal dressings are: a. Coe pak b. Kirkland periopak c. Peridres d. Periocare e. Periodontal pack f. Perioputty g. Zone periodontal pak. 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 2. Hemorrhage Treatment: Pressure pack, cotton pellet dipped in ferric subsulphate powder. Thrombin, hastens the process of blood clotting, oxidized cellulose and Gel foam are most commonly used to control the hemorrhage.  Complications during the First Postoperative Week 1. Persistent bleeding after surgery: The pack is removed, the bleeding points are located and the bleeding is stopped with pressure, sutures, electrosurgery or electrocautery. After the bleeding is stopped the pack is replaced.  Complications during the First Postoperative Week 2. Sensitivity to percussion may be due to extension of inflammation into periodontal ligament. Relieving the occlusion is usually helpful. Sensitivity to percussion may also be caused by excess pack which interferes with occlusion. Removal of excess should correct the condition.  Complications during the First Postoperative Week 3. Swelling: Within the first two postoperative days patient reports a soft, painless swelling of the cheek in the area of operation. There may be lymph node enlargement and temperature may be slightly elevated. This is due to localized inflammatory reaction to operative procedures. If the swelling persists with increased pain. Antibiotics like amoxicillin, 500 mg every 8 hours for 1 week should be prescribed  Complications during the First Postoperative Week 4. Postoperative pain: Common sources : a. Over-extension of pack beyond mucogingival junction. b. Extensive and excessively prolonged exposure and dryness of bone can also induce severe pain. c. 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  Complications during the First Postoperative Week 6. Sensitive Roots/Root hypersensitivity: May occur spontaneously when the root becomes exposed as a result of gingival recession or pocket formation or it may appear after scaling and root planing and surgical procedures because the cementum at cementoenamel junction is extremely thin and is removed during the above procedures.  Complications during the First Postoperative Week Mechanism: Transmission of stimuli from the surface of dentin to the nerve endings is located in the dental pulp, which may occur through the odontoblastic process or owing to a hydrodynamic mechanism. Example: by displacement of fluid. Treatment include, use of various desensitizing agents like, Strontium chloride, potassium nitrate and sodium citrate available in the form of pastes and can be used by the patient.  Be a lamp, or a lifeboat, or a ladder. Help someone's soul heal. Walk out of your house like a shepherd. Rumi