General Principles Of Periodontal Surgery Question And Answers

Principles Of Periodontal Surgery

Question 1. Write short note on periodontal dressings.
Or
Write short answer on periodontal pack.
Answer. In most cases after the surgical periodontal procedures are completed the area is covered with a surgical pack which is known as periodontal pack or periodontal dressing.

The dressing has no curative properties, they assist the healing by protecting the tissue rather than providing healing factors.

Advantages of Periodontal Dressings

• It minimizes likelihood of postoperative infection and bleeding.
• It facilitates healing by preventing surface trauma during mastication.
• It protect against pain induced by contact of wound with food or with tongue during mastication.

Types of Packs

• Zinc oxide eugenol packs
• Non-eugenol packs

Read And Learn More: Periodontics Question And Answers

Zinc Oxide Eugenol Packs

• Example is Wonder-pack.
• Supplied in liquid and water form which is mixed before use.
• These packs are based on reaction of zinc oxide and eugenol
• Apart from zinc oxide, they also consists of zinc acetate which act as accelerator; asbestos which act as binder and filler and Tannic acid.
• Addition of zinc acetate provides the dressing a better working time.
• In some of the patients eugenol produces allergic reaction which leads to erythematous area combine by burning sensation.

Non-eugenol Packs

• Example is Coe-pack
• It is based on the reaction between metallic oxide and fatty acid.
• It is supplied in two tubes, contents of which get mixed immediately before use till uniform color is obtained.
• One tube contains zinc oxide, oil for plasticity, a gum for cohesiveness and lorothidol as fungicide.
• Other tube contains liquid coconut fatty acid thickened \with resin and chlorothymol—a bacteriostatic agent.
• Other non-eugenol packets consists of boric acid, a light curing dressing, cyanoacrylates and tissue conditioner.
• Fracture strength is good compared to eugenol packs.

Preparation and Application of Periodontal Pack

• 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 till a thick paste is formed.
• Coe-pack is prepared by mixing equal length of paste from tubes containing the accelerator and the base until the resulting paste is of uniform color.
• The pack is then placed in a cup of water at room temperature for 2–3 minutes so that the paste loses its tackiness and can be molded. It remains workable for 15–20 minutes.
• 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 and gently pressed into place along the gingival margin and inter-proximally.
• 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 inter-proximally by applying gentle pressure on the facial and lingual surfaces of the pack. For isolated teeth separated by edentulous spaces, the pack should be made continuous from tooth-to-tooth covering the edentulous areas.
• When split flaps have been performed, the area should be covered with the tin foil to protect the sutures before placing the pack.
• Pack should cover gingiva but overextension in an uninvolved mucosa is avoided. Excess pack irritates the mucobuccal fold as well as floor of the mouth and interferes with the tongue.
• Overextension jeopardizes remainder of pack because the excess tends to break-off, taking pack from the operated area with it. Pack which interferes with occlusion is trimmed before relieving the patient.
• Clinician should ask the patient to move the tongue out forcibly to each side and cheek and lips should displace in all the directions to mold the pack while it is still soft. As pack is set, it is trimmed to eliminate all the excess material.
• As per the general rule, pack is kept for 1 week after surgery. But this is not the rigid requirement. The time can be extended or area is repacked for additional one week.

Instructions for the Patient when Periodontal Pack is Placed After Surgery

• Pack should remain in place till it is removed in office in next appointment.
• Hot foods are avoided for first three hours after operation to permit pack to harden.
• Avoid smoking and brushing over the pack.
• During first day ice is applied on the face over the operated area which decreases the inflammation and swelling.
• Carry on the daily activities but without exertion.

Removal of Pack and Return Visit

• As patient returns after the one week, periodontal pack should be taken off by inserting a surgical hoe along the margin and exerting gentle lateral pressure.
• Scalers should be used to remove the pieces of pack retained interproximally and particles adhering to the tooth surfaces. Complete area should be rinsed with peroxide to remove the debris.

Question 2. Write short note on different types of sutures.
Answer.

• Simple loop/direct loop suture: It should be performed when bone grafts are used or when close apposition of the scalloped incision is required. It is used to approximate buccal and lingual flaps.
• Figure of eight suture: It is simpler to perform. It is used when the flaps are not in close apposition because of apical flap position or non-scalloped incisions.
• Sling suture: It can be interrupted or continuous. It is used to adapt the flap around the tooth.
• Vertical mattress suture: This suture enters the flap at or near the mucogingival junction and exits flap through the interdental papilla. In this way, much more of the suture lies on top of the flap and it is able to hold the full extent of the flap in close contact with the underlying bone or periosteum. Flaps that involve dissection beyond the mucogingival junction require the use of mattress sutures.
• Criss-cross suture: It is used to close a wound over an edentulous saddle area and is particularly helpful in mucogingival surgery where root coverage is desired. Here the mattress suture is placed horizontally, not vertically.
• Horizontal mattress suture: It is used for the inter-proximal areas of diastema or for wide interdental spaces to adapt interproximal papilla properly against bone.
• Anchor suture: It is used to close the flap mesial or distal to a tooth.
• Periosteal suture: It is of two types: Holding suture and closing suture. The holding suture is a horizontal mattress suture placed at the base of the displaced flap to secure it into new position. Closing sutures are used to secure the flap edges to the periosteum. It is used to hold in place apically displaced partial-thickness flaps.

Question 3. Describe general principles of periodontal therapy. Write in detail about Phase 1 and Phase 2 therapy.
Answer. General principles of periodontal surgery include:

• Preparation of the patient.
• The general conditions that is common to all periodontal surgical techniques.
• Complications that may occur during or after surgery.

Preparation of the Patient

• Every patient has to undergo the preparatory phase of therapy, which consists of scaling as well as root planning and removal of etiotropic elements because it:
  • Completely eliminates some of the lesions.
  • Renders the tissues more firm and consistent, facilitating more accurate and delicate surgery.
  • Reduces the patient’s apprehension and fear by developing acquaintance of the patients with the office and with the operator and assistants.
• Re-evaluation phase consists of reprobing and reexamining all the findings that previously indicated the need for the surgical procedure.
• Persistence of these findings will confirm the indication for surgery. All the surgical procedures, the outcome and the postoperative care that is needed are decided before.
• After explaining the details of surgical procedures, both verbally and in writing, an informed consent should be taken from the patient.

General Conditions Which are Common to all Periodontal Surgical Procedures

Premedication

• Prophylactic use of antibiotics has been advised for both medically compromised patients as well as patients undergoing bone-grafting procedures.
• Emergency equipment should be readily available at all the times.
• All the measures should be taken to prevent the transmission of infections by following strict sterilization and asepsis, e.g. the use of disposable gloves, surgical masks and protective eye wear.

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 such as sedatives and antianxiety drugs.

Tissue Management

• Operate gently and carefully; tissue manipulation should be gentle because it plays an important role in postoperative healing. Excessive tissue injury causes postoperative discomfort and delays healing.
• Observe the patient at all times.
• All the instruments should be sharp. Dull instruments will cause unnecessary trauma because of excess force usually applied to compensate for their ineffectiveness.

Suturing

Goals of suturing are:

• Suturing permits healing by primary intention, reduces postoperative pain and maintains hemostasis.
• Suturing materials are classified as either non – absorbable or absorbable.

Examples of non-absorbable suture material are:

Natural: Braided silk

Synthetic: Dacron-coated and impregnated with teflon.

Examples of absorbable suture material are:

Natural: Surgical gut.

Synthetic: Polyglycolic acid derivatives like vicryl.

Periodontal Dressing

• Various commercially available periodontal dressings are Coe-pak, Kirkland periopak, peridres, periocare, perioputty.
• Advantages of periodontal packs/ dressings are:
  • It minimizes the likelihood of postoperative infection and hemorrhage.
  • Facilitates healing by preventing surface trauma during mastication.
  • Protects against pain induced by contact of the wound with food or with tongue during mastication.
• Types of packs:
  • Zinc oxide eugenol packs
  • Non-eugenol packs.

Zinc Oxide Eugenol Packs

• Example is Wonder-pack.
• Supplied in liquid and water form which is mixed before use.
• These packs are based on reaction of zinc oxide and eugenol
• Apart from zinc oxide, they also consists of zinc acetate which acts as accelerator; asbestos which act as binder and filler and Tannic acid.
• Addition of zinc acetate provides the dressing a better working time.
• In some of the patients eugenol produces allergic reaction which leads to erythematous area combine by burning sensation.

Non-eugenol Packs

• Example is Coe-pak
• It is based on the reaction between metallic oxide and fatty acid.
• It is supplied in two tubes, contents of which get mixed immediately before use till uniform color is obtained.
• One tube contains zinc oxide, oil for plasticity, a gum for cohesiveness and lorothidol as fungicide.
• Other tube contains liquid coconut fatty acid thickened with resin and chlorothymol-a bacteriostatic agent.
• Other non-eugenol packets consists of boric acid, a light curing dressing, cyanoacrylates and tissue conditioner.
• Fracture strength is good compared to eugenol packs.

Instructions for the Patient after Periodontal Surgery

• Patients should be advised to take medication.
• If any periodontal pack is placed, it should remain in place until it is removed after 1 week.
• Application of cold packs following surgery only on first day.
• Following periodontal surgery, patient should be instructed to avoid:
  • Hot foods to permit the pack to harden
  • Chewing on the operated side of the mouth
  • Citrus juices and spiced food because they will cause pain and burning sensation.
  • Avoid smoking and brushing over the pack.
• Swelling is not unusual and if bleeding continues, ask patient to report to the doctor immediately.

Complications During Surgery

Syncope

• Syncope or transient loss of consciousness owing to reduction in cerebral blood flow.
• 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 weak pulse.
• Patient should be placed in a supine position with legs elevated. Tight clothes should be loosened and an open airway should be ensured. Administration of oxygen is also useful.

Hemorrhage

• Periodontal surgery produces profuse bleeding in its initial incisional steps until the granulation tissue is removed. Later, 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 is pressure pack, cotton-pellet dipped in ferric sulphate powder. Thrombin that 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

Persistent Bleeding After Surgery

• The pack is removed, the bleeding points are located and the bleeding is stopped with pressure, sutures, electrosurgery or electrocautery.
• The pack is replaced after the bleeding is stopped.

Sensitivity to Percussion

• It may be due to extension of inflammation into periodontal ligament.
• The pack should be removed and the gingiva should be checked for localized areas of infection or irritation.
• Any overlooked particles of calculus should be removed.
• Sensitivity to percussion may also be caused by excess pack which interferes with occlusion. Relieving the occlusion is usually helpful.
• Gradual diminution of severity of sensitivity is a favorable sign.

Swelling

• Patient reports a soft, painless swelling of the cheek in the area of operation within the first two postoperative days.
• There may be lymph node enlargement, and temperature may be slightly elevated due to localized inflammatory reaction to operative procedures.
• If the swelling persists and associated with increased pain, the patient should be prescribed antibiotics like amoxicillin (500 mg) every 8 hours for 1 week.

Generalized Weakness

• Patients may experience a weakened feeling for about 24 hours after the surgery due to a systemic reaction to a transient bacteraemia induced by operative procedure.
• It can be prevented by prescribing prophylactic antibiotics.

Postoperative Pain

• Periodontal surgery performed following basic principles should produce only minor pain and discomfort.
• A study revealed that mucogingival procedures result in maximum discomfort followed by osseous surgery than any other plastic gingival surgeries.
• When severe postoperative pain is present, the patient should be treated on an emergency basis. This type of pain is related to infection accompanied by localized lymphadenopathy and a slight elevation in temperature hence antibiotics and analgesics should be prescribed.

Sensitive Roots/Root Hypersensitivity

• It may occur spontaneously when the root becomes exposed as a result of gingival recession or pocket formation or following scaling and root planning or surgical procedures because the cementum at cementoenamel junction is extremely thin and is removed during the above procedures.
• Treatment is application of agents used by the patient, i.e. various desensitizing agents such as strontium chloride, potassium nitrate and sodium citrate available in the form of pastes.
• In the dental office, cavity varnishes, anti-inflammatory agents and various agents which partially obturate dentinal tubules such as silver nitrate, zinc chloride, formalin, calcium compounds, sodium fluoride, stannous fluoride, etc. are used.
• Other procedures such as iontophoresis, restorative resins and dentine-bonding agents have been used.

Management

Phase 1 Therapy

Phase 1 therapy is also known as non-surgical periodontal therapy, initial therapy, cause, related therapy and etiotropic phase of therapy.

• It is the first step in chronologic sequence of procedures which constitute periodontal treatment.
• Objective of Phase 1 therapy is to alter or eliminate the microbial etiology and contributing factors for gingival and periodontal diseases.
• Following are the therapies which are needed to control or eliminate the local contributing factors:
  • Complete removal of calculus
  • Correction or replacement of poorly fitting restorations and prosthetic devices
  • Restoration of carious lesions
  • Orthodontic tooth movement
  • Treatment of food impaction areas
  • Treatment of occlusal trauma
  • Extraction of hopeless teeth.
• Following conditions must also be considered to plan the Phase 1 treatment sessions needed:
  • General health and tolerance of treatment
  • Number of teeth present
  • Amount of subgingival calculus
  • Probing pocket depths and attachment loss
  • Furcation involvements
  • Alignment of teeth
  • Margins of restorations
  • Developmental anomalies
  • Physical barriers to access (i.e. limited opening or tendency to gag)
  • Patient cooperation and sensitivity.

Dentist should estimate the number of appointments needed on the basis of the conditions presented by each patient. Consideration should be given to the control of infectious organisms during period of active Phase 1 treatment.

Sequence of Procedures in Phase 1 Therapy

Step 1: Limited plaque control instruction

• This step should start in the first treatment appointment and should include only the correct use of the toothbrush on all smooth and regular surfaces of the teeth.
• The use of dental floss should follow the removal of calculus and the overhanging restorations.

Step 2: Supragingival removal of calculus

This step should be carried out with scalers, curettes or ultrasonic instrumentation.

Step 3: Recontouring defective restorations and crowns

• This step may require replacing the complete restoration or crown or correcting it with finishing burs as well as diamond-coated files mounted on a special handpiece.
• For overhangs which are located subgingivally, it may be require to reflect a miniflap to facilitate access.

Step 4: Obturation of carious lesions

• This involves complete removal of the carious tissue and placement of a final or a temporary restoration.
• Caries control as well as treatment of active carious lesions are often overlooked aspects of Phase I therapy.
• Caries is now recognized as infection. Frank carious lesions, particularly class V lesions in the cervical areas of teeth and those on root surfaces, provide a reservoir for bacteria and can contribute to the repopulation of the periodontal plaque.
• Cavities are the receptacles where plaque is sheltered from even the most energetic mechanical plaque removal attempts.
• For these reasons, it is imperative that caries control and at least temporization of carious lesions be completed during Phase 1 therapy.

Step 5: Comprehensive plaque control instruction

At this step, the patient should learn to remove plaque completely from all supragingival areas, using toothbrush, dental floss and any other necessary complementary method.

Step 6: Subgingival root treatment

At this step, complete calculus removal and root planning can be effectively performed and constitute the final step in achieving smooth and regular contours on all tooth surfaces.

Step 7: Tissue Re-evaluation

• Periodontal tissues are re-examined to determine the need for further therapy. Pockets are reprobed, and all related anatomical conditions are carefully evaluated to decide whether surgical treatment is indicated.
• Additional improvement through surgery can be expected only if Phase 1 therapy has been successful.
• Surgical treatment of periodontal pockets should be attempted only when the patient is doing effective plaque control and the gingiva is free from overt inflammation.

Results of Phase 1 Therapy

Periodontal cases should be re-evaluated 4 weeks after completion of scaling and root planning. This permits time for both epithelial and connective tissue healing and allow the patient sufficient practice with oral hygiene skills to achieve maximum improvement.

Phase 2 Therapy

Phase 2 therapy is also known as surgical therapy.

• Phase 2 therapy serves the following purposes, i.e.
  • Controlling or eliminating the periodontal disease
  • Correcting the anatomic conditions which may favor the periodontal disease, impair esthetics and impede placement of correct prosthetic appliances.
  • Placing the implants to replace lost teeth and improving the environment for their placement and function.
• Phase 2 therapy has two main objectives, i.e.
  • Improvement of prognosis of teeth and their replacements
  • Improvement of aesthetics
• Phase 2 therapy consists of techniques which are performed for the pocket therapy and for correction of related morphological problems such as mucogingival defects. In many of the cases, procedures are combined so that one surgical intervention fulfills both the objectives.
• Removal of pockets by Phase II therapy eliminates the pocket, which establishes an environment conducive to progression of periodontal disease. It also increases the accessibility for scaling the root surfaces and for self performed tooth cleaning after therapy.