Periodontal Surgery

Perry chapter 13 and Nield-Gehrig chapter 21

Historical Perspective

• Originally, surgery was for removing damaged tissues that were thought to be diseased

Belief Today

• Modern belief is that surgery is part of an integral part of most aspects of dental care

• As severity of periodontitis increases, controlling the disease becomes more difficult

• Need for periodontal surgery as part of comprehensive patient care becomes more likely

• Used to support other aspects of care

Surgery as Supportive Care

• Enhancing restorative procedures

• Improving patient appearance• Preparing a patient for

implant-supported prosthesis

Indications

• Surgery is necessary when the periodontium is unhealthy and cannot be repaired with nonsurgical treatment

Indications

• Provide access for improved root surface debridement

• Reduce pocket depths• Provide access for treatment of

periodontal osseous defects• Resect or remove tissues

Indications

• Regenerate periodontium lost because of disease

• Graft bone or bone-stimulating materials into osseous defects

• Improve appearance of the periodontium

• Enhance prosthetic dental care• Allow for placement of a dental implant

Provide Access for Improved Instrumentation of Root Surfaces

• The deeper the probe depth, the more difficult it is to instrument root surfaces

Reduce Pocket Depth

• Pocket depth can be too deep for adequate daily self-care

• Plaque thrives in the deeper pockets• Surgery reduces pocket depths,

making it easier for patients to maintain

Provide Access to Osseous Defects

• Osseous defect is a deformity in alveolar bone

• As disease advances, bone loss can change the shape of alveolar bone

• Surgery can modify the bone level or shape

Resect or Remove Tissue

• Enlarged gingival tissues are unsightly and can inhibit good oral hygiene

• Surgery can remove and reshape enlarged gingiva

Regenerate Periodontium Lost Because of Disease

• Regenerate implies growing back lost cementum, periodontal ligament, and alveolar bone

• Lost bone and tissue can be regenerated through sophisticated periodontal surgical techniques

Graft Bone Into Osseous Defects

• Bone or bone-stimulating materials can be grafted into osseous defects

• Grafting bone does not imply regeneration

Improve Appearance of Periodontium• Some gingival levels or contours

result in an unattractive smile• Surgery can improve the

appearance of gingiva

Enhance Prosthetic Dental Care

• Altering alveolar ridge contours• Crown lengthening• Augmenting amount of gingiva

present• Enhancing restorative dentistry• Many types of surgery are involved

Allow for Placement of Dental Implant• Surgery prepares the site for the

implant• Implant must be surrounded by sound

alveolar bone• Edentulous sites are often deficient in

bone• Some bone augmentation may be

necessary before placement of implant

“Relative” Contraindications• Most contraindications for periodontal

surgery are relative, meaning each patient is different from all others:– Systemic diseases or conditions– Totally noncompliant with home care– High risk for dental caries– Unrealistic expectations for surgical

outcomes

Systemic Diseases and Conditions

• Recent history of heart attack• Uncontrolled hypertension• Uncontrolled diabetes• Certain bleeding disorders• Kidney dialysis• History of radiation to the jaws• HIV infection

Totally Noncompliant with Self-Care• Outcomes of many types of surgery

depend on the level of patient’s efforts with plaque control

• Poor self-care can cause an unacceptable periodontal surgical outcome

High Risk for Dental Caries

• Periodontal surgery can expose portions of tooth roots

• Patients at risk for dental caries can be devastated with rampant root caries

Unrealistic Expectations for Surgical Outcomes

• Surgical correction of damage to diseased tissues does not always result in a perfectly restored periodontium

• Patients have to develop realistic expectations for surgical outcomes

Terms

• Four terms used to describe healing of periodontium after surgery:

1. Repair2. Reattachment3. New attachment4. Regeneration

Healing by Repair

• Healing of a wound by formation of tissue that does not truly restore the original architecture or original function of the body part

Healing by Repair

• Example of repair is a scar• Healing is complete, but the tissue is not

completely the same in appearance or function

• Example of repaired periodontium is healing that takes place after instrumentation

• Results in a long junctional epithelium

Healing by Reattachment

• Reattachment is reunion of connective tissue and root that was separated by incision or injury, not disease

• Moving healthy tissue on a tooth may be necessary to access damaged tissue on an adjacent tooth

• The healing from this type of incision is reattachment

Healing by New Attachment• New attachment describes union of

pathologically exposed root with connective tissue or epithelium

• Occurs when epithelium and connective tissues are newly attached to root where periodontitis previously destroyed the attachment

New Attachment vs. Reattachment

• New attachment must occur in an area formerly damaged by disease

• Reattachment occurs when tissues are separated in the absence of disease

Healing by Regeneration

• Regeneration is a biologic process by which architecture and function of lost tissue are completely restored

• Tissues look exactly the same as before

• Reforming of lost cementum, periodontal ligament, alveolar bone

Section 3

Overview of Common Types of Periodontal

Surgery

Chapter 21: Periodontal Surgical Concepts for the

Dental Hygienist

Historical Perspectives

• Surgery was recommended mainly to remove what was thought to be dead or infected tissue in the periodontium

• Early procedures were mainly resective

Modern Periodontal Surgical Techniques• Resective surgery has limited use • Resective surgery is no longer

recommended as part of modern periodontal therapy

• Refinement of goals and techniques for periodontal surgery has taken place

• Emphasis has shifted from resective surgery to surgical procedures that attempt to regenerate lost periodontal tissues

Types of Surgery

• Periodontal flap• Bone replacement

graft• Guided tissue

regeneration• Apically positioned

flap with osseous surgery

• Mucogingival plastic surgery

• Crown lengthening

• Dental implant placement

• Gingivectomy• Gingival curettage

Periodontal Flap

• Incisions are made in gingiva around necks of teeth

• Underlying soft tissues are elevated from tooth roots and bone

Indications for Periodontal Flap Surgery• Most periodontal surgical procedures

require a flap• Performed to provide access for

treatment of tooth roots or bone• Flap can be elevated for periodontal

instrumentation• Flap can be elevated to access bone to

reshape or fill defects

Description of Procedure

• Also called modified Widman flap surgery

• Provides access to tooth roots for improved root preparation

• Tissue is lifted long enough for procedure

• After completion of procedure, tissue is replaced at original position

• Sutured in place

Healing After Flap Surgery

• Healing by repair• Involves formation of long junctional

epithelium• Can be maintained by patient and

professional care

Special Considerations for the Dental Hygienist• Pocket depths deeper than 5 to 7 mm • Flap for access surgery allows more

efficient instrumentation of root surfaces

Description of Procedure

• Surgery used to encourage the body to rebuild alveolar bone lost from periodontal disease

• Involves:– Elevation of a flap– Cleaning granulation tissue from bone– Treating roots as needed– Placement of grafting material into defect

Materials Used for Bone Replacement• Harvested bone taken from the

patient’s jaw• Treated bone from cadavers and

other species• Artificial material that stimulates

bone regrowth

Materials Used for Bone Grafts

Synthetic bone materialAlloplast

Treated cow boneXenograft

Taken from a cadaverAllograft

Taken from patient’s body; jawAutograft

Healing After Bone Grafting

• Partial or complete rebuilding of alveolar bone

• Reformed bone may not actually be attached to cementum by periodontal ligament fibers

Special Considerations for the Dental Hygienist

• Site of bone graft should not be disturbed for many months

• Do not probe until appropriate interval has lapsed

• Meticulous plaque control is critical to maintain health in the area

Description of Procedure

• Surgical procedure that attempts to regenerate lost periodontal structures

• Widespread use

Description of Procedure

• Involves:– Elevation of flap– Cleaning alveolar bone defects– Treatment of roots– Placement of barrier materials to control

rapid growth of epithelium into wound

• Barrier materials require removal, necessitating a second surgery

Healing After Guided Tissue Regeneration• Connective tissue components from the

periodontal ligament space provide the cells needed to regrow cementum, periodontal ligament, and alveolar bone

• Barrier materials prevent epithelial tissue from covering the tooth root too soon

Special Considerations for the Dental Hygienist• Effort is made during surgery to

close the wound to cover barrier material

• During postsurgical visit, if part of barrier is exposed, minimize bacterial contamination

• May suggest topical antimicrobial• Do not probe site for several months

Description of Procedure

• Designed to eliminate or minimize pocket depths

• Involves:– Elevation of flap– Removal of granulation tissue– Treatment of roots– Correction of bone contours to mimic

healthy alveolar bone

Description of Procedure

• Flap is sutured in a more apical position to its original level

• Ideal for minimizing pocket depth in patients with moderate periodontal disease

Healing of an Apically Positioned Flap• Results in a stable dentinogingival

junction• Outcome depends on meticulous home

care by the patient combined with professional maintenance visits

• Final healing results in normal attachment at a more apical position on the root

Special Considerations for the Dental Hygienist• Surgery results in more root

exposure in the oral cavity• Patient may experience temporary

root sensitivity

Description of Surgery

• Also called periodontal plastic surgery• Designed to alter components of

attached gingiva• Restores gingiva to tooth surface as a

result of disease or trauma• Removes frenum to deepen vestibule• May alter the appearance of the tissue

Types of Surgery

• Soft tissue graft – Covering roots because of excessive recession

• Connective tissue graft– Harvesting donor connective tissue (palate)

• Free gingival graft– Harvesting donor tissue that includes both

surface epithelium and underlying connective tissue

Healing After Mucogingival Surgical Procedures

• Harvesting from a donor site creates two wounds that have to heal

• Expected new attachment of grafting material to the tooth root

Special Considerations for the Dental Hygienist• Donor site on palate can actually bother

the patient more than wound at site• Discuss postsurgical discomfort with the

patient• Do not disturb grafted sites during early

stages of healing• Encourage patient to maintain good plaque

control

Description of Procedure

• Designed to create longer clinical crown

• Gingiva is removed from the tooth• Alveolar bone is removed from necks

of teeth• Performed for aesthetics, restorative

dental procedures

Description of Procedure

• Involves:– Elevating a flap– Recontouring of the bone– Suturing tissue back in place

Healing After Crown Lengthening Surgery• Similar to apically positioned flap

with osseous surgery• Results in a normal attachment at a

position more apical on root

Special Considerations for the Dental Hygienist• Patient may experience some temporary

dentinal hypersensitivity• Institute measures to deal with sensitivity• Encourage patient to maintain meticulous

oral hygiene, especially during healing phase• May be difficult because mechanical plaque

control must be restricted after surgery

Description of Procedure

• Artificial tooth root placed into alveolar bone to hold a replacement tooth

• Requires exposure of alveolar bone using flap surgery

• A precise hole is drilled into bone and metallic implant is inserted

• Some implants are covered by gingiva during healing

Healing

• Bone growth is in close proximity to implant surface

• Implant must be stable enough to support a tooth or dental prosthetic appliance

• Implants are not surrounded by cementum and ligaments

Special Considerations for the Dental Hygienist• Patient self-care is critical• After the implant site heals, gingiva

can be maintained as usual

Description of Procedure

• Surgery designed to remove gingival tissue

Indications for Gingivectomy• Use is limited to removing enlarged

gingiva to improve esthetics or allow for better access during home care

Disadvantages

• Leaves large open connective tissue wound

• Slower surface healing than other surgeries

• More discomfort for patient during healing

• Teeth appear longer

Healing After Gingivectomy

• Normal attachment of the soft tissues to the tooth root

• Attachment is more apical in position than original level

• Teeth appear longer

Special Considerations for the Dental Hygienist• Healing phase can be very uncomfortable

for patient• Can be managed with a periodontal

dressing over the wound• Prescribe analgesics• Dressing may need to be changed at

several postsurgical visits until total epithelization has occurred

Description of Procedure

• Involves an attempt to scrape away lining of the periodontal pocket with a curette

• Benefits of this procedure are the same as periodontal instrumentation and meticulous plaque control

• No longer a recommended procedure

Section 4Management of the Patient

Following Periodontal Surgery

Chapter 21: Periodontal Surgical Concepts for the

Dental Hygienist

Purpose of Sutures

• Sutures stabilize the position of the soft tissues during early phases of healing

• A suture is a stitch taken to repair an incision, tear, or wound

Material Used

• Nonresorbable– Does not dissolve in body fluids and

must be removed by a clinician

• Resorbable– Dissolves slowly in body fluids and does

not need to be removed

Suture Removal

• Nonresorbable sutures placed during surgical procedures are removed as part of routine postsurgical visits

• Remnants of resorbable sutures are removed to avoid inflammation

• Sutures should be removed when they are loose in the tissues

Suture Removal

• Sutures are usually loose in the tissue 1 week after surgery

• Sutures should not be left in place longer than 2 weeks

• They become irritants if left in the tissue too long

Suture Removal Guidelines

• Count the number of sutures placed and enter it in the treatment notes

• Assures the correct number is removed

• Write suture size in treatment notes:– 3-0, 4-0, 5-0

• 3-0 is largest; 5-0 smallest

Suture Removal Guidelines

• Sutures are removed by cutting material near the knot and grasping the knot with pliers

• Gently pull through the tissue• Usually not painful for the

patient

Surgical Wound Dressing

• Periodontal surgical wound dressing• Material from two tubes is mixed

together for a putty-like consistency• Light-cured gel• Does not stick to the tissue• Is retained by pressing firmly

interdentally

Surgical Wound Dressing

• Use the least amount possible• Just enough to cover the wound• Should be no dressing on occlusals• Take care not to trap sutures in

dressing

Postsurgical Instructions

• Supplying the patient with both verbal and written instructions minimizes confusion

• Restrict mechanical plaque removal• Encourage patient to take medications

as prescribed

Postsurgical Instructions

• Advise the patient to chew food in such a way that it does not disturb the surgical site

• Manage facial swelling• Supply patient with an emergency

number in case excessive bleeding occurs

Postsurgical Visits

• Patients are usually seen in 5 to 7 days for the first postsurgical visit

• It is the dentist’s responsibility to manage postsurgical problems

• The dental hygienist performs most of the postsurgical management

Step 1

• Interview the patient about:– Pain experience and use of analgesics– If antibiotic prescriptive instructions

were followed– Swelling– Postsurgical bleeding– Sensitivity to cold

Step 2

• Take patient’s vital signs:– Blood pressure– Pulse– Temperature

• Elevated temperature may indicate a developing infection

Step 3

• Remove periodontal dressing and examine surgical site

• Rinse site with warm, sterile saline solution

• Use cotton-tipped applicator to remove debris adherent to teeth, soft tissue, or sutures

• Swelling or exudate indicates an infection

Step 4

• Cut sutures and remove using sterile scissors

Step 5

• Plaque accumulation is likely• Remove plaque from surgical

area

Step 6

• Replace periodontal dressing, if indicated• Discontinue dressing as soon as patient is

able to resume mechanical plaque control

Step 7

• Instruct patient in self-care• Use brushes with extra soft

bristles• May introduce additional self-

care aids

Step 8

• Reappoint for second postsurgical visit

• Usually 2 to 3 weeks after surgery