GENERAL

PRINCIPLES
OF PERIODONTAL SURGERY

Dr. Anuj Singh Parihar

MDS, MBA, (Ph.D), FICOI (USA), FISOI
Department of Periodontics
RKDF Dental College & Research
 OUT PATIENT SURGERY
Preparation of patient
Reevaluation after Phase I therapy
* Elimination of some lesions
Reduced need for surgery
* Firm and consistent tissue
Permits comfortable handling of tissues
* Acquainting of patient with clinic
Reduction of stress
 OUT PATIENT SURGERY
Preparation of patient
Premedication
* Antibiotic prophylaxis
Medically compromised patients
Reduction of post operative pain and swelling
Enhancement of bone graft procedures
Aggressive periodontitis
* Anxiolytic drugs
In anxious patients
* Anti inflammatory drugs
* Pre procedural rinse
Chlorhexidine
 OUT PATIENT SURGERY
Preparation of patient
Cessation of smoking
* Prior to surgery
* 3 4 weeks post operative
* No advanced surgery for those who do
not quit
Regenerative
Esthetic
mucogingival
Informed consent
* All information to be provided to patient
 OUT PATIENT SURGERY
Preparation of patient
Sterilization
* Chemical
* Heat
* Pressure and heat
Autoclave
Barrier techniques
* Cap, mask, gowns, drapes, gloves
 OUT PATIENT SURGERY
Preparation of patient
Emergency equipment
* Oxygen cylinder and mask, ambu bag,
airway
* B.P. apparatus, stethoscope, I.V. sets
Emergency drugs
* Adrenalin, atropine, corticosteroids
* Anti allergy, anti hypertensive, anti angina
* Sedatives, haemostatic agents
Emergency treatment
* Management of syncope, anaphylaxis, CPR
etc.
 ANESTHESIA & SEDATION
Anesthesia
Regional block, infiltration, vasoconstrictors
used
Sedation
Nitrous oxide/oxygen inhalation
* Quick onset, rapid recovery, adjustable levels
* No post operative sensory/motor impairment
Intra venous sedation
* Quick onset, titrated levels, need trained
anesthetist
* Recovery depends upon drug used
Oral administration of benzodiazepine
* Profound anesthesia, incomplete recovery
 TISSUE MANAGEMENT
Operate gently and carefully
Tissue management should be
precise, gentle and deliberate
* Avoid roughness and tissue injury
* Prevent post operative pain and swelling
Observe patient at all times
Facial expression, pallor, perspiration
* Pain, fear, anxiety
Use sharp instruments
Reduce time, effort, improve healing
 TISSUE MANAGEMENT
Scaling and root planing
Purpose of surgery is to gain access
and visibility to root surface
* To eliminate root deposits and irritants
Difficult to reach areas assessed
* Furcations
* Distal surfaces of molars
* Palatal/lingual regions
Ultrasonic and manual instruments
used
* Root planing completed
 HEMOSTASIS
Permits visualization of
Disease extent, bone destruction pattern,
anatomy of roots essential for good
debridement
Bleeding pattern
Profuse bleeding during incision and flap
reflection
Gradually reduces after removal of granulation
* Managed by aspiration, pressure pack, gauze packs
Flap design
Do not incise medium of large vessels
* Lingual, inferior arterioles, grater palatine vessels
 HEMOSTASIS
Management of excessive bleeding
Pressure packs
Gauze pack soaked in ice water
Use of vasoconstrictors in anesthetic
injection
Haemostatic agents
* Absorbable gelatin sponge, oxidized cellulose
* Micro-fibrillar collagen hemostat, thrombin
* Snake venom
Evaluate possibility of hemorrhage
* B.T., C.T., P.T., P.P.T.
 PERIODONTAL DRESSINGS
Uses of periodontal packs
Have no curative properties
Assist in healing by providing protection
* Minimize chance of post operative infection,
bleeding
* Prevents surface trauma during mastication
* Prevents pain caused by contact of surgical area
Zinc oxide Eugenol pack (Wondr-Pak*)
Available in powder-liquid form
* Zinc acetate is used as accelerator
Eugenol irritates area thus this pack is not
used
 NON EUGENOL PACK (Coe
Pack)
Reaction between metallic oxide &
fatty acid
Available in two tubes
Tube 1
* Zinc oxide, oil for plasticity
* Gum for cohesiveness
* Lorothidol as fungicide
Tube 2
* Liquid coconut fatty acid
* Colophony resin or rosin for thickening
* Chlorothymol as bacteriostatic
 PERIODONTAL DRESSINGS
Retention of pack
Mechanical interlocking in interdental
areas
Connecting facial and lingual parts
Placement of dental floss in edentulous
areas
Anti-bacterial properties of packs
Incorporating of antibiotics in the pack
* Bacitracin
* Tetracycline
* Neomycin
* Nitrofurazone
NON EUGENOL PACK (Coe
Pack)
 POST OPERATIVE
INSTRUCTIONS
Do not eat or drink for two hours
Till pack has initially set
No spitting, gargling or rinsing
For 12 hours
No consumption of hot substances
For 24 hours
Extra oral & intra oral cold
fomentation
On first day
Avoid brushing over sutures/pack
Till they are removed
 POST OPERATIVE
INSTRUCTIONS
No smoking or consumption of alcohol
Do not consume very hot, hard or spicy
food
For 7 days
Warm salt water intra oral fomentation
From 2nd. To 7th. day post operatively
Avoid exertion for 24 to 48 hours
Take medication as prescribed
Report at 1st. sign of postoperative
complication
Bleeding, uncontrolled pain, fever etc.
 POST OPERATIVE
PRESCRIPTION
Analgesic
Tab. Ketorol DT 3
* 1 tab. stat; 1 tab. S.O.S.
Antibiotic
Tab. Dox T 100 7
* 2 tab. stat; 1 tab once a day X 5 days
Anti-inflammatory
Tab Hifenac D 10
* 1 tab. 2 times a day X 5 days
Nutritional supplement
Cap. Becosule Z 14
* 1 cap. 2 times a day X 7 days
Antiseptic oral rinse
Hexidine mouthwash 1
* 1 capful to be rinsed for 30 seconds every 12 hours
 POST OPERATIVE
COMPLICATIONS
Persistent Bleeding
Pack removed
Bleeding points identified
Hemostasis
Sensitivity to percussion
Extension of inflammation to PDL
Remove pack and recheck area for
irritants
Irrigate area
Relieve occlusion
Remove excess pack if any
 POST OPERATIVE
COMPLICATIONS
Swelling
Surgical edema of dependant area
* Subsides in 3-4 days
* Prevented by cold fomentation
Antibiotics and anti-inflammatory
drugs used
Feeling of weakness
Transient bactermia
Prevented by antibiotic prophylaxis
Avoid exertion
Ample nutrition
FINDING ON PACK REMOVAL
Gingivectomy
Cut surface covered by fibrin meshwork
Granulation will persist if calculus has
not been completely removed
Flap operation
Incised area will be epithelized but may
bleed
Suture area will be slightly inflamed
Pocket area should not be probed for 6
weeks
FINDING ON PACK REMOVAL
Other findings
Facial/lingual surface
* Covered by grayish-yellow granular
layer
* Food debris, plaque, materia alba
* Removed by wet cotton pledget
Mobility
* Increased after surgery
* Reduces below pre-treatment level
In 4 6 weeks
 POST OPERATIVE CARE
In between surgical procedures
Started on removal of pack
Gentle but complete plaque control
* With soft tooth brush
* Oral irrigation
Water pic
Chlorhexidine rinses
Encourage mastication
Interdental aids to be used
* After 2 weeks
 SENSITIVE ROOTS
Caused due to exposure of root/dentin
Reduces in few weeks
* Plaque control is essential
Desensitizing pastes can be used but need time to act
Desensitizing agent
Used by patients (dentifrices/mouthwashes)
* Formaldehyde, Strontium Chloride, Potassium
Nitrate, Sodium Citrate, Sodium Fluoride
Used by dentist (in office)
* Varnish, Bonding agent, Silver Nitrate, Zinc
Chloride, Potassium Oxalate, Stannous Fluoride,
Lasers
 HOSPITAL PERIODONTAL
SURGERY
Indications
Apprehensive patients
* To reduce stress/anxiety caused due to conscious
state
Single sitting full mouth surgery done under sedation/GA
Patient convenience
* Faster total healing time, lesser medications
* Patients who cannot come for repeated appointments
Lawyers, doctors, teachers, actors, executives, sports
persons
Patient protection in medically compromised
patient
Cardiac, hypertensive, bleeders, hyperthyroid, patients,
diabetics
HOSPITAL PERIODONTAL
SURGERY

Patient Preparation:
Pre medication
Anaesthesia
Positioning and periodontal dressing

Post Operative Instructions

 HOSPITAL PERIODONTAL
SURGERY
Procedure
Premedication
* NBM (8 hours); Atropine (IM) 1- 2 hours before
surgery
Anesthesia
* GA (nasal intubation); local anesthesia
infiltration
Surgery
* Full mouth surgery; pack placed after cough
reflex
Discharge and follow up
* After 4-8 hours
* Suture removal after 7 days
THANK YOU
STORY OF THE DAY
A dental student luved his classmate
since 1st yr. In 4th yr he finally proposed
her. She didnt replied and next day she
returned his CARRANZA which was wit her.
Angrily d boy decided not 2talk 2her
again. After internship he started 2prepare
4PG n opened CARRANZA n found a note
inside "I LUV U TOO". It was 2late. D gal
was already married 2 some1 else.
MORAL OF THE STORY
 CARRANZA SHOULD BE READ IN
FINAL YEAR, NOT IN INTERNSHIP
HAVE A GREAT
WEEKEND