1. Perry chapter 13 and Nield-Gehrig chapter 21
Periodontal Surgery
Perry chapter 13 and Nield-Gehrig chapter 21

2. Historical Perspective
Originally, surgery was for removing damaged tissues that were thought to be diseased

3. 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

4. Surgery as Supportive Care
Enhancing restorative procedures
Improving patient appearance
Preparing a patient for implant-supported prosthesis

5. Indications for
Periodontal Surgery

6. Indications
Surgery is necessary when the periodontium is unhealthy and cannot be repaired with nonsurgical treatment

7. Indications Provide access for improved root surface debridement
Reduce pocket depths
Provide access for treatment of periodontal osseous defects
Resect or remove tissues

8. 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

9. Provide Access for Improved Instrumentation of Root Surfaces
The deeper the probe depth, the more difficult it is to instrument root surfaces

10. 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

11. 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

12. Resect or Remove Tissue
Enlarged gingival tissues are unsightly and can inhibit good oral hygiene
Surgery can remove and reshape enlarged gingiva

13. 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

14. Graft Bone Into Osseous Defects
Bone or bone-stimulating materials can be grafted into osseous defects
Grafting bone does not imply regeneration

15. Improve Appearance of Periodontium
Some gingival levels or contours result in an unattractive smile
Surgery can improve the appearance of gingiva

16. Enhance Prosthetic Dental Care
Altering alveolar ridge contours
Crown lengthening
Augmenting amount of gingiva present
Enhancing restorative dentistry
Many types of surgery are involved

17. 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

18. Contraindications for
Periodontal Surgery

19. “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

20. 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

21. 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

22. 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

23. 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

24. Terms
Four terms used to describe healing of periodontium after surgery:
Repair
Reattachment
New attachment
Regeneration

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Overview of Common Types of Periodontal Surgery
Chapter 21: Periodontal Surgical Concepts for the Dental Hygienist
Section 3
Overview of Common Types of Periodontal Surgery

32. 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

33. 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

34. 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

35. Periodontal Flap
for Access

36. Periodontal Flap Incisions are made in gingiva around necks of teeth
Underlying soft tissues are elevated from tooth roots and bone

37. 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

41. 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

43. Healing After Flap Surgery
Healing by repair
Involves formation of long junctional epithelium
Can be maintained by patient and professional care

44. 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

45. Bone Replacement Graft

46. 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

48. 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

49. Materials Used for Bone Grafts
Synthetic bone material
Alloplast
Treated cow bone
Xenograft
Taken from a cadaver
Allograft
Taken from patient’s body; jaw
Autograft

50. Healing After Bone Grafting
Partial or complete rebuilding of alveolar bone
Reformed bone may not actually be attached to cementum by periodontal ligament fibers

51. 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

53. Guided Tissue
Regeneration

54. Description of Procedure
Surgical procedure that attempts to regenerate lost periodontal structures
Widespread use

55. 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

56. 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

58. 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

59. Apically Positioned Flap

60. 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

61. 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

63. 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

64. Special Considerations for the Dental Hygienist
Surgery results in more root exposure in the oral cavity
Patient may experience temporary root sensitivity

65. Mucogingival Surgery

66. 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

67. Types of Surgery Soft tissue graft Connective 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

69. 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

70. 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

71. Crown Lengthening Surgery

72. 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

73. Description of Procedure
Involves:
Elevating a flap
Recontouring of the bone
Suturing tissue back in place

74. 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

75. 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

76. Dental Implant
Placement

77. 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

78. 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

79. Special Considerations for the Dental Hygienist
Patient self-care is critical
After the implant site heals, gingiva can be maintained as usual

80. Gingivectomy

81. Description of Procedure
Surgery designed to remove gingival tissue

83. Indications for Gingivectomy
Use is limited to removing enlarged gingiva to improve esthetics or allow for better access during home care

84. Disadvantages Leaves large open connective tissue wound
Slower surface healing than other surgeries
More discomfort for patient during healing
Teeth appear longer

86. 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

87. 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

88. Gingival Curettage

89. 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

90. Management of the Patient Following Periodontal Surgery
Chapter 21: Periodontal Surgical Concepts for the Dental Hygienist
Section 4
Management of the Patient Following Periodontal Surgery

91. Suture Placement
and Removal

92. 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

93. Material Used Nonresorbable Resorbable
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

97. 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

98. 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

99. 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

100. 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

102. Periodontal Dressing
Placement

103. 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

104. 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

106. Post Surgical Instructions

107. Postsurgical Instructions
Supplying the patient with both verbal and written instructions minimizes confusion
Restrict mechanical plaque removal
Encourage patient to take medications as prescribed

108. 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

109. Post Surgical Visits

110. 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

111. Step 1 Interview the patient about:
Pain experience and use of analgesics
If antibiotic prescriptive instructions were followed
Swelling
Postsurgical bleeding
Sensitivity to cold

112. Step 2 Take patient’s vital signs:
Blood pressure
Pulse
Temperature
Elevated temperature may indicate a developing infection

113. 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

114. Step 4
Cut sutures and remove using sterile scissors

115. Step 5
Plaque accumulation is likely
Remove plaque from surgical area

116. Step 6 Replace periodontal dressing, if indicated
Discontinue dressing as soon as patient is able to resume mechanical plaque control

117. Step 7 Instruct patient in self-care
Use brushes with extra soft bristles
May introduce additional self-care aids

118. Step 8 Reappoint for second postsurgical visit
Usually 2 to 3 weeks after surgery