PERIODONTAL SURGERY
Objectives, principle, indications, contraindications, classification
Plan
1. INTRODUCTION:
2. HISTORY
3. DEFINITION AND OBJECTIVES:
3.1 Definition
3.2 Objectives
3.2-1 General objectives:
3.2-2 Specific objectives
3.2.2.1 – Create an access route for carrying out descaling
and root planing
3.2.2.2 – Facilitate plaque control by the patient and restore aesthetics:
3.2.2.3 – Facilitate the regeneration of periodontal tissues:
4 – GENERAL PRINCIPLES OF SURGERY:
5. CLASSIFICATION OF PERIODONTAL SURGERY PROCEDURES.
• Gum surgery
• Pocket surgery
• Mucogingival surgery or plastic surgery
• Bone surgery
• Inductive surgery
6- CONTRAINDICATIONS:
6.1- Local order
6.2- General
6.2.1- Cardiovascular diseases
6.2.2- Hematological disorders
6.2.3- Hormonal disorders
6.2.4- Neurological disorders
7. PROGRAMMING OF PERIODONTAL SURGERY
8. INSTRUMENTS AND MATERIALS FOR PERIODONTAL SURGERY
9. GENERAL OPERATING CONDITIONS
10 – COMPLICATIONS RELATED TO PERIODONTAL SURGERY
CONCLUSION
PERIODONTAL SURGERY:
1. INTRODUCTION :
Periodontal diseases are cyclical, painless diseases that progress over time. Acute episodes, resulting from the combined action of bacterial products and the host response, cause the progressive destruction of the alveolus, cementum and connective tissue attachment apparatus. This results in the deepening of periodontal pockets and the appearance of mucogingival defects. Initial therapies alone are not sufficient in some cases to treat them and prevent their recurrence.
Periodontal surgery remains the major therapeutic chapter allowing to cure or stabilize periodontal disease. It has also evolved towards techniques dominated by two now fundamental notions:
– Tissue economy
– the reconstruction of weakened or destroyed structures.
2. HISTORY :
Over the years, a large number of different surgical techniques have been described and used in periodontics. It is sometimes difficult to establish precisely which was the precursor of a technique and the exact date on which it first appeared.
3. DEFINITION AND OBJECTIVES :
3.1 Definition :
By definition, the term surgery means “the act and art of treating lesions or diseases by manual operation”. Periodontal surgery is a therapy which is proposed with a view to correcting gingival or bone conditions which are an obstacle to good oral hygiene.
3.2 Objectives
3.2-1 General objectives:
The main goal of periodontal surgery is to contribute to the preservation of the periodontium by facilitating plaque removal and control, periodontal surgery can achieve this goal by:
– ensuring the effectiveness of scaling and root planing.
– restoring optimal gingival aesthetics and architecture for plaque control exercised by the patient.
In addition to this, periodontal surgery may aim to:
– regeneration of periodontal anchorage destroyed by the disease.
3.2-2 Specific objectives
3.2.2.1 – Create an access route for scaling and root planing:
Complete removal of soft and hard deposits on root surfaces is necessary for successful treatment of periodontal disease. Subgingival scaling and root planing are difficult techniques to master and their effectiveness is markedly influenced by pocket depth and certain anatomical factors (fissures
and root concavities, interradicular spaces). In order to achieve complete subgingival debridement, the root surfaces should be exposed during surgical intervention to obtain complete ease of access.
3.2.2.2 – Facilitate plaque control by the patient and restore aesthetics:
The patient’s daily efforts in performing hygiene care are of the utmost importance for maintaining periodontal health after treatment, for this reason, they should be facilitated by establishing optimal conditions (deflector architecture and harmonious contour of the superficial periodontium) for performing oral hygiene care.
Major abnormalities such as gingival hyperplasia, gingival craters, and recessions should be corrected surgically, as they pose serious cosmetic problems and can also promote the retention and accumulation of bacterial plaque.
3.2.2.3 – Facilitate the regeneration of periodontal tissues:
The ultimate goal that periodontal therapy must achieve is not only to stop the progression of progressive periodontal disease but also to restore the destroyed parts of the supporting apparatus (restitution ad integrum) by regenerating the tissue anchorage (main fibers, alveolar bone and root cementum).
4 – GENERAL PRINCIPLES OF SURGERY :
The final decision regarding the type and extent of necessary surgical treatment should be made after evaluation of the results of etiological therapy. This practice has the following advantages:
1- the elimination of tartar and bacterial plaque has eliminated or significantly reduced gingival inflammation , thereby allowing an assessment of gingival architecture and the depths of actual pockets.
2- the resolution of gingival inflammation allows the firming of tissues which facilitates surgical treatment. The tendency to bleed is reduced which makes inspection of the surgical field easier.
3- establishment of a long-term prognosis based on the patient’s resistance and his degree of cooperation and motivation for oral hygiene.
PERIODONTAL SURGERY
5. CLASSIFICATION OF PERIODONTAL SURGERY PROCEDURES.
Periodontal surgery techniques can be classified as follows:
• Gingival surgery : mainly aimed at the gum (external bevel gingivectomy “GBE”, internal bevel gingivectomy “GBI” to retouch the gingival contour. ENAP and periodontal curettage are used whenever access to the site is easy, in order to remove as much internal lining tissue as possible from the supraosseous pocket, which should be of limited depth (4 mm).
• Pocket surgery , involving the gum and bone, commonly referred to as “flap procedures”. Flaps can be full-thickness mucoperiosteal or partial-thickness mucosal. Flaps
allow to excise the epithelium of the infrabony pockets with maximum tissue economy thanks to the internal bevel incision, to surface and disinfect the roots to promote connective reattachment to allow healing by first intention. Example: (Modified Widman flap, aesthetic access flap (LEA), apical sliding flap, etc.).
• Mucogingival surgery or plastic surgery , aims to restore or maintain an area of attached gingiva compatible with the resistance of the superficial periodontium, i.e. 1 mm minimum. (Grafts, free or pedicled
• Bone surgery: Flap procedures accompanied by bone remodeling (subtractive bone surgery), with filling of defects (additive bone surgery).
• Inductive surgery: Flap procedures accompanied by Guided Tissue Regeneration “RTG” or the addition of bone growth factors (EMDOGAIN) are indicated in the presence of gingival recession, bone defects and furcation damage.
6- CONTRAINDICATIONS:
6.1- Local : Patient cooperation: since the existence of optimal plaque control during the postoperative period is decisive for the success of periodontal treatment, a patient who cannot cooperate during etiological therapy should not undergo surgical treatment.
6.2- General :
As a general rule, periodontal surgery is contraindicated in people who have a systemic disease such that surgery would put them at risk from a general health perspective.
6.2.1- Cardiovascular diseases : high blood pressure, angina pectoris, patients with a history of myocardial infarction, patients under
anticoagulants or wearers of valve and vascular prostheses,
patient with a pacemaker, endocarditis or congenital heart disease. The majority of these conditions only represent relative contraindications to periodontal surgery, which will be performed after agreement from the treating physician and preparation of the patient.
6.2.2- Hematological disorders : moderate forms of anemia do not prohibit surgical treatment. More severe and less compensated forms require consultation with the treating physician.
Acute leukemia, agranulocytosis, and lymphogranulomatosis, hemostasis disorders are absolute contraindications to surgical treatment.
6.2.3- Hormonal disorders : advice from the treating physician and special procedures to follow.
6.2.4- Neurological disorders:
Epilepsy requires special precautions to be taken in collaboration with the treating physician. Multiple sclerosis and Parkinson’s disease may require treatment to be carried out under general anesthesia.
7. PROGRAMMING OF PERIODONTAL SURGERY
After the success of the initial therapy, which will have consisted in making the patient aware that the elimination of dental plaque and harmful habits (parafunctions, smoking) constitutes the basis of his treatment, surgery logically fits into the progression of the therapy, each time it proves essential (debridement of the deepest residual pockets, compensation of periodontal destruction). Temporary balancing of the occlusion and minor orthodontics will have compensated for the functional anomalies likely to compromise the favorable outcome of the treatment.
8. INSTRUMENTS AND MATERIALS FOR PERIODONTAL SURGERY
Special instruments exist for the type of surgery planned. They must be preconditioned and sterilized as well as the materials used during the periodontal surgery procedure.
Below we present the list of instruments in a typical kit.
· Examination Tray
· Cotton tweezers
· Mouth mirror
· Exploratory probes
· Graduated periodontal probe
· Scaling instruments (scrapers and curettes)
· Orban scalpels 1 and 2
· Bard-Parker scalpel holder (2)
· Friedman rongeur
· Ochsenbein bone scissors, 1 and 2
· Goldman Fox Scissors
· Suture scissors
· Needle holder,
· Curved hemostasis forceps,
· Spatula
· Handpiece and round burs, small diamond tips + polishing burs
· Bard-Parker scalpel blades 11, 12B, and 15
· 3/0, 4/0, 5/0, 6/0 sutures with normal atraumatic curved needles or reverse bevel needles.
· Sterile compresses
· Vacuum cleaner nozzle
· Physiological serum and disposable syringes for irrigation and washing of lesions.
· Periodontal dressings.
9. GENERAL OPERATING CONDITIONS :
Periodontal surgery requires specific operating conditions to be performed properly:
1- Respect the notions of asepsis essential to any surgical procedure.
2- Local anesthesia must be carried out gradually and completely, the presence of vasoconstrictor allows to partially control the bleeding.
3- Reexamine the anesthetized tissues, depth of pockets and bone lesions.
4- The incision depends on the technique used, it is a function of the thickness of the tissues, the height of GA, aesthetic considerations and the anatomy of the region.
5- The detachment is done delicately without tearing the tissues, respecting the vascularization, whether it is a mucosal or mucoperiosteal flap.
6- The removal of pathological tissues must be complete and controlled. It is followed by careful cleaning and polishing of the root surfaces.
7- Sutures play a crucial role in the final result. They must be done carefully with precise equipment, without pulling or tearing the tissues.
8- The surgical dressing protects the operated area and ensures the contention of the gum. It must be placed well so as not to injure the tissues and bother the patient.
9- Local and general postoperative care is very important depending on the procedure performed. Antibiotics, analgesics and anti-inflammatories will be prescribed.
10- Strict control of oral hygiene.
10 – COMPLICATIONS RELATED TO PERIODONTAL SURGERY
Most, but not all, complications of periodontal surgery can be prevented by proper diagnosis and careful pre- and postoperative care by a responsible and skilled surgeon.
Therefore, it is important to be well aware of the complications that may occur and how to avoid and treat them if they do occur. The most significant are:
1. Shock, syncope.
2. Hemorrhage.
3. Pain.
4. Swelling, hematoma.
5. Delayed healing.
6. Allergic reaction to the dressing.
7. Tooth sensitivity.
PERIODONTAL SURGERY
CONCLUSION :
Surgical treatment is an adjunct to etiological treatment. It aims to correct defects induced by periodontal disease .
There is not one, but several periodontal surgeries. Periodontal surgeries are only means to achieve a therapeutic goal. These goals are, first to control the evolution of the pathological process and then, possibly, to regenerate the destroyed periodontal structures to facilitate occlusal-functional rehabilitation (prosthesis, orthodontics, implant). Whatever the goal, surgery can only be performed after suppression of inflammation and evaluation of the patient’s cooperation and tissue response.
PERIODONTAL SURGERY
Deep cavities may require root canal treatment.
Interdental brushes effectively clean between teeth.
Misaligned teeth can cause chewing problems.
Untreated dental infections can spread to other parts of the body.
Whitening trays are used for gradual results.
Cracked teeth can be repaired with composite resins.
Proper hydration helps maintain a healthy mouth.