Periodontal surgery: Goals-indications-contraindications-classification
Plan :
-Introduction
1-Definition
2-History
3-Goals
4-General principles
5-Classification
6-Indications
7-Contraindications
8-Instrumentation
9-Bandage
10-Post-operative advice
11-Complications
-Conclusion
-Bibliography
Introduction : The importance of periodontal surgery has continued to grow as our knowledge of the pathogenesis and etiology of periodontal diseases and our diagnostic and therapeutic possibilities have improved.
1-Definition of periodontal surgery : periodontal surgery includes surgical treatments performed on the periodontal soft tissues and on the underlying alveolar bone.
2-History : the first techniques were described by ROBiCSEK, gingivectomy in 1884, the flap in 1862, and currently we are improving old techniques and creating new ones based on clinical research and the laboratory. During this century many techniques have been described and used, some have been abandoned because their side effects were too important, others finally have emerged, based on solid experimental clinical data.
Surgical techniques have evolved from a subtractive approach to a more conservative approach, leading today to minimalist approaches in terms of access and/or using tissue-engineered products. The principle of managing root surface decontamination has also changed over time, from aggressive removal of “necrotic” cementum to gentle instrumentation of the contaminated root surface. Initially, only methods of excision of inflammatory soft tissue were described. Subsequently, procedures for excision of bone, considered “necrotic”, were developed with the intention of maintaining healthy residual bone tissue. Later, interventions sought to maintain the components of the mucogingival complex, including the height of attached gingiva.
3-Goals : periodontal surgery has a predominant place in complete periodontal treatment and must fulfill several objectives:
-create an access route for scaling and root planing.
-Eliminate pathological tissues that maintain and aggravate periodontal tissue destruction.
-Eliminate gingival and periodontal pockets that allow the disease to progress by promoting and protecting the accumulation of microbial and food deposits and making complete personal periodontal care impossible.
-Recreate a physiological and functional tissue morphology by correcting gingival and bone deformations in order to restore a healthy periodontal environment that can be maintained by the patient and to avoid relapses and allow possible prosthetic restorations.
-Reconstruct superficial and deep periodontal tissues.
-facilitate the regeneration of periodontal anchorage destroyed by the disease.
4-General principles : although the techniques are numerous and each case requires specific surgical care, there are a certain number of principles common to all periodontal surgery procedures.
- The surgical procedure must always be placed in the context of the treatment.
- We will always choose the simplest technique that will give the best result.
- Temporary or permanent, local or general contraindications to surgery will be sought by a complete clinical examination.
- To be performed properly, periodontal surgery requires specific operating conditions.
Periodontal surgery: Goals-indications-contraindications-classification
5-Classification of periodontal surgery techniques : several classifications have been described. FRIEDMAN N and LEVINE L (1964), KRAMER G and KOHN D (1966), GOLDMAN H and COHEN W (1968), CALANDRIELLO and BAR (1969), SPIRGI Met TECUCIANU JF (1971).
They are based on the anatomical region concerned (distal operation, palatal flap), on the nature of the lesions to be treated (gingival hypertrophy) or on the type of tissue concerned (gum, alveolar mucosa, bone), finally on the nature of the surgical wound (first or second intention) and the flaps (mucosal or mucoperiosteal). Each technique has a predominant character that can be classified as: reductive, corrective, conservative, reconstructive.
Tecucianu JF 1976 classification:
- Reduction techniques:
Gingival tissue: gingivectomy
Mucosal tissue: frenectomy
Gingival and mucosal tissue: mucoperiosteal flap
Bone tissue: osteotomy
Gingival, mucosal, bone and dental tissues: treatment of pulpo-periodontal lesions
- Conservative techniques:
Gingival tissue: periodontal curettage
Gingival and mucosal tissue: repositioned flap
Bone tissue: curettage of 1- or 2-walled bone lesions and furcations
- Corrective techniques:
Gingival tissue: gingivoplasty
Mucosal tissue: frenotomy
Bone tissue: osteoplasty
- Reconstructive techniques:
Mucogingival: sliding flap, gingival graft
Conjunctivo-periosteal: conjunctivo-periosteal graft
Bone: bone graft
Implant: bone implant
Bouchard classification : periodontal surgeries can be classified into several types:
-Diagnostic surgery (intervention on a sick subject) : this surgery aims to provide the elements contributing to the diagnosis. The surgical procedure is usually the access flap which should then be called: exploration flap. (Ex: identification of an anatomical defect). The surgical exploration procedure is almost always immediately completed by the surgical elimination of the pocket. Given the quality of the imaging, there is no longer any reason today to consider diagnostic surgery to assess the extent or severity of periodontal defects.
-curative surgery (intervention on a sick subject) : it aims to treat the disease and cure the patient, that is to say, eliminate the periodontal pockets and stop the loss of attachment. The classic approach is resective surgery and regenerative surgery.
-prophylactic surgery (intervention on healthy subjects at risk) : intervenes as a preventive measure in order to avoid the appearance or development of a periodontal disease or lesion. Prophylactic surgery is essentially mucogingival (elimination of frenums and bridles). Interventions aimed at promoting access to hygiene by creating a favorable tissue environment belong to this category.
– restorative and reconstructive surgery (intervention on healthy subjects who have been ill and have after-effects) : periodontal treatments, generally surgical, generate significant aesthetic and functional after-effects. Restorative or reconstructive surgery can remedy these side effects, and therefore generate the after-effects of the disease. This surgery can also remedy after-effects not resulting from periodontal treatments. (endodontic, orthodontic, prosthetic, etc.)
-palliative surgery (intervention on a sick subject) : it allows to preserve teeth affected by severe periodontitis. It is indicated in the event of continued loss of attachment after non-surgical treatment. It classically consists of a simple access flap. It allows to maintain satisfactory oral comfort for the patient. Indicated in the elderly, the disabled or on reduced periodontium.
6-Indications:
-Insufficient accessibility hindering the performance of scaling and root planing
– Insufficient accessibility hindering plaque control carried out by the patient.
Periodontal surgery: Goals-indications-contraindications-classification
7-Contraindications:
-Patient cooperation: since the existence of an optimal plaque control during the postoperative period is decisive for the success of periodontal treatment, a patient who cannot cooperate during the etiological therapy should not undergo surgical treatment.
-Cardiovascular diseases: high blood pressure and angina pectoris do not prohibit surgery. Patients with a history of myocardial infarction should not undergo surgery in the months following hospitalization, and beyond this period, only for solid reasons and in cooperation with the treating physician. Anticoagulant treatment leads to an increased tendency to bleeding. Periodontal surgery should be scheduled after consultation with the physician. Salicylates should not be used to combat pain in the postoperative period since there is an increased tendency to bleeding. The presence of rheumatic endocarditis, congenital heart lesions of valvular and vascular prosthesis implies risks of bacterial grafting at the level of the cardiac tissues during the bacteremia that follows the manipulation of periodontal pockets. Treatment of these patients should be preceded by mouthwash with 0.2% chlorhexidine antiseptic solution and appropriate antibiotic therapy should be prescribed and started a few hours before the procedure.
– haematological disorders: patients with acute leukaemia, agranulocytosis and lymphogranulomatosis should not undergo surgical treatment. Moderate or compensated forms of anaemia do not preclude surgical treatment. More severe and less compensated forms may lead to a decrease in resistance to infection and an increase in the tendency to bleed. In such cases, surgical treatment should be performed only after consultation with the treating physician.
– Hormonal disorders: Diabetes mellitus leads to a decrease in resistance to infection, a tendency to delayed healing and a predisposition to arteriosclerosis. Well-balanced patients can undergo surgical procedures provided that precautions are taken not to disrupt either the diet or the need for insulin.
-adrenal function may be blocked in patients who have been taking high doses of corticosteroids for a long time. This implies a decrease in resistance to physical and psychological stress; doses of corticosteroids sometimes have to be modified during the period of surgical treatment. The treating physician should be consulted.
– neurological disorders: epilepsy is often treated with phenytoin, which can (in 50% of cases) promote the development of gingival hyperplasia. These patients can, without special restrictions, undergo surgical treatment. Multiple sclerosis and Parkinson’s disease can, for severe forms, make outpatient surgical treatment impossible. The existence of paresis, reduced muscle function, tremor and uncontrollable reflexes may require treatment to be carried out under general anesthesia.
8-Preparation of the patient for periodontal surgery : all surgery is preceded by:
From a clinical and radiographic examination
Blood test (FNS, blood sugar, TP)
From an initial preparation including the following steps
-hygiene motivation
– scaling and polishing of dental surfaces
-extraction of irrecoverable teeth
-care for decayed teeth
-removal of iatrogenic fillings and prostheses
– production of functional temporary prostheses
-occlusion treatment
Sedative premedication if necessary.
9-Instrumentation: Instruments should be stored in sterilized “ready to use” boxes or trays.
-mouth mirror
-tweezers
-periodontal probe
-handles for disposable blade scalpels (Bard-Parker handle, Blake handle with screw tightening)
-surgical knives
-detachers
-hemostatic forceps
– gum cutting pliers, gouge pliers
-scaler and curette-gum scissors
-gum scissors
-bone scissors and files
-suture scissors
– strawberries
-suture thread and needle holder forceps
-mouth spatula.
-syringe for irrigation
-suction cannula
Additional material:
-Fields
-sterile gloves
-Physiological serum
-syringe for local anesthesia
– compresses
-surgical aspiration.
Periodontal surgery: Goals-indications-contraindications-classification
10-Dressing : 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.
11-Postoperative advice and care : depending on the procedure performed, antibiotics, analgesics, and anti-inflammatories will be prescribed. During postoperative check-ups, the operated areas will be cleaned and the patient will be instructed on personal periodontal care (brushing, stimulation, massage).
-Prescription of analgesics : the analgesic of choice seems to be paracetamol at a rate of 20 to 30 mg/kg/day. Acetylsalicylic acid is not recommended because of its antiplatelet effect, a source of hemorrhage and postoperative hematoma. Similarly, it is better to avoid prescribing noramidopyrine and its derivatives (Visceralgine) as a first-line treatment because of the risk of developing immunoallergic agranulocytosis, which is fatal in 10% of cases. For the same allergic reasons, glafenine derivatives should be avoided. The use of high-dose nonsteroidal anti-inflammatory drugs for analgesic purposes (niflumic aid or ibuprofen) should be avoided because of the risk of extending a possible septic process. As a second-line treatment, the paracetamol-codeine combination is prescribed.
– Edema is extremely common in post-operative stomatology. If it is not possible to avoid it and prevent it and avoid it completely, it is possible to limit its importance. The simplest method is the application of an ice pack (avoiding burning the skin). Non-steroidal anti-inflammatory drugs are commonly prescribed, sometimes intravenous corticosteroid therapy for a short period, in its interest. (in the absence of medical contraindications, of all infectious foci and under antibiotic cover) methylprednisolone, solumedrol R at a dosage of 0.5 to 1 mg / kg / day for a period not exceeding 48 to 72 hours.
-oral hygiene : it is essential for good healing. It includes brushing after each meal and mouthwashes which will be started the day after an operation associated with the use of silk floss.
-Food : it can begin, if possible, the same evening as the operation. Solid foods, hot or acidic liquids or spicy foods should be avoided, however iced drinks are recommended.
-Antibiotic : postoperative antibiotic treatment is not systematic. The antibiotic of choice is amoxicillin at a rate of 2 to 3 g/day.
-Tobacco : It is very important to abstain from smoking for at least one week.
12-Complications:
-postoperative bleeding : simple pressure applied for a few minutes to the affected area is generally sufficient to achieve hemostasis . More significant hemorrhage requires ligation of the vessels using sutures. For grafts, a gutter will be made before the operation. If the palatine artery is affected, inject a local anesthetic into the greater palatine canal and apply pressure to the wound.
-edema : it is not worrying, it disappears spontaneously in a few days, it can be prevented by applying ice within 6 hours following the operation.
-sensitivity to pressure : it disappears spontaneously within a few days
-dental mobility : it disappears a few days after surgery.
– Conclusion : the importance of periodontal diseases is growing in the concerns of practitioners who must diagnose and treat these conditions. The place of periodontal surgery in the treatment of periodontal diseases is increasing in parallel with the better knowledge we have of the pathogenesis and the scarring phenomena. But it is only of interest in a complete treatment where the periodontologist, the prosthetist and the patient combine their efforts for real and lasting success.
” While periodontal surgery is not the whole of periodontics, there is no complete periodontal treatment without surgery ”
Bibliography:
-Francois Vigouroux Practical guide to periodontal surgery Elsevier MASSON
-Jan Lindhe Manual of Clinical Periodontology cdp edition
-JFTECCUCIANU Periodontal surgery EMC Paris, Stomatology, 6-1978,23602 A-10
-L Chikhani, F Guilbert postoperative care in stomatology and maxillofacial surgeries EMC 22-091-p-10
-OTTO ZUHR MARC HÜRZELER plastic and aesthetic surgery in periodontics and implantology a microsurgical approach.
-Philipe Bouchard Periodontology implant dentistry volume 2-surgical therapeutics Lavoisier Medicine sciences
Good oral hygiene Regular scaling at the dentist Dental implant placement Dental x-rays Teeth whitening A visit to the dentist The dentist uses local anesthesia to minimize pain