Periodontal surgery Goals-Indications-Contraindications-Classifications
Plan
INTRODUCTION
- HISTORICAL
- DEFINITION OF PERIODONTAL SURGERY
- PLACE OF SURGICAL THERAPY IN PERIODONTAL TREATMENT
- OBJECTIVES OF PERIODONTAL SURGERY
- INDICATIONS FOR PERIODONTAL SURGERY
- CONTRAINDICATIONS OF PERIODONTAL SURGERY
- CLASSIFICATIONS OF PERIODONTAL SURGERY
7.1.KRAMER CLASSIFICATION 1966
7.2. TECUCIANU CLASSIFICATION 1976
7.3. SATO CLASSIFICATION 2002
8. PREPARATION OF THE PATIENT FOR PERIODONTAL SURGERY
9. INSTRUMENTS AND MATERIALS FOR PERIODONTAL SURGERY
10. POST-OPERATIVE ADVICE AND CARE
11. INCIDENTS AND COMPLICATIONS OF PERIODONTAL SURGERY
12. HEALING
13. MAINTENANCE
CONCLUSION
BIBLIOGRAPHY
Periodontal surgery
Introduction :
After completion of nonsurgical periodontal treatment, which consists of patient education on biofilm control, thorough disinfection and debridement of root surfaces, the affected periodontal areas are reevaluated. Sometimes, additional treatment in the form of surgical intervention is necessary in the second phase of periodontal treatment, when better access for complete root planing is required, or correction of anatomical or morphological defects is necessary. Placement of dental implants may be part of this surgical phase of treatment.
- The surgical treatment phase:
This phase aims to improve the prognosis of the teeth and improve aesthetics. In many cases, different therapies are combined to achieve these goals, or one therapy can achieve several goals such as gingivectomy to improve aesthetics and reduce pocket depths.
- HISTORY:
In the past, the primary goals of periodontal surgery were the removal of pockets greater than 3 mm deep, and the creation of optimal contours for the alveolar processes and gingiva. Both of these goals have been shown to be of no value for the future maintenance of healthy, functioning teeth. They complicate periodontal treatment by unfavorable root exposure and discomfort, and can no longer be considered viable goals. Periodontal surgery itself is of no value if it is not followed by adequate plaque control.
Therefore, the history of periodontal surgery can be divided into two major periods, both focused on the symptom of the disease: the periodontal pocket. The first was dominated by the elimination (or reduction) of the pocket, with the use of resective techniques. The second, the attempt to regenerate the lost periodontal support was the essential idea.
Periodontal surgery Goals-Indications-Contraindications-Classifications
- DEFINITION OF PERIODONTAL SURGERY:
Surgery is “a medical discipline specializing in treatment by manual and instrumental intervention on the body.” It is also defined as the art of treating diseases or injuries using the hands.
It therefore appears that almost all periodontal treatments could be considered, by definition, as “surgical”. However, the term “periodontal surgery” seems to define all types of manipulation of the hard and/or soft periodontal tissues including an incision with or without elevation of a flap.
3- PLACE OF SURGICAL THERAPY IN TREATMENT
PERIODONTAL:
Periodontal surgery is only one part of periodontal treatment.
If intervention is necessary, it is performed only in a second (corrective) phase of treatment, after a reassessment of the results obtained. The patient must be motivated and adequate plaque control must be ensured.
4-OBJECTIVES OF PERIODONTAL SURGERY:
With Sato (2002), we can summarize the objectives of periodontal surgery as follows:
• accessibility of instruments to root surfaces and underlying bone
• elimination of inflammation;
• creation of an oral environment allowing effective plaque control:
– by the elimination of periodontal pockets;
– by correcting gingival defects and bone morphology that can hinder plaque control
– by performing root amputations or treatments likely to facilitate maintenance;
– by creating embrasures accessible for hygiene;
• regeneration of lesions induced by periodontal disease.
5-INDICATIONS FOR PERIODONTAL SURGERY:
-Eliminate or reduce periodontal pockets.
-Correct mucogingival anomalies: frenulum, bridles, insufficiency or absence of attached gingiva.
-Correct aesthetic anomalies: gingival hypertrophy, recessions.
-Eliminate inter-radicular lesions.
-Preparation of the tissue environment for prosthetic insertion, for example coronal lengthening.
6-CONTRA-INDICATIONS OF PERIODONTAL SURGERY:
- Absolute contraindications:
-In patients with severe heart disease, or malignant hemophilia.
-In patients at risk of bleeding: patients on anticoagulants or with severe bleeding disorders (hemophilia, WILLBRAND disease)
-In patients with reduced defense mechanisms against bacterial infection (AIDS, acute leukemia, etc.)
-Cervicofacial radiotherapy.
- Relative contraindications :
-Refuse any intervention in patients with absent, defective or insufficient oral hygiene.
-In pregnant women, surgery should be avoided during the first trimester (risk of abortion) and last trimester (risk of premature delivery).
-In subjects suffering from diabetes, chronic nephritis, it is necessary to seek the agreement of the treating physician and perform the intervention under antibiotic cover after stabilization.
-When the teeth present advanced destruction due to caries (coronal or root) advanced periodontal disease requiring extraction.
The agreement of the treating physician must be sought. In the event that the disease presents a risk of infection, the intervention must be carried out under antibiotic cover.
Critical tissue areas in pouch therapy:
The choice of periodontal surgical technique in pocket therapy depends on the evaluation of four different critical tissue areas that make up the periodontal pocket:
. Zone 1: soft tissue pocket wall
. Zone 2: tooth surface
. Zone 3 underlying bone
. Zone 4: attached gingiva.
Periodontal surgery Goals-Indications-Contraindications-Classifications
7-CLASSIFICATIONS OF PERIODONTAL SURGERY :
7.1*KRAMER CLASSIFICATION 1966:
-Depending on the tissues concerned:
Keratinized area:
*periodontal curettage
*gingivectomy
*gingivoplasty
Mucous area:
*Frenectomy
*Shreds
*Gingival grafts
Bone area:
*Osteotomy/Osteotomy
*osteoplasty
*bone graft
*substitutions
-Depending on the type of surgery:
*Reparative by incision
*Reducing by excision
-Depending on the therapeutic chronology:
*Immediate hot intervention (abscess)
*Intervention after etiological treatment
-Depending on the type of healing:
*Reattachment by repair:
Long junctional epithelium
Epithelial or connective tissue adhesion
No new cementum, new ligament, maybe new bone
SGD deeper than normal
*New attachment by regeneration:
Short junctional epithelium
Neo-cementum, neo-ligament, a new bone
SGD short.
7.2* TECUCIANU 1976 CLASSIFICATION:
-Reduction techniques:
-gingival tissue gingivectomy
-mucous tissue frenectomy
-gingival and mucosal tissue, mucoperiosteal flaps.
-bone tissue osteotomy
-gingival, mucosal and dental tissue treatment of pulpo-periodontal lesions.
-Conservative techniques:
-gingival tissue periodontal curettage
-gingival tissue and mucosal flaps repositioned
– bone tissue curettage of 1- to 2-walled bone lesions and furcations.
-Corrective techniques :
-gingival tissue gingivoplasty
-mucous tissue frenectomy
-bone tissue osteoplasty
-Reconstructive techniques:
-mucogingival tissue: sliding flap, gingival graft.
-connective-periosteal-bone tissue rotation flap, bone graft, implants.
7.3* SATO 2002 CLASSIFICATION:
1. Blind curettage.
2. Gingivectomy.
3. Flap:
a. Open curettage.
b. Bone resection:
* Osteoplasty.
* Osteotomy.
c. Bone graft.
d. guided tissue regeneration (GTR):
* RTG with bone graft.
* RTG without bone graft.
4. Mucogingival surgery:
a. Increase in attached gingival height:
* Free gingival autografts.
* Pedicled gingival grafts.
* Apically displaced flap.
b. Root coverage.
* Pedicled gingival grafts.
* Apically displaced crescentic flaps.
* Free gingival autografts.
* Buried connective tissue grafts
*RTG.
c. Brake surgery.
Periodontal surgery Goals-Indications-Contraindications-Classifications
5. Combination of several surgical approaches.
8-PREPARATION OF THE PATIENT FOR SURGERY
PERIODONTAL :
All surgery is preceded by:
*a clinical and radiological examination;
*routine laboratory tests (FNS, TP, blood sugar);
*of an initial preparation which includes the following steps:
-Motivation for hygiene and teaching of personal periodontal care;
– Descaling and polishing of dental surfaces;
-Extraction of teeth deemed unsalvageable;
-Care for dental caries;
-Removal of iatrogenic fillings and prostheses;
-Manufacture of functional prophylactic temporary prostheses;
-Treatment of occlusion.
*of a medicinal preparation which consists of the preparation of a sedative premedication especially in emotional subjects.
9-INSTRUMENTS AND MATERIALS FOR PERIODONTAL SURGERY:
The instrumentation used in periodontal surgery is specific; it must be sharpened, sterilized and adapted to the procedure.
The instruments listed below are often found in a tray:
*tweezers
*mouth mirror
*exploratory probe
*graduated periodontal probe
*descaling instruments (curettes, scrapers, etc.).
*handle for disposable scalpels.
*Scalpel: There are two types:
Manuals: with different types of blades (11, 12,15)
Electric: for gingival plastic surgery
– scalpel blades:
- No. 15 and No. 15c, the most used
- No. 12, for tuberosity regions or distal surfaces of posterior teeth.
- No. 11, recommended for abscess drainage, it is useful for taking a connective graft
*gum scissors.
*hemostatic forceps.
*suture scissors.
*suture threads: 3/0, 4/0, 5/0, 6/0.
-threads: as a reminder, there are several categories of suture threads; absorbable or non-absorbable, single-thread or braided
Absorbable threads, regardless of the material, are absorbed by hydrolysis. They exist either with normal absorption (around 35 days, which requires their removal) or with rapid absorption (between 10 and 14 days).
-the needles: the curvature of the needle will be chosen according to the accessibility of the site.
*needle holder clamp.
*sutures: sutures are the last operating step of our surgical procedure, which is crucial for the sustainability of everything that came before.
*compress
*physiological serum.
*periodontal dressing to protect the surgical wound.
NB: Minimally invasive periodontal surgery is made possible thanks to more specific equipment which includes:
*microsurgical instruments
*microscopes
*magnifying glasses.
Periodontal surgery Goals-Indications-Contraindications-Classifications
10-POST-OPERATIVE TIPS AND CARE:
In periodontal surgery, the postoperative prescriptions and recommendations are:
following:
Take a class 1 painkiller every 4 hours for 48 hours then as needed
of pain.
Use chlorhexidine mouthwashes. Start 24 hours after surgery and continue morning, noon and evening for 7 days.
Apply ice to the face opposite the surgical area for 20 minutes,
Immediate postoperative which helps to stun the inflammatory reaction.
Do not interrupt brushing.
Massage the surgical area with a postoperative toothbrush with bristles
7/100th.
Abstain from smoking for at least one week.
Prefer warm, soft food and avoid any acidic foods such as lemon or
vinegar.
Antibiotic therapy is not indicated unless the patient has medical indications.
11-INCIDENTS AND COMPLICATIONS OF PERIODONTAL SURGERY:
-Hemorrhages:
Small amounts of bleeding will subside with simple digital pressure.
Significant bleeding requires removal of the dressing and the wound is dusted with thrombase before another dressing is applied.
-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.
– Pressure sensitivity :
it gives way spontaneously in a few days.
-Cellular complications and postoperative fever :
Order antibiotic therapy, the removal of the dressing will be exclusively reserved for possible drainage .
-Dental hyperesthesia:
after removing the dressing , it is frequent, it is not a complication but a simple reaction to the cementum curettage.
-Aesthetic damage :
Post-surgical gingival recession, empty interdental space, must be anticipated and controlled.
12- HEALING :
-scarring involves the healing of a wound.
-it is presented by the restoration by regeneration in the form of reattachment or new attachment.
-healing is different depending on the pathological or physiological state of the tissues involved and depending on the nature of the interventions performed.
13-MAINTENANCE:
It is important for the patient to know that the long-term outcome of periodontal therapy depends mainly on his or her cooperation.
In fact, this maintenance will therefore consist of systematic reassessments, renewed motivation of the patient, and reinforcement of oral hygiene methods with the patient.
Failure to provide maintenance treatment will lead to failure of any periodontal therapy.
Periodontal surgery Goals-Indications-Contraindications-Classifications
CONCLUSION :
The place of periodontal surgery in the treatment of periodontal diseases is increasing in parallel with better knowledge of the pathogenesis and scarring phenomena.
Periodontal surgery is best achieved through a complete treatment where the periodontist, the prosthetist and the patient combine their efforts for real and lasting success.
Periodontal surgery Goals-Indications-Contraindications-Classifications
BIBLIOGRAPHY :
- Newman.MG Newman and Carranza’s Essentials of Clinical Periodontology. Elsevier. 2022.
- Glickmann Clinical periodontology. Editions Cdp Paris 1983.
- Lindhe.J; Manual of clinical periodontology.EditionsCdp; 1986
- Bercy.Tenenbaum;Periodontology from diagnosis to practice De Boeck.University
- Mattout.p and Mattout.c: periodontal and implant therapies; Quintessence International, .2003.
- Sato.N.Clinical Atlas of Periodontal Surgery,Quintessence International;2002.
- Waite-Strahan.Atlas of periodontology.
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.