PERIODONTAL SURGERY
I. 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 progressive destruction of the alveolus, cementum, and connective tissue attachment apparatus. This results in deepening of periodontal pockets and the appearance of mucogingival defects.
Initial therapies alone cannot in some cases be enough 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.
II- History:
Periodontal surgery has evolved from gingivectomy (the oldest procedure) to plastic surgery (the current concept of more aesthetic periodontal surgery) through pocket (flap) surgery, frenum and vestibule surgery, bone surgery and interceptive surgery (GA).
III- Definition :
The term surgery refers to “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.
IV- Place of periodontal surgery in the periodontal treatment plan:
Periodontal surgery is performed during the corrective phase to reinforce the results of the etiological therapy.
V- Objectives :
*General objectives:
- contribute to the preservation of the periodontium by facilitating the elimination of plaque and its control, periodontal surgery can achieve this goal by:
- ensuring the effectiveness of scaling and root planing.
restoring the aesthetics and optimal gingival architecture for plaque control exercised by the patient. - regeneration of periodontal anchorage destroyed by disease.
*Specific objectives:
- Create an access route ( by making the root surfaces accessible) for scaling and root planing and establish a situation more favorable to plaque control: certain situations can prevent plaque control such as: gingival hypertrophy and recessions
- Solving muco-gingival problems
- Improved aesthetics
- The radical elimination of bags
- performance of root amputation which can improve morphology, development of a periodontal environment compatible with restorative dentistry and prosthetic treatments.
- peri-implant tissue arrangement thus allowing optimal tissue integration.
- Facilitate the regeneration of periodontal tissues .
PERIODONTAL SURGERY
VI- classifications:
1-KRAMER CLASSIFICATION 1966:
A-Depending on the tissues concerned:
- Keratinized area: Curettage, Gingivectomy, Gingivoplasty, ENAP
- Mucosal area: Frenotomy, frenotomy, repositioned flaps, gingival grafts
- Bone area: Osteotomy/Osteectomy, Osteoplasty, Bone grafts, Open periodontal curettage
b- Depending on the type of surgery:
- reductive with excision: gingivectomy, gingivoplasty
- restorative with incision: partial or total thickness flap, posterior incisions (distal WEDGES)
c-Depending on the type of healing:
REATTACHMENT BY REPAIR : is at the origin of a (long junctional epithelium characterized by epithelial or connective tissue adhesion, no new cementum or new ligament, may be new bone formation, a gingivodental groove a little deeper than normal). approximately the same position of the attachment as before the intervention, often apically to the anterior marginal position.
Repair: is a biological process during which the continuity of damaged tissues is reestablished by new tissue formations that incompletely restore the architecture and function of the destroyed tissue.
NEW ATTACHMENT BY REGENERATION: is at the origin of a short junctional epithelium characterized by (neocementum, neoligament, new bone, short gingivodental sulcus), approximately the situation of the most coronal attachment possible (JE\c).
Regeneration: is a biological process by which the morphology and function of tissues destroyed during a pathological process are completely restored.
D- Depending on the therapeutic chronology:
- IMMEDIATE INTERVENTION: HOT (ABCES )
- COLD INTERVENTION (AFTER initial therapy)
NB: Periodontal surgery techniques can be classified as follows:
- Gingival surgery: GBE, GBI, ENAP, and periodontal curettage
- Pocket surgery: “flap procedures”.
- Muco-gingival surgery or plastic surgery
- Bone surgery: subtractive bone surgery, additive bone surgery
- Inductive surgery: RTG , EMDOGAIN,
VII-indications:
- difficult access to carry out scaling – surfacing.
- areas inaccessible to oral hygiene.
- preparation before dental or prosthetic restoration.
- muco-gingival problem.
- before ODF treatment in children.
- correct certain cariogenic problems.
PERIODONTAL SURGERY
VIII-contraindications:
- Local : uncooperative patient
- General:
1 – absolute:
-Osler’s endocarditis, congenital heart disease, valve prosthesis… (at risk of infection)
-Acute leukemia, agranulocytosis, lymphogranulomatosis… ( at risk of hemorrhage)
– multiple sclerosis, Parkinson’s disease, cervico-facial radiotherapy, AIDS, prolonged cortisone treatment, patients on bisphosphonate
2 – relatives: Seek the advice of your doctor and take precautionary measures:
-HTA
-angina pectoris
-patient on anticoagulants
-diabetes
– pregnancy
– nutritional deficiency
IX-General principles of periodontal surgery:
Periodontal surgery requires specific operating conditions to be performed properly:
-preparation of the patient: (preventive or sedative drug prescription)
– asepsis and operating field
-anesthesia: local with slow and careful administration
-the incision: will depend on:
- From the height of keratinized gum
- surgical technique
- Pocket depth
- Thickness of the gingiva and alveolar processes
- Aesthetic constraints
- Need for post-operative prosthetic treatment
- Clinical crown height required for prosthetic abutment
And because of this, there are several types of incisions:
*apico-coronal incision: external bevel incision (EBI)
*incisions directed towards the apex:
- intrasulcular incision
- internal bevel incision (GBI)
- right angle incision: placed at the same level as the bottom of the periodontal pocket
-tissue manipulation:
Polishing is only done on the root parts that have lost their fibrous attachments
Flaps should be limited to the minimum area necessary for access to exposed root surfaces.
-perfect elimination of granulation tissues
-careful detachment without tearing the tissues
-use suction to improve visibility
-use physiological serum irrigation to avoid bone decalcification.
-the sutures
– The surgical dressing:
Traditional zinc oxide eugenol dressing (to be avoided after surgery)
Eugenol-free dressing to which bacteriostatic and bactericidal substances are added (coé pack, peri pack)
The dressing has several roles (protection of the wound, stabilization of the flap and grafts)
-Post-operative advice:
-Inform the patient of any possible post-operative consequences (pain, etc.), as well as the importance of keeping the dressing in place
-Avoid high fiber diet and hard and spicy food about a week after the procedure
-Avoid heat sources and limit physical effort
-Prescription of diluted mouthwash, and continue brushing without touching the operated area
-Prescription of antibiotics, painkillers, if necessary
-Avoid aspirin
-post-operative care:
-removal of the first dressing after 7 days
-cleaning the site using cotton soaked in hydrogen peroxide
-if the wound is not completely epithelialized, a second dressing is placed
-schedule maintenance sessions
X-INSTRUMENTS AND MATERIALS FOR PERIODONTAL SURGERY
Special instruments exist for the type of surgery planned. They must be pre-packaged and sterilized as well as the materials used during the periodontal surgery procedure. Below is a 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 holders (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, Sutures 3/0, 4/0, 5/0, 6/0 with atraumatic curved needles, normal or reverse bevel needles. Sterile compresses
Aspirator tip, Physiological serum and disposable syringes for irrigation and washing of
lesions. Periodontal dressings.
PERIODONTAL SURGERY
XI-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 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.
XII-CONCLUSION:
The importance of periodontal diseases increases in the concerns of practitioners who must diagnose these conditions and treat them. Periodontal surgery is only part of the overall treatment plan. Any indication for surgical intervention must be preceded by a careful clinical examination in order to collect precise clinical data and consequently deduce precise objectives to be achieved.
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.