c hapter 14 periodontal surgery copyright © 2014, 2007, 2001, 1996 by saunders, an imprint of...

CHAPTER 14

Periodontal Surgery

Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

INTRODUCTION

Periodontal surgery has been used since early in the twentieth century to help control the progression of periodontal disease.

Although advances in root instrumentation techniques and antibiotic therapy have improved the available treatments for periodontal infections, periodontal surgery will continue to be a necessary procedure in the foreseeable future.

2


RATIONALE FOR PERIODONTAL SURGERY

Periodontal surgery is indicated to control the progression of periodontal destruction and attachment loss when more conservative nonsurgical treatments are not sufficient.

Periodontal surgery involves techniques that intentionally cut into soft tissues to control disease or change the size and shape of tissues.

3


ADVANTAGES OF PERIODONTAL SURGERY

The major benefit and indication for periodontal surgery is to gain access to root surfaces for scaling and root planing.

Surgery also improves access for patient control of plaque biofilm.

Other advantages of surgery include: Improving access to periodontal abscesses Exposing root surfaces for restorative dentistry Altering the position of the gingival margin to

improve patient esthetics

4


DISADVANTAGES AND CONTRAINDICATIONS OF PERIODONTAL SURGERY

A number of disadvantages and contraindications to periodontal surgery exist: Health status or age of the patient Specific limitations for each of the periodontal

surgical procedures From the patient’s perspective, the

disadvantages of surgery are time, cost, esthetics, and discomfort.

5


GENERAL CONSIDERATIONSFOR PERIODONTAL SURGERY

The following considerations must be made when periodontal surgical therapy is prescribed: Probing pocket depth Amount of bone loss Importance of the tooth to function Esthetics Patient’s level of plaque biofilm control Patient’s general health

6


PROBING POCKET DEPTH

A periodontal pocket is a deepened gingival sulcus with an infected root surface covered by an ulcerated epithelial surface with underlying inflamed connective tissue.

The pocket is coronally bound by the gingival margin on one side by the root surface, on the other side by the epithelial surface, and at the base by the junctional epithelium.

7


PROBING POCKET DEPTH (CONT.)

Scaling and root planing are effective in controlling periodontal disease to probing depths of approximately 4 mm.

Pockets deeper than 5 mm are difficult to instrument and often remain infected after the best dental hygiene care.

Pockets with probing depths greater than 9 mm suggest extreme loss of attachment, which makes the long-term prognosis for retaining the affected teeth poor.

8



Probing pocket depth is not always equal to clinical attachment loss.

The probing depth is the measurement from the crest of the gingival margin to the base of the pocket.

Attachment loss is measured from the cementoenamel junction to the base of the pocket.

9



If the gingival margin is on the root surface, as when recession has occurred, then the attachment loss is greater than the probing depth.

If the gingival margin is on the enamel surface of the crown, as in gingival hypertrophy, then the attachment loss is less than the probing depth.

Attachment loss represents bone destruction, which in turn affects the long-term prognosis of the tooth. 10



Although surgery may be needed to treat pockets deeper than 5 mm, not all of these pockets require surgery. The 5-mm guideline is only the first step in

identifying patients who may be helped by periodontal surgery.

11


BONE LOSS

The base of the periodontal pocket is not at the level of the crest of the alveolar bone.

Usually, 1 to 2 mm of connective tissue attachment covered by epithelium is between the probing depth and the alveolar bone.

This area is termed the biologic width and must be considered when estimating the amount of attachment remaining on a periodontally involved tooth.

12


BONE LOSS (CONT.)

Bone loss caused by periodontal disease results in osseous defects. These defects may occur in either a horizontal

dimension or a vertical dimension. A defect in the horizontal dimension occurs when

bone resorption is equal on the mesial and distal surfaces of the teeth.

A defect in the vertical dimension occurs when

bone resorption is unequal around the teeth.

13


BONE LOSS (CONT.)

Horizontal bone loss is demonstrated in the following figure.

14


BONE LOSS (CONT.)

Vertical bone loss is demonstrated in the following figure.

15


BONE LOSS (CONT.)

Pockets that are coronal to horizontal bone loss are often called suprabony pockets.

Pockets that extend apically beyond the crest of the bone are called infrabony pockets.

Vertical bone loss may also occur in a variety of configurations that are usually described by the number of bony walls remaining.

When all of the walls of the osseous defect are within the bone housing, the term is intrabony pocket. 16


BONE LOSS (CONT.)

The types of bony defects are demonstrated in the following figure.

17


BONE LOSS (CONT.)

The amount of bone remaining around a tooth is an important consideration in the decision to perform periodontal surgery.

Large amounts of bone supporting a tooth may allow the clinician to take a wait-and-see approach to postpone or avoid periodontal surgery.

If the amount of bone is already reduced, then delaying periodontal surgery may radically decrease the prognosis for the tooth.

18


BONE LOSS (CONT.)

This rationale is illustrated in the following figure.

19


BONE LOSS (CONT.)

Periodontal surgery that includes modification of the bone level or shape is called osseous surgery.

Generally, osseous surgery is indicated when at least one half of the bone support remains.

If too much bone has been lost, then osseous surgery becomes a less-attractive option.

20


BONE LOSS (CONT.)

Bone loss is demonstrated in the following figure.

21


VALUE OF THE TOOTH

Not all teeth have equal value when periodontal surgery is considered.

Some teeth cannot be saved, and others are not worth saving.

Third molars, for example, may be extracted without altering the patient’s chewing pattern.

In contrast, an abutment tooth for a bridge is important to the patient, and every attempt is made to save that particular tooth.

22


PERSONAL PLAQUE BIOFILM CONTROL OF THE PATIENT

Every patient should have established the best possible supragingival plaque biofilm control before surgical therapy is initiated.

If plaque biofilm control is poor, then surgical intervention should be postponed or abandoned because it will not prevent the recurrence of periodontal infection and the possible loss of teeth.

23


AGE AND HEALTH OF THE PATIENT

Patients who are in poor health are not good candidates for periodontal surgery.

However, the periodontal disease may contribute to the poor general physical condition, and the periodontist may decide, in concert with the patient’s physician, that periodontal surgery is appropriate.

24


AGE AND HEALTH OF THE PATIENT (CONT.)

Age, in itself, is not a contraindication to surgery.

Patients with pocket depths exceeding 5 mm and one half their supporting bone lost who are relatively young (younger than 30 years of age) have an aggressive form of periodontal disease— Surgery is strongly indicated.

Older patients (older than 60 years of age) with the same clinical conditions usually have a more slowly progressing disease— Surgery may be less critical for these patients.

25


PATIENT PREFERENCE

Some patients are reluctant to have periodontal surgery.

These patients need to know the ramifications of delaying periodontal surgery and the possible effects on the long-term prognosis of their teeth.

Patients who decide not to have surgery must be willing to undergo more frequent periodontal maintenance procedures and perform more complex subgingival plaque control in an effort to slow the progression of their disease. 26


TYPES OF PERIODONTAL SURGERY

Lang and Löe classified periodontal surgical procedures into five basic categories—procedures for:

1. Pocket reduction or elimination2. Access to the root surface3. Treatment of osseous defects4. Correcting mucogingival defects5. New attachment

27


PROCEDURES FOR POCKET REDUCTION OR ELIMINATION

The goal of pocket reduction surgery is to reduce periodontal pocket depth by removing soft tissues to a level at which plaque biofilm control and maintenance procedures are effective. This level does not usually exceed 3 to 4 mm in

depth. Methods for pocket reduction include:

Excisional periodontal surgery (gingivectomy)

Incisional periodontal surgery (flap)

28


EXCISIONAL PERIODONTAL SURGERY

Excisional periodontal surgery removes the excess tissue from the wall of the periodontal pocket.

This procedure is useful for the rapid reduction of gingival pockets.

The most basic excisional surgical procedures are termed: Gingivectomy—excision of the gingiva Gingivoplasty—surgical reshaping of the

gingival tissues

29


EXCISIONAL PERIODONTAL SURGERY (CONT.)

Indications for Excisional Periodontal Surgery The presence of deep periodontal pockets

with thick fibrous tissue is the major indication for gingivectomy. Drug-induced gingival hyperplasia is treated by

this form of excisional surgery. Other indications include:

Familial gingival hyperplasia Localized crown lengthening for restorative

dentistry

30



Procedure for Excisional Periodontal Surgery During gingivectomy, the surgeon marks the

bottom of the pockets with a periodontal probe or forceps.

The gingiva is excised with knives at a 45-degree angle to the gingival surface, keeping the incision within the keratinized gingiva.

After the removal of a majority of the gingival tissues, the underlying exposed connective tissue is refined and trimmed with knives, burs, or other instruments.

31



Procedure for Excisional Periodontal Surgery (cont.)

Exposed root surfaces are cleaned and smoothed as necessary with curettes.

The surgical area is packed with a periodontal dressing to reduce postoperative discomfort and to protect the underlying connective tissue.

The gingival epithelium is reestablished approximately 2 weeks after surgery.

32



The gingivectomy procedure is demonstrated in the following figure.

33



Contraindications for Excisional Periodontal Surgery

The procedure does not permit access to infrabony pockets.

Healing is relatively slow. Postoperative discomfort is significant. The anatomy may prevent incising the

tissues at the proper angle.

34



Contraindications for Excisional Periodontal Surgery (cont.) Minimal width of attached gingiva may prevent

keeping the incision within the keratinized tissue. The procedure exposes root surfaces, which may:

Result in unacceptable esthetics Leave the teeth sensitive to heat and cold Leave the teeth susceptible to root caries

35



Contraindications for excisional periodontal surgery are illustrated in the following figure.

36


INCISIONAL PERIODONTAL SURGERY

Incisional surgery is called periodontal flap surgery or simply flap surgery.

The tissues are pushed away from the underlying tooth roots and alveolar bone. The alveolar bone may be resected or modified

during the surgical procedure. The incisional technique for pocket reduction

with flap surgery is called the apically positioned flap.

37


INCISIONAL PERIODONTAL SURGERY (CONT.)

Indications for Incisional Periodontal Surgery Deepened periodontal pockets, which are

contraindicated for gingivectomy, are the primary indication for incisional surgery.

Suprabony pockets are often best treated by flap surgery.

38



Procedure for Incisional Periodontal Surgery After the anesthesia is administered, the

pockets are probed to determine their depths, and the bony contours are “sounded” by pushing the periodontal probe through the tissues until the crest of the alveolar bone is detected.

The surgeon uses this information to design the incision around the necks of the teeth to retain as much tissue as possible while allowing for pocket reduction.

39



Procedure for Incisional Periodontal Surgery (cont.)

Flaps of gingiva are pushed away from the alveolar bone and teeth, usually on the buccal and lingual surfaces, with a periosteal elevator.

Infected epithelium, connective tissue, and granulation tissues are removed with curettes, scalers, and ultrasonic instruments.

Residual calculus is cleaned, and roots are smoothed as necessary.

The flaps are then readapted at a more apical level to reduce the pockets.

40



Procedure for Incisional Periodontal Surgery (cont.)

The surgeon may reduce the bony ledges or may further elevate the flaps past the mucogingival junction to position it for proper adaptation.

The surgical wound is closed by suturing the flaps together in the interproximal papillae.

A periodontal dressing may be applied to help adapt the gingiva to the alveolar bone.

41



The incisional periodontal surgery procedure is illustrated in the following figure.

42



Contraindications for Incisional Periodontal Surgery

The gingival tissues must be wide and thick enough to allow for proper incision.

Apically positioned gingival flaps expose root surfaces. Positioning may have to be altered for esthetics

or for patients who are prone to caries. Fluoride mouth rinses should be

recommended to reduce the potential for root caries.

43



Special modifications of pocket reduction surgery include combinations of incisional and excisional techniques, such as distal wedge surgery and internal beveled gingivectomy.

These techniques are indicated in specific areas, such as the palatal tuberosity region or where tissues are thick and not easily managed by one method alone.

44



The distal wedge procedure is demonstrated in the following figure.

45


PROCEDURES FOR GAINING ACCESSTO THE ROOT SURFACE

The goal of access flap procedures is to provide access to the root surfaces for débridement and to create conditions for the reattachment of the gingival tissues to the root.

These access procedures include the: Modified Widman flap Excisional new attachment procedure Open-flap curettage

46


PROCEDURES FOR GAINING ACCESSTO THE ROOT SURFACE (CONT.)

Most of these procedures are similar and differ only in the details of the technique.

The goal of all these procedures is the same: To gain access to the root surface for plaque

biofilm and calculus removal, including scaling and root planing.

Pocket reduction by apical positioning is not the goal of access flap procedures.

47



Indications for Access Flap Procedures Access flap procedures are used to treat

periodontal pockets in esthetically sensitive areas or where pocket reduction is not desired or indicated.

Many periodontists perform access flap procedures rather than pocket reduction procedures because little data support the belief that reducing the pocket depths through surgery extends the life of the teeth.

48



Procedure for Access Flap Procedures Incisions are made through the crest of the

gingiva, and the gingival tissues are reflected only far enough to allow the clinician to see the root surfaces and the crest of the alveolar bone.

After complete débridement is performed, the gingival flaps are readapted to recover the roots.

The major goal is reattachment of the connective tissues to the root surface during healing or the creation of a long junctional epithelium, resulting in increased attachment for the teeth.

49



A modified Widman flap procedure is demonstrated in the following figure.

50



51



Contraindications for Access Flap Procedures No specific contraindications exist to access

flap procedures. The patient should understand that pocket

depths may continue to be greater than 3 or 4 mm after therapy.

52


PROCEDURES FOR THE TREATMENTOF OSSEOUS DEFECTS

Periodontitis, by definition, involves the loss of the connective tissue attachment to the root surface of the tooth and loss of alveolar bone. This bone loss creates osseous defects around

the teeth. During osseous surgical procedures, the

periodontist sculpts the alveolar bone with chisels or specially designed dental burs to remove these osseous defects or allow for apical positioning of the flaps.

53


PROCEDURES FOR THE TREATMENTOF OSSEOUS DEFECTS (CONT.)

If alveolar bone is removed that contains periodontal fibers that support the tooth, then the procedure is termed ostectomy.

If only bony ledges or nonsupporting bone is removed, then the procedure is termed osteoplasty.

54


PROCEDURES FOR THE TREATMENTOF OSSEOUS DEFECTS (CONT.)

Osseous recontouring is illustrated in the following figure.

55


OSSEOUS DEFECTS

Indications for Surgically Treating Osseous Defects

Periodontal pockets extend below the level of the osseous crest or infrabony pockets.

Thick bony ledges prevent the gingival flap from being adapted at a more apical level.

Reverse alveolar bony architecture is present. Bone loss, in which the interproximal bone is

apical to the facial and lingual bone, is the reverse of the configuration of alveolar bony architecture in periodontal health. 56


OSSEOUS DEFECTS (CONT.)

The reverse bony architecture and the procedure to correct it are presented in the following figure.

57



Procedure for Surgically Treating Osseous Defects

The mucoperiosteal flaps are elevated. Bony ledges and craters are modified with

burs and chisels. This modification allows the overlying gingiva to

follow a more physiologic contour. If possible, the walls of bony craters are

removed. Ledges are thinned, and interproximal bony

regions are fluted to a form more generally found in periodontal health. 58



Bone loss associated with a lingual groove, access flap surgery, and bone recontouring are presented in the following figure.

59



60


PROCEDURES FOR CORRECTING MUCOGINGIVAL DEFECTS

Periodontal disease often causes deformities in the oral tissues because of the recession of the marginal gingiva and the development of fissures and clefts.

Recession can lead to extension of the periodontal pocket beyond the mucogingival junction, resulting in no attached gingiva existing on the tooth surface. These areas are called mucogingival defects.

61


PROCEDURES FOR CORRECTING MUCOGINGIVAL DEFECTS (CONT.)

A mucogingival defect and its corrective surgery are presented in the following figure.

62


PROCEDURES FOR CORRECTING MUCOGINGIVAL DEFECTS (CONT.)

Mucogingival surgery includes a variety of periodontal plastic surgery–type procedures. These include: Augmenting the thickness of keratinized gingival

tissues Increasing the zone of attached gingiva Covering recessed root surfaces

Recession is treated by either pedicle grafts or free mucosal grafts. Connective tissue grafts have recently

been used. Augmenting edentulous spaces 63


MUCOGINGIVAL DEFECTS

Indications for Mucogingival Surgery Areas of recession have significantly reduced

the width of the keratinized gingiva or have progressed beyond the mucogingival junction.

Is possibly indicated before orthodontic tooth movement.

Broad labial or lingual frenum attachments near the gingival margin may result in diastemata.

Shallow vestibular depth must be deepened to improve the fit and retention of removable dental prostheses.

64


MUCOGINGIVAL DEFECTS (CONT.)

Procedure for Mucogingival Surgery The procedures differ, depending on the

specific mucogingival problem. The most common procedures are:

Lateral pedicle gingival graft Free autogenous gingival graft Subgingival connective tissue graft

65



Lateral Pedicle Gingival Grafts This procedure slides gingival tissue from an

adjacent tooth or papilla. It is dependent on an adequate source of tissue

adjacent to the area that needs augmentation. A risk of causing gingival recession to the donor

site exists. The donor pedicle is dissected from the

underlying periosteal bed, rotated to the recipient site, and sutured in place.

66



Free Autogenous Gingival Grafts Donor sites are located somewhere in the

mouth. The most common site is the palate, but

edentulous areas are also used. The recipient site is prepared in a manner

similar to the pedicle graft site. Surgical excision removes a donor graft of

keratinized epithelium with some underlying connective tissue.

The graft is sutured in place and held with firm pressure until the initial blood clot forms to stabilize the graft.

67



Subgingival (Subepithelial) Connective Tissue Graft

Grafting subepithelial connective tissue has become the procedure of choice when root coverage is the objective of mucogingival surgery.

Advantages of subepithelial connective tissue grafting include: Postoperative discomfort and bleeding are

reduced. Tissue color and texture are more similar to the

preoperative appearance. 68



Contraindications for Mucogingival Surgery Lack of donor tissue Lack of adequate keratinized tissue at the

recipient site

69


PROCEDURES FOR REGENERATIONOF THE PERIODONTIUM

Regeneration surgery procedures include a variety of surgical techniques that attempt to restore the periodontal tissues lost through disease.

Periodontal regeneration is the formation of new alveolar bone, new cementum, and new periodontal ligament on a tooth root surface that was previously diseased.

Current techniques include bone grafting and guided-tissue regeneration.

70


PERIODONTAL BONE GRAFTING

Transplanting bone to restore bone lost from periodontal disease has been attempted for many years. Only in the last 20 years has it been a

reasonably predictable procedure. The anatomy of the periodontal defect is the

most critical factor in determining the success of bone grafting.

The classification of periodontal bone grafts is based on the source of graft material.

71


AUTOGRAFTS

Autografts are created from donor bone from the patient’s own body.

Bone may be taken from intraoral sites, such as mandibular tori, the maxillary tuberosity, or bone removed during osteoplasty. The small amount of donor material limits

intraoral grafts. Bone may also be taken from extraoral sites,

such as the iliac crest of the hip or the sternum. Problems may occur with obtaining the graft, and

the possibility of root resorption makes the graft less useful.

72


ALLOGRAFTS

Allografts are created from bone that comes from another person.

Cadaver bone, obtained from bone banks accredited by the American Association of Tissue Banks, is the most common source of bone allografts used in periodontics.

The best clinical results have been obtained with bone that has been freeze-dried and demineralized with hydrochloric acid.

73


ALLOPLASTS

Alloplastic grafts use a variety of synthetic bone minerals: Hydroxyapatite mineral or ceramics, such as

plaster of Paris and tricalcium phosphate Porous hydroxyapatite appears to be the

most successful material.

74


XENOGRAFTS

Xenografts are created from bone taken from another species, such as bovine (cow) or porcine (pig) bone.

Tissues from nonhuman species have strong antigenic reactions with human graft recipients.

The most successful use of these materials has been as fillers for large osseous defects, using graft material with all organic tissue chemically removed.

75


PERIODONTAL BONE GRAFTING

Indications for Periodontal Bone Grafting Bone grafting in infrabony defects shows a

potential for regeneration. Infrabony defects, ideally three-wall defects,

usually have sufficient osseous walls to promote healing.

Furcation defects, particularly mandibular molar buccal furcations of grade II (not through-and-through), are often good candidates for bone regeneration with osseous grafts.

76


PERIODONTAL BONE GRAFTING (CONT.)

Procedure for Periodontal Bone Grafting Full-thickness mucoperiosteal flaps are

elevated. All granulation tissues are removed with

curettes. The bone graft material is prepared

according to the distributor’s instructions or harvested from the donor site and inserted into the defects.

The best results appear to be obtained with primary closure of the flaps over the wound site.

77



Radiographic images show the successful result of a bone grafting procedure in the following figure.

78



Contraindications for Periodontal Bone Grafting No specific contraindications exist to bone fill

procedures. The most predictable bone fills occur in

patients who have a maximum number of bony walls, improving the chances of success.

79


GUIDED-TISSUE REGENERATION

Guided-tissue regeneration, or healing by selected cell repopulation, is a technique that permits the primary healing cells to proliferate from the alveolar bone and periodontal ligament rather than from the growth of epithelium from the gingiva.

A barrier membrane, which excludes epithelial cells, is placed between the periodontal flap and the alveolar bone; only cells from the periodontal ligament space and the medullary bone are allowed to repopulate the site of lost tissue. 80


GUIDED-TISSUE REGENERATION (CONT.)

Guided-tissue regeneration selectively causes a new attachment apparatus to grow.

A number of materials have been suggested for these barriers including: Expanded polytetrafluoroethylene (ePTFE)

membranes Polylactic acid with citric acid ester membranes

81



Indications for Guided-Tissue Regeneration Infrabony defects and furcations appear to be

the best candidates for guided-tissue regeneration.

In general, osseous lesions that are likely to respond well to other forms of bone fill or grafting are also the most promising sites for guided-tissue regeneration.

82



Procedure for Guided-Tissue Regeneration Flaps are reflected, and débridement of the

intraosseous lesion occurs. A membrane is placed over the opening in

the bone or furcation and fastened to the tooth by suture or other stabilizing methods.

The epithelium is closed over the membrane and allowed to heal for of 30 to 60 days.

When nonresorbable ePTFE material is used, the membrane must be surgically removed.

The polylactic acid material resorbs through hydrolysis in 6 to 12 months. 83



A guided-tissue regeneration procedure is illustrated in the following figure.

84


PROCEDURES IMMEDIATELYAFTER PERIODONTAL SURGERY

A number of procedures are required to complete the periodontal surgery.

These procedures include closing the wound with the placement of sutures, possibly covering the surgical wound with a protective dressing called a periodontal pack, and providing the patient with postoperative instructions.

85


PROCEDURES IMMEDIATELYAFTER PERIODONTAL SURGERY (CONT.)

Sutures Sutures are required to close periodontal

surgical wounds and to secure grafts in position.

If a nonresorbable suture material is placed, then the sutures must be removed in 7 to 14 days.

Resorbable sutures are designed to dissolve in tissue fluids, but they do not always dissolve and may require removal.

86



Many techniques are used for suturing periodontal flaps and grafts. Simple stitches

These are termed interrupted sutures. Complex sling sutures

These sutures use the teeth for an anchor. Mattress sutures

These sutures allow flaps to be placed in a variety of positions.

87



Basic Rules for Sutures Suture knots for any type or style of suture

are tied on the buccal surface. At least 2 or 3 mm of suture “tail” should be

left beyond the knot. The location and number of sutures placed

must be documented in the patient’s chart. During removal of the sutures, documenting the

location and number of sutures prevents the possibility of missing a suture.

88



Periodontal Dressing A periodontal dressing or pack is

sometimes placed over the sutures to hold the flaps tightly to the teeth and underlying bone when pocket-reduction surgery has been performed.

Periodontal dressing is also used after excisional surgery, such as gingivectomy, to protect the surgical wound from the oral environment and to increase patient comfort during healing.

89



Periodontal Dressing (cont.) The most common type of periodontal

dressing consists of a paste mixture that chemically sets to a firm, rubbery consistency.

A light-cured product is available that allows the working and setting times to be more precisely controlled.

Whatever dressing is selected, it is mixed according to the manufacturer’s instructions and placed in a thin ribbon around the necks of the teeth.

90



Periodontal Dressing (cont.) Periodontal dressing should be compressed

into the interproximal spaces for a mechanical lock. The material should not extend coronally to the

height of contour of the teeth. Bleeding must be controlled before a

periodontal dressing is placed; the pack will not control bleeding.

91



The use of the periodontal dressing is demonstrated in the following figure.

92


POSTOPERATIVE INSTRUCTIONSAND PROCEDURES

After periodontal surgery, postoperative procedures may include a prescription for an analgesic and possibly an antibiotic.

Many periodontists recommend the use of a disinfectant rinse twice a day to help with plaque biofilm control. A chlorhexidine or essential oil mouthwash may

be used to freshen the mouth and inhibit plaque.

93


POSTOPERATIVE INSTRUCTIONSAND PROCEDURES (CONT.)

Postoperative instructions Limiting physical activity Control bleeding with light finger pressure on a

gauze sponge in the area of surgery Soft diet for the first few days Review of any prescriptions for medications with

the patient

94



Postoperative instructions (cont.) Portions of the periodontal dressing may

break off. Swelling may occur.

An ice pack can be used for short intervals for the first few hours after surgery.

Smoking should be avoided. The surgical site should be cleaned with an

extra soft toothbrush, using warm water and gentle interproximal cleaning. Unaffected teeth should be cleaned normally.

95



Postoperative instructions (cont.) The patient must be given a list of

postoperative instructions that include a telephone number if problems arise.

The patient should be urged to contact the office if any problems develop or questions arise.

A postoperative visit should be scheduled for approximately 7 days after the surgery.

96



A sample postoperative instruction sheet is demonstrated in the following figure.

97


POSTOPERATIVE TREATMENT

At the postoperative appointment, the patient is examined, the periodontal dressing and sutures are removed, and the surgical site is cleaned.

The wound is usually well epithelialized by 7 to 10 days after surgery.

98


POSTOPERATIVE TREATMENT (CONT.)

A surgical site with the periodontal dressing, sutures, and accumulated plaque removed after 1 week is demonstrated in the following figure.

99


POSTOPERATIVE TREATMENT (CONT.)

Homecare instructions for plaque biofilm control should be reviewed. Interproximal brushes may be indicated. Dental floss should be carefully used to avoid

damaging the healing junctional epithelium and connective tissue attachment.

Tooth sensitivity, especially to cold, is common. Use of home fluoride gels or rinses and

desensitizing toothpastes should be suggested. Topical desensitizing office treatments with

potassium oxalate or ferric oxalate may help with hypersensitivity. 100


HEALING AFTER PERIODONTAL SURGERY

Healing of the periodontal surgical wound begins shortly after the procedure is completed. Gingivectomy wounds require slightly more time

to heal than flap procedures. A blood clot forms at the surgical site,

protecting the wound and allowing the tissue to begin to heal.

The epithelial cells are the first to heal.

101


HEALING AFTER PERIODONTAL SURGERY (CONT.)

Connective tissue healing begins after the epithelium has begun to heal.

Osseous healing does not begin until late in the healing process. Bone grafting procedures usually take more time

for healing than other osseous procedures.

102



The clinical appearance of an access flap procedure after 1 week is demonstrated in the following figure.

103



Healing 3 months after periodontal surgery is demonstrated in the following figure.

104



Long epithelial attachments form coronally, and new connective tissue attachments form only at the most apical levels of the pocket, as illustrated in the following figure.

105


ROLE OF THE DENTAL HYGIENISTIN PERIODONTAL SURGERY

The dental hygienist may be the most appropriate member of the dental team to discuss the advantages and disadvantages of surgical treatment with the patient. The periodontist or dentist is legally charged with

the responsibility of informing the patient of the risks, benefits, and alternatives to periodontal surgery.

106


ROLE OF THE DENTAL HYGIENIST IN PERIODONTAL SURGERY (CONT.)

The dental hygienist often provides postoperative care, including suture and dressing removal, postsurgical biofilm removal, follow-up wound care, and homecare instructions.

The success of periodontal surgery primarily depends on long-term plaque biofilm control by the patient.

107


c hapter 14 periodontal surgery copyright © 2014, 2007, 2001, 1996 by saunders, an imprint of...

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