Principles of periodontal surgery

Similar to the general principles of surgery, there are three primary objectives which should be achieved during periodontal surgery, including inflicting the wound without pain, adequate control of bleeding during the procedure and adequate healing of the wound following the procedure. Adequate asepsis and gentle handling of the tissue during the procedure ensure appropriate post-operative healing. Asepsis, sterilization, as well as aseptic conduct by the operator, are the fundamental requirements of periodontal surgical procedures. The surgical procedure should be carried out in an environment which is conducive to patient comfort and appropriate post-operative healing.

Rationale for the periodontal surgical therapy

Access to root surfaces and alveolar bone:

Surgical periodontal therapy is primarily done to get access to the root surfaces of the teeth and alveolar bone defects. It facilitates the removal of hard deposits from the root surfaces and allows appropriate root surface treatment. Surgical intervention facilitates access to the bone defects and allows execution of appropriate resective or regenerative procedures. Bony recontouring is done to achieve physiologically acceptable bone architecture, conducive for the maintenance of periodontal health.

Periodontal pocket reduction:

Periodontitis is characterized by the formation of periodontal pockets, thereby resulting in the loss of periodontal support. One major rationale for surgical periodontal therapy is to eliminate or reduce periodontal pockets. Elimination of the pocket lining and granulation tissue can be done effectively by the surgical intervention. Furcation involvement due to the progression of the inflammatory periodontal disease is a poor prognostic factor for a tooth. Various surgical procedures are intended to eliminate or manage furcation involvement.

Regenerative periodontal therapy:

Regeneration of the lost periodontal tissue is one major objective of the periodontal treatment. Various periodontal regenerative therapies can be executed only by getting access to the periodontal bone defects.

Correction of mucogingival problems:

Loss of soft tissue around the teeth such as in the case of recession can be effectively treated by periodontal esthetic surgeries. Surgical intervention is required to increase the width of attached gingiva in the areas with minimal attached gingiva.

To prepare for restorative dentistry:

Teeth with insufficient crown length are prepared for restoration by recontouring of the alveolar bone. If the biological width around the tooth is not maintained, it can result in persistent inflammation in that area.

Fundamental principles of periodontal surgery

The clinicians should have a thorough knowledge of the principles followed during periodontal surgery so that any unwanted event during or after the surgery can be avoided. The following principles are followed during surgical periodontal therapy,

  • Pre-operative evaluation of the patient
  • Informed consent
  • Pre-medication
  • Asepsis and disinfection
  • Preparation of the operating room, operating team and the patient
  • Local anesthesia
  • Management of emergencies
  • Intra-operative management of the patient
    • Soft tissue management
    • Hemostasis
    • Bone reshaping
    • Suturing
    • Periodontal dressing
  • Post-operative instructions to the patient

Let us now discuss these principles in detail,

Pre-operative evaluation of the patient

Plaque accumulation in the area to be operated can severely jeopardize healing. The preparation of the patient for surgical periodontal therapy is primarily aimed at the removal of all local factors and patient education regarding the maintenance of good oral hygiene. In other words, we can say that it is the re-evaluation of phase I periodontal therapy. Before operating on the patient, it must be made sure that the patient is maintaining an adequate oral hygiene. There should be minimal gingival inflammation so that tissue handling is easy and bleeding is minimal during the surgical procedure. The oral hygiene status and gingival inflammation can be assessed by quantifying plaque accumulation 1, 2 and the presence of bleeding on probing, respectively. Tonetti et al. (1995) 3 and Lang (1996) 4 have recommended that………………………

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A complete medical and dental history of the patient should be thoroughly reviewed before making a treatment plan for surgical intervention. The radiographs should be re-evaluated and periodontal probing should be done to accurately assess the present status of the patient. If the patient is suffering from conditions like uncontrolled diabetes or has hypertension, such conditions should be addressed first and then surgical treatment should be planned. A careful medical history should be recorded for patients who had congestive heart failure in the past. Patients with bleeding disorders should be evaluated for their condition, and if required, the patient should be referred to the physician. A written consent should be taken from the patient’s physician regarding the surgical procedure.

In addition to this, the patient with medical problems may be taking numerous medicines that may affect dental procedures and have oral manifestations. Medically compromised patients are commonly on medications like anticoagulants, beta blockers, calcium channel blockers, diuretics, etc. Any potential drug interaction should be taken into consideration during treatment planning.

Informed consent

An informed consent should be taken from the patient before the treatment. The patient should be clearly explained the benefits and possible risks/complications of any proposed procedure. The patient should also be explained the alternatives to surgical procedures so that after knowing the benefits of the surgical procedure over other procedures, the patient gives the consent to the surgical procedure. The informed consent should be in a language, the patient can understand. The informed consent should be attached to the patient’s record and a copy of the signed document should be given to the patient.

Pre-medication

Antibiotics:

Medically compromised patients, such as patients at a risk of developing bacterial endocarditis or patient with joint replacement surgery, need to be given antibiotic prophylaxis before any periodontal treatment that may cause bacteremia. Premedication with antibiotics needs to be provided for the following conditions,

  • Congenital heart disease
  • Bacterial endocarditis
  • Mitral valve prolapse syndrome with mitral insufficiency
  • Prosthetic heart valves
  • Cardiac transplantation recipients who develop cardiac valvulopathy.
  • Patients who have undergone joint replacement surgery
  • Immunocompromised patients (along with physician’s consultation).

A detailed description of antibiotic prophylaxis required for the above conditions has been discussed in detail in chapter 32 “Periodontal treatment of medically compromised patients”.

In patients, who are not medically compromised, using antibiotics as premedication has been recommended in bone grafting procedures. It has been proposed to enhance the chances of new attachment. However, no scientific evidence is available to support it 9.

Anxiolytics:

For patients who are not medically compromised, the most common pre-medication drugs given are sedatives to reduce anxiety. These drugs are indicated in apprehensive and neurotic patients to reduce the level of anxiety. The anxiolytic drugs used include sedatives (Table 56.1), hypnotics, tranquilizers or barbiturates. These may be given through oral, intramuscular or intravenous routes. 5-10 mg of diazepam the night before and 1-2 hours before the treatment is commonly prescribed anxiolytic drug.  Some authors use inhalatory sedation in the form of nitrous oxide/oxygen 10.

Table 56.1 Commonly used oral benzodiazepines as premedication

[table “134” not found /]

Antiseptics:

Chlorhexidine gluconate is the drug of choice for pre-surgical mouth rinses. It reduces the bacterial load and is continued postoperatively for plaque control.

Non-steroidal anti-inflammatory drugs (NSAIDs):

The rationale for using NSAIDs as pre-medication before periodontal surgery is focused on the reduction of chemical inflammatory mediators (PGs) involved in pain. Ibuprofen, ketorolac, aceclofenac etc. are the commonly used NSAIDs as pre-medication.

Asepsis and disinfection

Serialization and disinfection of instruments and clinical items:

The instruments and clinical items which are involved during surgical procedures have been divided into three categories by the Centers for Disease Control and Prevention (CDC) 2003 as 11 (Table 56.2),

  • Critical items
  • Semi-critical items
  • Non-critical items

Critical items:

Those instruments/items which are used to penetrate soft tissue or bone during the surgical procedure are included in critical items category. These carry a higher risk of disease transmission and must be sterilized before the surgical procedure.

Semi-critical items:

These are the instruments/items which come in contact with the mucous membrane but are not used to penetrate soft tissues or contact bone. The instruments in this category include mouth mirror and instruments used for restoration of teeth. Although the risk of disease transmission is intermediate with these instruments, these must be sterilized in the same way as critical items.  Semi-critical items which are susceptible to heat damage should be subjected to high-level disinfection with agents registered with the US Food and Drug Administration (FDA) as chemical sterilants / high-level disinfectants.

Non-critical items:

These are the items that come in contact with the intact skin only, such as the dental chair. These carry a low risk of disease transmission and intermediate-level disinfection should be used to disinfect these items before and after the surgical procedure to minimize the risk of disease transmission.

Table 56.2 Dental instrument classification according to CDC categories

[table “135” not found /]

Know more………………

Disposable items:

The items which cannot be sterilized adequately or have not been designed to be reused should be disposed off. These items include local anesthesia cartridges, saliva ejectors, paper cups,brushes and prophylaxis cups, scalpel blades, needles, matrix bands, gloves, and sutures.

 

For the ease of understanding, the basic sterilization and disinfection procedures followed during periodontal surgical treatment can be discussed under the following headings,

  1. Sterilization of instruments
  2. Sterilization of handpieces
  3. Dental chair disinfection
  4. Waterlines asepsis
  5. Suction / Evacuation system asepsis

Sterilization of the instruments:

Sterilization is the removal of all microorganisms and their spores and other pathogens from an object or surface by treating it with chemicals or subjecting it to high heat or radiation. There are various methods used for sterilization of instruments (Table 56.3) including,

  • High temperature/pressure sterilization (autoclave)
  • Chemical sterilization
  • Radiation sterilization

Table 56.3 Various sterilization techniques

[table “136” not found /]

High temperature/pressure sterilization:

All the critical and semi-critical items used during periodontal surgery, which can withstand steam/chemical vapor under pressure or dry heat should be sterilized using these techniques.

Steam autoclave:

The most common method used for sterilization is the application of steam under pressure (Figure 56.1). Steam in itself is inadequate for…………………….

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Appropriate indicators must be used each time to make sure that complete sterilization has been accomplished. The sterilization time varies with the variations in temperature and pressure of the steam (Table 56.4).

Figure 56.1 Front loading autoclave with dry cycle

Front loading autoclave

Dry heat:

In this method of sterilization, items are kept at 160-170°C for a minimum of two hours (Figure 56.2). Due to its high temperatures, its applicable use is limited. The sterilization time varies at different temperatures during dry heat sterilization (Table 56.4).

Figure 56.2 Hot air Owen used for dry heat sterilization of instruments

Hot air Owen

Table 56.4 Sterilization cycles for steam and dry heat sterilization

[table “137” not found /]

Know more……….

Biological indicators (BI’s) used to ensure sterilization:

Although, modern autoclaves have gauges or displays which indicate sterilization cycle time, temperature and pressure, the most authentic method to confirm complete sterilization is by the BI’s.

The BI’s are used to ensure that complete sterilization has been achieved after the recommended sterilization cycle is complete. BI’s contain the bacterial spores of some of the most resistant bacteria: Geobacillus stearothermophilus (for testing steam or chemical vapor sterilization) or Bacillus subtilis (for testing dry heat or ethylene oxide gas sterilization). Because these bacterial spores are more resistant than……………………….

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Chemical sterilization:

Ethylene oxide gas:

Ethylene oxide can be used to sterilize items that are heat or moisture sensitive. It kills microorganisms, including spores, but the sterilization time is longer than steam sterilization and ranges from 16-18 hours for a complete cycle. Temperatures reached during sterilization are usually in the range of 50-60°C. Because ethylene oxide is highly inflammable, it is used in the explosion-proof sterilizing chamber in a controlled environment.

Low temperature hydrogen peroxide plasma (Sterrad®):

This system uses hydrogen peroxide plasma as the active medium for sterilization. Plasma is ionized gas made up of ions and electrons and is distinguishable from solid, liquid, or gas. This system works at a temperature range of 45-50°C with sterilization time ranging from 45-70 minutes. H2O2 is bactericidal and is capable of inactivating resistant bacterial spores. The sterilization cycle occurs in two stages. In first stage air from the sterilization chamber is removed and a vacuum is created. Then, an aqueous solution of H2O2 is injected and vaporized into the chamber. It diffuses in the sterilization chamber and comes in contact with the surface of various items where it causes bacterial killing.  After this, radio frequency (RF) energy is applied in the chamber which creates an electric field and thus forms a low temperature plasma. It causes ionization of the H2O2 molecules, creating free radicals which actively kill the micro-organisms.

Steris System 1®:

It is another low temperature sterilization system that uses a peracetic acid solution (Steris 20â„¢  Sterilant) to destroy potentially dangerous microorganisms. This process is achieved at a temperature of 50-56°C. The process of sterilization is carried out with a Steris 20â„¢ Sterilant concentrate mixed with sterile water to make a solution which is introduced into sterilization chamber. The sterilization cycle is completed in 12 minutes, followed by repetitive sterile water rinses to complete the process. The total sterilization procedure is completed in 30 minutes. The bactericidal action of peracetic acid is because of the presence of the extra oxygen atom attached to acetic acid, which reacts with most cellular components to destroy cells. Items which are immersible and which cannot be sterilized by heat or moist heat application are sterilized by this method.

Cidex® OPA solution:

It is a high level disinfectant which contains ortho-phthalaldehyde (OPA) as the active ingredient. It provides a high level of disinfection at room temperature (20⁰ C) in 12 minutes. The solution is particularly active against…………………….

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VHP® MD Series:

It is a vaporized Hydrogen Peroxide (VHP) sterilization system. It uses the oxidation potential of H2O2 molecules to kill microorganisms.

Ozone Gas:

It is a form of oxygen that kills microorganisms by oxidation. It penetrates membrane of the cells and causes irreversible damage to the membrane, resulting in cell death. It is an unstable gas, which can be easily generated from oxygen. It is introduced into the sterilization chamber in 6 to 12 percent concentration. Its activity can be enhanced by adding humidity. At the completion of exposure time, oxygen is allowed to flow through the chamber to purge the ozone. A complete sterilization cycle may take up to 60 minutes, depending on the size of the chamber or load.

Radiation sterilization:

Sterilization can also be achieved by the application of electromagnetic radiations. Two types of radiation are used for sterilization purpose: ionizing and non-ionizing. Ionizing radiations are high energy radiations with a good penetrative power. On the other hand non-ionizing radiations have low energy and low penetrative power.

Non-ionizing radiations:

These are radiations with a longer wavelength than visible light. For space disinfection radiation are used with wavelength ranging from 200-280 nm, with 260 nm being most effective. UV radiations are commonly used non-ionizing radiations for space disinfection. These are generated using a high-pressure mercury vapor lamp. UV rays induce formation of thymine-thymine dimers, which ultimately inhibits DNA replication. These rays inactivate micro-organisms such as bacteria, viruses, yeast, etc. within seconds.  These are not capable of killing spores, so are used only for surface disinfection.

Ionizing radiations:

There are primarily two types of electromagnetic rays utilized for the purpose of sterilization: electron beams and γ-radiation. The electron beam is made up of high speed electrons which are produced by a linear accelerator from a heated cathode. Electron beam has a poor penetration power and can be used for the sterilization of articles like syringes, gloves and dressing packs. γ-rays are produced by nuclear disintegration of certain radioactive isotopes such as (Co 60, Cs137). These have more penetration power as compared to an electron beam, but require a longer time of exposure. These radiations damage the nucleic acids of microorganisms, thus destroying them.

Sterilization of handpieces:

Handpieces should be sterilized according to the manufacturer’s instruction. However, the following steps are commonly followed during handpiece sterilization,

Air-rotor handpiece:

After use, the first step in sterilization of the handpiece is lightly washing the handpiece under cool running water to remove excess debris. The air rotor handpiece is then lubricated by applying appropriate multiflex nozzle. A paper towel is put over the handpiece head for 20 seconds to expel excess lubricant. The handpiece is then connected to multiflex connection and is activated for 30-40 seconds. Bur is removed from the chuck of the handpiece. The external surface of the handpiece is cleaned with isopropyl alcohol. The handpiece is dried thoroughly and sterilized in the autoclave at maximum of 135⁰C. It is then allowed to dry thoroughly to complete the sterilization cycle.

Scaler handpiece:

After use on the patient, scaler inserts are soaked in a container containing…………………………

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Dental chair disinfection:

Dental chair may be a potential source of infection dissemination and should be disinfected before and after the patient’s treatment. Preferably, dental chair should be foot controlled and should allow adjustment by food paddle at any point of time during treatment. A barrier film must be placed over the hand controls on the chair. At the conclusion of an appointment all the surfaces of the dental chair must be wiped clean with neutral detergent and water and/or detergent wipes. The single use barrier film may be used in addition to this procedure, but must not be used instead of this procedure. The light of the dental chair should be pre-adjusted and preferably should have sensor controlled non-touching device. Only the handles of the overhead light should be touched, and these must be covered with a barrier film. In between the appointments, the light handles should be wiped clean with neutral detergent and water and/or detergent wipes and new barrier film should be placed. The chair headrests and difficult to clean areas such as triple syringe buttons should also be covered with a barrier film.

Waterlines asepsis:

The maintenance of waterlines is essential to ensure optimal water quality in the dental unit. It has been shown that the level of microorganisms in untreated dental unit waterlines is greater than 500 CFU/ml, which exceeds the drinking water standard. The microbial biofilm develops in the water tubing may put the patient at a risk of getting infected. CDC (1993) recommended flushing of dental waterlines at the beginning of the clinic day to reduce the microbial load. As a general rule water and suction lines must be flushed for a minimum of 2 minutes at the start of the day and for 30 seconds after each patient. Presently, dental chair units are equipped with various options to improve the quality of water, including independent water reservoirs, chemical treatment regimens, source water treatment systems, daily draining and air purging regimens and point-of-use filters. The dental unit water lines should be flushed every day according to the instructions provided by the manufacturer.

Suction / Evacuation system asepsis:

The suction/evacuation lines of the dental unit should be cleaned every day with an evacuation system cleaner to remove blood and debris. An appropriate disinfectant should be run through the tubing of the evacuation system. A small amount of disinfectant should be used to disinfect the suction lines in between the patients. The manufacturer of the dental unit should be consulted regarding a compatible disinfectant with the suction/evacuation system. Chlorine based products should not be used for this purpose because…………………

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Management of instruments:

Every dental office should have a separate instrument re-processing area. If instrument re-processing is done in the same room where the patient has to be treated, the risk of cross-contamination is increased. The following steps are followed during processing of instruments following periodontal surgery,

Cleaning of instruments:

Once the periodontal surgery is completed, the first step in instrument re-processing is mechanical cleaning of the instruments. The mechanical cleaning of instruments using hands should be done carefully and heavy-duty (utility) gloves, mask, eyewear and gown should always be worn while cleaning. Only one instrument should be cleaned at a time to reduce the risk of puncture injury.

Ultrasonic cleaners should be utilized for removing debris from the instruments. These use sound waves outside the human hearing range, resulting in the formation of oscillating bubbles by a process called cavitation. In some ultrasonic cleaners intermittent or sweeping sound waves are used to improve the cleaning efficacy of the device. Another equipment used for instrument cleaning is thermal instrument washer. It uses water at high temperature and chemical additives (disinfectants). Use of thermal instrument washer increases the safety of dental healthcare professional handling the instruments.

 Instrument examination:

Following cleaning, instruments are visually inspected for their cleanliness, replacement or removal of damaged instruments should be done. The instruments are dried before packaging. Instruments can also be placed in metal cassettes after drying.

Packaging:

The individual instrument or instrument cassette is then wrapped with wrap paper/pouches, plastic pouches, combination paper/plastic pouches or nylon tubing. These packaging materials allow penetration of heat, steam or vapor so that adequate sterilization is achieved. Instruments are then sterilized by steam autoclaving as discussed in the previous sections.The instruments remain in the packaging after sterilization and the packaging is opened just before the treatment of the patient.

Know more…..Difference between sterilization and disinfection:

Sterilization results in the destruction of all forms of microbial life, while disinfection results in the destruction of specific pathogenic microorganisms. Because all the items used during periodontal surgery cannot be sterilized, a high-level disinfectant can be used to disinfect these items.

 

Universal precautions:

Universal precautions are the standard precautions meant to reduce the risk of transmission of blood-borne and other pathogens from both recognized and unrecognized sources. These precautions are mandatory and should be followed during periodontal surgical procedures. Following are the standard precautions followed,

  • The hand hygiene should be taken care of regularly before gloving and after glove removal;
  • Personal protective barriers such as…………

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Preparation of the operating room, operating team and the patient

Preparation of the operating room:

The operating room should be well ventilated. The operating room should have polished stone or glazed tiled floor. Appropriate cleaning and disinfection is the cornerstone of the operating room asepsis. Cleaning removes organic matter and visible soils that interfere with the action of disinfectant. Following cleaning, the operating room floor should be mopped with an appropriate disinfectant. All the items that cannot be sterilized (such as dental chair, instrument trolleys, stools, tables) should be adequately disinfected by various chemical disinfection methods discussed previously in this chapter.

 A through sterilization of instruments, gloves, drapes, sponges, sutures should be ensured. It should be noted that anything that may come in contact with the operating field directly or indirectly, should also be adequately sterilized, for example, the table cover on which the instruments are to be placed or instrument tray to keep the instruments. The instruments are arranges on the instrument table in a specific order starting, with the diagnostic instruments followed by instrument used for placing incision, then instruments used for debridement (scalers, curettes and scissors) and finally, the suturing instruments (Figure 56.3).

Figure 56.3 The sequence of instrument placement during periodontal surgery . Starting from left to right, the diagnostic instruments are laced in the beginning, followed by BP handles and knives for the placement of incision. After that, scaling and root planing instruments (scalers and curettes) are placed. At the right end of the tray , instruments used to place sutures  needle holders) are kept.

Arrangement of instruments in a tray

Dressing of the operator and assistant:

After removing street cloths, both, the operator and assistant should put on a clean cotton scrub suit. The rationale for wearing a scrub suit is that along with eliminating the dust laden cloths from operating room, it also provides comfort to the operator. Then the operator and assistant put on clean head caps and masks. If the operator doesn’t wear glasses, he/she puts on a pair of shatter-resistant glasses to protect the eyes from coming in contact with the contaminated debris/aerosol.

Preparation of arms and hands and wearing gown and gloves:

 The operator and assistant should roll the sleeves well above the elbows. All jewellery and watch should be removed and nails should be short and smooth. Hands and forearms are then thoroughly cleaned with soap. Hands are cleaned by………………..

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Figure 56.4 The method for putting on the gloves for a right handed clinician. After tearing the seal, the sterile pouch containing the gloves should be placed on a sterile cloth (a). The left glove is put on first in such a way that the hand touches only the inner surface of the glove (b). Once the left glove is put on, the right glove is engaged by putting figures between the fold of the glove so that only outer surface of the glove is touched (c). Finally, the right glove is pulled over the sleeves of sterile gown and the same is done for left glove (d).

How to wear gloves

(a)

How to wear gloves

(b)

How to wear gloves

(c)

How to wear gloves

(d)

Patient preparation:

Once the operating team is ready, the assistant prepares the patient. The patient is draped in such a way that only the area to be operated (oral cavity) is open to the environment. Rest all the surfaces are completely coved with sterile drapes (Figure 56.5 a-c). Assistant then uses a large sponge folded into 1½ inch square to apply antiseptic solution widely around the mouth, extending below the chin to the neck and upto the nose, including both cheeks. If the antiseptic solution used is a tincture, the area should be dried with a sterile sponge so as to avoid any chemical burn. Sterile petrolatum is then applied to the lips and commissures of the mouth to keep these areas well lubricated.

Figure 56.5 The protocol followed during periodontal surgeries. The operator and the assistant should follow the aseptic procedure for putting on the sterile gown and gloves. Except for the small area around oral cavity , all the surfaces of the patient should be covered with sterile drapes. The head of the patient should be properly covered with the drape which covers the eyes also. The tubing of the suction should be covered with a sterile cloth with only sterile suction tip exposed for suction.

Surgical protocol for periodontal surgeries

(a)

Surgical protocol for periodontal surgeries

(b)

Surgical protocol  for periodontal surgeries

(c)

Local anesthesia

The primary requirement of the periodontal surgical procedure is achieving profound anesthesia so that optimum patient comfort is ensured. The application of local anesthesia serves three purposes,

  1. Anesthesia during surgery
  2. Aids in hemostasis during surgery (due to vasoconstrictor in local anesthesia solution); and
  3. Helps in a prolonged post-surgical pain control (due to inhibition of peripheral neuronal discharges).

Local anesthetic agents belong to one of the two classes: aminoamide and aminoester local anesthetics (Table 56.5). Most commonly used local anesthetics are amides, of which lidocaine is most widely used. Biotransformation of amides occurs primarily in the liver, whereas esters are biotransformed by plasma cholinesterase, also known as pseudocholinesterase.

The alterations in Plain local anesthesia is used in such patients……………………

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Table 56.5 Properties of various local anesthetic agents

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Table 56.6 Factors affecting depth of anesthesia achieved

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Table 56.7 Adverse reactions associated with the use of Local anesthetic agents 16

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During periodontal surgery, a nerve block or local infiltration is used to achieve local anesthesia. It is advised that after giving a nerve block or infiltration, a small amount of local anesthesia should be injected in the interdental papillae in the area to be operated. It helps in making the tissue firm and reduces bleeding during surgery.

Management of medical emergencies

There are various medical emergencies which may be encountered during periodontal surgical treatment. These conditions demand immediate treatment. In a survey which included over 4000 dentists, it was observed that incidence of 7.5 emergencies per dentist was experienced by dentists over a period of 10-years 17. Every dental office should be well equipped with drugs required during an emergency (Table 56.8) and the facility to transport the patient to the hospital immediately after the initial management of the patient in the dental office. If any medical emergency happens, the first step is to terminate the dental treatment, followed by checking the vital statistics of the patient (pulse rate, respiratory rate, and blood pressure) and taking steps for maintenance of airway, breathing, and circulation. The clinician must be prepared to support respiration, circulation, provide cardiopulmonary resuscitation (CPR) and to call medical emergency services. Various medical emergencies and their management have been given in the table 56.9.

Table 56.8 Drugs used to manage medical emergencies

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Table 56.9 Various medical emergencies and their management

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Intra-operative management of the patient

Soft tissue management:

Any surgical procedure is initiated with the placement of incisions. Once an incision is placed, it can be altered only partially. So, selection of the incision and its placement should be precise so that incision related problems can be avoided. Following points should be considered while the placement of an incision,

  1. An adequate blood supply to the flap should be secured.
  2. Adequate overview of the surgical site and osseous topography.
  3. Adjacent vital structures should be protected.
  4. Adequate adaptation of the flap after surgery.
  5. Wound closure on underlying bone.

Incisions:

While designing a tissue flap, various incisions can be selected. These include horizontal incision, submarginal incision, sulcular incision and vertical releasing incision. The flap can be full thickness or partial thickness. In a full thickness, flap periosteum is included in the flap, exposing the bone while in a partial thickness flap, periosteum is left on the bone surface. Following are the most commonly used incisions in periodontal surgical procedures,

Horizontal incision:

The objective of placing a horizontal incision is to detach the soft tissue from the root surface. The horizontal incision may be………………….

123 This incision can be marginal or paramarginal or sulcular. In the case of paramarginal incision, the distance of the incision from the gingival margin depends on the pocket depth, thickness of the gingiva, width of attached gingival and postoperative flap positioning.

Sulcular incision:

This incision is placed into the gingival sulcus and the scalpel is pushed as far as possible into the interdental space around a tooth (Figure 56.6). This incision detaches the soft tissue from the root surface, causing least possible loss of soft tissue. The pocket lining and granulation tissue on the inner surface of the flap is removed by using a sharp surgical scissor or scalpel. This incision is indicated in cases with narrow width of keratinized gingiva (≤ 3 mm), areas with esthetic concern and during regenerative procedures such as guided tissue regeneration. As minimal soft tissue loss is there, the flap margins can be adapted at its pre-surgical level. Minimum recession is expected with this incision.

Marginal incision:

 This incision is difficult to make and is usually placed only in cases where the gingival margin is very thick. The scalpel is placed on the top of gingival margin and is directed towards the alveolar crest moving it forward and keeping the scalpel on gingival margin (Figure 56.6). This incision is rarely used due to problems associated with its placement.

Figure 56.6 Diagrammatic representation of sulcular (a), marginal (b) and para-marginal (c) incisions

Incisions used in periodontics

Para-marginal incision:

This incision is placed at a distance from the gingival margin (Figure 56.6). The scalpel is placed at an acute angle to the tooth surface directed towards the alveolar bone crest. The incision is placed at a distance from the gingival margin, which is half the pocket depth measured in that area. However, the thickness of the incision also depends on the thickness of soft tissue, the width of keratinized gingiva and esthetic zone. This incision is placed in combination with sulcular incision so that the collar of the gingival soft tissue containing the pocket lining can be removed.

While placing this incision on the buccal aspect, a minimum width of attached gingiva (≥3 mm) should remain after incision placement.  The incision should be more scalloped than the gingival margin itself so that interdental papillae in flap adapt appropriately in the interdental areas.

In crown lengthening cases, the incision is placed according to the desired clinical length of the crown for restoration or for esthetic requirements. It must be remembered that while doing crown lengthening for the restorative purpose, the biological width should be maintained by doing the necessary osseous reduction. This incision should be placed cautiously in areas with esthetic concern because recession may result, leading to a un-esthetic smile.

Vertical incisions:

These incisions help in increasing the mobility of the flap, thus providing better access to the surgical area. These incisions are must if the flap has to be positioned in some other location than its pre-surgical position, such as coronal or lateral or apical. The incisions are placed in such a way that they render base of the flap wider than the coronal marginal flap.

Know more………Releasing incision:

We must remember that the primary objective of reflecting flap is to get access to the underlying structures for various purposes, including simple debridement or osseous recontouring or regenerative procedures or mucogingival problems. So regardless of the procedure, releasing incision is/are required to attain access to the underlying structures.  The releasing incisions may be horizontal or vertical.

Horizontal releasing incision:

It is generally used when a ………………….

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Figure 56.7 The placement of vertical incisions (arrows). The incisions have been placed in such a way that papillae are included in the flap

Vertical releasing incisions

Dimensions of flap reflection:

It is important to establish the dimensions of flap reflection after carefully investigating the soft tissue. As already stated, when the horizontal releasing incision is placed; it should be extended more mesially and distally to the actual area to be operated. The level of the incision determines the final closure of the flap. In the case of insufficient keratinized gingiva, the incision should be placed as coronal as possible so that the width of keratinized gingiva does not reduce further.

Flap reflection:

Once the objective of the surgery is established, clinician decides whether to reflect a full thickness or a partial thickness flap.  In most of the cases, full thickness flap is reflected. For raising full thickness flap, the periosteal elevator is used. The reflection of the flap begins at the papilla. The sharp end of the……..

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It must be remembered that tissue should be handled gently. Undue stretching or pulling of the tissue may cause excessive tissue injury and may result in increased post-operative discomfort to the patient and delayed wound healing.  The primary requirement of a precise flap reflection is using sharp instruments. Dull instruments cause excessive trauma to the tissue.

Hemostasis during surgery:

Bleeding during periodontal surgery depends on various factors such as systemic factors, local factors, and surgical technique. Hemorrhage varies significantly between patients and within the same patient at various times 18-20. Studies have been done to measure blood loss during various periodontal surgical procedures. Ariaudo (1970) 21 observed that full-mouth periodontal flap procedures performed under general anesthesia resulted in blood loss of 350 ml. Another study demonstrated that during periodontal flap procedures involving an average of 5 1/2 teeth in posterior sextants, an average blood loss was 134 ml with a range of 16 to 592 ml 22. On an average, the volume of blood lost during a single quadrant flap surgery, which involves thinning of the flap, tuberosity reduction and some amount of bone re-contouring ranges from 300-350 ml.

During periodontal surgery, if a bleeding episode is encountered, the most effective way of stopping the bleeding is identifying the bleeder and tying off the offending vessel. Because blood vessels can be rarely isolated in periodontal tissue, tying off the blood vessel is done by a suture noose. The clinician must have the basic knowledge of blood vessels supplying that area. The most effective way to identify the bleeding vessel is to apply pressure with the back of instrument on a trial basis over the soft tissue from where the bleeding vessel is suspected to reach the bleeding site. Once the bleeding stops after applying pressure the soft tissue in that area is tied up tightly with a blind suture. If bleeding does not stop, another trial suture may be placed. After the bleeding has stopped, the patient should be placed in a recumbent position for 15-30 minutes. If the bleeding does not recur during this period, the patient can be dismissed after giving usual post-operative instructions.

Bleeding from minor blood vessels can be controlled by using local hemostatic measures, the most common of them being the application of local pressure. Following local hemostatic techniques and agents are used to control local bleeding,

  1. Positive Pressure
  2. Vasoconstrictor
  3. Surgicel (Johnson and Johnson)
  4. Bone Wax (Ethicon)
  5. Tranexamic acid
  6. Hemostatic collagen
  7. Gelfoam (Pharmacia)
  8. Topical thrombin
  9. Tisseel (Baxter)
  10. HemCon (HemCon Medical Technologies)
  11. Electrocautery
  12. Avitene (Davol)
  13. Bleed-X

A detailed description of these agents is available in Table 32.17 in chapter 32 (Periodontal treatment of medically compromised patients).

Bone reshaping:

While doing bone reshaping during periodontal flap surgery, extra care should be exercised not to remove excess of bone. The objective of bone reshaping is to achieve a physiological bony architecture which is conducive to the maintenance of periodontal health and does not facilitate re-formation of the periodontal pocket. Most of the clinicians use slow or intermediate speed handpieces for bone reshaping. A straight handpiece at slow speed provides better control to the operator during bone removal. It must be remembered that overzealous bone removal over the root prominences may result in fenestration or dehiscence. Air driven turbines are not recommended for bone reshaping because these operate at a high speed and may gauge into the bone. Secondly, the escaping aerosols from the handpiece may cause emphysema.

Least damaging of all techniques of bone reshaping is hand instrumentation using file and chisel. These are available in various sizes and shapes which facilitate their use on different types of bony architecture. Because they remove a small amount of bone, they are used in areas where little bone modification is required. These are commonly used in combination with slow or intermediate speed handpieces. The bulk of the bone is removed with a round bur and fine reshaping is done with the file or chisel.

Suturing:

The primary objective of suturing is to position and secure surgical flaps to promote optimal healing (primary healing). In other words, we can say that the flaps are immobilized to stabilize the wound. Suturing reduces post-operative pain & increases patient comfort. It also reduces the chances of infection in deeper tissues, like bone. Suturing has been done for centuries and presently there are many suture materials available for this purpose. Adequate wound care and perfect suture approximation are extremely important for achieving good results following periodontal esthetic surgeries and regenerative procedures 23. For various surgical procedures such as periodontal plastic, cosmetic, and reconstructive procedures, selection of appropriate suturing technique, thread type, thread diameter and surgical needle is of paramount importance.

History of sutures:

The closing of wounds with the help of needle and thread has been practiced by mankind for several thousand years. The earliest reported sutures belong to ancient Egypt (3000 BC). Eyes needles were invented somewhere between…………..

123Advancements in suture materials took place after the introduction of nylon in 1938 and polyester around the same time. In 1960’s new resorbable suture material, polyglycolic acid and polylactic acid were introduced. By 1970’s FDA started giving approval for new suture materials.

Surgical needle:

Surgical needles are produced from stainless steel alloys, which have excellent resistance to corrosion. The stainless steel used to make needles contain a minimum of 12% chromium, which results in the formation of a thin layer of chromium oxide on its surface when exposed to oxygen. The high nickel content in the metal provides high strength, making it resistant to bending and breakage.

Ideal properties of a surgical needle:

  1. It should be made up of high-quality stainless steel possessing high resistance to bending and breakage.
  2. It should be sterile and corrosion resistant.
  3. It should have a diameter as small as possible.
  4. It should provide a stable grasp in the needle
  5. It should be capable of implanting suture material through the tissue with minimal trauma.
  6. It should be sharp enough to enter the tissue with minimum resistance.

Anatomy of surgical needle:

The surgical needle is composed of three components: swage, body, and point (Figure 56.8).

Figure 56.8 Various parts of a needle

Suturing needle

Swage:

It is the suture material attachment to a needle which makes a single, continuous unit of suture material and needle.  The primary function of swage is to provide a smooth transition from needle to suture thread. Swaged needle is also referred to as eyeless needle because it does not have a hole at the suture side of the needle as seen in eyed needle.

Body:

Most part of the surgical needle is made up of the body. The body of the needle is the part where it interacts with a needle holder. The needle holder pushes the needle into the tissue by putting force on the body of the needle. Various properties of the needle which affect its interaction with the needle holder include needle diameter and radius, body geometry, and quality of stainless steel alloy used.

Point:

It is the portion of the needle that extends from the tip to the maximum cross-section of the body.

Classification of surgical needles:

Surgical needles can be classified on the basis of curvature or their cutting edges as,

Based on curvature:

Surgical needles vary in their curvature and are described as the proportion of a circle completed. Commonly used needles for general surgical procedures are with 1//4, 3/8, 1/2 and 5/8 curvatures (Figure 56.9). For dental surgical procedures, most commonly used needles are 3/8 and 1/2 circle needles 25, 26. The 3/8 needle can be easily passed from buccal to lingual surface in one motion by rotating the needle in a single rotation along the central axis. 1/2 circle needles are used in restricted areas such as posterior areas around molars and mandibular incisors. This needle is commonly used for mucogingival surgeries 25, 27, 28 .

Figure 56.9 The curvature of the needle as described by the proportion of a circle completed

Suturing needle length

Based on cutting edges:

On the basis of the presence or absence of cutting edges, the needle can be classified as (Figure 56.10),

  • Conventional cutting needle
  • Reverse cutting needle
  • Taper point needles
  • Tapercut surgical needles
  • Blunt point needles

Figure 56.10 The cross section of needles used in surgeries

Cross section of suturing needles

Conventional cutting needle:

It is triangular in cross section with three cutting edges and flattened body. The third cutting edge of the needle is present on the concave side of needle curvature. The problem associated with this needle is that it can ‘cut-out’ of the tissue. This is because inner cutting edge of the needle cuts toward the edges of the wound. This needle is commonly used during periodontal flap surgeries.

Reverse cutting needle:

It is also triangular in cross section with the third cutting edge on the……………….

123

Taper point needles:

These are also called as round needles. The needle has a round body and the point tapers into a sharp tip. It pierces and spreads the tissue without cutting it. This needle is commonly used during periodontal flap surgeries.

Tapercut surgical needle:

This needle has combined features of a taper point and a reverse cutting needle. The three cutting edges of the needle point extend 0.8 mm back from the tip and merge into a round taper body. It is primarily used to suture dense and tough tissues and is not commonly used in periodontal surgeries.

Blunt point needles:

These needles have a rounded, blunt point rather than a sharp tip. It dissects friable tissue rather than cutting it and is rarely used for periodontal surgical procedures.

Suture materials:

Presently, a variety of suturing materials is available. The ideal properties of a suture material include good tensile strength, tissue biocompatibility, ease of tying and minimal chances of knot slippage. The clinician should select the specific suture thread and diameter based on the type of surgical procedure to be done. Surgical sutures are available in a number of sizes based on the diameter of the thread. Suture sizes are defined by the United States Pharmacopeia (USP) (Table 56.10). Presently available sutures range from #5 (heavy braided suture for orthopedic surgeries) to #11-0 (fine monofilament suture for ophthalmic surgeries).  In periodontal flap surgeries usually #3-0 to #4-0 sutures are used, whereas in periodontal esthetic surgeries #5-0 to #6-0 sutures are used.

Table 56.10 Diameter of various suture threads according to USP

[table “143” not found /]

Classification of suture materials:

Sutures can be classified in three different ways (Figure 56.11),

On the basis of origin

  • Natural
  • Synthetic

On the basis of their absorbability

  • Absorbable
  • Non-absorbable

On the basis of number of threads in suture thread

  • Monofilament
  • Braided

Most commonly used classification for suture materials is, on the basis of their absorbability i.e. absorbable and non-absorbable (Table 56.11). Non-absorbable sutures are made up of inert materials which cause a minimal reaction when placed in the tissue. These have to be removed after the initial healing, usually within 7-10 days. The absorbable sutures are absorbed either by digestion or hydrolysis. The digestion of suture materials takes place by enzymes secreted from PMN’s, whereas hydrolysis of suture takes place in the presence of water which causes the breakdown of suture material.

Table 56.11 Properties of various suture materials

[table “144” not found /]

General principles of suturing:

  1. The needle should be grasped at approximately one-third the distance from the eye and two-thirds from the point.
  2. The needle should enter the tissues perpendicular to the tissue surface and no less than 2-3 mm from the incision.
  3. The needle should be passed through the tissues along its curvature.
  4. The suture should be passed at an equal depth and distance from the incision on both sides.
  5. The needle always passes from the thinner tissue to the thicker tissue.
  6. Suture, whenever possible, should be placed……………….

123

Various periodontal suturing techniques:

Suturing techniques used during periodontal surgical procedures can be broadly classified as interrupted suturing and continuous suturing. The interrupted suture technique is one where each suture is made from a separate piece of the suture thread and is fixed by tying the ends together. In other words, individual knots are placed for each piece of suture thread. On the other hand, in the continuous suture, only one knot is placed after approximating the flap margins.

Interrupted sutures:

Simple-loop (interrupted) suture technique:

This is the most commonly used suturing technique used to stabilize elevated flaps and to stabilize tissue along the incision line (Figure 56.12). The technique of suturing is as follows,

  • The needle is stabilized in a needle holder and the outer surface of the buccal flap is pierced keeping the needle perpendicular to the surface.
  • The needle is pushed along its curvature, moving it towards the lingual flap and piercing the inner aspect of the lingual flap.
  • Once the needle and suture thread are out from lingual flap the needle is passed below the contact area to bring the suture thread on the buccal aspect.
  • The free ends of the suture are tied and the suture thread is cut off, leaving 2-3 mm of suture material.

Figure 56.12 The simple loop suture technique

The simple loop suture technique

Figure-eight (interrupted) suture technique:

This is also a commonly used suturing technique used in periodontal surgical procedures (Figure 56.13 a-d). Their indications are similar to that of simple loop technique. The main advantage of this technique is that it is easy to perform. The disadvantage of this technique is that the suture remains in between the flaps, thereby preventing ideal approximation of the flap edges. The technique of suturing is as follows,

  • After stabilizing the needle in a needle holder, the outer surface of the buccal flap is pierced.
  • The needle is pushed along its curvature to bring it on the lingual aspect and without piercing the lingual flap the thread is brought to the lingual aspect below the contact area.
  • Then the outer surface of the lingual flap is pierced and the needle is passed below the contact area to bring it on the buccal aspect.
  • The free ends of the suture thread are tied and cut off, leaving 2-3 mm of suture material.

Figure 56.13 The figure of eight suturing technique

The figure of eight suturing technique

Vertical-mattress (interrupted) suture technique:

This suturing technique facilitates precise adaptation of interdental papillae and is frequently used in conjunction with periosteal sutures. It is also very useful for appropriate tissue approximation in GTR and other regenerative procedures. The technique of suturing is as follows (Figure 56.14 a-d),

  • The needle is inserted on the outer surface of the buccal flap just above the mucogingival junction. Then it is pushed towards bone to engage the periosteum. It should be noted that periosteum has not been reflected with the flap.
  • When moved along its curvature, the needle should come out from the center of the papilla 2 to 3 mm from the flap edge.
  • The needle is then passed through the contact area and suture thread comes on the lingual aspect.
  • The needle engages the lingual flap in the same way as it engaged the buccal flap starting from the center of the lingual papilla, 2-3 mm from the edge of the flap.
  • The needle is then passed through the contact area to reach the buccal aspect where knots are placed and the suture is cut off leaving 2-3 mm of the suture material.

Figure 56.14 The vertical mattresses suturing technique

Vertical mattresses suturing technique

Horizontal-mattress (interrupted) suture technique:

Technique 1:

This type of suture is placed primarily to resist flap tension caused by muscle pull and soft-tissue contraction, providing stability to the healing wound. It is placed away from the wound edges, thus it does not facilitate closure of wound edges. That is why this suture is considered as the secondary suture line. A primary suture line usually composed of simple loop suture is placed to approximate the flap edges together (Figure 56.15 a-e). This technique is primarily used in edentulous areas. The technique of suturing is as follows,

  • The needle is pierced on the outer surface of the buccal flap 3-4 mm from the flap margin.
  • The needle is then brought on the lingual aspect and the internal side of the lingual flap, 3 to 4 mm from the lingual flap margin.
  • The needle then pierces at a distance of around 5 mm from the second piercing in the horizontal
  • The needle is then brought on the buccal aspect, piercing the inner surface of the buccal flap.
  • Knots are placed and excess suture is removed.

Figure 56.15 The horizontal mattresses suturing technique

The horizontal mattresses suturing technique

Technique 2:

In this technique is opposite to the technique 1. Here, suture thread lying over the tissue in technique 1 is placed below the tissue and vice versa. The advantage of this technique is that the suture thread crosses from buccal or lingual flap to the opposite flap over the tissue surface, thus eliminating the requirement of placing the primary suture line. The technique of suturing is as follows,

  • The needle is engaged with a needle holder and the outer surface of the buccal flap is engaged 5 to 7 mm from the flap margin. The needle is moved along its curvature in a horizontal direction and a bite of 4-5 mm is taken on the buccal flap.
  • The needle and suture thread are passed on the lingual aspect through contact area and a similar procedure is repeated on the lingual aspect, engaging the lingual flap.
  • The needle is passed on the buccal side where knots are placed and the excess suture material is cut off.

Technique 3 (Criss-cross):

In this variant of horizontal mattress suture, the suture thread passes over to the opposite side in a criss-cross manner.  The advantage of this suture is that when placed in the interdental area, it precisely controls the papilla and keeps the suture out of the healing interproximal sulcus area. Thus, it provides adequate holding of soft tissue in the interdental areas.

Sling suture:

Sling sutures are usually required when flap has to be coronally positioned. In this technique, only one flap is engaged with suture. The outer aspect of the flap is pierced at the distal end of the tooth and the needle is passed below the contact area. The suture is wrapped mesially around the tooth and the inner aspect of the same flap is pierced on the mesial end. The suture thread is then again wrapped around the tooth back in the same way and is brought at the site of the initial piercing. The knots are placed and the excess suture material is cut (Figure 56.16 a-d).

Figure 56.16 The sling suture

The sling suture

Continuous suture techniques:

Continuous interlocking suture technique:

This technique is used to suture long edentulous spans. It is usually utilized after the implant placement in edentulous span or during ridge augmentation or reduction surgeries. This is a quick technique for closing long horizontal or vertical incisions. The technique of suturing is as follows,

  • A simple loop suture is placed at…………….

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Continuous sling suture:

The continuous sling suture may be dependent or independent. When both buccal and lingual/palatal flaps are raised, this suturing method is referred to as dependent sling suture whereas when only one flap is elevated, the suturing is referred to as independent.

Independent sling suture:

As already stated, this technique secures only one flap and is utilized when only one flap is raised. The technique of suturing is as follows,

  • A simple loop suture is placed at the mesial end of the flap and the free suture thread is cut off.
  • Then suture is then slung around the tooth on the lingual side.
  • Suture is then brought on the buccal aspect by passing it through the contact area.
  • The buccal flap is pierced at the next papilla at 2 to 3 mm from the flap margins.
  • The suturing is completed be slinging the suture around the lingual surface of all teeth until whole span is completed.
  • At the distal end, a loop of the suture is left, which is used to place the second knot to finish the procedure.

Dependent sling suture:

It is placed when both buccal and lingual flaps are elevated. There are two techniques to place this suture: technique 1 where only one knot is placed and technique 2 where two knots are placed.

Technique 1 (with single knot):

In this technique suturing is started at the distal end of the flap. The technique of suturing is as follows (Figure 56.17 a-j),

  • The buccal flap is engaged by piercing the suture needle at the distal most interdental papilla of the elevated flap.
  • The suture is slung around the lingual surface of the tooth and is passed through the contact area to come on the buccal aspect to engage the next mesial papilla.
  • The next mesial papilla is pierced by needle 2-3 mm from the flap margin and the needle is passed through the contact area to reach lingual aspect.
  • The suture is then slung around the tooth and passed from the mesial contact area to reach the buccal aspect.
  • The next papilla is then engaged and the procedure is continued till the mesial-most
  • It should be noted that till the mesial-most papilla is reach, the lingual/palatal flap is not engaged with suture.
  • At the mesial end, after engaging the buccal papilla the needle is passed through the contact area to reach the lingual aspect.
  • Now, the mesial-most interdental papilla of the lingual/palatal flap is engaged and the suture is passed to the buccal aspect through the contact area.
  • The suture is slung around the buccal surface of the tooth and is brought on lingual/palatal aspect.
  • The next interdental papilla is then engaged and procedure is continued till we reach the distal most end of the flap from where suturing was started.
  • After engaging the last lingual/palatal interdental papilla, the suture is brought on the buccal aspect and knot is placed to complete the suturing.

Figure 56.17 Technique of placing continuous sling suture with single knot

Continuous sling suture

Technique 2 (two-knot technique):

In this technique, one knot is placed at one end of the entire span and another knot on the other end. The technique of suturing is as follows,

  • A simple loop suture is placed at the distal most interdental papilla, the suture is tied off and remaining free end is cut.
  • The needle is then passed to the lingual/palatal aspect through the same interdental area and is slung around the lingual surface of the tooth.
  • The needle is brought to the………….

123

Continuous horizontal-mattress suture technique:

It is primarily applied to suture edentulous areas. The procedure is as follows,

  • A simple loop suture is placed at the distal end of the span and free end of the suture is cut off.
  • Both the flaps are pierced at 5 mm from the initial simple loop.
  • Continue the piercings in increments of 5 mm, alternating between buccal and lingual flaps.
  • At the mesial end of the span, after piercing both the flaps a small loop is left for placing a knot.
  • The knot is placed and the excess suture material is cut off, leaving 2-3 mm.

Continuous vertical-mattress suture technique:

This suturing technique is indicated during resective procedures where the flap has to be positioned apically to prevent re-formation of periodontal pockets. It is also frequently used during the crown lengthening procedure. The procedure is as follows,

  • An interrupted vertical mattresses suture is placed at the mesial or distal end of the span and free suture end is cut off.
  • The suture is then passed through the same interdental area and is wrapped around the lingual tooth surface to reach next buccal interdental area.
  • A vertical mattresses suture is placed on the buccal aspect in the next interdental area and the needle is passed on the lingual aspect to place a vertical mattresses suture.
  • The needle is then passed on the buccal aspect and is wrapped around the tooth to reach the lingual aspect of the next interdental area.
  • A vertical mattresses suture is placed and a needle is passed to the buccal aspect where again a vertical mattresses suture is placed.
  • The needle is wrapped around the tooth to reach the next buccal interdental area and procedure is continued for the whole span.
  • In the final segment, a loop is left, which is used to tie a knot and finish the suturing.

Advantages of continuous suture:

  1. It allows as many teeth as required to be involved in suturing.
  2. Minimizes placement of knots.
  3. Teeth are used to anchor the flap allowing better adaptation of flaps in the interdental area.
  4. The tension on the flap is equally distributed along the whole span.
  5. Buccal or lingual/palatal flaps may be independently engaged.
  6. Requires less time for both placement and removal.

Disadvantages of continuous suture:

The main disadvantage of the continuous suture is that if the knot loosens or threads breaks, a portion or the entire flap may loosen, exposing bone, implants, grafts, etc.  Hence, the knots should be re-checked before cutting the suture thread to ensure its stability.

Special sutures:

Periosteal suture:

The periosteal suturing technique is primarily used to immobilize partial thickness flap, or a free gingival graft, to a new position by utilizing the subjacent and/or adjacent periosteum to anchor the flap. For placing these sutures, there are some pre-requisites,

  1. Good access to the surgical site.
  2. A partial thickness flap dissection is required to place these sutures because the sutures are placed in intact periosteum on the bone surface.
  3. The periosteal bed should be well fixed to the underlying bone and should not be easily disturbed by manipulation of the external flap or the vestibular attachments.
  4. The shape and dimensions of the needle should allow manipulation of the extremely delicate tissues with a minimum trauma.

The procedure of suture placement is similar to simple loop suture where the needle is pierced into the tissue to engage the periosteal layer and the flap is stabilized.

Suture knots:

Surgical knot tying is an important component of the art of suturing. There are primarily four types of knots used,

Square knot: Two single ties in opposite direction

Granny’s knot: Two or three ties in the same direction.

Surgeon’s knot 2-1: Two ties in one direction and third in the opposite.

Surgeon’s knot 2-2: Two tie in one direction and two in opposite direction.

Principles of suture removal:

Sutures are removed 7-10 days post-operatively. The area should be first irrigated with normal saline to remove gross debris. A swab containing normal saline should be used to clean the area to remove encrusted necrotic debris and blood. A sharp suture scissor should be used to remove the sutures. The suture material should be cut as close as possible to the tissue because it will prevent the suture material, which was exposed to the oral environment and has been laden with bacteria, from passing through tissue while suture removal. Sutures can be then pulled out with the help of a cotton plier. The knots should be removed first so that their accidental entrapment into the tissue can be prevented.

Complications following suturing:

  1. If the suture is loosened the primary objective of suturing; healing by primary intention is compromised.
  2. The opening of the incision line (dehiscence of the wound) due to suture loosening may increase chances of infection.
  3. In the case of braided sutures, because of the“wicking‐effect”, there can be spread of infection all along the suture line.
  4. If the suture material is left in‐situ for longer periods than 3 weeks, the epithelial cells migrate down the suture pathway leading to epithelial inclusion cyst or “railroad track” scar.
  5. If the non‐resorbable sutures like silk, are left in place for a longer duration the lead to abscess formation known as “stitch abscess”.

Periodontal dressing:

The rationales 29, 30 for placing periodontal dressing are protection of wounds from post-operative irritation, preventing trauma, preventing salivary contamination, preventing gingival detachment from root surface, preventing coronal displacement of the flap where the flap has been apically positioned, providing additional support to free gingival grafts, splinting mobile teeth, reducing tooth hypersensitivity in the first hours after surgery, and to provide patient comfort. According to Prichard (1972) 31, the periodontal dressing is used to prevent postoperative hemorrhage and to protect the wound area from contact with food. Further, he stated that it “has no other virtue”. In spite of all fore-stated advantages, indications for periodontal dressing are limited. Studies 32, 33 using a split-mouth design have demonstrated that surgical sites with dressing resulted in more amount of plaque accumulation as compared to similar sites with no dressing. The authors concluded that dressing aids little to the healing process. In the following sections, we shall study the present status of periodontal dressings.

Figure 56.18 Placement of periodontal pack

Periodontal pack placement

Ideal properties of periodontal dressing:

An ideal dressing material should be 34,

  • It should be slow setting to allow manipulation;
  • It should have a smooth, non-irritating surface;
  • It should not interfere with healing;
  • It should be flexible enough to withstand distortion and displacement in the mouth without fracturing;
  • It should be strong and coherent without being bulky, and
  • It should have good adhesive properties to the tooth surface and soft tissue, along with dimensional stability to prevent salivary leakage and accumulation of plaque and debris.

History of periodontal dressing:

History of periodontal dressing dates back to 1918 when Zentler 35 reported the use of a…………….

123The composition of the periodontal pack has changed over a period of time and potential tissue irritants have been eliminated from its composition.

Types of periodontal dressings:

There are primarily three types of periodontal dressings: zinc oxide eugenol dressings, zinc oxide non-eugenol dressings, and dressings containing neither zinc oxide nor eugenol. Zinc oxide eugenol dressing is also known as ‘hard pack’ whereas zinc oxide non-eugenol dressing is known as ‘soft pack’. Other periodontal dressing materials include collagen materials, methacrylate gels, light cure dressing, cyanoacrylates, oral adhesive bandage and wax pack.

Zinc oxide eugenol dressing:

The components of zinc oxide eugenol dressing consist of powder and liquid. These dressings are available in powder-liquid or paste forms.

Powder-liquid form:

The powder-liquid dressing is prepared by mixing the powder and liquid. The powder consists of zinc oxide, tannic acid, rosin, kaolin, zinc stearate, cellulose fibers and asbestos. The liquid contains eugenol, peanut oil, rosin. The specific functions of its components are,

  • Zinc oxide: Antiseptic and astringent.
  • Tannic acid: Haemostatic.
  • Rosin: Filler, increases strength and speeds the reaction.
  • Asbestos: Binder and  filler
  • Cellulose fibers: Improve  setting
  • Eugenol: Anesthetic, antiseptic, and obtundent.
  • Peanut oil: Regulates the setting time.

The setting reaction between zinc oxide and eugenol results in the formation of zinc eugenolate. After the completion of the reaction, some eugenol remains un-reacted, which may induce a burning sensation or allergic reaction in the mucosa. Tannic acid is added in the dressing material as a hemostatic agent, but its systemic absorption is associated with liver disease 37. Asbestos, which was added as a filler, is toxic and has been associated with the development of asbestosis, lung cancer and mesothelioma 38. Hence, it is no more added in periodontal dressing materials. On the other hand, some components, such as zinc acetate, which acts as an accelerator for the reaction have been added in new dressing materials 39. The examples of these dressings are Wards wondrpak, Kirkland formula, Peridress, and PPC.

Paste form:

These are supplied in two paste system. One tube contains base zinc oxide (87%) and fixed vegetable or mineral oil (13%). It also contains lorothidol as a fungicide. The other tube contains an accelerator which is oil of clove or eugenol (12%), gum or polymerized rosin (50%), filler (silica type) (20%), lanolin (3%), non-ionizing carboxylic acids and chlorothymol (bacteriostatic agent).

Disadvantages of zinc oxide eugenol dressing material:

There are some problems associated with the use of eugenol-containing dressing material,

  • The taste of the material is spicy, which is unpleasant.
  • In some patients, it causes a burning sensation.
  • It lacks adequate smoothness.
  • It is difficult to adapt.
  • It has more chances of fracturing.

Zinc oxide non-eugenol dressings:

These periodontal dressing materials set due to the reaction between the metallic oxide and fatty acid. These periodontal dressings do not contain materials like asbestos or eugenol, so are devoid of problems associated with these substances. The examples of these dressing materials are Coe-pack, Peripac, Vocopac, Periocare, Septopack, Perioputty, Zone periodontal pack, Nobeteca and PPC noneugenol pack.

Coe-pak:

The most common and widely used non-eugenol dressing is Coe-pak (De Trey/Denstply, Konstanz, Germany). It is supplied in two paste system where one paste contains cellulose, rosin, natural gums (for cohesiveness) and waxes, fatty acids, chlorothymol (bacteriostatic agent), zinc acetate and alcohol. It is referred to as the base paste. The second paste which is called as accelerator paste contains zinc  oxide,  vegetable  oil  (for  plasticity),  chlorothymol,  magnesium  oxide,  silica, synthetic resin, coumarin lorothidol (a fungicide) (Figure 56.18).

Mechanism of mixing and placement of dressing:

Coe-pack periodontal dressing is prepared by mixing equal lengths of the base and accelerator pastes to obtain a paste with a uniform color. Within 2-3 minutes the material loses its tackiness and becomes moldable. The material remains workable for 15-20 minutes during which it is placed over the operated area and is adapted. Once in workable condition, the material is then rolled into two strips which are approximately of the same length as the operated area. The end of one strip is adapted at the distal end of the last tooth of the operated area and is adapted along the whole length of the operated area. The dressing material is gently pressed along the margins and interproximal areas. The second strip is then adapted on the lingual/palatal side and both the strips are joined interproximally by applying gentle pressure on both the facial and lingual/palatal surfaces. The dressing should not cover more than cervical one third to half of the tooth surface and should not be overextended over the gingiva. Excess of dressing material may irritate the tissue and may fracture easily.

PeriPac:

PeriPac (GC America Inc., Chicago, USA) is supplied as a single paste. The paste consists of…………….

123 Therapeutic agents such as antibiotics in powder form can be added to the dressing material and can be used in cases such as necrotic gingivitis. The dressing provides a constant delivery of the therapeutic agent in the operated area.

Vocopac:

Another periodontal dressing material is Vocopac (Voco, Cuxhaven, Germany). It is supplied in a two paste system: accelerator and base pastes. The main constituents of vocopac are purified colophonium, zinc oxide, zinc acetate, magnesium oxide, fatty acids, natural resin and natural oils and colorant e127. In patients who are allergic to the colorant, this dressing is contraindicated.

PerioCare®:

PerioCare® (Pulpdent®Corp., Watertown, MA, USA) is a two tube system (paste and gel) which sets resiliently hard in the oral cavity. After mixing the paste and gel for 45-60 seconds, the dressing material can be picked up with wet fingers. It has a working time of 4-5 minutes and sets in 15 minutes.

SeptoPack:

SeptoPack (Septodont, Saint-Maur-Des-fosses, France) is supplied as a self-hardening paste in 60 gm packaging. The main components of the material are amyl acetate, dibutyl phthalate (10-25%), methyl polymethacrylate, zinc oxide (20-50%) and zinc sulfate (2.5-10%). Medicaments such as antimicrobials can also be combined with the paste before placement of the dressing. The material sets by chemical reaction when it comes in contact with water. The working time for this material is 2-3 minute and it completely sets in 20-30 minutes.

Perio Putty:

Perio Putty (Cadco Dental Products Inc., Los Angeles, CA, USA) is another non-eugenol periodontal dressing which in addition to the basic components contains methylparabens and propylparabens (fungicidal) and benzocaine (topical anesthetic).

PeriogenixTM:

PeriogenixTM (OroScience (New Line Medical Inc., Lafayette, LA, USA) contains perfluorodecalin, purified water, glycerine hydrogenated phosphatidylcholine, cetearyl alcohol, polysorbate 60, tocopheryl acetate, benzyl alcohol, methylparaben, propylparaben, and oxygen. The dressing has been shown to aid in the healing process by multiple mechanisms 40.

Periodontal dressings containing neither zinc oxide nor eugenol:

Light cure periodontal dressings:

These include single component light activated dressing material which is placed over the tissue surface followed by curing with the visible light application. It is cured in increments and after curing it maintains its elastic properties. The dressing has a tinted pink translucent color and is preferred in the anterior tooth segment and for mucogingival surgical procedures. Bucrylate® (Ethicon Inc., Somerville, NJ, USA) and Barricaid (Dentsply International Inc., Milford, DE, US) are the examples for light cure periodontal dressings.

Know more……..

Barricaid:

Barricaid is a light cure periodontal dressing. The material is provided in a syringe and is applied on the operated area which is then light cured. It achieves a

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Collagen containing periodontal dressings:

Collagen is a physiological component of connective tissue. It forms a physiologic interface when placed over healing tissue and thus enhances healing by deposition and organization of the fibers in granulation tissues formed during the healing process. It is an excellent hemostatic, promoting hemostasis by facilitating the aggregation of platelets during coagulation cascade. Other advantages of using collagen as a dressing material are: it is non-immunogenic, nonpyrogenic and has minimal allergic potential.  Commercially, the collagen materials are available in three forms: tape (CollaTape; Zimmer Dental, Carlsbad, CA, USA), cote (CollaCote, Zimmer Dental, Carlsbad, CA, USA) and plug (CollaPlug; Zimmer Dental, Carlsbad, CA, USA). The collagen in these dressing materials has been derived from bovine Achilles tendon consisting of collagen Type I. It is a completely resorbable dressing that is used to cover and protect palatal graft sites. The tape is used in case of socket grafting, localized ridge defects, Schneiderian membrane tears, subantral augmentations and protection of soft tissue donor sites. Cote is used primarily during sinus graft containment, guided bone regeneration, soft tissue recontouring and management of sinus membrane perforations. The plug is used as a dressing for biopsy sites 41.

Reso-Pac®:

Reso-Pac® (Hager & Werken GmbH & Co. KG, Duisburg, Germany) is easy to mix periodontal dressing. It does not require removal because it dissolves in the mouth. The material is squeezed out of the tube and is taken on a moist glove or moist spatula. It is hydrophilic in nature and when put in the oral cavity, it takes a gel-like consistency due to the presence of saliva. This dressing remains in place for up to 30 hours.

Cyanoacrylates:

Cyanoacrylate alkyls were first isolated by A E Ardis in 1949 42. Coover et al. (1959) 43 who suggested their use as tissue adhesive material. Cyanoacrylates have a chemical formula, H2C = C(CN)COOR, where R- can be substituted for any alkyl group, ranging from methyl to decyl.

This material was introduced to dentistry by Dr. S N Bhaskar (1996) 44, who advocated its use as a dressing as well as suture replacement material. It is a liquid which can be applied directly or sprayed over the wound surface. The material sets when it comes in contact with the moisture. Cyanoacrylate is a good hemostatic and stops post-operative bleeding quickly. Another important advantage of this material is that it facilitates precise positioning of soft tissue graft in mucogingival surgeries. However, it should be remembered that the material is only for surface application. If the material gets entrapped under the flap, it may delay healing.

XOIN® (Reevax  Pharma  Private  Limited,  Hyderabad, India) periodontal dressing material consists of N-butyl cyanoacrylate which is an effective tissue adhesive, hemostatic and bacteriostatic. Other commercially available cyanoacrylate periodontal dressing material  are PeriAcryl®, which is a blend of N-butyl and 2-octyl cyanoacrylate and Histoacryl® (B. Braun Biosurgicals, Germany).

Controversy regarding the use of periodontal dressings:

Whether to use or not to use a periodontal dressing after periodontal surgery has been a topic of discussion for years.  As already stated, it was Ward (1923) 45 who advocated the……………..

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On the other hand, other researchers did not support the placement of periodontal dressing following periodontal surgery. It was Waerhaug (1955) 50 who first reported that application of a surgical dressing did not influence the final result of healing. Similar findings were reported by Löe and Silness (1961) 51 who stated that exposed tissues will heal irrespective of the application of a dressing material. Baer et al. (1969) 37, in experimental studies, observed that periodontal dressings following periodontal surgery did not exert any perceptible influence on the final healing. Jones et al. (1979) 33 in a split-mouth study where internal beveled full thickness, apically positioned flaps with osseous recontouring were performed in 20 quadrants, evaluated the effects of placing periodontal dressings in one quadrant as compared to the other quadrant where dressing was not placed. The authors found no significant difference between post-operative healing parameters in quadrants where periodontal dressing was applied and quadrants where it was not applied. Hence, results of the study suggested that a surgical dressing serves no useful purpose when periodontal flap surgery is performed.

Presently, most of the clinicians believe that in cases where adequate primary closure of the flap margins has been achieved, there is no requirement for the placement of periodontal dressing. In cases where the primary closure of flaps is not adequate or cases where the protection of the operated area is required (e.g. mucogingival surgeries), placement of periodontal dressing has been recommended.

Post-operative instructions to the patient:

The post-operative instructions should be given to the patient verbally and in written, so that any complication related to the surgical procedure can be avoided. Following instructions are given to the patient before he/she is discharged,

  • The patient should take analgesics and antibiotics as prescribed by the clinician. Ibuprofen 600 to 800 mg can be started pre-operatively and should be continued 1 tablet every 8 hours for 24 to 48 hours is quite effective in controlling post-operative pain. Amoxicillin 500 mg every 8 hours for one week can be prescribed to provide antibiotic cover during initial healing.
  • The patient should be asked to apply ice intermittently for alternating 20 minutes on and 20 minutes off, on the face over the operated area on the first day after surgery.
  • If surgery has been done on one quadrant, the patient should be asked to chew on the non-operated side.
  • The patient is asked to…………..

123

  • To enhance plaque control, the patient may be advised to use mouth rinses as follows,
    • Warm salt water (¼ tsp. per cup of warm water) can be used 24 hours after the surgery with a frequency of 2-3 rinses a day.
    • Chlorhexidine mouthwash can be used 24 hours (the next day) after the surgery. The mouthwash should be used by swishing with ½ oz. of the solution for 30 seconds after breakfast and before bedtime. As the ingredients of toothpaste interfere with the activity of chlorhexidine, a gap of 30 minutes should be maintained between toothbrushing and mouth rinsing.
  • In case periodontal dressing has been placed, the patient should be told about its protective function and should be asked to protect it from breaking off. If a small piece of dressing breaks off, there is no need to be concerned. However, if a large piece of the dressing breaks off, then dental office should be consulted.
  • The patient should visit the dental office after one week or 10 days whenever he/she has been given an appointment for dressing and/or suture removal.

Post surgical complications:

If a proper pre-surgical and surgical protocol is followed, healing progresses uneventfully and efficiently with the acquisition of treatment objectives. However, sometimes post-operative complications are encountered which may include persistent hemorrhage or exudation from the operated site, persistent inflammation at the operated site, retarded healing, necrotic or hyperplastic changes in the operated area, malformations and tumor-like lesions. The following are the commonly encountered complications following periodontal surgical procedures,

Persistent haemorrhage or exudation:

A small amount of bleeding is expected after surgery. However, if the bleeding is continuous then active measures are required to stop bleeding. Bleeding following a surgical procedure may be primary, reactionary or secondary. The primary hemorrhage occurs at the time of surgery. Reactionary hemorrhage may follow primary hemorrhage within 24 hours (usually 4-6 hours). It is usually caused by dislodgement of an incomplete clot. Secondary hemorrhage occurs 24 hours to 10 days post-operatively. The protocol for stopping the bleeding is as follows,

  • The source of bleeding should be identified and local pressure should be applied. Application of vasoconstrictor may be combined with pressure application to control bleeding.
  • For slow, constant blood flow and oozing, hemostasis may be achieved with hemostatic agents such as absorbable gelatin sponge, oxidized cellulose, oxidized regenerated cellulose or thrombin.
  • Capillary bleeding can be stopped by the application of electrocoagulation.
  • If bleeding from larger arteriole is encountered, the best way to stop bleeding is to place a noose around the arteriole with the help of a fine suture and tighten it to occlude the arteriole.
  • For bleeding from the bone, surface bone wax can be used to stop bleeding.

Swelling:

Swelling is the result of inflammation in the operated area. It generally appears within 24 hours of the surgery and may increase for another 24 hours. It generally starts reducing by the third day and usually subsides by the 4th post-operative day. If the swelling does not reduce and gets worse then the reason for the swelling should be determined. Persistent swelling may be due to persistent inflammation or bleeding in the tissues in the operated area. If such a situation is encountered, removal of the cause of persistent inflammation is indicated. Development of infection may also cause post-operative pain and swelling. Administration of appropriate antibiotics and irrigation of the operated area with an anti-microbial solution should be done to eliminate the infection.

Retarded epithelization:

In case of external bevel gingivectomy or mucoperiosteal flap surgeries, the epithelization of the wound margins may be retarded due to various reasons such as rough and irregular wound surfaces, presence of tissue tags, embedding of foreign substances (bacterial plaque, food debris, bristles of toothbrush, hair or periodontal dressing) in the tissue, inadequate primary closure, development of hyperplastic connective tissue substratum as a result of formation of irregular connective tissue and development of post-operative infection. All these problems can be very well avoided by the gentle handling of the tissue during surgery. However, if the situation is encountered; the reason for retarded epithelisation should be identified and eliminated.

Flap displacement and evulsion:

If the flap does not reattach to the bone, tooth or marginal aspect of the periodontal ligament, flap evulsion may result. It usually happens in cases with ……………………

123

Bone exposure/resorption:

 The exposure of underlying alveolar bone following periodontal surgeries is the result of inadequate vascular supply to flap tissue from its base and from the surrounding periosteum. Bone exposure is especially common in areas with thin cortical bone such as root prominences. This type of bone is made up of thin cortical bone with few marrow spaces. If blood supply from overlying periosteum is lost, the only source of blood supply that may remain is from the adjacent periodontal ligament. Gentle manipulation of the tissue and maintenance of adequate blood supply to the area is required to prevent this complication.

Post-operative infection:

Post-operative infection is a post-operative complication that results if adequate sterilization and disinfection protocol is not followed. It is more commonly seen in association with teeth which have endodontic involvement (endo-perio lesion). It may also develop in cases with flap displacement and bone exposure, in association with sutures and particles of impacted debris/calculus, and in areas of tissue laceration and impaired vascularization. Patients with systemic conditions such as diabetes mellitus, atherosclerosis, and malignancy are more vulnerable for the development of post-operative infection. Patients on therapeutic agents such as antineoplastics, immunosuppressives or corticosteroids are also predisposed to the development of post-operative infection. Local and systemic antibiotic therapy is indicated for the treatment of post-operative infections.

Periodontal abscess:

A periodontal abscess may develop as an area with soft tissue enlargement due to exudate accumulation. The area demonstrates signs and symptoms of intense inflammation. It is usually a result of embedding of a foreign body or remaining calculus with plaque on the root surfaces. Inadequate scaling of the root surface is the most common reason for the formation of the periodontal abscess. Thus, it can be prevented by adequate cleaning of the root surfaces during periodontal surgery.

Increased tooth mobility:

 Increased tooth mobility is a common complication following periodontal surgical procedures, especially after excisional procedures, osseous resection and any other procedure which divest teeth of gingival and periosteal support on a temporary basis. The increased tooth mobility after periodontal surgery may reduce as the healing progresses. The initial re-attachment usually occurs within 10-14 days after surgery, however, further maturation and remodeling of the connective tissue may take up to 30-45 days or more 52.

Root hypersensitivity:

Root hypersensitivity is a common post-operative problem. It usually occurs due to exposure of root surface to the oral environment because of recession and due to root surface instrumentation. It has been demonstrated that scaling and root planning procedures may remove 20-50 micrometers of cementum, thus exposing the dentinal tubules to external stimuli 53. Further, it has been shown that flap surgeries with osseous reduction result in the highest degree of discomfort which may be as a result of a time-consuming procedure together with and exposure of bone 54. Usually, dentinal sensitivity reduces with time as the healing process continues. However, if sensitivity persists anti-hypersensitivity agents can be used to treat the problem.

Conclusion

It is important to adhere to the principles of periodontal surgery to achieve uneventful healing and desired post-operative results. Adequate sterilization and disinfection are the cornerstones of any surgical procedure. Presently, various methods are available to achieve sterilization and disinfection. Along with this, the aseptic behavior of the operating team during the surgery is also equally important. Gentle handling of the tissue and adequate stabilization of the operated area is important to achieve adequate healing. One should also know the complications that may occur during or after the surgical procedure and their management. Following these principles an adequate healing and desired results can be ensured.

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