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Periodontal Surgery Perry chapter 13 and Nield-Gehrig chapter 21 Historical Perspective • Originally, surgery was for removing damaged tissues that were thought to be diseased Belief Today • Modern belief is that surgery is part of an integral part of most aspects of dental care • As severity of periodontitis increases, controlling the disease becomes more difficult • Need for periodontal surgery as part of comprehensive patient care becomes more likely • Used to support other aspects of care Surgery as Supportive Care • Enhancing restorative procedures • Improving patient appearance • Preparing a patient for implantsupported prosthesis Indications • Surgery is necessary when the periodontium is unhealthy and cannot be repaired with nonsurgical treatment Indications • Provide access for improved root surface debridement • Reduce pocket depths • Provide access for treatment of periodontal osseous defects • Resect or remove tissues Indications • Regenerate periodontium lost because of disease • Graft bone or bone-stimulating materials into osseous defects • Improve appearance of the periodontium • Enhance prosthetic dental care • Allow for placement of a dental implant Provide Access for Improved Instrumentation of Root Surfaces • The deeper the probe depth, the more difficult it is to instrument root surfaces Reduce Pocket Depth • Pocket depth can be too deep for adequate daily self-care • Plaque thrives in the deeper pockets • Surgery reduces pocket depths, making it easier for patients to maintain Provide Access to Osseous Defects • Osseous defect is a deformity in alveolar bone • As disease advances, bone loss can change the shape of alveolar bone • Surgery can modify the bone level or shape Resect or Remove Tissue • Enlarged gingival tissues are unsightly and can inhibit good oral hygiene • Surgery can remove and reshape enlarged gingiva Regenerate Periodontium Lost Because of Disease • Regenerate implies growing back lost cementum, periodontal ligament, and alveolar bone • Lost bone and tissue can be regenerated through sophisticated periodontal surgical techniques Graft Bone Into Osseous Defects • Bone or bone-stimulating materials can be grafted into osseous defects • Grafting bone does not imply regeneration Improve Appearance of Periodontium • Some gingival levels or contours result in an unattractive smile • Surgery can improve the appearance of gingiva Enhance Prosthetic Dental Care • • • • • Altering alveolar ridge contours Crown lengthening Augmenting amount of gingiva present Enhancing restorative dentistry Many types of surgery are involved Allow for Placement of Dental Implant • Surgery prepares the site for the implant • Implant must be surrounded by sound alveolar bone • Edentulous sites are often deficient in bone • Some bone augmentation may be necessary before placement of implant “Relative” Contraindications • Most contraindications for periodontal surgery are relative, meaning each patient is different from all others: – – – – Systemic diseases or conditions Totally noncompliant with home care High risk for dental caries Unrealistic expectations for surgical outcomes Systemic Diseases and Conditions • • • • • • • Recent history of heart attack Uncontrolled hypertension Uncontrolled diabetes Certain bleeding disorders Kidney dialysis History of radiation to the jaws HIV infection Totally Noncompliant with Self-Care • Outcomes of many types of surgery depend on the level of patient’s efforts with plaque control • Poor self-care can cause an unacceptable periodontal surgical outcome High Risk for Dental Caries • Periodontal surgery can expose portions of tooth roots • Patients at risk for dental caries can be devastated with rampant root caries Unrealistic Expectations for Surgical Outcomes • Surgical correction of damage to diseased tissues does not always result in a perfectly restored periodontium • Patients have to develop realistic expectations for surgical outcomes Terms • Four terms used to describe healing of periodontium after surgery: 1. 2. 3. 4. Repair Reattachment New attachment Regeneration Healing by Repair • Healing of a wound by formation of tissue that does not truly restore the original architecture or original function of the body part Healing by Repair • Example of repair is a scar • Healing is complete, but the tissue is not completely the same in appearance or function • Example of repaired periodontium is healing that takes place after instrumentation • Results in a long junctional epithelium Healing by Reattachment • Reattachment is reunion of connective tissue and root that was separated by incision or injury, not disease • Moving healthy tissue on a tooth may be necessary to access damaged tissue on an adjacent tooth • The healing from this type of incision is reattachment Healing by New Attachment • New attachment describes union of pathologically exposed root with connective tissue or epithelium • Occurs when epithelium and connective tissues are newly attached to root where periodontitis previously destroyed the attachment New Attachment vs. Reattachment • New attachment must occur in an area formerly damaged by disease • Reattachment occurs when tissues are separated in the absence of disease Healing by Regeneration • Regeneration is a biologic process by which architecture and function of lost tissue are completely restored • Tissues look exactly the same as before • Reforming of lost cementum, periodontal ligament, alveolar bone Chapter 21: Periodontal Surgical Concepts for the Dental Hygienist Section 3 Overview of Common Types of Periodontal Surgery Historical Perspectives • Surgery was recommended mainly to remove what was thought to be dead or infected tissue in the periodontium • Early procedures were mainly resective Modern Periodontal Surgical Techniques • Resective surgery has limited use • Resective surgery is no longer recommended as part of modern periodontal therapy • Refinement of goals and techniques for periodontal surgery has taken place • Emphasis has shifted from resective surgery to surgical procedures that attempt to regenerate lost periodontal tissues Types of Surgery • Periodontal flap • Bone replacement graft • Guided tissue regeneration • Apically positioned flap with osseous surgery • Mucogingival plastic surgery • Crown lengthening • Dental implant placement • Gingivectomy • Gingival curettage Periodontal Flap • Incisions are made in gingiva around necks of teeth • Underlying soft tissues are elevated from tooth roots and bone Indications for Periodontal Flap Surgery • Most periodontal surgical procedures require a flap • Performed to provide access for treatment of tooth roots or bone • Flap can be elevated for periodontal instrumentation • Flap can be elevated to access bone to reshape or fill defects Description of Procedure • Also called modified Widman flap surgery • Provides access to tooth roots for improved root preparation • Tissue is lifted long enough for procedure • After completion of procedure, tissue is replaced at original position • Sutured in place Healing After Flap Surgery • Healing by repair • Involves formation of long junctional epithelium • Can be maintained by patient and professional care Special Considerations for the Dental Hygienist • Pocket depths deeper than 5 to 7 mm • Flap for access surgery allows more efficient instrumentation of root surfaces Description of Procedure • Surgery used to encourage the body to rebuild alveolar bone lost from periodontal disease • Involves: – – – – Elevation of a flap Cleaning granulation tissue from bone Treating roots as needed Placement of grafting material into defect Materials Used for Bone Replacement • Harvested bone taken from the patient’s jaw • Treated bone from cadavers and other species • Artificial material that stimulates bone regrowth Materials Used for Bone Grafts Autograft Taken from patient’s body; jaw Allograft Taken from a cadaver Xenograft Treated cow bone Alloplast Synthetic bone material Healing After Bone Grafting • Partial or complete rebuilding of alveolar bone • Reformed bone may not actually be attached to cementum by periodontal ligament fibers Special Considerations for the Dental Hygienist • Site of bone graft should not be disturbed for many months • Do not probe until appropriate interval has lapsed • Meticulous plaque control is critical to maintain health in the area Description of Procedure • Surgical procedure that attempts to regenerate lost periodontal structures • Widespread use Description of Procedure • Involves: – – – – Elevation of flap Cleaning alveolar bone defects Treatment of roots Placement of barrier materials to control rapid growth of epithelium into wound • Barrier materials require removal, necessitating a second surgery Healing After Guided Tissue Regeneration • Connective tissue components from the periodontal ligament space provide the cells needed to regrow cementum, periodontal ligament, and alveolar bone • Barrier materials prevent epithelial tissue from covering the tooth root too soon Special Considerations for the Dental Hygienist • Effort is made during surgery to close the wound to cover barrier material • During postsurgical visit, if part of barrier is exposed, minimize bacterial contamination • May suggest topical antimicrobial • Do not probe site for several months Description of Procedure • Designed to eliminate or minimize pocket depths • Involves: – – – – Elevation of flap Removal of granulation tissue Treatment of roots Correction of bone contours to mimic healthy alveolar bone Description of Procedure • Flap is sutured in a more apical position to its original level • Ideal for minimizing pocket depth in patients with moderate periodontal disease Healing of an Apically Positioned Flap • Results in a stable dentinogingival junction • Outcome depends on meticulous home care by the patient combined with professional maintenance visits • Final healing results in normal attachment at a more apical position on the root Special Considerations for the Dental Hygienist • Surgery results in more root exposure in the oral cavity • Patient may experience temporary root sensitivity Description of Surgery • Also called periodontal plastic surgery • Designed to alter components of attached gingiva • Restores gingiva to tooth surface as a result of disease or trauma • Removes frenum to deepen vestibule • May alter the appearance of the tissue Types of Surgery • Soft tissue graft – Covering roots because of excessive recession • Connective tissue graft – Harvesting donor connective tissue (palate) • Free gingival graft – Harvesting donor tissue that includes both surface epithelium and underlying connective tissue Healing After Mucogingival Surgical Procedures • Harvesting from a donor site creates two wounds that have to heal • Expected new attachment of grafting material to the tooth root Special Considerations for the Dental Hygienist • Donor site on palate can actually bother the patient more than wound at site • Discuss postsurgical discomfort with the patient • Do not disturb grafted sites during early stages of healing • Encourage patient to maintain good plaque control Description of Procedure • • • • Designed to create longer clinical crown Gingiva is removed from the tooth Alveolar bone is removed from necks of teeth Performed for aesthetics, restorative dental procedures Description of Procedure • Involves: – Elevating a flap – Recontouring of the bone – Suturing tissue back in place Healing After Crown Lengthening Surgery • Similar to apically positioned flap with osseous surgery • Results in a normal attachment at a position more apical on root Special Considerations for the Dental Hygienist • Patient may experience some temporary dentinal hypersensitivity • Institute measures to deal with sensitivity • Encourage patient to maintain meticulous oral hygiene, especially during healing phase • May be difficult because mechanical plaque control must be restricted after surgery Description of Procedure • Artificial tooth root placed into alveolar bone to hold a replacement tooth • Requires exposure of alveolar bone using flap surgery • A precise hole is drilled into bone and metallic implant is inserted • Some implants are covered by gingiva during healing Healing • Bone growth is in close proximity to implant surface • Implant must be stable enough to support a tooth or dental prosthetic appliance • Implants are not surrounded by cementum and ligaments Special Considerations for the Dental Hygienist • Patient self-care is critical • After the implant site heals, gingiva can be maintained as usual Description of Procedure • Surgery designed to remove gingival tissue Indications for Gingivectomy • Use is limited to removing enlarged gingiva to improve esthetics or allow for better access during home care Disadvantages • Leaves large open connective tissue wound • Slower surface healing than other surgeries • More discomfort for patient during healing • Teeth appear longer Healing After Gingivectomy • Normal attachment of the soft tissues to the tooth root • Attachment is more apical in position than original level • Teeth appear longer Special Considerations for the Dental Hygienist • Healing phase can be very uncomfortable for patient • Can be managed with a periodontal dressing over the wound • Prescribe analgesics • Dressing may need to be changed at several postsurgical visits until total epithelization has occurred Description of Procedure • Involves an attempt to scrape away lining of the periodontal pocket with a curette • Benefits of this procedure are the same as periodontal instrumentation and meticulous plaque control • No longer a recommended procedure Chapter 21: Periodontal Surgical Concepts for the Dental Hygienist Section 4 Management of the Patient Following Periodontal Surgery Purpose of Sutures • Sutures stabilize the position of the soft tissues during early phases of healing • A suture is a stitch taken to repair an incision, tear, or wound Material Used • Nonresorbable – Does not dissolve in body fluids and must be removed by a clinician • Resorbable – Dissolves slowly in body fluids and does not need to be removed Suture Removal • Nonresorbable sutures placed during surgical procedures are removed as part of routine postsurgical visits • Remnants of resorbable sutures are removed to avoid inflammation • Sutures should be removed when they are loose in the tissues Suture Removal • Sutures are usually loose in the tissue 1 week after surgery • Sutures should not be left in place longer than 2 weeks • They become irritants if left in the tissue too long Suture Removal Guidelines • Count the number of sutures placed and enter it in the treatment notes • Assures the correct number is removed • Write suture size in treatment notes: – 3-0, 4-0, 5-0 • 3-0 is largest; 5-0 smallest Suture Removal Guidelines • Sutures are removed by cutting material near the knot and grasping the knot with pliers • Gently pull through the tissue • Usually not painful for the patient Surgical Wound Dressing • Periodontal surgical wound dressing • Material from two tubes is mixed together for a putty-like consistency • Light-cured gel • Does not stick to the tissue • Is retained by pressing firmly interdentally Surgical Wound Dressing • • • • Use the least amount possible Just enough to cover the wound Should be no dressing on occlusals Take care not to trap sutures in dressing Postsurgical Instructions • Supplying the patient with both verbal and written instructions minimizes confusion • Restrict mechanical plaque removal • Encourage patient to take medications as prescribed Postsurgical Instructions • Advise the patient to chew food in such a way that it does not disturb the surgical site • Manage facial swelling • Supply patient with an emergency number in case excessive bleeding occurs Postsurgical Visits • Patients are usually seen in 5 to 7 days for the first postsurgical visit • It is the dentist’s responsibility to manage postsurgical problems • The dental hygienist performs most of the postsurgical management Step 1 • Interview the patient about: – Pain experience and use of analgesics – If antibiotic prescriptive instructions were followed – Swelling – Postsurgical bleeding – Sensitivity to cold Step 2 • Take patient’s vital signs: – Blood pressure – Pulse – Temperature • Elevated temperature may indicate a developing infection Step 3 • Remove periodontal dressing and examine surgical site • Rinse site with warm, sterile saline solution • Use cotton-tipped applicator to remove debris adherent to teeth, soft tissue, or sutures • Swelling or exudate indicates an infection Step 4 • Cut sutures and remove using sterile scissors Step 5 • Plaque accumulation is likely • Remove plaque from surgical area Step 6 • Replace periodontal dressing, if indicated • Discontinue dressing as soon as patient is able to resume mechanical plaque control Step 7 • Instruct patient in self-care • Use brushes with extra soft bristles • May introduce additional self-care aids Step 8 • Reappoint for second postsurgical visit • Usually 2 to 3 weeks after surgery