General guidelines for periodontal surgery: instruments, local anesthesia, periodontal dressing, suturing.

1. General guidelines for periodontal
surgery: instruments, local anesthesia,
periodontal dressing, suturing.
Dr. Salar Zeinali Oct.2013

2. Objectives of the Surgical Phase
1. Improvement of the prognosis of teeth and their replacements.
Techniques performed for pocket therapy and for the correction of related
morphologic problems, namely, mucogingival defects.
the purpose of surgical pocket therapy is to eliminate the pathologic changes in
the pocket walls; to create a stable, easily maintainable state; and if possible, to
promote periodontal regeneration.To fulfill these objectives, surgical techniques
(1) increase accessibility to the root surface, making it possible to remove all
irritants; (2) reduce or eliminate pocket depth, making it possible for the patient
to maintain the root surfaces free of plaque; and (3) reshape soft and hard tissues
to attain a harmonious topography. Pocket reduction surgery seeks to reduce
pocket depth by either resective or regenerative means or often by a
combination of both methods
2. Improvement of esthetics.

3. Pocket Reduction Surgery
• Resective (gingivectomy, apically displaced flap,
and undisplaced flap with or without osseous
resection
• Regenerative (flaps with grafts, membranes, etc)
Correction of Anatomic/Morphologic Defects
• Plastic surgery techniques to widen attached
gingiva (free gingival grafts, other techniques, etc)
• Esthetic surgery (root coverage, recreation of
gingival papillae)
• Preprosthetic techniques (crown lengthening,
ridge augmentation, and vestibular deepening)
• Placement of dental implants, including
techniques for site development for implants
(guided bone regeneration, sinus grafts)

4. General Principle
• Patient Preparation: Almost every patient undergoes the so-called initial or preparatory phase of therapy,
which basically consists of thorough scaling and root planing and removing all irritants responsible for the
periodontal inflammation.
• Premedication: The prophylactic use of antibiotics in patients who are otherwise healthy has been
advocated for bone-grafting procedures and purported to enhance the chances of new attachment.
Although the rationale for such use appears logical, no research evidence is available to support it
Other pre-surgical medications include administration of a nonsteroidal antiinflammatory drug (NSAID)
such as ibuprofen (Motrin) 1 hour before the procedure and an oral rinse with 0.12% chlorhexidine
gluconate
• Smoking:The deleterious effect of smoking on healing of periodontal wounds has been amply
documented. Patients should be clearly informed of this fact and asked to quit or stop smoking for a
minimum of 3 to 4 weeks after the procedure. For patients who are unwilling to follow this advice, an
alternate treatment plan that does not include more sophisticated techniques (e.g., regenerative,
mucogingival, esthetic) should be considered.
• Informed ConsentThe patient should be informed at the initial visit about the diagnosis, prognosis, and
different possible treatments, with their expected results and all pros and cons of each approach

5. Periodontal Dressings (Periodontal Packs)
In most cases, after the surgical periodontal procedures are completed, the area is covered with a surgical pack. In
general, dressings have no curative properties; they assist healing by protecting the tissue rather than providing
“healing factors.”The pack minimizes the likelihood of postoperative infection and hemorrhage, facilitates healing by
preventing surface trauma during mastication, and protects against pain induced by contact of the wound with food
or the tongue during mastication.
Zinc Oxide–Eugenol Packs
Zinc oxide–eugenol dressings are supplied as a liquid and powder that are mixed before use. Eugenol in this type of
pack may induce an allergic reaction that produces reddening of the area and burning pain in some patients.
Noneugenol Packs
the most widely used dressing in the United States.This is supplied in two tubes, the contents of which are mixed
immediately before use until a uniform color is obtained. One tube contains zinc oxide, an oil (for plasticity), a gum
(for cohesiveness), and Lorothidol (a fungicide); the other tube contains liquid coconut fatty acids thickened with
colophony resin (or rosin) and chlorothymol (a bacteriostatic agent).This dressing does not contain asbestos or
eugenol, thereby avoiding the problems associated with these substances.
Antibacterial Properties of Packs
Improved healing and patient comfort with less odor and taste have been obtained by incorporating antibiotics in
the pack, Incorporation of tetracycline powder in Coe-Pak is generally recommended, particularly when long and
traumatic surgeries are performed

6. Preparation and Application of Dressing
Zinc oxide packs are mixed with eugenol or noneugenol liquids on a wax paper pad with a wooden tongue
depressor.The powder is graduallyincorporated with the liquid until a thick paste is formed.
Coe-Pak is prepared by mixing equal lengths of paste from tubes containing the accelerator and the base until
the resulting paste is a uniform color.A capsule of tetracycline powder can be added at this time.The pack is
then placed in a cup of water at room temperature. In 2 to 3 minutes the paste loses its tackiness and can be
handled and molded; it remains workable for 15 to 20 minutes.Working time can be shortened by adding a
small amount of zinc oxide to the accelerator (pink paste) before spatulating.
The pack is then rolled into two strips approximately the length of the treated area.The end of one strip is
bent into a hook shape and fitted around the distal surface of the last tooth, approaching it from the distal
surface.The remainder of the strip is brought forward along the facial surface to the midline and gently
pressed into place along the gingival margin and interproximally.The second strip is applied from the lingual
surface. It is joined to the pack at the distal surface of the last tooth, then brought forward along the gingival
margin to the midline.The strips are joined interproximally by applying gentle pressure on the facial and lingual
surfaces of the pack

7. • Inserting the periodontal pack.A, Strip of
pack is hooked around the last molar and
pressed into place anteriorly. B, Lingual pack is
joined to the facial strip at the distal surface
of the last molar and fitted into place
anteriorly. C, Gentle pressure on the facial
and lingual surfaces joins the pack
interproximally.
• Periodontal pack should not interfere with
the occlusion.

8. Surgical instruments
1. Excisional and incisional instruments
2. Surgical curettes and sickles
3. Periosteal elevators
4. Surgical chisels
5. Surgical files
6. Scissors
7. Hemostats and tissue forceps

9. Excisional and incisional
instruments
Periodontal Knives (Gingivectomy Knives)
Interdental Knives
Surgical Blades
Gingivectomy knives.A, Kirkland knife. B, Orban interdental knife.
Surgical blades.Top to bottom, #15, #12D, and #15C.These blades are disposable.

10. Surgical Curettes and Sickles
Larger and heavier curettes and sickles are often needed during
surgery for the removal of granulation tissue, fibrous interdental
tissues, and tenacious subgingival deposits
Prichard surgical curette. Curettes used in surgery have wider blades
than those used for conventional scaling and root planing. Woodson periosteal elevator.
Periosteal Elevators

11. Surgical Chisels
Back-action chisel.
Ochsenbein chisels are paired, with the cutting edges in opposite directions.

12. Tissue Forceps
DeBakey tissue forceps.

13. Scissors and Nippers
Scissors and nippers are used in periodontal surgery to remove tabs of tissue during
gingivectomy, trim the margins of flaps, enlarge incisions in periodontal abscesses, and
remove muscle attachments in mucogingival surgery.
Goldman-Fox scissors.

14. Needleholders
Conventional needleholder. B, Castroviejo needleholder.

15. Suturing
Almost all periodontal surgical wounds arc closed with sutures, and a wide variety
of suturing techniques have been developed to aid the surgeon in achieving the
surgical objectives. Successful suturing is an exercise in tissue control, and different
surgical procedures will require different types of suture mate rials and suturing
methods."
There are two general methods of suturing periodontal flaps: interrupted suturing
and continuous suturing," With interrupted sutures, each interdental papilla is
sutured separately from the others; with continuous sutures, several papillae arc
sutured together with one knot.There arc several variations within these two
categories.

16. Simple interrupted suture
The simple interrupted suture is the easiest suture to perform. It is used to rejoin
a buccal interdental papilla and a lingual interdental papilla that have been
separated by a flap. Beginning on the buccal aspect, the suture needle is passed
through the interdental papilla . leaving approximately 2 cm of free suture
material on the buccal aspect.Th is called the tag end of the suture.The needle is
then passed, back end first so as no t to dull the point, through the same
interdental space to the lingual aspect, where the lingual flap is engaged in a
similar manner. Finally, the needle is once again passed through that interdental
space, and a knot is tied on the buccal aspect.As a general rule , sutures are
always tied with the knot on the facial or buccal surfaces of the teeth .This makes
them easier to remove and protects the tongue from soreness or ulceration

17. Continues suture
As the name implies, continuous sutures are used to join two or more interdental papillae of the same flap.They
are usually used when the buccal flap is sutured separately from the lingual flap or when no lingual flap is
performed. In a continuous suture, the suture needle is first passed through an interdental papilla on the buccal
aspect of a flap.The needle is then passed through the interdental space to the lingual aspect , where it does not
engage the lingual tissue. Instead, the needle is passed around the tooth, either mesially or distally, and through the
adjacent inerdental space back to the buccal aspect . Here the buccal flap is again engaged.The needle is once again
passed through the interdental space and back around the tooth, to emerge,At the position from which the suture
began.The suture is tied at this point. Continuous sutures are very useful in a variety of different clinical situations.
For example, they may be used to suture a barrier membrane over the buccal surface of a tooth,The overlying flap
may then he sutured coronally with a separate continuous (or interrupted) suture.

18. Mattress suture
In this type of suture, the needle enters the flap through the papilla and exits
under the free margin of the flap.These flaps cannot be sutured coronally, apically,
or laterally because they are hound down at the mucogingival junction, limiting
their movement. flaps that involve dissection beyond the mucogingival junction
(either split- or full thickness flaps) require the use of a mattress suture.This
suture enters the flap at or near the mucogingival junction and exits the flap
through the interdental papilla. In this way, much more of the suture lies on to p
of the flap, and it is able to hold the full extent of the flap in close contact with
the underlying bone or periosteum .This aids in healing and flap reattachment
and reduces the chance of postoperative bleeding. If the surgeon merely relies on
the periodontal dressing or a primary blood clot to hold the flap in contact with
the bone or periosteum, postoperative complications, such as bleeding under the
flap, flap detachment, or flap necrosis, may occur.

19. Cross (Criss-Cross) Suture
This is a useful variation of a continuous mattress suture. Here, the mattress
sutures are placed horizontally, not vertically. For example, at an edentulous space
with buccal and lingual flaps, the suture needle enters the buccal flap at the
distobuccall line angle and exits the buccal flap at the mesiobuccal line angle.The
same maneuver is duplicated on the lingual or palatal aspect; the needle enters
the flap at the distobuccal Iine angle and exits through the mesiobuccal line angle.
The knot is then tied and will form a cross on top of the flap

20. Knots
There are three types of knots that are useful to the periodontal surgeon: the
square knot, the surgeon's knot, and the slip or "granny" knot.

21. Square knot
This is a simple knot to tie and consists of two overhand knots, each done in
opposite directions.The first overhand knot is made by making a loop over the
jaws of the needle holder, grabbing the tag end of the suture material, and pulling
the knot snugly to the flap .A second overhand knot is then made by making a
loop under the jaws of the needle holder again , grabbing the tag end of the
suture, and pulling the two ends of the suture (the one held by the needle holder
and the one held in the surgeon's hand) tight.

22. Surgeon’s knot
The surgeon's knot is a modified square knot with (two overhand knots, each
done in opposite directions.The first knot, however, is a double overhand knot ,
and the second one is a single.This doubling of the first overhand knot prevents
slipping and loosening, especially if the flaps are under tension.This is probably the
most commonly used knot in periodontal surgery. It is quick and simple to tie and
can hold flaps securely, even if they are under slight or moderate tension.

23. Slip knot
This extremely useful knot is sometimes called the granny knot. It too is a
variation of the square knot made with two single overhand knots; with the slip
knot, however, both overhand knots arc made in the same direction.The first
overhand knot is made by making a loop over the needle holder, grabbing the
free end of the suture, and pulling the ends tight .The second overhand knot is
made the same way, so that the loop again goes over the needle holder.The great
advantage of the slip knot is that, once it is tied, it can he tightened further. Once
it is tightened to the desired extent , it can be locked into place by another
overhand knot, made in the opposite direction of the first two.