General principles of periodontal surgery DR JEBIN,MDS.,D.ICOI

Transcription

1 General principles of periodontal surgery DR JEBIN,MDS.,D.ICOI

2 Introduction All surgical procedures should be carefully planned. The patient should be adequately prepared medically, psychologically, and practically for all aspects of intervention.

3 OBJECTIVES OF PERIODONTAL SURGERY

4 To establish drainage of gingival & periodontal abscess

5 To improve esthetic appearance of tissue overgrowth or recession of gingiva

6 To prepare for restorative dentistry

7 Aberrant frenum Gingival recession

8 Minimal keratinized gingiva

9 For osseous regenerative & guided tissue regeneration.

10 For surgical pocket elimination by removal of soft tissue, to correct gingival contours that interferes with oral hygiene.

11 INDICATIONS OF PERIODONTAL SURGERY

12 Areas with irregular bony contours and craters

13 Infra bony pockets in the distal areas of last molars

14 Persistent inflammation in areas with moderate to deep pockets

15 In cases of grade II or grade III furcation involvement

16 CONTRAINDICATIONS HAEMORRHAGIC DISORDERS Haemophilia Thrombocytopenic purpura, Following anticoagulant therapy During first two days of menstrual period Neutropenia Uncontrolled diabetes, Prolonged cortisone therapy.

17 SPECIFIC CONTRAINDICATIONS HANDICAPPED POOR ORAL HYGIENE

18 Specific contraindications

19 TIMING FOR PERIODONTAL SURGERY

20 Timing for periodontal surgery Except for emergency, all periodontal surgery should be at least one month after completion of phase I therapy. The need for mucogingival surgery cannot be assessed properly at the time of the initial examination.

21 Temporary splinting and/or occlusal adjustments procedures should be completed prior to the periodontal surgery

22 PRE OPERATIVE EVALUATION Medical and dental history should be reviewed. The patient s ability to remove plaque should be evaluated. Tooth sensitivity should be noted and measures taken to control it. In case of anxiety or history of syncope, premedication should be considered.

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24 PREOPERATIVE EVALUATION No specific nutritional regime is indicated before periodontal surgery. The need for adequate fluid intake should always be emphasized. Advise to quit smoking Informed consent

25 Emergency equipment The operator, all assistants and office personnel should be trained to handle all emergencies. Drugs and equipment for emergency use should be readily available at all times. Most common emergency is syncope

26 SYNCOPE

27 Syncope Transient loss of consciousness caused by reduction in cerebral blood flow. Common cause fear and anxiety. Syncope usually preceded by 1. Malaise 2. Pallor 3. Sweating 4. Coldness of the extremities 5. Dizziness,Tachycardia 6. Slowing of the pulse.

28 Syncope management Patient should be placed in the supine position with legs elevated.

29 Tight clothes should be loosened and wide open airway Syncope is ensured. management Administration of oxygen is also useful

30 MATERIALS & METHODS FOR PERIODONTAL SURGERY

31 INSTRUMENTS All instruments prepacked and presterilized Inspected carefully and sharpened when indicated. Additional instruments, sterilized in sealed paper bags, available if needed Prepacked new disposable syringe needles, scalpel blades, sutures & materials should be used.

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34 SURGICAL ASSISTANT

35 SURGICAL ASSISTANT The assistant is an active participant in all surgical procedures, serving as a second pair of hands. The role of an assistant is to make it easier for the surgeon to administer treatment smoothly and efficiently.

36 Duties of an assistant

37 BEFORE SURGERY

38 DURING SURGERY

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40 After surgery Will provide an instruction sheet, gauze, and a temporary ice pack. The assistant delivers and explains prescriptions and postsurgical care

41 Principles of atraumatic surgery Anaesthesia Sharp instruments and minimum force less trauma Atraumatic tissue management Suturing.

42 Tissue management Flaps and grafts should be handled gently, Elevators or tissue retractors should be used in such a way that they do not tear or compress soft tissues. Use suction during periodontal surgery rather than to compress the tissues with a dry sponge in order to gain better vision. The use of sponges also may result in cotton fibers being left in the wound, which may be a source of future irritation.

43 Avoid drying of bone, which will cause necrosis of surface bone. Do not blow air into the field of surgery, as it may induce emphysema, or even air emboli, which can be fatal.

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45 Hemostasis Intra operative bleeding is best controlled with pressure using moist gauze for 2 to 5 minutes. Resorbable suture to control the arterial bleeding. Bleeding from bone can be stopped by burnishing the bone in the area of the bleed with a molt, elevator, or curette. If this is ineffective, bone wax can be compressed into the area of the bleed.

46 According to Edward S Cohen, A surgical suture is one that approximates the adjacent cut surfaces or compresses blood vessels

47 PURPOSE OF SUTURING The primary objective is to position & secure surgical flaps to promote optimal healing ( Primary healing ) Hastens the wound healing time Reduces post operative pain & increases Patient comfort Prevention of infection to the deeper tissues like bone Permit proper flap position

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49 The suturing SUTURING needles are NEEDLE made of either stainless steel or carbon steel The needle consists of 3 parts Needle point Body Eyed / Swaged end

50 Suturing needles are of different types Depending on the curvature, they can be classified as ¼ circle 3/8 th circle ½ circle ¾ th circle Straight with curved end Straight

51 Depending on the shape of the needle body, they can be classified as Tapered / round body Cutting Conventional cutting Reverse cutting

52 Tapered / round body In these needles, the body is circular in cross section & tapers gradually to the needle point.

53 Cutting needles Triangular in cross section. The angles of the triangle represent the blades. Conventional cutting cutting edges along the inner curvature of the needle. cutting edge on inner curvature Of the needle

54 Reverse cutting doesn t have any cutting edge along its inner curvature & has flat internal surface Flat internal surface

55 SELECTION CRITERIA OF NEEDLE IN PERIODONTAL SURGERY DEPENDING UPON THE TYPE OF NEEDLE BODY The tapered needle is generally used for soft, nonkeratinized, easily penetratable tissues. Used for thin mucoperiosteal flaps & closure of releasing incisions extending on to the alveolar mucosa

56 In periodontal surgeries-always use Reverse cutting needles. This prevents the suture material tearing through the papillae or surgical flap edges, referred to as cut-out, which most commonly happens while using conventional cutting needles

57 Depending the attachment of suture material to the needle classified as Eyed / Traumatic Swaged / Atraumatic French eye(split or spring )

58 Eyed / Traumatic needles It consists of a hole / eye Eye of the needle larger than the diameter of the suture produce larger hole in the tissue than the diameter of their own

59 Swaged / Atraumatic needles Inserted into the hollow end during manufacture& the metal is compressed around it. This doesn t cause injury to the tissues compared to eyed needle Atraumatic needles.

60 NEEDLE HOLDERS Types Locking: The lock on a suture forceps is a convenient means for parking the needle and passing it to the surgeon. Non locking

61 Castroviejo needle holders are fine, flat handle needle holders. It can be used where operation site is limited.

62 Scissors Held similar to the needle holder They have relatively long handles and thumb/ finger rings. Short cutting edges.blades may

63 SUTURE MATERIAL / SUTURE THREAD IDEAL REQUISITES OF SUTURE MATERIAL Adequate tensile strength Good handling properties Ease to tie the knot, without slips Biocompatible with minimal tissue reaction Sterilizable Favorable absorption profile Resistant to infection

64 Depending on the microstructure of the Suture material, they can be classified as Monofilament suture Braided suture

65 Monofilament suture Structurally it is a solid string. The whole diameter of the suture is made up of a single block of material.

66 Braided suture It consists of many thinner filaments, twisted together to form a string of desired diameter.

67 Monofilament suture is advantageous over the Braided suture as, the Braided suture does have the wicking effect. i.e, it pulls the bacteria & fluid into the wound site. Hence Monofilament suture are more sterile than the braided suture.

68 TYPES OF SUTURE MATERIAL

69 SUTURING THE PERIODONTIUM PRINCIPLES OF SUTURING: The needle holder should grasp the needle at approximately 3/4th of the distance from the needle point

70 The needle should enter the tissue perpendicular to the surface Sutures should be located below the imaginary line that forms the base of the triangle of the interdental papillae.

71 The suture should be placed at an equal distance [ 2 3 mm ] on both sides of the incision

72 Suture should be always inserted through the more mobile flap first. The suture should be tied so the tissue is merely approximated & not blanched. The knot shouldn t be placed on the incision line.

73 PERIODONTAL SUTURING TECHNIQUES

74 SIMPLE LOOP SUTURE Most commonly used suture because of its simplicity. Suture forms a simple circular loop uniting the two edges of the surgical incision.

75 FIGURE 8 SUTURE As the name tells, this suture forms a loop with a figure of eight, with the criss cross limbs of eight placed between the two flap edges.

76 Periosteal Sutures Used to hold apically displaced flaps in place Mainly consists of 2 sutures 1. Holding sutures 2. Closing sutures

77 Sutured Knot Components

78 KNOT TYING The knot may be tied in 2 techniques INSTRUMENT TIE Using needle holder ONE HANDED & TWO HANDED TIE Using fingers As periodontal surgeries instrument tie is the most appropriate & extensively used technique.

79 Principles of Knot tying Ethicon Knot must be firm.no slippage. 2. Knot should not be placed on incision lines..avoid wicking. 3. Avoid excessive tension..crimping of suture. 5. Knot ends must be 2 3mm. 6. An added throw does not increase the strength of the knot. 8. Final tension or final throw should be as nearly horizontal as possible.

80 TYPES OF KNOTS SQUARE KNOT SURGEON S KNOT GRANNY S KNOT

81 SQUARE KNOT This knot appears squarish before tightening the knot. Technique: It is formed by tying 2 ties. The first one in one direction & the second tie by throwing the suture in opposite direction

82 SURGEON S KNOT It is the most commonly used knot as it reduces slippage of the first tie, while the 2nd tie is placed. Technique: It is formed by tying 2 ties. The first tie is formed by 2 throws in one direction & the 2nd tie in opposite direction.

83 GRANNY S KNOT Same knot is used after completion of sewing the cloth. Technique: It involves a first tie in one direction followed by a second tie in the same direction as first. Later a third tie is made to hold the knot permanently.

84 SUTURE REMOVAL When to do it As a rule Intra oral sutures are removed 5 7 days after the suturing. Natural non resorbable sutures, like silk are removed after 1 week of suturing.

85 Complications following Suturing The knot slips gives rise to 90% of the complications following suturing, leading to dehiscence of wound. If the non resorbable sutures like silk, are left in place for longer duration the lead to abcess formation. Here termed as Stich Abcess

86 Complications following Suturing In case of braided sutures,because of the wicking effect there can be spread of infection all along the suture line 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 cysts Railroad track scar

87 Periodontal dressing Periodontal dressings were first introduced in 1923 by A.W. Ward following gingival surgery. This material was called Wonder pak which consisted of zinc oxide eugenol mixed with alcohol, pine oil and asbestos fibres.

88 Uses of periodontal dressing Uses of periodontal dressing Protection of the wound area. Enhancement of the patient comfort Maintainence of a debris free area Helps to control bleeding Helps to maintain the position of repositioned soft tissues Periodontal dressings also protect newly exposed root surfaces from temperature changes, stabilize mobile teeth protect suture.. Act as a template to prevent formation of excessive granulation tissue Protects the surgical healing areas from irritants such as hot and spicy foods.

89 The two most widely used type of dressing materials : Zinc oxide eugenol zinc oxide noneugenol dressings. In addition, Cyanoacrylates, Tissue conditioners, Periodontal dressing that contain anti microbial agents, photo curing periodontal dressing materials are also available.

90 The various zinc oxide non eugenol dressings available are Coe Pak, Peripac, Vocopac, Perio care, Collagen dressings, Barric aid, Cyanoacrylates Tissue conditioners.

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92 Coe pak composition Base Rosin, Cellulose, Natural gums and waxes, fatty acids, Chlorothymol, Zinc acetate, Alcohol. Accelerator: Zinc oxide, Vegetable oil, Cholrothymol, Magnesium oxide, Silica, synthetic resin, Coumarin Lorothiodol [a fungicide].

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95 Retention of packs Periodontal dressings are usually kept in place mechanically by interlocking in interdental spaces and by joining the lingual and facial portions of the pack. Around isolated teeth or several missing teeth, splints and stents are used for retention purpose.

96 Cyanoacrylate: Use of Cyanoacrylates is an alternative to suturing and as a surface adhesive and periodontal dressing. Cyanoacrylates is either applied in drops or sprayed on the tissue.

97 Post operative instructions Avoid brushing in that area for about a week. Advice a good mouth rinse to minimize plaque deposits. Advice to avoid solid food for 24 hours. If patients feels excessive pain he should return to clinic. If there is bleeding, should see the dentist. If at all periodontal dressing falls off within three days, should come to clinic for new dressing. Give analgesics. Advisable to use antiinflammatory analgesic when soft tissue surgery is carried out.

98 First post operative week If properly performed no serious post operative problems. Patient advised to rinse with 0.12% chlorhexidin immediately after the surgical procedure and twice daily thereafter until normal plaque control technique can be resumed

99 Complications that may arise in the first post operative week 1. Persistent bleeding after surgery 2. Sensitivity to percussion 3. Swelling 4. Feeling of weakness

100 Feeling of weakness Occasionally, patients report having experienced a washed out, weakened feeling for about 24hrs after surgery. Transient bacteremia induced by the procedure. Avoided by premedication with amoxicillin 500mg every 8 hrs, beginning 24 hrs before the next procedure and continuing for 5 days post operatively.

101 Removal of pack & return visit One week after surgery pack is removed. gentle lateral pressure. pack retained interproximally and adhering to the tooth surface are removed with scalers.

102 After flap operation may bleed readily when touched; they should not disturbed. Pockets should not be probed. Grayish yellow or white granular layer of food debris that has seeped under the pack should be removed with moist cotton pellet.

103 Post operative pain Analgesics are used for relief of pain

104 THANK YOU