PHASE I

THERAPY
Initial Phase
Non-surgical
1

Management of
Periodontal Disease
 phase I therapy is the first in the chronologic sequence of
procedures that constitute periodontal treatment.

 AKA initial therapy, nonsurgical periodontal therapy, cause-

related therapy, and the etiotropic phase of therapy.

 All terms refer to the procedures performed to treat gingival

and periodontal infections, up to and including tissue
reevaluation, which is the point at which the course of ongoing
care is determined

 objective:- alter or eliminate the microbial etiology and factors

that contribute to gingival and periodontal disease and
returning the dentition to a state of health and comfort. 2
 Factors that must be considered when determining and
developing the phase I treatment plan

 General health and tolerance of treatment

 Number of teeth present
 Amount of subgingival calculus
 Probing pocket depths and attachment loss
 Furcation involvements
 Alignment of teeth
 Margins of restorations
 Developmental anomalies
 Physical barriers to access (i.e., limited opening or tendency to gag)
 Patient cooperation and sensitivity

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 PRINCIPLES OF INITIAL PHASE
1. Eliminate microorganisms
2. Eliminate source of infection
3. Establish an environment to promote healing
4. Consider the host factor
5. Use of Antimicrobials to help the host’s defense to
cope with invading microorganism

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STAGES OF PHASE I THERAPY
 Step 1: Plaque Control Instruction
 Step 2. Removal of Supragingival and Subgingival
Calculus
 Step 3. Recontouring Defective Restorations and
Crowns.
 Step 4. Management of Carious Lesions
 Step 5. Occlusal Evaluation and Therapy
 Step 6. Tissue Reevaluation
 RESULTS

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PHASE I THERAPY
PROCEDURES
Step 1. Patient plaque control education
Step 1. Patient plaque control education – educate the
patient to maintain oral health and to motivate the
patient to help combat the disease so that they would
care about their oral health.
 Essential step

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 a. Information – one way to educate them is to give
them information about the period disease process,
role of plaque and microorganisms, caries, and how
these can be prevented through proper tooth brushing
techniques.
 Explain the etiology of the disease to the patient
 Instruct the correct technique- targeted oral hygiene- bass
technique

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 b. Plaque control –
 is the regular removal of microbial plaque and the prevention
of its accumulation on the teeth and adjacent gingival surfaces
 Microbial plaque growth occurs within hours, and it must be
completely removed at least once every 48 hours
 gaining patient cooperation in daily plaque removal is critical
to long-term success of all periodontal and dental treatment
 improve home care management of plaque by giving them oral
hygiene reinforcements or instructions.

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I .TOOTH BRUSH

 ADA recommends that individuals brush twice per day

and use floss or other interdental cleaners once per day
 Toothbrushes vary in size and design as well as in length,
hardness, and arrangement of the bristles
 no one design was superior to others
 amount of force used to brush is not critical for effective
plaque removal
 Vigorous brushing is not necessary and can lead to
gingival recession, wedge-shaped defects in the cervical
area of root surface
 ADA recommends that toothbrushes be replaced every 3
to 4 months.
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II. DENTIFRICES
 aid in cleaning and polishing tooth surfaces, but should
cause a minimum of abrasion to root surfaces
 in the form of pastes, although tooth powders and gels

 made up of abrasives, water, humectants, soap or

detergent, flavoring and sweetening agents, therapeutic
agents, coloring agents, and preservatives
 Oral hygiene procedures mainly cause hard tissue
damage from abrasive dentifrices

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BRUSHING TECHNIQUES
 Many methods for brushing the teeth have been
described and promoted as being efficient and effective
 Roll: Roll or modified Stillman technique
 Vibratory: Stillman, Charters, and Bass techniques
 Circular: Fones technique
 Vertical: Leonard technique
 Horizontal: Scrub technique

 Bass techniques are preferable

 Place the toothbrush so that the bristles are angled
approximately 45 degrees from the tooth surfaces.
 Start at the most distal tooth in the arch, and use a vibrating,
back-and-forth motion to brush 13
 III. INTERDENTAL PLAQUE CONTROL

 Tooth brushing is not enough to clean all areas with tight

contact
- different methods:
A) Flossing – to clean the interdental areas and the sub-interdental
papillary areas
 made from nylon filaments or plastic monofilaments, and can
be waxed, unwaxed, thick, thin, and even flavored

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 b) Toothpicks -only in areas which are accessible like
areas with diastema
 Access is easier from the buccal surfaces for tips
without handles but is limited primarily to the anterior and
bicuspid areas

c) Interdental brush – for use in interproximal areas

especially in patients with orthodontic brackets

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STEP 2. REMOVAL OF
SURAGINGIVAL AND SUBGINGIVAL
PLAQUE AND CALCULUS
I. Scaling
Scaling is the process by which plaque and calculus is
removed from both supragingival and subgingival root
surfaces.

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II. ROOT PLANING
 Root planing: the process by which residual embedded
calculus and portion of cementum are removed from the
tooth surface to produce smooth, hard and clean surface.
(Glickman)
 definitive treatment
 to remove diseased and soft cementum
 to create a smooth and hard cemental surface

 AKA closed deep cleaning, root detoxification, root surface

debridement, root surface instrumentation
 Debridement of root surface with only few strokes and not
to undertake aggressive instrumentation to remove the
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endotoxin and other root surface irregularities
CLARITY
 Root planing implies removal of cementum and possibly
dentin exposed within the pocket to maximise the chance
of removing all components of the subgingival plaque
 Subgingival scaling is the removal of deposits of
subgingival calculus

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TREATMENT
GOALS
1. Elimination of microorganisms
2. Creation of a clean, hard, and
smooth surface cementum
3. Removal of necrotic cementum
4. New attachment
 
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PERIODONTAL INSTRUMENTS FOR SCALING
AND ROOT PLANING
 Most of the periodontal instruments are made up of
either stainless steel or high carbon steel
 They are available as single-ended and double-ended
instruments.
 Periodontal instruments are composed of:
‰ Handle
 ‰ Shank
 ‰ Working end.

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CLASSIFICATION OF PERIODONTAL
INSTRUMENTS  Scaling and root planing
instruments:
 Classified according to  Hand instruments
their purpose According  Scalers
to their purpose:  Sickle scalers
 Nonsurgical Instruments  File scalers
 Chisel
 ‰ Diagnostic
 Hoe
instruments:
 Curettes
 Mouth mirror
 Ultrasonic and sonic instruments
 Periodontal probes
 Cleaning and polishing
 Explorers instruments
 Surgical instrument

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 Periodontal probes: a tapered, rodlike instrument
calibrated in mm, with a blunt, rounded tip
• locate, measure, and mark pockets
• Furcation areas can be best evaluated with the curved and
blunt Nabers probe
 Types of Periodontal Probes
 ‰ Color-coded probes
 ‰ Noncolor-coded probes.

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 Explorers: used to locate calculus deposits and caries
 check the smoothness of the root surfaces after root planing.
 Types of Explorers
‰ Shepherd’s hook
 ‰ Straight explorer
 ‰ Curved explorer
 ‰ Pigtail/cowhorn explorer

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HAND SCALING AND CURETTAGE
INSTRUMENTS:

 Sickle Scalers:- have a flat surface and two cutting edges

that converge in a sharply pointed tip.
• used primarily to remove supragingival calculus
• difficult to insert a large sickle blade under the gingiva
without damaging the surrounding gingival tissues
• inserted under ledges of calculus, not more than 1 mm below
the gingival sulcus and used with a pull stroke

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 Curette: has a cutting edge on both sides of the blade and
a rounded toe (spoon-shaped blade and rounded tip)
• is the instrument of choice for removing deep subgingival
calculus, root planing altered cementum, and removing the
soft tissue lining the periodontal pocket
• can be adapted and provide good access to deep pockets, with
minimal soft tissue trauma
• Has two types universal and area specific

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 Universal curettes: have cutting edges that may be
inserted in most areas of the dentition by altering and
adapting the finger rest, fulcrum and hand position of the
operator.

 Examples of universal curettes:

 Barnhart curettes No. 1–2 and 5–6

 Columbia curettes No. 13–14, 2R-2L, 4R-4L.

 Younger-Good No. 7–8,

 the McCalls No. 17–18

 Indiana University No. 17–18

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 Area-specific curettes (Gracey curettes): designed and
angled to adapt to specific anatomic areas of the
dentition
 provide the best adaptation to complex root anatomy
 Double-ended Gracey curettes are paired in the following
manner:
 Gracey No. 1–2 and 3–4 : For anterior teeth
 Gracey No. 5–6 : For anterior teeth and premolars
 Gracey No. 7–8 and 9–10 : Posterior teeth; facial and lingual
 Gracey No. 11–12 : Posterior teeth; mesial
 Gracey No. 13–14 : Posterior teeth; distal

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 Hoe Scalers:- blade is bent at a 99-degree angle; the
cutting edge is formed by the junction of the flattened
terminal surface with the inner aspect of the blade
 used for scaling of ledges or rings of calculus

 Files:- a series of blades on a base

• to fracture or crush large deposits of tenacious calculus or
burnished sheets of calculus
 Chisel Scalers:- double-ended instrument with a curved
shank at one end and a straight shank at the other the
blades are slightly curved and have a straight cutting
edge beveled at 45 degrees
 designed for the proximal surfaces of teeth too closely spaced
to permit the use of other scalers, is usually used in the
anterior part of the mouth. 30
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ULTRASONIC AND SONIC
INSTRUMENTS AND IRRIGATION
 Sonic units work at a frequency of 2000 to 6500 cycles
per second and use a high or low speed air source from
the dental unit
 Ultrasonic vibrations range from 20,000 cycles/second to
45,000.
 Water is delivered via the same tubing
 tips are large in diameter and universal in design
 travels in an elliptical or orbital stroke pattern

 tips designed to remove heavy supra-gingival calculus or

to definitively debride periodontal pockets.
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Sonic scalers Ultrasonic scalers

They are attached to a dental unit Free standing unit

Need compressed air Have electric generator

Frequency is 2,500–6,500 Frequency is 18,000–50,000 cycles/

cycles/second second

Tips are universal in design Variety of tips available

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 SPECIAL CONSIDERATIONS
 Aerosol Production
 Cardiac Pacemakers

 Indications
 Supragingival debridement of dental calculus and extrinsic
stain
 Subgingival debridement of calculus, oral biofilm, root
surface constituents, and periodontal pathogens
 Removal of orthodontic cement
 Gingival and periodontal conditions and diseases
 Surgical interventions
 Margination (reduces amalgam overhangs) 34
 Precautions
 Unshielded pacemakers
 Infectious diseases: human immunodeficiency virus, hepatitis,
tuberculosis (active stages)
 Demineralized tooth surface
 Exposed dentin (especially associated with sensitivity)
 Restorative materials (porcelain, amalgam, gold, composite)
 Titanium implant abutments unless using special insert
 Children (primary teeth)
 Immunosuppression from disease or chemotherapy
 Uncontrolled diabetes mellitus

 Contraindications
 Chronic pulmonary disease: asthma, emphysema, cystic fibrosis,
pneumonia
 Cardiovascular disease with secondary pulmonary disease
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 Swallowing difficulty (dysphagia)
 ADVANTAGES AND DISADVANTAGES OF
HAND AND ULTRASONIC INSTRUMENTS
Instruments Advantages Disadvantages

Hand instruments Superior tactile sensation Correct angulation is

mandatory

Good access Frequent sharpening is

required

Good adaptation Considerable working force

is required

No aerosol production Tiring for operator

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No heat development Negative time factor
Instruments Advantages
Ultrasonic instruments Instrumentation without
pressure
Highly accessible to reach
difficult areas
Minimal soft tissue damage
Requires less time
Disadvantages
Poorer tactile sensation
Aerosols are highly
contaminated
Not all handpieces can be
autoclaved
Possible risk for patients
with pacemakers

Pocket irrigation is possible Contraindicated in infectious

patients
No sharpening of tips
Better patient acceptance

Less tiring for the operator 37

PRINCIPLES OF PERIODONTAL
INSTRUMENTATION
1. Accessibility –
 The position of the patient and operator should provide maximal
accessibility to the area of operation
 ability to reach the involved areas
 Inadequate accessibility impedes thorough instrumentation, pre-
maturely tires the operator and diminishes his or her effectiveness
 Neutral Seated Position for the Clinician
 Forearm parallel to the floor
 Weight evenly balanced
 Thighs parallel to the floor
 Hip angle of 90 degrees
 Seat height positioned low enough so that the heels of your feet touch the floor
 Back straight and erect
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 Patient’s Position
 The patient should be in a supine position and placed in
such a way that the mouth is close to the resting elbow of
the clinician
 patient’s heels should be slightly higher than the tip of
his or her nose
 foremost of the patient’s head should be even with the
upper edge of the headrest
 patient’s neck and head are aligned with the torso

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2. Visibility – ability of the operator to see the involved
areas
 direct vision with direct illumination from the dental
light is most desirable.
 If this is not possible, indirect vision may be
obtained by using a mouth mirror to reflect light
where it is needed

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3. Instrument stabilization – use of finger rests
 Stability and control is essential for effective
instrumentation and to avoid injury to the patient or
clinician.
 The two factors that provide stability are
(1) finger rest
(2) instrument grasp
 Finger rest: stabilize the hand and the instrument by
providing a firm fulcrum, as movements are made to
activate the instrument
 prevents injury and laceration of the gingival and
surrounding tissues
 Two types of finger rest
 Intraoralfinger rest
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 Extraoral fulcrums
4. Instrument grasps –palm grasp, modified pen grasp

Pen grasp

Modified pen grasp

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5. Instrument Activation and Adaptation
 the tip should be adapted properly to the tooth surface to be
able to activate it and work
 Improper adaptation causes burnishing of the calculus
 4 methods of instrument activation
 Adaptation: manner in which the working end of a periodontal
instrument is placed against the surface of a tooth
 Angulation: the angle between the face of a bladed instrument and

the tooth surface

 Lateral pressure: the pressure created when force is applied against

the surface of a tooth with the cutting edge of a bladed instrument

 Strokes.

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6. Sharpness of Instruments
 the working ends of pointed or bladed instruments
must be sharp to be effective
 Advantages of Sharpness
‰ Easier calculus removal
 ‰ Improved stroke control
 ‰ Reduced number of strokes
 ‰ Increased patient comfort
 ‰ Reduced clinician fatigue.

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ANTI-INFECTIVE THERAPY
 An anti-infective agent- chemotherapeutic agent that acts by
reducing the number of bacteria present.
 An antibiotic- naturally occurring, semisynthetic, or synthetic
type of anti-infective agent that destroys or inhibits the
growth of selective microorganisms, generally at low
concentrations
 An antiseptic is a chemical anti-microbial agent applied
topically or subgingivally to mucous membranes, wounds, or
intact dermal surfaces to destroy microorganisms and inhibit
their reproduction or metabolism

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 can be administered locally (placing anti-infective agents
directly into the periodontal pocket) or systemic/ orally
(oral antibiotics)

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COMMON ORAL ANTIBIOTICS
REGIMENS USED TO TREAT
PERIODONTAL DISEASES

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LOCAL DELIVERY AGENTS
 adjuncts to scaling and root planing
 aids in the control of growth of bacteria on barrier
membranes
 they reduce the subgingival microflora, probing depths,
and clinical signs of inflammation
 Subgingival Chlorhexidine
 Tetracycline-Containing Fibers
 Subgingival Doxycycline
 Subgingival Minocycline

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STEP 3. RE-CONTOURING DEFECTIVE
RESTORATIONS AND CROWNS.
 Corrections for restorative defects, which are plaque
traps, may be made by smoothing surfaces and
overhangs with burs or hand instruments or by replacing
restorations.
 These procedures can be completed concurrently with
other phase I procedure

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STEP 4. MANAGEMENT OF CARIOUS LESIONS

Removal of the carious tissue and placement with either

temporary or permanent restorations is indicated in
phase I therapy because of the infectious nature of the
caries process.
 Healing of the periodontal tissues will be maximized by
removing the reservoir of bacteria in these lesions so that
they cannot repopulate the microbial plaque

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STEP 5. TISSUE RE-EVALUATION.

 After scaling, root planing, and other phase I procedures,

the periodontal tissues require approximately 4 weeks to
heal sufficiently to be probed accurately.
 Patients also need the opportunity to improve their
plaque control skills to both reduce inflammation and
adopt new habits.

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STEP 6: OCCLUSAL EVALUATION AND
THERAPY
 trauma from occlusion amplifies loss of attachment
 eliminating occlusal interferences had a positive influence on
the outcome of treatment when trauma from occlusion was
found to be a contributing local factor
 No or minimal occlusal contact-disuse/atrophy of the
periodontium, which may result in instability
 Harmonious occlusal force-stimulates physiologic arrangement
of its periodontal attachment and encourages its stability
 forces that exceed the tolerance of the periodontium result in
resorption of the bone and disruption of the attachment.

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*Recall and analyze how the tissues would respond to the
treatment
 
a. 1st sitting – remove all supragingival and some subgingival
calculus
b. 2nd sitting – remove all subgingival calculus because with
decrease of inflammatory process.
Subgingival calculus become more visible.
c. 3rd sitting – remove remaining deposits
*Maintenance part is all up to the patient. Patient should also
do his part.
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*Periodic recall every 6 months.
RESULTS PHASE I THERAPY
 Studies ranging from 1 month to 2 years in length
demonstrated up to 80% reduction in bleeding on
probing and mean probing depth reductions of 2 to 3 mm
 Additional individual treatments, such as caries control
and correction of poorly fitting restorations, clearly
augment the healing gained through good plaque control
and scaling and root planing by making tooth surfaces
accessible to cleaning procedures.
 attachment epithelium reappears 1 to 2 weeks after
therapy.

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 Gradual reductions in inflammatory cell population,
crevicular fluid flow, and repair of connective tissue
result in decreased clinical signs of inflammation
 One or two millimetres of recession is often apparent as
the result of tissue shrinkage

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DECISION TO REFER FOR SPECIALIST
TREATMENT
 following factors must also be considered in the decision to refer
 Incase of severe periodontitis with 5mm attachment loss
 Extent of disease and generalized or localized deep involvement
 Root length
 Hypermobility
 Difficulty of scaling and root planing
 Restorability and importance of particular teeth for reconstruction
 Age of the patient
 Lack of resolution of inflammation after scaling and planing

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58
 Periodontal surgery is defined as intentional severing or
incising of gingival tissue with the purpose of controlling
or eliminating periodontal disease.
 purpose of surgical pocket therapy is to
 eliminate the pathologic changes in the pocket walls/
periodontal disease
 to create a stable, easily maintainable state
 to promote periodontal regeneration

 The surgical phase consists of techniques

 performed for pocket therapy
 the correction of related anatomic morphologic problems,
mucogingival defects
 Plaque accumulation
 Recurrence of periodontal pocket

 Impair esthetics
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NEED OF SURGICAL TREATMENT
 A. impaired access for scaling and root planing
 Increasing depth of periodontal pocket
 Teeth with wider surfaces
 Presence of root fissures, root concavities, furcations,
defective restoration margins
 B. impaired access of self performed plaque control
 Lack of motivation
 Ginigval hayperplasia
 Faulty restoration margins

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 RATIONALE FOR DOING PERIODONTAL
SURGERY

1. To Gain Access
 at the deeper layers of the periodontium to remove remaining
plaque and calculus
 To access the deep and tortuous pockets for adequate cleaning
and smoothening of the root surface.
2. To Facilitate Plaque Control 
 Achieved by reduction or elimination of any potential
plaque retentive areas after phase I therapy
eliminating periodontal pockets, redundant gingiva,
and bony ledges.
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 Removal of any hyperplastic fibrous gingival
tissue in the retromolar areas or tuberosity areas
distal to the last molar, which represents
potential plaque retentive areas.
 Shallow vestibules and frenal attachment close
to the gingival margins may make oral hygiene
difficult, necessitating surgical correction to
facilitate patient plaque control.

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3. To Control any Persistent Disease Activity and

Persistent Bleeding on Probing
 To halt the persistence of progressive disease
after all forms of conservative treatment has
been done, and halt any persistent BOP after
control of marginal inflammation.
 

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4. Pre-restorative Procedure
 To provide an adequate environment for a
prosthesis.
 Preposthetic surgical procedures such as crown
lengthening, alveolar ridge alteration, correction
of mucogingival defects, frenotomy, vestibule
deepening, and increasing the amount of
attached gingiva.

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Soft and hard tissues of the
periodontium may need to be
removed, to expose subgingival
carious lesions, crown margins,
and endo perforations, for
corrective purposes.
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 5. To Encourage Periodontal
Regeneration
To restore the lost functional
attachment apparatus and for
regeneration of new bone,
particularly in teeth with deep
infrabony pockets or open furcations.
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 6. To Improve Esthetics and Correct
any Cosmetic Abnormalities
 To improve esthetics, periodontal surgery can also be
used to halt gingival recession and to cover denuded
areas.
 To correct the appearance of the gingiva which maybe
bulbous, receded or have clefts.
 Gingivectomy and gingivoplasty to improve appearance
at the cervical areas.

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INDICATIONS FOR PERIODONTAL
SURGERY
1. Areas with irregular bony contours, deep craters and
other defects
2. Pockets on teeth in which a complete removal of root
irritants is not possible
3. In case of furcstion involvement of grade II or III- root
resection or hemisection
4. Intrabony pockets on distal areas of last molars
5. Persistent inflammation in areas with moderate to deep
pockets may require a surgical approach
6. In areas with shallow pocket with persistent
inflammation
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7. Correction of mucogingival problem
CONTRAINDICATIONS
1. Poor patient cooperation.
Do not perform perio-surgery on patients with
poor oral hygiene and inadequate plaque control.
2. Where thorough subgingival scaling and good home
care will resolve or control the lesion
3. ‰ In the presence of infection.
4. Where the prognosis is so poor that tooth loss is
inevitable
5. Patients with uncontrolled or progressive systemic
disorder.

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 a. Recent myocardial infarction
b. Anticoagulant therapy
c. Leukemia, Neutropenia unless patient is on
remission
d. Anemias
e. Diabetes mellitus unless controlled
f. Corticosteroid therapy
g. Severe neurologic disorders
h. Advanced cases where patient have not agreed to
restorative treatment plan 70
PERIODONTAL SURGERY
 Consists of
 Pocket reduction surgery
• Resective
 Gingivectomy
 Flap procedures with or without osseous resection

 Undisplaced flap

 Apically displaced flap

 Regenerative( flap with grafts, membranes etc)

 Correction of anatomic/ morphologic defects
 periodontal plastic surgery
 Esthetic surgery
 Pre-prosthetic surgery
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 Placement of implants and sinus grafting
CLASSIFICATION OF PERIODONTAL
SURGERY

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CRITERIA FOR METHOD SELECTION
 Characteristics of the pocket
 Accessibility for instrumentation

 Existence of mucogingival problems

 Response to phase I therapy

 Patient cooperation

 Age and general health of the patient

 Overall diagnosis of the case

 Esthetic considerations

 Previous periodontal treatments

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POCKET REDUCTION SURGERIES
 periodontal pocket reduction surgery limited to the
gingival tissues only and not involving the underlying
osseous structures, without the use of flap surgery, can
be classified as gingival curettage and gingivectomy.
I.GINGIVAL CURETTAGE
 Curettage- the scraping of the gingival wall of a
periodontal pocket to remove diseased soft tissue
 inadvertent curettage- some degree of curettage is
accomplished unintentionally during scaling and root
planing
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 Curettage in periodontics has been defined as gingival
and subgingival curettage
 the removal of the inflamed soft tissue lateral to the
pocket wall and the JE
 Subgingival curettage refers to the procedure that is
performed apical to the JE and severing the connective
tissue attachment down to the osseous crest.

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RATIONALE
 Curettage accomplishes
 the removal of the chronically inflamed granulation tissue
that forms in the lateral wall of the periodontal pocket
 pocket elimination
 Esthetics

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 Indication
 as part of new attachment attempts in moderately deep intra-bony
pockets
 a non-definitive procedure to reduce inflammation when aggressive
surgical techniques (e.g., flaps) are contraindicated
 performed in patients where extensive surgical procedures are
contraindicated like aging, systemic complications
 on recall visits as a method of maintenance treatment for areas of
recurrent inflammation and pocket depth, especially where pocket
reduction surgery has previously been performed

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TECHNIQUES FOR GINGIVAL
PROCEDURE

 should always be preceded by scaling and root planing

 always require some type of local anesthesia

 curette is selected so that the cutting edge is against the tissue

 instrument is inserted to engage the inner lining of the pocket

wall and is carried along the soft tissue, usually in a horizontal
stroke
 pocket wall may be supported by gentle finger pressure on the
external surface

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 In subgingival curettage, the tissues attached between the
bottom of the pocket and the alveolar crest are removed
with a scooping motion of the curette to the tooth surface
 The area is flushed to remove debris, and the tissue is
partly adapted to the tooth by gentle finger pressure.

Gingival curettage
performed with a
horizontal stroke of the
curette
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OTHER TECHNIQUES FOR GINGIVAL
CURETTAGE
 Excisional New Attachment Procedure
 After adequate anesthesia, make an internal bevel incision
from the margin of the free gingiva apically to a point below
the bottom of the pocket
 Carry the incision inter-proximally on both the facial and the
lingual side, attempting to retain as much interproximal tissue
as possible
 Remove the excised tissue with a curette
 perform root planing on all exposed cementum to achieve a
smooth, hard consistency
 Approximate the wound edges; if they do not meet passively,
recontour the bone until good adaptation
80
81
HEALING AFTER SCALING AND
CURETTAGE
 Immediately after curettage, a blood clot fills the pocket
area
 Hemorrhage is also present in the tissues

 abundant polymorphonuclear leukocytes

 followed by a rapid proliferation of granulation tissue

 Restoration and epithelialization of the sulcus generally

require 2 to 7 days
 Healthy gingival fibers inadvertently severed from the
tooth and tears in the epithelium are repaired in the
healing process.
82
POCKET REDUCTION SURGERIES

Resection techniques for Soft Tissues

1. Gingivectomy
Gingivectomy is excision of the gingiva
is the excision of the soft tissue wall of the pocket
(its objective is the elimination of pockets)
provides visibility and accessibility necessary for
complete removal of surface deposits and thorough
smoothening of the roots.
By removing diseased tissue and local irritants, it also
creates a favorable environment for gingival healing and
the restoration of a physiologic gingival contour.
83
 
 The gingivectomy technique may be performed surgically
by means of
 Scalpels
 electrodes (electrocautery)

 laser beams (CO lasers or Nd:YAG lasers)

2

 chemicals (5% para-formaldehyde or potassium hydroxide).

 Gingivoplasty is similar to gingivectomy but its purpose is

different.
 Gingivoplasty is reshaping of the gingiva to create physiologic
gingival contours, with the sole purpose of recontouring the
gingiva in the absence of pockets.

84
PREREQUISITES
 There should be adequate zone of attached gingiva so
that excision of part of it will still leave a functionally
adequate zone. ‰
 The underlying alveolar bone must be in normal or
nearly normal form.
 If there is bone loss, it should be of horizontal in nature. ‰
 There should be no infrabony defects or pockets

85
INDICATIONS
 Elimination of suprabony pockets and abscess
 Remove fibrous or edematous enlargements of the gingiva.

 Transform rolled or blunted margins to physiologic form.

 Elimination of suprabony periodontal abscesses.

 Create more esthetic form in cases in which exposure of the

anatomic crown has not fully occurred.
 ‰ Create bilateral symmetry

 Expose additional clinical crown to gain added retention for

restorative procedures
 Correct gingival craters.

86
CONTRAINDICATION
S
 The need for bone surgery
 Bottom of the pocket located apical to the mucogingival
junction
 Aesthetic challenging areas particularly in maxillary anteriors
 When infrabony pockets are present
 Inadequate oral hygiene maintenance by the patients
 Uncooperative patients
 ‰Medically compromised patients
 Dentinal hypersensitivity before the surgical procedure

87
TYPES OF GINGIVECTOMY

 ‰ Surgical gingivectomy.
 ‰ Gingivectomy by electrosurgery.

 ‰ Laser gingivectomy.

 ‰ Gingivectomy by chemosurgery

88
SURGICAL GINGIVECTOMY
 Armamentarium as follows:
‰ Mouth mirror, probe.
 Pocket markers, Kirkland and Orban interdental
 gingivectomy knives.
 Surgical blade, Bard-Parker handle.
 Surgical curettes, Gracey curettes, tissue forceps,
 scissors.
 Periodontal dressing.

89
EXCISIONAL AND INCISIONAL
INSTRUMENTS
 Periodontal Knives (Gingivectomy Knives):-Kirkland
knife
 Interdental Knives. The Orban knife #1-2 and the
Merrifield knife #1, 2, 3, and 4
 Surgical Blades. most common blades are #12D, 15, and
15C

90
 The periosteal elevators are needed to reflect and move
the flap after the incision has been made for flap surgery

 The tissue forceps is used to hold the flap during

suturing. It is also used to position and displace the flap
after the flap has been reflected

91
 Scissors and Nippers:- to remove tabs of tissue during
gingivectomy, trim the margins of flaps, enlarge
incisions in periodontal abscesses, and remove muscle
attachments in mucogingival surgery

 Needleholders Needleholders are used to suture the flap

at the desired position after the surgical procedure has
been completed

92
SURGICAL GINGIVECTOMY
 Step 1. The pockets on each surface are explored with a
periodontal probe and marked with a pocket marker

 Step 2. Periodontal knives (e.g., Kirkland knives) are

used for incisions on the facial and lingual surfaces and
those distal to the terminal tooth in the arch.

93
 Orban periodontal knives are used for interdental
incisions
 incision is started apical to the points marking the course
of the pockets and is directed coronally to a point
between the base of the pocket and the crest of the bone
 close as possible to the bone without exposing it, to
remove the soft tissue coronal to the bone

94
 Step 3. Remove the excised pocket wall, clean the area,
and closely examine the root surface
 most apical zone consists of a light, bandlike zone where
the tissues were attached.
 Coronally, calculus remnants, root caries, or resorption
may be found

95
 Step 4. Carefully curette the granulation tissue and
remove any remaining calculus and necrotic cementum
to leave a smooth and clean surface.
 Step 5. Cover the area with a surgical pack

96
97
98
HEALING AFTER SURGICAL
GINGIVECTOMY
 initial response after gingivectomy is the formation of a protective
surface blood clot
 clot is then replaced by granulation tissue
 In 24 hours, there is an increase in new connective tissue cells
 By 3rd day, numerous young fibroblasts are located in the area
 After 12 to 24 hours, epithelial cells at the margins of the wound
begin to migrate over the granulation tissue, separating it from the
contaminated surface layer of the clot
 After 5 to 14 days, surface epithelialization is generally complete.
 Complete epithelial repair takes about 1 month.

99
GINGIVECTOMY BY ELECTROSURGERY
 Indications
 ‰ Removal of gingival enlargements.
 Gingivoplasty.
 Relocation of frenum and muscle attachments.
 Incision of periodontal abscesses and pericoronal abscess
 Advantage
 Permits adequate contouring of the tissues and controls hemorrhage.
 Disadvantages
 ‰ Cannot be used in patients with poorly shielded cardiac pacemaker.
 ‰ Causes unpleasant odor.
 ‰ If it touches the bone, irreparable damage may result.
 ‰ Heat generated by this may cause tissue damage and areas of
cemental necrosis.
100
 2. PERIODONTAL FLAP
 A periodontal flap is a section of the gingiva and/or mucosa
surgically elevated from the underlying tissues to provide
visibility of and access to the bone and root surface.
 allows the gingiva to be displaced to a different location.
 The elevated flap has to maintain an adequate blood supply in
order to avoid tissue necrosis during healing.
 Periodontal flaps can be classified based on the following:
 Bone exposure after flap reflection
 Placement of the flap after surgery
 Management of the papilla

101
 Classification of Periodontal Flaps
 A. Based on bone exposure after reflection
1.Full-thickness flap – all the soft tissue, including the
periosteum, is reflected to expose the underlying bone.
 this complete exposure of and access to the underlying bone is
needed if osseous surgery is contemplated.

102
 2. Partial-thickness flap – includes only the epithelium and a
layer of underlying connective tissue; the bone remains
covered by a layer of connective tissue, including the
periosteum.
 This type of flap is also called the split-thickness flap.
 This is indicated when the flap is to be positioned apically or
when the operator does not desire to expose the bone.

103
104
 B. Based on flap placement after surgery
1. non-displaced flaps: when the flap is returned and sutured in its
original position
2. Displaced flaps: which are placed apically, coronally, or
laterally to their original position
 also called repositioned flap
 accomplish the double objective of eliminating the pocket
and increasing the width of the attached gingiva

105
 C. Based on management of the papilla
1. Conventional flap – the interdental papilla is split beneath the
contact point of the two approximating teeth to allow reflection of
the buccal and lingual flaps.
 the incisions for the facial flap and the lingual flap reach the tip of
the interdental papilla thereby splitting the papilla into a facial
half and lingual half.
 This design is used
 when the interdental spaces are too narrow, thereby precluding the
possibility of preserving the papilla
 when the flap is to be displaced.
 include the
 modified Widman flap
 the undisplaced flap
 the apically displaced flap
106
 2. Papilla Preservation flap – the incisions are such that the entire
papilla is incorporated into one of the
flaps.
 This flap offers the advantage of better post-surgical aesthetics
and more protection for the interdental bone,
 which is especially important when bone regeneration techniques
are attempted.

107
INDICATIONS/OBJECTIVES OF FLAP
SURGERY
 Gain access for root debridement
 ‰Reduction or elimination of pocket depth, so that patient can
maintain the root surfaces free of plaque
 ‰Reshaping soft and hard tissues to attain a harmonious
topography (physiologic architecture)
 Regeneration of alveolar bone, periodontal ligament and
cementum

108
INCISIONS
 For conventional flap
 Horizontal incision
 Internal bevel incision
 Crevicular incision

 Interdental incision

 Vertical incision
 Oblique releasing incision

109
INCISIONS
 Periodontal flaps use horizontal and vertical incisions
 Horizontal incisions are directed along the margin of the
gingiva in a mesial or a distal direction.
 internalbevel incision:- starts at a distance from the gingival
margin and is aimed at the bone crest
 It removes pocket lining
 conserves relatively uninvolved outer surface of the gingiva

 produces a sharp, thin flap margin for adaptation to tooth

1. First (internal bevel) incision;

2. second (crevicular) incision; 110
3. third (interdental) incision
  crevicular incision, which starts at the bottom of the pocket
and is directed to the bone margin
 AKA second incision
 carried around the entire tooth

 No. 12B

 results in V-shaped wedge of tissue containing inflamed

granulomatous tissue
 Interdental Incision, used to separate the collar of the gingiva
that is left around the tooth
 Orban knife is usually utilized

If no vertical incisions are

made, the flap is called
envelope flap.
111
 Vertical Incisions
 Vertical or oblique releasing incisions can be used on one or
both ends of the horizontal incision, depending on the design
and purpose of the flap
 necessary if the flap is to be apically displaced

 must extend beyond the mucogingival line, reaching the

alveolar mucosa, to allow for the release of the flap to be
displaced
 vertical incisions in the lingual and palatal areas are avoided

 should not be made in the center of an interdental papilla or

over the radicular surface of a tooth.

112
THE FLAP TECHNIQUE FOR POCKET
THERAPY
 Flaps are used for pocket therapy to
1. Increase accessibility to root deposits for scaling and root
planing
2. Eliminate or reduce pocket depth by resection of the pocket
wall.
3. Gain access for osseous resective surgery if it is necessary.
4. Expose the area to perform regenerative methods.

113
 The three different categories of flap techniques used in
periodontal flap surgery are
(1) the modified Widman flap
(2) the undisplaced flap
(3) apically displaced flap

114
MODIFIED WIDMAN FLAP
 for exposing the root surfaces for meticulous
instrumentation and for removal of the pocket lining.
 it is not intended to eliminate or reduce pocket depth,
except for the reduction that occurs in healing by tissue
shrinkage
 “unrepositioned mucoperiosteal flap”

 provides access for adequate instrumentation of the root

surfaces and immediate closure of the area.

115
116
 Steps on modified widman flap
 Step 1: internal bevel incision to the alveolar crest starting 0.5
to 1 mm away from the gingival margin
 Step 2: The gingiva is reflected with a periosteal elevator
 Step 3: A crevicular incision is made from the bottom of the
pocket to the bone
 Step 4: After the flap is reflected, a third incision is made in
the interdental spaces coronal to the bone
 Step 5: Tissue tags and granulation tissue are removed with a
curette
 Step 6: Bone architecture is not corrected, except if it prevents
good tissue adaptation to the necks of the teeth
 Step 7: Continuous, independent sling sutures are placed in
both the facial and palatal and covered with a periodontal
surgical pack.
117
UNDISPLACED FLAP
 In this procedure, the entire soft tissue pocket wall is
removed with the initial incision
 Step 1: The pockets are measured with the periodontal
probe and a bleeding point is produced
 Step 2: The initial, internal bevel incision is made. This
incision is usually carried to a point apical to the alveolar
crest depending on the thickness of the tissue.
 Thethicker the tissue, the more apical will be the end point.
The flap should be thinned with the initial incision only.

118
 Step 3: The second or crevicular incision is made from the bottom of
the pocket to the bone.
 Step 4: The flap is then reflected with a periosteal elevator (blunt
dissection).
 Step 5: Interdental incision is made with an Orban’s interdental
knife.
 Step 6: Triangular wedge of tissue is removed with a curette

 Step 7: The area is debrided, removing tissue tags and granulation

tissue with sharp curettes. The roots are scaled.
 Step 8: The flap is then placed back to end at the root bone junction.

 Step 9: The flaps are sutured together with continuous sling suture or
interrupted sutures

119
120
APICALLY DISPLACED FLAP
 Used for both pocket eradication and/widening the zone of
attached gingiva
 Step 1: Internal bevel incision is made 1 mm from the crest of the gingiva
and directed toward the crest of the bone.
 Step 2: Crevicular incisions are made followed by initial elevation of flap
and then interdental incision is performed; the wedge of tissue containing
the pocket wall is removed.
 Step 3: Vertical releasing incisions are made extending beyond the
mucogingival junction and flap is elevated with a periosteal elevator (either
split thickness or full thickness).
 Step 4: Remove all the granulation tissue, root planing is done and flap is
positioned apically at the tooth bone junction.
 Step 5: Flaps are sutured together. 121
PERIODONTAL SURGICAL PROCEDURES
B. Osseous Surgery
 Osseous surgery may be defined as the procedure by
which changes in the alveolar bone can be accomplished
to rid it of deformities induced by the periodontal disease
process or other related factors, such as exostosis and
tooth supraeruption.
 According to the AAP, it is defined as “procedures to
modify bone support altered by periodontal disease either
by reshaping the alveolar process to achieve physiologic
form, without the removal of the alveolar supporting bone
or by the removal of some alveolar bone, thus changing
the position of crestal bone relative to the tooth root."
122
RATIONALE
 discrepancy in levels and shapes of the bone and gingiva
predisposes patients to the recurrence of pocket depth
 reshaping the marginal bone to resemble the alveolar
process undamaged by periodontal disease
 Since the technique involves apically displaced flap it
eliminates periodontal pockets and also improves
tissue contour to provide a more easily maintainable
environment.
 It involves osteoplasty and ostectomy

123
EXAMINATION AND TREATMENT
PLANNING
 Transgingival probing/ sounding
1. Osseous topography

2. Intrabony defects(one, two or three wall defects)

3. Furcation involvement(class I.II or III)

4. Root shape or form

 Radiographs are important to locate the area of bone loss

124
TYPES OF OSSEOUS SURGERY
 Depending on the relative position of the interdental bone to
radicular bone, osseous surgery is of following types
 Positive architecture: When the radicular bone is apical to the
interdental bone.
 ‰Negative architecture: If the interdental bone is more apical
than the radicular bone.
 ‰Flat architecture: It is the reduction of interdental bone to
the same height as radicular bone.
 ‰ Ideal: When the bone is consistently more coronal on the
interproximal surface than on the facial and lingual surfaces.
125
126
 Depending on the thoroughness of the osseous reshaping
techniques
 ‰ Definitive osseous reshaping: Implies that further
reshaping would not improve the overall result.
 ‰Compromise osseous reshaping: It indicates a bone
pattern that cannot be improved without significant
osseous removal that would be detrimental to the overall
result.

127
 Osseous surgery can also be either additive or subtractive
 Additive osseous surgery- procedures directed at restoring the
alveolar bone to its original level. Includes bone graft and GTR
 Subtractive/resective osseous surgery- designed to restore the
form of pre-existing alveolar bone to the level present at the time of
surgery or slightly more apical to this level.includes osteoplasty and
ostectomy
 morphology of the osseous defect largely determines the
treatment technique to be used

128
 ‰ Osteoplasty: It refers to reshaping the bone without
removing the bone supporting the tooth.
 Osteoplasty is defined as reshaping of the alveolar process
to achieve a more physiologic form without removal of
supporting bones.
 Indications of osteoplasty:
 Removal of tori, exostosis
 In the treatment of grade I furcation involvement
 It is performed to counter alveolar ridge in pre-prosthetic
surgery
 In grade IV furcation involvement to perform tunneling
procedure 129
 Small intrabony defects
 ‰ Ostectomy: It refers to removal of bone supporting
the tooth.
 According to (AAP) , it is defined as the excision of
bone or portion of a bone in periodontics
 ostectomy is done to correct or reduce deformities
caused by periodontitis and includes removal of the
supporting bone.
 Indications of ostectomy
 Thick bony margins
 For crown lengthening

130
 RESECTIVE OSSEOUS SURGERY
 Indications
‰ One-walled angular defects.
 ‰ Thick, bony margins.
 ‰ Shallow crater formations

 Contraindications
‰ Anatomic factors, such as close proximity of the roots to the
maxillary antrum or the ramus
 ‰ Age
 ‰ Systemic health
 Improper oral hygiene
 High caries index
 Extreme root sensitivity
 Advanced periodontitis
 Unacceptable esthetic result. 131
STEPS FOR RESECTIVE OSSEOUS
SURGERY
 Vertical grooving
 Redicular bending

 Horizontal grooving

 Scribing

 Gradualizing interproximal bone

132
 Vertical grooving:- indicated to reduce the thickness of
alveolar housing, and it provides continuity from the
interproximal surface into the radicular surface.
 firststep of the resective process
 performed with rotary instruments
 indicated in thick bony margins, shallow crater formation
 contraindicated in areas with close root proximity or thin
alveolar housing.

133
 Radicular blending:- attempts to gradualize the bone
over the entire radicular surface and thereby provides a
smooth, blended surface for good flap adaptation
 isthe second step of the osseous reshaping technique
 indications are the same as in step one.
 Both step one and step two are purely osteoplastic
procedures.
 grade I and grade II furcation involvements are treated with
these two steps.

134
 Flattening of the interproximal bone requires removal of very
small amount of supporting bone.
 indicated when interproximal bone levels vary horizontally, e.g.
one-walled defects or hemiseptal defects.
 The step is also best-utilized in areas where there are combined
defects, i.e. coronally one-walled defect and apically three-walled
defect,
 it cannot be utilized in advanced defects, where removal of
inordinate amounts of bone may be required.

135
 Gradualizing Marginal Bone
 The final step in the osseous resective technique
 is an ostectomy procedure.
 Bone removal is minimal, but necessary to provide a sound
regular base for the gingival tissue to follow.
 Failure to do so may result in "widow’s peaks", which allows
the tissue to rise to a higher level than the base of the bone
loss in the interdental area.
 This may result in selective recession and incomplete pocket
reduction.
 performed with great care so as to not damage the roots

136
BASIC RULES OF OSSEOUS SURGERY
 A full thickness mucoperiosteal flap should be raised
 The scalloping of the flap should anticipate the final underlying
osseous contour, which is most prominent anteriorly and decreases
posteriorly
 The scalloping of the flap should depict patient’s own healthy
gingival architecture
 Osteoplasty generally precedes ostectomy
 Osseous resective surgery, whenever possible, should result in a
positive osseous architecture.
 High-speed rotary instrumentation should never be used adjacent to
the teeth and should always be used with a generous spray.
 the final bony contours should approximate the expected 137
postoperative healthy gingiva.
RECONSTRUCTIVE PERIODONTAL
SURGERY
 When periodontitis is resolved, an anatomic defect
remains in the periodontium.
 anatomic defect is characterized by
 reformation of gingival fibers
 substantial reduction in inflammation
 persistent loss of bone and ligament
 the formation of long junctional epithelium

 here are two primary approaches for eliminating these

anatomic defects—
 (1) resective
 (2) regenerative,
138
 The reconstructive surgical techniques can be:-‰
 Non-graft-associated new attachment‰
 Graft-associated new attachment ‰
 Combination of both

139
NON-GRAFT ASSOCIATED NEW
ATTACHMENT
 techniques that must be considered for a periodontal
bone regeneration
 (1) the removal of the junctional and pocket epithelium;
 (2) the prevention of their migration into the healing area
after therapy;
 (3) clot stabilization, wound protection, and space creation;
 (4) Preparation of root surface (biomodification of the root)

140
 Removal of pocket and junctional epithelium
 Curettage
 Chemical Agents
 sodium sulfide, phenol camphor, Antiformin, and sodium hypochlorit
 Surgical Techniques
 ENAP
 modified Widman flap

141
 Prevention or Impeding the Epithelial Migration
 Elimination of the junctional and pocket epithelium may not
be sufficient because the epithelium from the excised margin
may rapidly proliferate to become interposed between the
healing connective tissue and the cementum
 excluding the epithelium by amputating the crown of the tooth
and covering the root with the flap (“root submergence”)
 total removal of the interdental papilla covering the defect and
its replacement with a free autogenous graft obtained from the
palate
 use of coronally displaced flaps, which increase the distance
between the epithelial wound edge and the healing area
 GTR

142
GUIDED TISSUE REGENERATION
 method for the prevention of epithelial migration along
the cemental wall of the pocket and maintaining space
for clot stabilization
 consists of placing barriers of different types
(membranes) to cover the bone and periodontal ligament,
thus temporarily separating them from the gingival
epithelium and connective tissue

143
 Classification of barrier membranes
 First generation:Nonresorbable membranes: ‰
 Expanded polytetrafluoro ethylene (ePTFE) ‰
 Gore-Tex
‰ Dense PTFE (dPTFE)
 ‰ Nucleopore
 ‰ Millipore filters
 ‰ Ethyl cellulose

 Second generation: Resorbable membranes: Collagen:

 Biomed
 Periogen
 Paroguide
 Tissue guide
 Biostite
 Bio-Gide 144
 Third generation: Resorbable bioactive membranes with
added growth factors—ePTFE is one of the most inert
materials known

Nonresorbable membranes of
different shape and size

145
 Indications of guided tissue regeneration are:
‰ Narrow two or three-wall intrabony defects
 ‰ Circumferential defects
 ‰ Class II furcation defects
 ‰ Recession defects

 Contraindications of guided tissue regeneration are:

‰ Medical conditions contraindicating surgery
 ‰ Infection at defect site
 ‰ Poor oral hygiene
 ‰ Smoking
 ‰ Tooth mobility > 1 mm
146
 ‰ Defect < 4 mm deep‰
 Contraindications cont.
 Widthof attached gingiva at defect site < 1mm
 ‰ Thickness of attached gingiva < 5 mm
 ‰ Furcation with short root trunks
 ‰ Generalized horizontal bone loss
 ‰ Advanced lesions with little remaining support
 ‰ Multiple defects.

147
 Clot Stabilization, Wound Protection and Space Creation
 graft materials, barrier membranes and coronally
displaced flaps have been attributed to the fact that all of
these protect the wound and create a space for
undisturbed and stable maturation of the clot

148
 Preparation of the Root Surface (Root Biomodification)
 used to condition the root surface, for attachment of new
connective tissue fibers
 Using citric acid, fibronectin and tetracycline

 Steps involved are:

‰ Raise full thickness flap
 Perform thorough root planing
 Apply cotton pellets soaked in citric acid of pH 1.0 for 2–3
minutes
 Remove and irrigate root surface profusely with water
 Replace the flap and suture.

149
150
GRAFT-ASSOCIATED NEW ATTACHMENT
 Graft: a viable tissue/organ that after removal from donor site
is implanted/transplanted within the host tissue, which is then
repaired, restored and remodeled
 Xenograft or heterograft: The donor of the graft is from a
species different from the host.
 Allograft or homograft: A tissue transfer between individuals
of the same species, but with nonidentical genes
 ‰ Autograft: A tissue transfer from one position to a new
position in the same individual.
 ‰Alloplastic graft: A graft of inert synthetic material, which
is sometimes called implant material.
151
 Ideal requirements of bone graft
 should have biologic acceptability
 Predictability
 clinical feasibility
 minimal postoperative hazards
 minimal postoperative sequelae
 good patient acceptance

 All grafting techniques require

 presurgical scaling

 occlusal adjustment as needed

 exposure of defect with full thickness flap,papilla

preservation flap
152
CLASSIFICATION OF BONE GRAFTS
DEPENDING ON SOURCES

153
Autogenous bone grafting. (A) Preoperative radiograph; (B)
Harvesting of bone graft from symphysis region; (C) Harvested
autogenous cancellous bone graft; (D) Postoperative radiographic 154
view (after 3 month)
GENERAL PRINCIPLES OF PERIODONTAL
SURGERY
Out patient surgery
Patient preparation
1.Reevaluation after phase 1 therapy
2. Premedication
3. Smoking
4. Informed consent
EMERGENCY EQUIPMENTThe operator ,the assistant and office
personnel should be trained to handle all the possible emergencies that
may arise,drugs and equipment for emrgency should be readily
available at all times.
THE MOST COMMON EMERGENCY IS
Syncope – A transient loss of conciousness caused by a reduction in
cerebral blood flow. the most common cause is fear and anxiety.

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MEASURES TO PREVENT TRANSMISSION OF
INFECTION
* Acquired immunodeficiency syndrome
* Hepatitis b virus (hbv)
AS A UNIVERSAL PRECAUTIONS, these includes the
following:
a. Use of disposable sterile surgical masks,gloves,and
protective eye wear
b. Cover all surfaces that can not be sterilized by aluminum
foil or plastic wrap.

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Universal precautions, cont:
e.g., light handles
unit syringes

Aerosol-producing devices, e.g. cavitron

should not be use on patients with suspectedinfections.
Special care should be taken when using and their use
should be kept to a minimum in all other patients.special
care of use and disposing of sharp items like needle and
scalpel blades.

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GENERAL CONDITIONS (COMMON TO
ALL PROCEDURES)
 Premedication
• prophylactic use of antibiotics
 Sedation and Anesthesia
• by means of a regional block and local infiltration
 Tissue Management
• Operate gently and carefully
• Observe the patient at all times
• Be certain the instruments are sharp
 Suturing

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SEDATION AND ANESTHESIA:
Periodontal surgery should be performed painlessly. the
most effective way is to do an effective administration of
anesthesia.
Apprehensive and neurotic patients require special
management with anti anxiety or sedative-hypnotic
agents.it includes oral, intramuscular or intra venous
routes.examples are:nitrous oxide oxygen inhalation
sedation, benzodiazepine,oral or iv.

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TISSUE MANAGEMENT:
1. Operate gently and carefully- the surgery should be
done in a precise, deliberate and gentle manner.
2. Observe the patient at all times – it is essential to pay
attention to the patients reaction,facial
expressions,pallor,and perspiration are distinct signs that
the patient is experiencing pain,anxiety or fear.

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3. Be certain that all instruments to be used are
sharp- instruments must be sharp to be effective,
dull instruments may inflict unneccessary trama
, because of poor cutting and excessive force
application.sterile sharpening stones should be
available on the operating table.

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SCALING AND ROOT PLANING:
Although scaling and root plning have been
perforemed previously,as part of the phase i
therapy,all exposed root surfsces should be
carefully explored and planed as needed,this is a
part of the surgical procedurs.

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HEMOSTASIS:
This is an important aspect of periodontal
surgery, it will provide you with an accurate
visualization of the extent of the disease,pattern
of bone destruction,and anatomy and condition
of the root surfaces.it provides the operator with
a clear view of the surgical site.perio surgery can
produce profuse bleeding, especially during the
initial incission and flap reflection.

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 Typically ,control of intraoperative bleeding can
be managed with aspiration,and application of
preassure to the surgical wound with a moist
gauze,excessive bleeding may be caused by
laceration of venules, arterioles,or larger vessels.
The use of anesthetic agents with
vasoconstrictors may be used to control minor
bleeding.

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For slow ,constant blood flow and oozing,
hemostasis may be achived with hemostatic
agents like, absorbable gelatin
sponge(gelfoam) ,oxydized cellulose ( oxygel),
iodized regenerated cellulose (surgicel
absorbable hemostat),and microfibrilar collagen
hemostat(collacote,colla tape,colla plug),

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PERIODONTAL DRESSINGS:
ZINC OXIDE-EUGENOL PACKS
Have no curative properties, minimizes the likelyhood
of postoperative infections and hemorrhage.e.g. wondr-
pak
NONEUGENOL PACKS:
Ooe-pak is the most widely used.(read on coe-pak)

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RETENTION OF PACKS:
Periodontal dressing are usually kept in place by
mechanically interlocking them in the interdental spaces
and joining the labial and lingual portion of the pack.
ANTIBACTERIAL PROPERTY:
There is no antibacterial property unless otherwise you
will incorporate it in the mix.tetracycline powder in
coepak is generally recommended.

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POST OPERATIVE INSTRUCTIONS:
Usually printed instructions are given to the patient.
FIRST POST OPERATIVE WEEK :
Properly performed periodontal surgery presents no serious post-oprative
problems.
Patient should be instructed to rinse with 0.12% chlorhexidine gluconate after
surgery and twice daily thereafter.
THE FOLLOWING COMPLICATIONS MAY ARISE IN THE FIRST POST
OPERATIVE WEEK:
1. Persistent bleeding after surgery
2. Sensitivity to percussion
3. Swelling
4. Feeling of weakness
MANAGEMENT OF POST OPERATIVE PAIN

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SURGICAL INSTRUMENTS
Periodontal surgery is accomplished with numerous
instruments,they are classified as follows:
1. Excisional and incisional instruments
2. Surgical curetts and sickles
3. Periosteal elevators
4. Surgical chisels
5. Surgical files
6. Scissors
7. Hemostats and tissue forceps

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