General Principles of

Periodontal Surgery
Patient Preparation
Reevaluation After Phase I Therapy.
• Almost every patient undergoes the so-called initial or
preparatory phase of therapy, which basically consists
of thorough scaling and root planing and the removing
of all irritants responsible for the periodontal
inflammation.
• These procedures do the following:
(1) eliminate some lesions entirely;
(2) render the tissues more firm and consistent,
(3) acquaint the patient with the office, the operator, and
his or her assistants, thereby reducing the patient’s
apprehension and fear.
Reevaluation phase
The reevaluation phase consists of
• Re-probing and
• Re-examining all of the pertinent findings that previously indicated
the need for the surgical procedure.
• The persistence of these findings confirms the indication for surgery.
Premedication
• For patients who are not medically compromised, the value of
administering antibiotics routinely for periodontal surgery has not
been clearly demonstrated.
• Some studies have reported reduced postoperative complications,
including reduced pain and swelling
• When antibiotics are given before periodontal surgery and
continued for 4 to 7 days after surgery
Premedication
• The prophylactic use of antibiotics in patients who are otherwise
healthy has been advocated for bone-grafting procedures and
reported to enhance the chances of new attachment.
Pre-surgical medications include the administration of a
• Non-steroidal anti-inflammatory drug such as ibuprofen (e.g.,
Motrin) 1 hour before the procedure
• A mouth rinse with 0.12% chlorhexidine gluconate (Peridex,
PerioGard)
Smoking
• Patients should be clearly informed of this fact and asked to quit
smoking completely or to at least stop smoking for a minimum of
2days 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, aesthetic) should be considered
 Informed Consent

• The patient should be informed at the initial visit about the

diagnosis, prognosis, and different possible treatments his or her
condition, with the expected results and all pros and cons of each
approach discussed as well.
• At the time of surgery, the patient should again be informed,
verbally and in writing, of the procedure to be performed, and he
or she should indicate his or her agreement to undergo the
procedure by signing the consent form.
Treatment of Sensitive Roots
• Root sensitivity occurs more frequently in the
cervical area of the root, where the cementum is
extremely thin.
• Scaling and root planing procedures remove this
thin cementum, thereby inducing the
hypersensitivity.
Information about how to cope with the
problem of hypersensitivity
• The following should also be given to the patient:
1. Hypersensitivity appears as a result of the exposure of dentin, which
is inevitable if calculus, plaque, and their products, which are buried
in the root, are to be removed.
2. Hypersensitivity slowly disappears over a few weeks.
3. An important factor in reducing hypersensitivity is plaque control.
4. Desensitizing agents do not produce immediate relief and must
used for several days or even weeks to produce results.
Desensitizing Agents. MOA
(1) By the formation of a smear layer produced by burnishing the
exposed surface;
(2) Via the topical application of agents that form insoluble
precipitates within the tubules;
(3) With the impregnation of tubules with plastic resins; or
(4) By sealing the tubules with plastic resins.
Agents Used by the Patient
• Oral hygiene are dentifrices. Although many dentifrice
products contain fluoride, additional active ingredients for
desensitization are strontium chloride, potassium nitrate,
and sodium citrate.
• Fluoride rinsing solutions and gels can also be used after the
usual plaque control procedures
• Patients must be aware that their use will not prove to be
effective unless they are used continuously for at least 2
weeks.
Agents Used in the Dental Office
• Varnish or bonding agent
• Insoluble calcium oxalate crystals that occlude the dentinal tubules
• Glass-ionomer cements
• Dentin bonding agents
• Neodymium:yttrium-aluminum-garnet laser
• CPP-ACP (casein phosphopeptides and amorphous calcium
phosphate) (Tooth mousse)
• Novamin Technology (calcium silicate based)
Hospital Periodontal Surgery
Indications for Hospital periodontal
surgery
Indications for hospital periodontal surgery include
• the optimal control and management of apprehension,
• convenience for individuals who cannot endure multiple visits to
complete surgical treatment, and
• patient protection.
Tissue Management
1. Operate gently and carefully In addition to being most considerate to the patient,
this is also the most effective way to operate.
2. Tissue manipulation should be precise, deliberate, and gentle.
3. Thoroughness is essential, but roughness must be avoided, because it produces
excessive tissue injury, causes post operative discomfort, and delays healing.
4. Observe the patient at all times. It is essential to pay careful attention to the
patient’s reactions.
5. Facial expressions, pallor, and perspiration are distinct signs that may indicate
that the patient is experiencing pain, anxiety, or fear.
6. The physician’s responsiveness to these signs can be the difference between
success and failure
Tissue Management
• Be certain that the instruments are sharp. Instruments must be
sharp to be effective; successful treatment is not possible without
sharp instruments.
• Dull instruments inflict unnecessary trauma as a result of poor
cutting and excessive force applied to compensate for their
ineffectiveness.
• A sterile sharpening stone should be available on the operating table
at all times.
Tissue Management
• Absorbable gelatin sponge is a porous matrix prepared from pork
skin that helps to stabilize a normal blood clot. The sponge can be
cut to the desired dimensions and either sutured in place or
positioned within the wound (e.g., an extraction socket). It is
absorbed in 4 to 6 weeks (Religious Implications)
• Oxidized cellulose is a chemically modified form of surgical gauze
that forms an artificial clot. The material is friable, and it can be
difficult to keep in place. It is absorbed in 1 to 6 weeks
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 the patient from
pain induced by contact of the wound with food
or with the tongue during mastication
Zinc Oxide–Eugenol Packs
• Packs that are based on the reaction of zinc oxide and eugenol include
the Wonder Pak, which was developed by Ward in 1923.
• Eugenol in this type of pack may induce an allergic reaction that
produces reddening of the area and burning pain in some patients.
Non-eugenol Packs
• The reaction between a metallic oxide and fatty acids is the basis for the Coe-Pak,
One tube contains
• zinc oxide,
• an oil (for plasticity),
• a gum (for cohesiveness), and
• Lorothidol (a fungicide);
Second tube contains
• liquid coconut fatty acids that have been thickened with colophony resin (or
rosin) and
• chlorothymol (a bacteriostatic agent).
Retention of Packs.

mechanically
• Periodontal dressings are usually kept in place

by interlocking in interdental spaces

and joining the lingual and facial portions of
the pack.
Removal of Pack and Return Visit
• When the patient returns after 1 week
• the periodontal pack is taken off by inserting a surgical hoe along the
margin and exerting gentle lateral pressure
• Pieces of pack retained interproximally and particles adhering to the
tooth surfaces are removed with scalers.
Findings at Pack Removal
The following are usual findings when the pack is removed:
• If a gingivectomy has been performed, the cut surface is covered with a
friable meshwork of new epithelium, which should not be disturbed.
• If calculus has not been completely removed, red, beadlike
protuberances of granulation tissue will persist.
• The granulation tissue must be removed with a curette to expose the
calculus so that it can be removed and so the root can be planed.
• Removal of the granulation tissue without the removal of calculus is
followed by recurrence.
Repacking
After the pack is removed, it is usually not necessary to replace it.
(1) those with a low pain threshold who are particularly uncomfortable
when the pack is removed;
(2) those with unusually extensive periodontal involvement; or
(3) those who heal slowly.
Clinical judgment helps when deciding whether to repack the area or
leave the initial pack on for more than 1 week
Tooth Mobility
• Tooth mobility is increased immediately after surgery, but it
diminishes below the pretreatment level by the
fourth week
Surgical Instruments
• Periodontal surgery is accomplished with numerous instruments;
• Periodontal surgical instruments are classified as follows:
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
Excisional and Incisional Instruments
Periodontal Knives (Gingivectomy Knives).
• The Kirkland knife is representative of the knives that are typically
used for gingivectomy.
• These knives can be obtained as either double ended or single-ended
instruments.
• The entire periphery of these kidney-shaped knives is the cutting
edge
Periodontal Knives (Gingivectomy Knives).
The Kirkland knife
Interdental Knives
• The Orban knife and the Merrifield knife (nos. 1 through 4) are
examples of knives that can be used for interdental areas.
• These spear-shaped knives have cutting edges on both sides of the
blade
Surgical Blades
Electrosurgery (Radiosurgery) Techniques and
Instrumentation
The four basic types of electrosurgical techniques are:
• electrosection,
• electrocoagulation,
• electrofulguration, and
• electrodesiccation.
Prichard surgical curette. The curettes that are
used in surgery have wider blades than those that
are used for conventional scaling and root planing
Periosteal Elevators

Woodson periosteal elevator

Surgical Chisel

Back-action chisel
Tissue Forceps

DeBakey tissue forceps.

Scissors and Nippers

Goldman–Fox scissors
Needle holders

Conventional needle holder