Transcript Periodontal Surgery

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