Jan Lindhe. Clinical Periodontology

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PERIODONTAL SURGERY: ACCESS THERAPY • 535

Fig. 25-41.

Ostectomy.

(a) A combined one- and two-wall osseous defect on the distal aspect of a mandibular premo

lar has been exposed following reflection of mucoperiosteal flaps. Since esthetics is not a critical factor to consider

in the posterior tooth region of the mandible, the bone walls are reduced to a level close to the base of the defect us

ing rotating round burs under continuous saline irrigation. (b) The osseous recontouring completed. Note that

some supporting bone has to be removed from the buccal and lingual aspect of both the second premolar and the

first molar in order to provide a hard tissue topography which allows a close adaptation of the covering soft tissue

flap.

GENERAL GUIDELINES FOR

PERIODONTAL SURGERY

Objectives of surgical treatment

Traditionally,

pocket elimination

has been a main objec

tive of periodontal therapy. The removal of the pocket

by surgical means served two purposes: (1) the pocket,

which established an environment conducive to pro-

gression of periodontal disease, was eliminated and

(

2) the root surface was made accessible for scaling

and, after healing, for self-performed toothcleaning.

While these objectives cannot be entirely discarded

today, the necessity for pocket elimination in peri-

odontal therapy has been challenged. During recent

years our understanding of the biology of the perio-

dontium, the pathogenesis of periodontal disease and

the healing capacity of the periodontium has mark-

edly increased. This new information has thus formed

the basis for a more differentiated understanding of

the role played by periodontal surgery in the preser-

vation of teeth.

In the past,

increased pocket depth

was the main

indication for periodontal surgery. However, pocket

depth is no longer as unequivocal a concept as it used

to be. The

probeable depth,

i.e. the distance from the

gingival margin to the point where further periodon-

tal probe penetration is stopped by tissue resistance,

may only rarely correspond to the "true" depth of the

pocket (see Chapter 18). Furthermore, regardless of

the accuracy with which pockets can be measured,

there is no established correlation between probeable

pocket depth and the presence or absence of active

disease. This means that symptoms other than in-

creased probing depth should be present to justify

surgical therapy. These include clinical signs of in-

flammation, especially exudation and bleeding on

probing (to the bottom of the pockets), as well as

aberrations of gingival morphology. Finally, the fact

that proper plaque control, maintained by the patient,

is a decisive factor for a good prognosis (Rosling et al.

1976a, Nyman et al. 1977, Axelsson & Lindhe 1981)

must be considered prior to the initiation of surgery.

In conclusion, the main objective of periodontal

surgery is to contribute to the long-term preservation

of the periodontium by facilitating plaque removal

and plaque control, and periodontal surgery can serve

this purpose by:

•

creating accessibility for proper professional scaling

and root planing

•

establishing a gingival morphology which facili-

tates the patient's self-performed plaque control.

In addition to this, periodontal surgery may aim at:

•

regeneration of periodontal attachment lost due to

destructive disease. (New attachment procedures in

periodontal therapy are discussed in Chapter 28.)

Indications for surgical treatment

Impaired access for scaling and root planing

Scaling and root planing are methods of therapy

which are difficult to master. The difficulties in accom

plishing proper debridement increase with (1) increas

ing depth of the periodontal pockets, (2) increasing

536 • CHAPTER 25

Fig.

25-42.

Evaluation following non-surgical instru-

mentation reveals persistent signs of inflammation,

bleeding following pocket probing and probing depth

6 mm. Flap elevation to expose the root surface for

proper cleaning should be considered.

Fig.

25-43.

Examples of gingival aberrations, (a) gingival enlargement and (b) proximal soft tissue crater, which fa

vor plaque retention and thereby impede the patient's plaque control.

width of the tooth surfaces,

(3)

the presence of root

fissures, root concavities, furcations, and defective

margins of dental restorations in the subgingival area.

Provided a correct technique and suitable instru-

ments are used, it is usually possible to properly de-

bride pockets up to 5 mm deep (Waerhaug

1978,

Caf-

fesse et al.

1986).

However, this

mm limit cannot be

used as a universal rule-of-thumb. Reduced accessi-

bility and the presence of one or several of the above-

mentioned impeding conditions may prevent proper

debridement of shallow pockets, whereas at sites with

good accessibility and favorable root morphology,

proper debridement can be accomplished even in

deeper pockets (Badersten et al.

1981,

Lindhe et al.

1982).

It is often difficult to ascertain by clinical means

whether subgingival instrumentation has been prop-

erly performed. Following scaling, the root surface

should be smooth – roughness will often indicate the

presence of remaining subgingival calculus. It is also

important to monitor carefully the gingival reaction to

subgingival debridement. If inflammation persists

and

if bleeding is elicited by gentle probing in the

subgingival area, the presence of subgingival deposits

should be suspected (Fig.

25-42).

If such symptoms are

not resolved by repeated subgingival instrumenta-

tion, surgical treatment should be performed to ex-

pose the root surfaces for proper cleaning.

Impaired

access for self-performed

plaque control

The level of plaque control which can be maintained

by the patient is determined not only by his/her inter

est and dexterity but also, to some extent, by the

morphology of the dentogingival area.

The patient's responsibility in a plaque control pro-

gram must obviously include the cleansing of the

supragingival tooth surfaces and the marginal part of

the gingival sulcus. This means that the tooth area

coronal to the gingival margin and at the entrance to

the gingival sulcus should be the target for the pa-

tient's home care efforts.

Pronounced gingival hyperplasia and gingival cra-

ters (Fig.

25-43) are examples of morphologic aberra-

tions which may impede proper home care. Likewise,

the presence of restorations with defective marginal

fit

or adverse contour and surface characteristics at the

gingival margin may seriously compromise plaque

removal.

By the professional treatment of periodontal dis-

ease, the dentist prepares the dentition in such a way

that home care can be effectively managed. At the

completion of treatment, the following objectives

should have been met:

•

no sub or supragingival dental deposits

•

no pathologic pockets (no bleeding on probing to

the bottom of the pockets)

PERIODONTAL SURGERY: ACCESS THERAPY • 537

•

no plaque-retaining aberrations of gingival mor-

phology

•

no plaque-retaining parts of restorations in

relation

to the gingival margin

These requirements lead to the following indications

for periodontal surgery:

•

accessibility for proper scaling and root planing

•

establishment of a morphology of the dento-gingi-

val area conducive to plaque control

•

pocket depth reduction

•

correction of gross gingival aberrations

•

shift of the gingival margin to a position apical to

plaque-retaining restorations

•

facilitate proper restorative therapy

Contraindications for periodontal surgery

Patient cooperation

Since optimal postoperative plaque control is decisive

for the success of periodontal treatment (Axelsson &

Lindhe 1981), a patient who fails to cooperate during

the cause-related phase of therapy should not be ex-

posed to surgical treatment.

Even though short-term postoperative plaque con

trol entails frequent professional treatments, the long

term responsibility for maintaining good oral hygiene

must rest with the patient. Theoretically, even the

poorest oral hygiene performance by a patient may be

compensated for by frequent recall visits for suppor-

tive therapy (e.g. once a week), but it is unrealistic to

consider larger groups of patients being maintained

in this manner. A typical recall schedule for periodon

tal patients involves professional consultations for

supportive periodontal therapy once every 3-6

months. Patients who cannot maintain satisfactory

oral hygiene over such a period should normally be

considered unsuited for periodontal surgery.

Cardiovascular disease

Arterial hypertension

does not normally preclude peri-

odontal surgery. The patient's medical history should

be checked for previous untoward reactions to local

anesthesia. Local anesthetics free from or low in ad-

renaline may be used and an aspirating syringe

should be adopted to safeguard against intravascular

injection.

Angina pectoris

does not normally preclude periodon-

tal surgery. The drugs used and the number of epi-

sodes of angina may indicate the severity of the dis-

ease. Premedication with sedatives and the use of local

anesthesia low in adrenaline are often recommended.

Safeguards should be adopted against intravascular

injection.

Myocardial infarction patients

should not be subjected

to periodontal surgery within 6 months following

hospitalization, and thereafter only in cooperation

with the physician responsible for the patient.

Anticoagulant treatment

implies increased propensity for

bleeding. Periodontal surgery should be sched

uled

first after consultation with the patient's physi

cian to

determine whether modification of the antico

agulant

therapy is indicated. In patients on moderate

levels

of anticoagulation and only requiring minor

surgical

treatment no alteration of their anticoagulant

therapy

may be required. To keep the prothrombin

time

within a safety level for hemorrhage control dur

ing

surgery in patients with higher levels of antico-

agulation, adjustments of the anticoagulant drug ther

apy usually need to be initiated 2-3 days prior to the

dental appointment. Anticoagulation may be safely

resumed immediately after the periodontal surgical

procedure since several days are needed for full anti-

coagulation to return. Aspirin and other non-steroidal

anti-inflammatory drugs should not be used for post-

operative pain control since they increase bleeding

tendency. Furthermore, tetracyclines are contraindi-

cated in patients on anticoagulant drugs due to inter-

ference with prothrombin formation (Fay & O'Neil

1984).

Rheumatic endocarditis, congenital heart lesions and

heart/vascular implants

involve risk for transmission of

bacteria to heart tissues and heart implants during the

transient bacteremia that follows manipulation of in-

fected periodontal pockets. Surgical treatment (in-

cluding tooth extractions) of patients with these con-

ditions, as well as of patients at risk of hematogenous

prosthetic joint infection (for the first 2 years following

joint placement) (American Dental Association and

American Academy of Orthopedic Surgeons 1997),

should be preceded by antiseptic mouthrinsing (0.2 %

chlorhexidine) and prescription and administration of

an appropriate antibiotic in a high dose. According to

the recommendations by the American Heart Associa

tion (Dajani et al. 1997), 2 g of amoxicillin adminis-

tered 1 hour before the treatment is an adequate regi-

men. In case the patient is allergic to penicillin, clin-

damycin (600 mg) is recommended as an alternative.

No second doses are recommended for any of the

above dosing regimens. Tetracyclines and erythromy-

cin are not recommended for prophylactic cardiovas-

cular antibiotic coverage.

Organ

transplantation

In organ transplantation, medications are used to pre

vent transplant rejection. The drug of choice today is

cyclosporin A, a potent immunosuppressant drug.

The adverse effects seen following cyclosporin A treat-

ment include an increased risk for gingival enlarge-

ment as well as hypertension. In addition, hyperten-

sion seen in renal transplant recipients is often treated

with calcium channel blockers. These antihyperten-

sive agents have also been associated with gingival

enlargement. As in patients on phenytoin therapy,

• CHAPTER 25

gingival enlargement in patients on cyclosporin A

therapy or on antihypertensive therapy with calcium

blockers may be corrected by means of periodontal

surgery. However, due to the strong propensity for

recurrence, the use of intensified conservative peri-

odontal therapy to prevent gingival enlargement in

susceptible patients should be encouraged.

Prophylactic antibiotics are recommended in trans

plant patients taking immunosuppressive drugs, and

the patient's physician should be consulted before any

periodontal therapy is performed. In addition, anti-

septic mouthrinsing (0.2% chlorhexidine) should pre

cede the surgical treatment.

Blood disorders

If the medical history includes blood disorders, the

exact nature of these should be ascertained.

Patients suffering from

acute leukemias, agranulocy-

tosis

and

lymphogranulomatosis

must

not

be subjected

to periodontal surgery.

Anemias

in mild and compensated forms do not

preclude surgical treatment. More severe and less

compensated forms may entail lowered resistance to

infection and increased propensity for bleeding. In

such cases, periodontal surgery should only be per-

formed after consultation with the patient's physician.

Hormonal disorders

Diabetes mellitus

entails lowered resistance to infec-

tion, propensity for delayed wound healing and pre-

disposition for arteriosclerosis. Well compensated pa

tients may be subjected to periodontal surgery pro-

vided precautions are taken not to disturb dietary and

insulin routines.

Adrenal function

may be impeded in patients receiving

large doses of corticosteroids over an extended period.

These conditions involve reduced resistance to physi

cal and mental stress, and the doses of corticosteroid

may have to be altered during the period of periodon

tal surgery. The patient's physician should be con-

sulted.

Neurologic disorders

Multiple sclerosis and Parkinson's disease

may in severe

cases make ambulatory periodontal surgery impossi-

ble. Paresis, impaired muscular function, tremor, and

uncontrollable reflexes may necessitate treatment un

der general anesthesia.

Epilepsy is

often treated with

phenytoin

which, in ap-

proximately 50%) of cases, may mediate the formation

of gingival enlargement. These patients may, without

special restrictions, be subjected to periodontal sur-

gery for correction of the enlargement. There is, how-

ever, a strong propensity for recurrence of the enlarge

ment, which in many cases can be countered by

inten

sifying the plaque control.

Smoking

Although smoking negatively affects wound healing

(

Siana et al. 1989), it may not be considered a contra-

indication for surgical periodontal treatment. The cli-

nician should be aware, however, that less resolution

of probing pocket depth and smaller improvement in

clinical attachment may be observed in smokers than

in non-smokers (Preben & Bergstrom 1990, Ah et al.

1994, Scabbia et al. 2001).

Local anesthesia in periodontal surgery

Traditional views of pain and discomfort as an inevi-

table consequence of dental procedures, in particular

surgical procedures (including scaling and root plan-

ing) and extractions, are no longer accepted by pa-

tients. Pain management is an ethical obligation and

will improve patient satisfaction in general (e.g. in-

creased confidence and improved cooperation) as

well

as patient recovery and short-term functioning

after

oral/periodontal surgical procedures.

In order to prevent pain during the performance of

a periodontal surgical procedure, the entire area of the

dentition scheduled for surgery, the teeth as well as the

periodontal tissues, requires proper local anesthesia.

Mechanism of action

Local anesthesia is defined as a loss of feeling or

sensation that is confined to a certain area of the body.

All local anesthetics have a common mechanism of

action. To produce their effect they block the genera-

tion and propagation of impulses along nerve fibers.

Such impulses are transmitted by the rapid depolari-

zation and repolarization within the nerve axons.

These changes in polarity are due to the passage of

sodium and potassium ions across the nerve mem-

brane through ionic channels within the membrane.

Local anesthetics prevent the inward movement of

sodium ions which initiate depolarization and as a

consequence the nerve fiber cannot propagate any

impulse. The potassium efflux, on the other hand, is

influenced very little and there is no change in the

resting potential. The mechanisms behind the activity

of the local anesthetics are not fully understood, but

the most plausible theory is that the lipid-soluble free

base form of the local anesthetic, which is the form that

penetrates biologic membranes most easily, pene-

trates the connective tissue to reach the axons and

diffuses across the lipid membrane into the axon.

Inside the axon the drug interacts with specific recep-

tor sites on or within the sodium channels to exert an

inhibitory effect on sodium influx and, consequently,

on impulse conduction.

Dental local anesthetics

Anesthetics from the chemical group amino-amides,

for example lidocaine, mepivacaine, prilocaine and

articaine, are more potent and significantly less aller-

genic than amino-esters (e.g. procaine and tetracaine)

PERIODONTAL SURGERY: ACCESS THERAPY • 539

and have therefore replaced esters as the "gold stan-

dard" for dental local anesthetics.

Due to the specific need for bone penetration, den-

tal local anesthetics contain high concentrations of the

active agent. Although most amide local anesthetics

may cause local vasoconstriction in low concentra-

tions, the clinically used concentrations in dental so-

lutions will cause an increase in the local blood flow.

Significant clinical effects of this induced vasodilation

are an increased rate of absorption, thus decreasing

the duration of anesthesia. Major benefits can there-

fore be obtained by adding relatively high concentra-

tions of vasoconstrictors (e.g. epinephrine > 1:200 000

or > 5 mg/ml) to dental local anesthetic solutions; the

duration is considerably prolonged, the depth of an-

esthesia may be enhanced and the peak concentra-

tions of the local anesthetic in blood can be reduced.

Furthermore, in periodontal surgery, incorporation of

adrenergic vasoconstrictors into the local anesthetic is

of considerable value in keeping bleeding to a mini-

mum during surgery (avoiding considerable blood

loss, making it possible to visualize the surgical site

and thus with intact surgical quality shorten the time

spent on the procedure). As a matter of fact, the use of

a dental local anesthetic without a vasoconstrictor

during a periodontal surgical procedure is counter-

productive because the vasodilating properties of

such a local anesthetic will increase the bleeding in the

area of surgery.

Vasoconstrictors and local

hemostasis

Epinephrine is the vasoconstrictor of choice for local

hemostasis and is most commonly used in a concen-

tration of 1:80 000 (12.5 mg/ml). However, 1:100 000

epinephrine also provides excellent hemostasis and

most periodontists are unable to detect a clinical dif-

ference between the two concentrations. It therefore

seems prudent to use the least concentrated form of

epinephrine that provides clinically effective hemo-

stasis (i.e. the 1:100 000 concentration).

Although the cardiovascular effects of the usually

small amounts of epinephrine used during a peri-

odontal surgical procedure are of little practical con-

cern in most individuals, accidental intravascular in-

jections, unusual patient sensitivity and unantici-

pated drug interactions (or excessive doses) can result

in potentially serious outcomes. It must also be under

stood that the use of epinephrine for hemostasis dur-

ing periodontal surgery has some potential draw-

backs. Epinephrine will produce a rebound vasodila-

tion after the vasoconstriction has worn off, leading to

increased risk for bleeding in the immediate postop-

erative period. There is a greater potential for such

undesirable delayed hemorrhage following the use of

1:80.000 epinephrine than after the use 1:100 000.

Postoperative pain may increase and wound heal-

ing may be delayed when adrenergic vasoconstrictors

are used because of local ischemia with subsequent

tissue acidosis and accumulation of inflammatory me

diators. Furthermore, the possibility of an ischemic

necrosis of surgical flaps infiltrated with an adrenergic

vasoconstrictor (especially if norepinephrine is used

instead of epinephrine) cannot be discounted. For

these reasons as well as because of the possibility of

systemic reactions alluded to above, dental local an-

esthetics containing adrenergic vasoconstrictors for

hemostasis should be infiltrated

only

as needed and

not

merely from habit.

Felypressin, another commonly used vasoconstric-

tor, appears to act preferentially on the venous side of

the microcirculation and is not very active in constrict

ing the arteriolar circulation. Felypressin is therefore

not nearly as effective as adrenergic vasoconstrictors

in limiting hemorrhage during a surgical procedure.

Individual variability in response to dental local

anesthetics

Although it is possible for the periodontist to choose

from a broad spectrum of dental local anesthetics to

achieve the expected clinical action, there are a num-

ber of other factors (i.e. not related to the drug) that

can affect the drug action in a single patient.

During clinical conditions the variability in re-

sponse to dental local anesthetics administered can be

expected to be great, for example with regard to depth

and duration of anesthesia. The reason for the great

variation has not been adequately explained but has

to be accepted as it may have significant implications

in periodontal surgical procedures. A list of possible

factors that may cause anesthetic failures include:

•

Accuracy in administration of the drug

•

Anatomic variation between patients (e.g. in elderly

patients with bone resorption)

•

Status of the tissues at the site of injection (

vascular

ity, inflammation)

•

General condition of patient

•

Psychologic factors

Inaccuracy in administration is a major factor causing

anesthetic failures. Although not particularly signifi-

cant in infiltration anesthesia, the mandibular block is

a prime example of a technique in which duration of

anesthesia is greatly influenced by accuracy of injec-

tion.

The general condition of the patient as well as

psychologic factors may also affect the anticipated

duration of action. Infection, stress or pain will usually

lead to decreased duration of anesthesia, while an

increase in the patient's own defense mechanisms

against pain perception by, for example, release of

endogenous endorphins, may provide improved

depth and/or duration of anesthesia.

Techniques for anesthesia in periodontal surgery

Injections of dental local anesthetics prior to a peri-

odontal surgical procedure may be routine for the

dentist, but are often a most unpleasant experience for

the patient. Reassurance and psychologic support are

essential and will increase the patient's confidence in

540 • CHAPTER 25

his dentist. To create a relaxed atmosphere and to

decrease the patient's fear of an unusual situation is

of course also a useful way of increasing the patient's

own defense mechanisms against pain perception

(e.

g. release of endogenous endorphins).

Anesthesia for periodontal surgery is obtained by

nerve block and/or by local infiltration. In cases of

flap surgery, complete anesthesia must be attained

before commencing the operation, as it may be diffi-

cult to supplement the anesthesia after the bone sur-

face has been exposed. In addition, the pain elicited

by needle insertion can be significantly reduced if the

mucosa at the puncture site is anesthetized in advance

by the use of a suitable topical ointment or spray.

Local infiltration may have a greatly decreased rate

of success in areas where inflammation, in spite of

optimal conservative periodontal therapy and good

oral hygiene, remains in the periodontal tissues. The

suggested reason for this is that tissue pH tends to be

low in inflamed areas and anesthetic solutions are less

potent at low pH because there is a greater proportion

of charged cation molecules than of the uncharged

base molecules. Because of this, diffusion of the local

anesthetic into the axoplasm is slower, with sub-

sequent delayed onset and decreased efficacy. An-

other more recent hypothesis suggests that NGF

(

Nerve Growth Factor) released during tissue inflam-

mation will induce sprouting or proliferation of sen-

sory nerve endings, expressing a different (sub-)type

of sodium channel than in normal tissues. The dental

local anesthetics used at present may not be selective

enough for proper interaction with these sodium

channel subtypes to induce anticipated anesthesia.

Local anesthesia in the mandible

As a rule, analgesia of the teeth and the soft and hard

tissues of the mandible should be obtained by a

mandibular block and/or a mental block. In the ante

rior region of the mandible, canines and incisors can

often be anesthetized by infiltration, but there are

often anastomoses over the midline. These anasto-

moses must be anesthetized by bilateral infiltration,

or by bilateral mental blocks. The buccal soft tissues

of the mandible are anesthetized by local infiltration

or by blocking the buccal nerve. Local infiltration,

performed as a series of injections in the buccal fold of

the treatment area, has of course the added advantage

of providing a local ischemic effect if a suitable anes-

thetic is used.

The lingual periodontal tissues must also be anes-

thetized. This is accomplished by blocking the lingual

nerve and/or by infiltration in the floor of the mouth

close to the site of operation. If necessary to obtain

proper ischemia, and only then, supplementary injec-

tions may be made in the interdental papillae (in-

traseptal injections).

Local anesthesia in the maxilla

Local anesthesia of the teeth and buccal periodontal

tissues of the maxilla can easily be obtained by injec-

tions in the mucogingival fold of the treatment area. If

larger areas of the maxillary dentition are scheduled

for surgery, repeated injections (in the mucogingival

fold) have to be performed, e.g. at the central incisor,

canine, second premolar and second molar. In the

posterior maxillary region a tuberosity injection can

be used to block the superior alveolar branches of the

maxillary nerve. However, because of the vicinity to

the pterygoid venous plexus, this type of block anes-

thesia is not recommended due to the risk of intrave-

nous injection and/or hematoma formation.

The palatal nerves are most easily anesthetized by

injections made at right angles to the mucosa and

placed around 10 mm apical to the gingival margin

adjacent to teeth included in the operation. In cases of

advanced bone loss, the pain produced by injecting

into the non-resilient palatal mucosa can be mini-

mized if the injections are performed from the buccal

aspect, i.e. through the interdental gingiva. Sometimes

blocks of the nasopalatine nerves and/or the greater

palatine nerves can be applied. Especially for peri-

odontal surgery involving molars, supplementary

blocking of the greater palatine nerve should be con-

sidered.

Instruments used in periodontal surgery

General considerations

Surgical procedures used in periodontal therapy often

involve the following measures (instruments):

•

Incision and excision (periodontal knives)

•

Deflection and readaptation of mucosal flaps (pe-

riosteal elevators)

•

Removal of adherent fibrous and granulomatous

tissue (soft tissue rongeurs and tissue scissors)

•

Scaling and root planing (scalers and curettes)

•

Removal of bone tissue (bone rongeurs, chisels and

files)

•

Root sectioning (burs)

•

Suturing (sutures and needle holders, suture scis-

sors)

•

Application of wound dressing (plastic instru

ments)

The set of instruments used for the various periodon-

tal surgical procedures should have a comparatively

simple design. As a general rule, the number and

varieties of instruments should be kept to a minimum.

In addition to particular instruments used for peri-

odontal treatment modalities, equipment and instru-

ments generally used in oral surgery are often needed.

Within each category of surgical instruments used

for periodontal therapy there are usually several

PERIODONTAL SURGERY: ACCESS THERAPY • 541

Fig. 25-44. Set of instruments used

for periodontal surgery and in-

cluded in a standard tray.

brands available, varying in form and quality, leaving

ample room for individual preferences.

The instruments should be stored in sterile "ready

to-use" packs or trays. Handling, storing and labeling

of surgical instruments and equipment must be man

aged in such a way that interchanging of sterile and

non-sterile items is prevented.

It is also important that the instruments are kept in

good working condition. The maintenance routine

should ensure that scalers, curettes, knives with fixed

blades, etc., are sharp and that the hinges of scissors,

rongeurs and needle holders are properly lubricated.

Spare instruments (sterile) should always be available

to replace instruments found to be defective or acci-

dentally contaminated.

The instrument tray

Instrument trays for periodontal surgery may be ar-

ranged in several ways. Different trays can be used for

different procedures or a standard tray can be used for

all procedures supplemented with the particular in-

struments that are needed for a specific procedure.

A commonly used standard tray combines the basic

set of instruments used in oral surgery and a few

periodontal instruments. The instruments listed be-

low are often found on such a standard tray (Fig.

25-

44):

•

Mouth mirrors

•

Graduated periodontal probe/Explorer

•

Handles for disposable surgical blades (e.g. Bard-

Parker handle)

•

Mucoperiosteal elevator and tissue retractor

•

Scalers and curettes

•

Cotton pliers

•

Tissue pliers

(ad modum

Ewald)

•

Tissue scissors

•

Needle holder

•

Suture scissors

•

Plastic instrument

•

Hemostat

•

Burs

Fig. 25-45. Examples of gingivectomy knifes with fixed

blades. From left to right: Kirkland

/16,

Orban

/2,

and

Waerhaug

/2.

Additional equipment may include:

•

Syringe for local anesthesia

•

Syringe for irrigation

•

Aspirator tip

•

Physiologic saline

•

Drapings for the patient

•

Surgical gloves, surgical mask, surgeon's hood

Surgical instruments

Knives

Knives are available with fixed or replaceable blades.

The advantage of the fixed blade versions is that the

blade can be given any desired shape and orientation

in relation to the handle. A disadvantage is that such

instruments need frequent resharpening. Fig. 25-45

shows examples of knives with fixed blades.

New disposable blades are always sharp. They can

be rapidly replaced if found defective. The cutting

edge of the blades normally follows the long axis of

542 • CHAPTER 25

Fig. 25-46. Disposable blades which can be mounted in

various types of handles. The shape of the blades are

from left to right: No. 11, No. 12, No. 12D, No. 15 and

No. 15C.

Fig. 25-47. A universal360° handle for disposable

blades, which allows the mounting of the blade in any

angulated position of choice.

Fig. 25-48. Examples of double-ended sickle scalers and

curettes useful for root debridement in conjunction

with periodontal surgery. From left to right: Curette SG

215/16C Syntette, Sickle 215-216 Syntette and mini-cu

rette SG 215 / 16MC.

the handle, which limits their use. However, knives

with disposable blades fitted at an angle to the handle

are also available.

The disposable blades are manufactured in differ-

ent shapes (Fig. 25-46). When mounted in ordinary

handles (Bard-Parker

), they are used for releasing

incisions in flap operations and mucogingival surgery

and for reverse bevel incisions where access is obtain-

able. Special handles (Fig. 25-47) make it possible to

mount blades in angulated positions, which facilitates

the use of such knives for both gingivectomy excisions

and reverse bevel incisions.

Scalers and curettes

Scaling and root planing in conjunction with peri-

odontal surgery take place on exposed root surfaces.

Therefore access to the root surfaces for debridement

may be obtained also with the use of comparatively

sturdy instruments (Fig. 25-48). Tungsten carbide cu-

rettes and scalers with durable cutting edges are often

used when "access" is not a problem. Rotating fine-

grained diamond stones (Fig. 25-49) may be used

within infrabony pockets, root concavities and en-

trances to furcations.

Instruments for bone removal

Sharp bone chisels or bone rongeurs (Fig. 25-50) cause

the least tissue damage and should be employed

whenever access permits. With reduced access, surgi-

cal burs or files may be used. The burs should operate

at low speed and ample rinsing with sterile physi-

ologic saline should ensure cooling and removal of

tissue remnants.

Instruments for handling flaps

The proper healing of the periodontal wound is criti-

cal for the success of the operation. It is therefore

important that the manipulations of the soft tissue

flaps are performed with the minimum of tissue dam-

age. Care should be exercised in the use of periosteal

elevators when flaps are deflected and retracted for

optimal visibility. Surgical pliers and tissue retractors

which pierce the tissues should not be used in the

marginal area of the flaps. Needle holders with small

beaks and atraumatic sutures should be used.

Additional equipment

Hemorrhage is rarely a problem in periodontal sur-

gery. The characteristic oozing type of bleeding can

normally be controlled by a pressure pack (sterile

gauze moistened with saline). Bleeding from small

vessels can be stopped by clamping and tying using a

hemostat and resorbable sutures. If the vessel is sur-

rounded by bone, bleeding may be stopped by crush-

ing the nutrient canal in which the vessel runs with a

blunt instrument.

Sterile physiologic saline is used for rinsing and

moistening the field of operation and for cooling when

burs are employed. The saline solution may be kept in

a sterile metal cup on the instrument tray and may be

PERIODONTAL SURGERY: ACCESS THERAPY • 543

Fig.

25-49. A

set of burs which may be useful in peri

odontal surgery. The rotating fine-grained diamond

stones may be used for debridement of infrabony de

fects. The round burs are used for bone

recontouring.

applied to the wound by means of a sterile disposable

plastic syringe and a needle with rounded tip.

Visibility in the field of operation is secured by

using effective suction. The lumen of the aspirator tip

should have a smaller diameter than the rest of the

tube, in order to prevent clogging.

The patient's head may be covered by autoclaved

cotton drapings or sterile disposable plastic /paper

drapings. The surgeon and all assistants should wear

sterile surgical gloves, surgical mask and surgeon's

hood.

Selection of surgical technique

Many of the technical problems experienced in peri-

odontal surgery stem from the difficulties in assessing

accurately the degree and type of breakdown that has

occurred prior to surgery. Furthermore, at the time of

Fig.

25-50. Examples of instruments used for bone re

contouring. From left to right: Bone chisels Ochsenbein

no. 1 and

(Kirkland 13K/13KL), Bone chisel Ochsen

bein no. 3 and Schluger curved file no.

9/10.

surgery, previously undiagnosed defects may be rec-

ognized or some defects may have a more complex

outline than initially anticipated. Since each of the

surgical procedures described above is designed to

deal with a specific situation or to meet a certain

objective, it must be understood that in most patients

no single standardized technique alone can be applied

when periodontal surgery is undertaken. Therefore,

in each surgical field, different techniques are often

used and combined in such a way that the overall

objectives of the surgical part of the periodontal ther-

apy are met. As a general rule, surgical modalities of

therapy which preserve or induce the formation of

periodontal tissue should be preferred over those

which resect or eliminate tissue.

General indications for various surgical techniques

Gingivectomy

The obvious indication for gingivectomy is the pres-

ence of deep supra-alveolar pockets. In addition, the

gingivectomy technique can be used to reshape abnor

mal gingival contours such as gingival craters and

Fig.

25-51.

Internal beveled gingivectomy.

Schematic illustration of the incision technique in case of the presence of

only a minimal zone of gingiva.

544 • CHAPTER 25

gingival hyperplasias (Fig. 25-43). In such cases the

technique is often termed

gingivoplasty.

Gingivectomy is not considered suitable in situ-

ations where the incision will lead to the removal of

the entire zone of gingiva. This is the case when the

bottom of the probeable pocket to be excised is located

at or below the mucogingival junction. As an alterna-

tive in such a situation, an

internal beveled gingivectomy

may be performed (Fig. 25-51). Furthermore, since the

gingivectomy procedure is aimed at the complete

elimination of the periodontal pocket, the procedure

cannot be used in periodontal sites where infrabony

lesions or bony craters are present.

These limitations, combined with the development

in recent years of surgical methods which have a

broader field of application, have led to less frequent

use of gingivectomy in the treatment of periodontal

disease.

Flap operation with or without osseous surgery

Flap operations can be used in all cases where surgical

treatment of periodontal disease is indicated. Flap

procedures are particularly useful at sites where pock

ets extend beyond the mucogingival border and/or

where treatment of bony lesions and furcation in-

volvements is required.

The advantages of flap operations include:

•

existing gingiva is preserved

•

the marginal alveolar bone is exposed whereby the

morphology of bony defects can be identified and

the proper treatment rendered

•

furcation areas are exposed, the degree of involve-

ment and the "tooth-bone" relationship can be iden

tified

•

the flap can be repositioned at its original level or

shifted apically, thereby making it possible to adjust

the gingival margin to the local conditions

•

the flap procedure preserves the oral epithelium

and often makes the use of surgical dressing super

fluous

•

the postoperative period is usually less unpleasant

for the patient when compared to gingivectomy.

Treatment decisions for soft and hard tissue pockets

in flap surgery

Classifications of different flap modalities used in the

treatment of periodontal disease often make distinc-

tions between methods involving the marginal tissues

and those involving the mucogingival area and, fur-

ther, between tissue eliminating/resective varieties

and tissue preserving/reconstructive types (access

flaps for debridement). Such classifications appear

less than precise since several techniques are often

combined in the treatment of individual cases, and

since there is no clear-cut relationship between disease

characteristics and selection of surgical methods.

From a didactic point of view it seems more appropri-

ate to discuss surgical therapy with regard to how to

deal with (1) the soft tissue component and (2) the

hard tissue component of the periodontal pocket at a

specific tooth site (Fig. 25-52).

Soft

tissue pockets

The description of the various flap procedures reveals

that, depending on the surgical technique used, the

soft tissue flap should either be apically positioned at

the level of the bone crest (original Widman flap,

Neumann flap and apically repositioned flap) or

maintained in a coronal position (Kirkland flap, modi

fied Widman flap and papilla perservation flap) at the

completion of the surgical intervention. The mainte-

nance of the presurgical soft tissue height is of impor

tance from an esthetic point of view, particularly in the

anterior tooth region. However, long-term results

from clinical trials have shown that major differences

in the final position of the soft tissue margin are not

evident between surgical procedures involving coro-

nal and apical positioning of the flap margin. The

reported difference in final positioning of the gingival

margin between surgical techniques is attributed to

osseous recontouring (Townsend-Olsen et al. 1985,

Lindhe et al. 1987, Kaldahl et al. 1996, Becker et al.

2001). In many patients, however, it may be of signifi

cance to position the flap coronally in the anterior

tooth region in order to give the patient a prolonged

period of adaptation to the inevitable soft tissue reces

Fig. 25-52.

Surgical decisions.

Treat

ment decisions with respect to

the

soft and the hard tissue

compo

nent of a periodontal

pocket.