Principles of surgery Flashcards
Surgery Def
-Any surgical procedure used to treat periodontitis or to modify the morphology of the periodontium -Surgical manipulation of periodontal soft tissues, root and bone
Goal of periodontal surgery
To create an oral environment that is conducive to maintaining the patient’s dentition in health, comfort, function and esthetics
Indications for periodontal surgery
Indications: #1 Access to the root surface and bone Regeneration Pre-prosthetic Surgery Abscess treatment Mucogingival surgery Gingival enlargement Implant placement Exploratory surgery
Types of pre prosthetic surgery
Crown lengthening Gingival augmentation Ridge augmentation Sinus floor elevation Ridge augmentation Tori reduction Tuberosity reduction
Contraindications for periodontal surgery
Medical - uncontrolled disease Poor plaque control High caries risk Patient desires
Deferent surgical therapies
Gingivectomy/Gingivoplasty Curtain Procedure Modified Widman Flap Flap Curettage Osseous therapy Laser Surgery
Types of Osseous therapy
Resective Regenerative -GTR -Bone grafts -EMD, PDGF…
Surgical Approach is based on…
Type of disease Severity of disease Location of disease Morphology of osseous defects
Surgical Objectives
1 - Provide access Modify osseous architecture Repair / regenerate the periodontium Pocket reduction Establish acceptable soft tissue contours
Surgical Objectives #1 Access
Opened approach to debridement: Increased visibility Increased efficiency Less tissue trauma
Surgical Objectives Osseous Modification
Re-create physiologic contour Eliminate osseous defects Resection Regeneration Provide a maintainable periodontium
Surgical Therapy Repair/Regenerate
Reattachment Repair New Attachment Regeneration
Reattachment
To attach again The reunion of epithelial and connective tissue with a root surface following separation by incision or physical injury (not by disease). Not to be confused with new attachment.
Repair
Healing of a wound with tissue that does not fully restore the architecture or function of the original part. LJE and scar
New Attachment
The union of connective tissue or epithelium with a root surface that has been deprived of its original attachment apparatus. This new attachment may be epithelial adhesion and/or connective adaptation or attachment and may include new cementum. i.e. DISEASED
Regeneration
Reproduction or reconstitution of a lost or injured part in a manner similar or identical to its original form. In periodontics, refers to the formation of new bone, cementum, and a functionally-oriented periodontal ligament at a site deprived of its original attachment apparatus. In edentulous spaces, refers to the surgical augmentation of a resorbed ridge.
Surgical Objectives - Pocket Reduction
Reduce probing depth to a manageable level Improve subgingival access - Easier plaque control Improve long term stability of the periodontium
Surgical Objectives Acceptable Contours
Provide acceptable soft and hard tissue contours to: Reduce pocket depths Improve plaque control Improve esthetics
Surgical Principles
Know your patient Develop thorough treatment plan Know anatomy of surgical sites Provide profound anesthesiaAtraumatic tissue managementAseptic technique HemostasisNon-irritating sutures Obliterate dead space Quiescent wound healing
Atraumatic Tissue Management
Sharp, smooth incisions and dissection Adequate flap release Conserve vascular supply Keep it wide at base (2:1 width to height) Avoid - overthinning, excessive flap tension, perforation/tears Don’t desiccate the flap and bone, keep them well hydrated
Aseptic Technique
Sterile peri-operative field Sterile instruments and gloves Pre-operative mouthrinse/ peri-oral alcohol wipe Prophylactic antibiotics prn
Infections Post-surgically
1% infection rate post-surgery (<1% without, 2% with antibiotics) Pack & Haber, 1983 4.2% of 498 cases No difference if bone removed or teeth ext. Quad surgeries infected more often then sextant No difference between group with prophylactic antibiotics and those without BL: low rate of infection following periodontal surgery; use of antibiotics to prevent infection not warranted
Surgical Hemostasis
Preoperative Medical history Medications/coagulation disorders Intraoperative Pressure Vasoconstrictors Local agents Surgicel, Avitene, topical thrombin, HemCon (chitosan), bone wax, Gelfoam Bovie
Blood loss during surgery
134 ml, mean blood loss from periodontal flap surgery (range 16-592ml) Duration of surgery and amount of anesthetic used correlated with blood loss Mand surg ~151 ml Max surg ~ 110 ml
Post op hemostasis
rest wound stability Tranexamic acid
Surgical Principles Atraumatic Suturing
Small needle/fine suture Select suture with less tissue reactivity Use least number as is necessary Minimize flap tension Place in keratinized tissue when possible Take adequate “bite” of tissue
Surgical Principles Obliterate Dead Space
Attain hemostasis Primary closure Flap pressure
Pain Management Preoperative Assessment
medical / dental history past response to surgery/analgesics substance abuse
Pain Management Preemptive measures
administer analgesic 1-2 hrs prior long acting local anesthetics
Pain Management Postop care
appropriate analgesics Motrin 800mg x 40 tabs, take 1 tab q8h prn pain Tylenol 500mg x 40 tabs, take 2 tabs q6-8h prn pain Tylenol #3 x 12 tabs, take 1 tab q4-6h prn pain Others..Percocet, Norco, Ultram……
Stress Management
Patient - provider rapport Profound anesthesia Consider IV or oral sedation
Quiescent Wound Healing
Wound Stabilization Flap adaptation / hemostasis Appropriate suturing technique Avoid post-operative trauma limit oral hygiene delay suture removal periodontal dressing? Optimize infection control
Wound Stability
0-1 d - Fibrin linkage and clot adhesion - weak strength 3d - Granulation tissue - weak 14 D - Epithelial attachment and collagen adhesion - mod strength 21 d Maturation of CT and Cementum Formation - strong
Wound stability of full thickness flaps/sutures in dogs
2-3 d 225 gms flap separation 7 d 340 gms flap separation 14 d 1,700 gms suture pull through 1, 4, 6 mo 1,700 gms suture pull through
Types of incisions
External bevel Internal bevel Sulcular Releasing Thinning (dissecting) Stepback Cutback Periosteal release
External Bevel
Coronally directed Gingivectomy
Internal Bevel
–Apically directed
–Inverse bevel
–Reverse bevel
Sulcular incisions
Vertical Releasing locations
•Unfavorable
–Interdental
–Midfacial
•Favorable
–Line angles
Vertical Releasing advantages
–Increase access
–Avoid non-diseased sites
–Eliminate flap tension
–Allows flap positioning
Vertical Releasing contraindications
–Distal to second molars
–Exostoses
–Mandibular concavities
Flap design considerations
–Anatomical constraints
–Blood supply
–Tissue morphology
–Required access
–Degree of flap mobility required
–Final flap position
Flap design
To maintain adequate blood supply to the flap the ratio of flap height to flap base should not exceed 2 to 1.
Full thickness flap
Elevation of entire soft tissue complex
Full thickness advantages
–Increased visibility
–Access to alveolar bone
–Easier, quicker procedure
Full Thickness disadvantages
–Exposure of root dehisence/fenestration
–More alveolar bone loss?
Split Thickness flap
Elevation of only the superficial epithelialized portion of soft tissue leaving the periosteum intact
Split Thickness advantages
–Does not expose root dehisence/fenestrations
–Reduced alveolar bone loss
–Leaves a soft tissue bed for graft placement
Split Thickness disadvantages
–Not indicated in areas of thin tissue
–More technically demanding and time consuming
–Risk of perforation
Flap Reflection “Mopuse hole”
- Don’t “mouse hole”
- Increases surgical trauma
- Poorer visibility
- Inadequate debridement
- Increased operator fatigue/frustration
- Inferior surgical results
Type of flap repositioning
- Replaced
- Apically positioned
- Coronally positioned
what type of positioning is this
Coronal
What kind of repositioning is this
Apical
Suture needle facts
–Stainless steel
–3/8s, half, 5/8s
–tappered, cutting, reverse cutting
Suture selection
–tissue reactivity
–handling properties
–knot security
–tissue type
