Periodontal Plastic Surgery

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The term initially proposed by miller in 1993 and broadened to include the following areas:

–       Periodontal prosthetic corrections

–       Crown lengthening

–       Ridge augmentation

–        Esthetic surgical corrections

–       Coverage of the denuded root surface

–       Reconstruction of the papillae

–       Esthetic surgical correction around implants

–       Surgical exposure of unerupted teeth for orthodontics

Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa. Periodontal plastic surgery includes only the surgical procedure of mucogingival therapy.

Objectives of Periodontal Surgery

  • To establish drainage of gingival and periodontal abscess
  • To improve esthetic appearance of tissue overgrowth or recession of gingiva
  • To prepare for restorative dentistry
  • Aberrant frenum
  • Gingival recession
  • For osseous regenerative and guided tissue regeneration.
  • For surgical pocket elimination by removal of soft tissue
  • To correct gingival contours that interferes with oral hygiene.
  • Areas with irregular bony contours and craters
  • Infra bony pockets in the distal areas of last molars
  • Persistent inflammation in areas with moderate to deep pockets
  • In cases of grade II or grade III furcation involvement

Benefits

If you find yourself trying to hide a gummy smile, or have sensitive teeth because of exposed roots, you may be a good candidate for periodontal plastic surgery.

Periodontal Plastic Surgery can restore the gum line and create a more attractive smile with special crown lengthening, bone grafting and gum grafting techniques.

Contraindications

  • Haemorragic Disorders
  • Haemophilia
  • Thrombocytopenic purpura,
  • Following anticoagulant therapy
  • During first two days of menstrual period
  • Neutropenia
  • Uncontrolled diabetes
  • Prolonged cortisone therapy
  • Poor oral hygiene

Timing for periodontal surgery

Except for emergency, all periodontal surgery should be at least one month after completion of phase I therapy.

The need for mucogingival surgery cannot be assessed properly at the time of the initial.

Examination

Temporary splinting and/or occlusal adjustments procedures should be completed prior to the periodontal surgery.

Pre-operative

  • Medical and dental history should be reviewed.
  • The patient’s ability to remove plaque should be evaluated.
  • Tooth sensitivity should be noted and measures taken to control it.
  • In case of anxiety or history of syncope, premedication should be considered.
  • No specific nutritional regime is indicated before periodontal surgery.
  • The need for adequate fluid intake should always be emphasized.
  • Advice to quit smoking
  • Informed consent

Emergency equipment

  • The operator, all assistants and office personnel should be trained to handle all emergencies.
  • Drugs and equipment for emergency use should be readily available at all times.
  • Most common emergency is syncope

Principles of atraumatic surgery

  • Anaesthesia
  • Sharp instruments and minimum force‐less trauma
  • Atraumatic tissue management
  • Suturing
  • Tissue management Flaps and grafts should be handled gently, Elevators or tissue retractors should be used in such a way that they do not tear or compress soft tissues.
  • Use suction during periodontal surgery rather than to compress the tissues with a dry sponge in order to gain better vision.
  • The use of sponges also may result in cotton fibers being left in the wound, which may be a source of future irritation.
  • Avoid drying of bone, which will cause necrosis of surface bone.
  • Do not blow air into the field of surgery, as it may induce emphysema, or even air emboli, which can be fatal.
  • Hemostasis: Intra operative bleeding is best controlled with pressure using moist gauze for 2 to 5 minutes.
  • Resorbable suture to control the arterial bleeding.
  • Bleeding from bone can be stopped by burnishing the bone in the area of the bleed with a molt, elevator, or curette. If this is ineffective, bone wax can be compressed into the area of the bleed.

Purpose of suturing

  • The primary objective is to position & secure surgical flaps to promote optimal healing (Primary healing)
  • Hastens the wound healing time
  • Reduces post-operative pain & increases Patient comfort
  • Prevention of infection to the deeper tissues like bone
  • Permit proper flap position

Suture removal

  • As a rule intraoral sutures are removed 5‐7 days after the suturing.
  • Natural non‐resorbable sutures, like silk are removed after 1 week of suturing

Periodontal dressing

  • Periodontal dressings were first introduced in 1923 by A.W. Ward following gingival surgery.
  • This material was called Wonder pak which consisted of zinc oxide eugenol mixed with alcohol, pine oil and asbestos fibres.

Protection of the wound area.

  • Enhancement of the patient comfort
  • Maintainence of a debris free area
  • Helps to control bleeding
  • Helps to maintain the position of repositioned soft tissues
  • Periodontal dressings also protect newly exposed root surfaces from temperature changes, stabilize mobile teeth protect suture.
  • Act as a template to prevent formation of excessive granulation tissue
  • Protects the surgical healing areas from irritants such as hot and spicy foods.

Post-operative instructions

  • Avoid brushing in that area for about a week.
  • Advice a good mouth rinse to minimize plaque deposits.
  • Advice to avoid solid food for 24 hours.
  • If a patient feels excessive pain he should return to clinic.
  • If there is bleeding, should see the dentist.
  • If at all periodontal dressing falls off within three days, should come to clinic for new dressing.
  • Give analgesics.
  • Advisable to use anti-inflammatory analgesic when soft tissue surgery is carried out

First post-operative week

  • If properly performed no serious post-operative problems.
  • Patient advised to rinse with 0.12% Chlorhexidin immediately after the surgical procedure and twice daily there after until normal plaque control technique can be resumed

Complications that may arise in the first post-operative week

  1. Persistent bleeding after surgery
  2. Sensitivity to percussion
  3. Swelling
  4. Feeling of weakness
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