Periodontology

Geoffrey J Bateman

Shuva Saha and David Pearson

Contemporary Periodontal
Surgery: 2. Surgical Practice
Abstract: Contemporary surgical techniques emphasize gentle tissue handling with a minimum of trauma. This in turn provides a
predictable operative environment and promotes healing. A modern surgical armamentarium may be very different from that encountered
a decade ago. This is clear from the greater availability of dental microsurgical instruments. Whilst the complexity of microsurgery may not
be routinely necessary in general dental practice, many of the principles and equipment used may make standard surgical management
easier and more predictable.
Clinical Relevance: A greater understanding of the evidence base behind periodontal surgery will allow us to improve flap design,
closure and operative management. Also, the use of microsurgical techniques and equipment will improve the quality and outcomes of
periodontal surgery in practice.
Dent Update 2008; 35: 470-478

Intra-operative management Flap design

Meticulous technique and A myriad of flap designs
careful tissue handling married with a exist in periodontal surgery. In general,
microsurgical armamentarium will provide however, these can be described as having
predictable and aesthetic healing in the a horizontal and vertical component. The
majority of cases. Magnification using horizontal component of the flap normally
loupes is invaluable for periodontal involves an intrasulcular incision around
surgery. The limited field of the operating gingival margins of the teeth of interest.
microscope can make surgical management The vertical component of the flap is also
taxing. Specific surgical techniques will be known as a relieving incision and helps
applicable to particular flap designs and to relieve tissue tension and allow greater
procedures. The following therefore form access to the periradicular tissues. It is
general guiding principles for operative possible for a flap to involve solely an
surgical management. intrasulcular incision for surgical access.
This is often a convenient design for
Figure 1. Three-sided flap.
simple replaced flap surgical periodontal
root surface debridement or where simple
access for surgical exodontia is required.
Geoffrey J Bateman, BDS, MFDS RCS(Ed), Where there is a need for greater access
MMedEd, MRD RCS(Eng), FDS (Rest or relief of tissue tension, vertical relieving
Dent) RCS(Ed), Consultant in Restorative incisions are required. In general, two
Dentistry, Shuva Saha, BDS, MFDS relieving incisions (a three-sided flap)
RCS(Eng), MFDS RCS(Ed), Specialist provide optimal access to the surgical
Registrar in Restorative Dentistry and site and reduce tissue tension (Figure 1).
David Pearson, BDS, MFDS RCS(Ed), One relieving incision (a two-sided flap),
Staff Grade in Oral Surgery, Birmingham however, may provide adequate access
Dental Hospital, St Chads Queensway, and reduce suture numbers for closure
Birmingham, UK. Figure 2. Two-sided flap.
(Figure 2).
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Figure 3. Gingival blood vessels. Figure 4. Vertical orientation of incision. Figure 5. Full-thickness flap.

ischaemic flap necrosis secondary to a

compromised blood supply. Flap perfusion
has been shown to be compromised where
the ratio of flap length to width is greater
than 2:1.1 Where this is a risk, the operator
should extend flap width horizontally.
A flap may also be described
Figure 6. Partial-thickness flap. Figure 7. Papilla-sparing flap.
as full or partial (split) thickness. A full-
thickness flap involves incision through all
the gingival tissues down to bone. When the
flap is raised, the periosteal layer is stripped
from the surface of alveolar bone using the
bone as a fulcrum point (Figure 5). This flap
is the most frequently used in periodontal
surgery. The partial-thickness flap (Figure
6) is created by incision through gingival
tissues, but stopping short of contact with
bone. A sharp dissection technique is used
subsequently when raising the flap. This flap
is most commonly used for mucogingival
grafting techniques.
A useful contemporary
technique in periodontal surgery involves
papilla-sparing flaps (Figure 7). These,
in particular, may be useful in implant
surgery or endodontic apical surgery. One
variation described by Velvart2 describes an
Figure 8. Relative blade sizes for gingival dissection. intrasulcular incision around the cervical
margin and the preparation of a split
thickness flap at the base of the interdental
papillae. Where papillae have not been
Figure 9. Microsurgical blade and handle. raised, the potential for papillary recession
and subsequent unaesthetic black triangles
is greatly reduced.

Animal research has and also maximize blood supply to tissue

demonstrated that gingival blood vessels surrounding the raised flap. Where there
Incision
tend to have a relatively vertical orientation is a relatively oblique incision, this may Sharp anatomic dissection is
(Figure 3). Incisions therefore should compromise the blood supply to the bound critical to modern surgical management.
tend to remain as vertical as possible to tissue underneath the flap. In general, the Microsurgical instruments and techniques
minimize bisecting these vessels (Figure significant collateral circulation present have made this goal achievable in the
4). This will reduce operative bleeding in gingival tissues obviates any risks of technically demanding region of the

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accurate dissection around gingival margins The corner of horizontal and

(Figure 8). Round, textured handles permit vertical relieving incisions is often the
fine manual control of the microsurgical easiest place to begin raising a flap as
blades (Figure 9). They are not prohibitively tissue tension here is least. It is often
expensive and represent a simple change possible to undermine the flap with a
that practitioners can make that will horizontal approach through the vertical
improve surgical management of the relieving incision. If gingival margins have
gingival margin immensely. been well dissected, these should lift
The traditional blade shapes simply from marginal bone.
Figure 10. Curved end of 15 blade cutting onto will, however, still retain an important place
bone. in surgical management. In particular, the
number 15 blade is designed to allow Retraction
good contact with bone and is invaluable Numerous patterns of retractors
for vertical relieving incisions (Figure 10). are available. Adequate retraction of the flap
Figure 11. No 12 blade. Newer handle designs again may permit will allow good vision of the surgical site
fine manual control and greater operator of interest and help to hold lip and buccal
comfort. tissues out of the way (Figure 18). Useful
The number 12 blade design retractors commonly used by the authors
may be useful for posterior indications for include the Minnesota and Carr retractors
intrasulcular incisions (Figure 11). Newer (Sybron Dental Specialties, Orange, CA);
angled handles also permit improved access retractor choice is very much down to
for posterior indications or gingivectomy operator preference.
procedures (Figure 12). Flap retraction should also
Figure 12. Angled handle.
Blakes knives (Figure 13) allow room for instruments specific to the
represent a useful addition for periodontal operative procedure. It is important not
surgery. Here the blade is at an acute to impinge on flap tissue with retractors
angle to the instrument handle. These as this will cause localized ischaemia and
instruments, however, are relatively potential for bruising. This may result in
difficult to assemble and clean and leave impaired healing. Retractors may also be
the operator and assistant more prone to useful for tissue protection, particularly
needlestick injury. on the lingual aspect of mandibular third

Reflection
Traditionally, the Howarths
pattern elevator (also called nasal
rasparatory) has been used for tissue
elevation (Figure 14). However, this
particular elevator is relatively blunt. The
use of blunt or misdirected elevators may
damage the flap and impair subsequent
healing. They may also make raising a
flap more difficult and time consuming. Figure 15. Papillary elevation.
Modern periodontal surgery relies on
sharp elevators to cleave periosteum
Figure 13. Blakes knives. efficiently from bone. Examples include
the Buser papilla elevator (Hu-Friedy Mfg
Co, Inc, Leimen, Germany), which includes
a fine spear-shaped portion for papillary
Figure 14. Howarths nasal rasparatory. elevation (Figure 15) and a curved portion
to lift the remaining flap (Figure 16). The
use of a flat plastic instrument may also
be valuable for papillary elevation. Its
gingival margin. small shape helps to minimize trauma to
The Swann-Morton fine range these delicate tissues. A curved Warwick
(Swann Morton, Sheffield, UK) includes James elevator is also very useful for Figure 16. Sharp-edged elevator.
microsurgical blades contoured to allow interproximal elevation (Figure 17).
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Figure 17. Curved Warwick-James elevator.

molars. Damage to retractors with rotary

instruments should be avoided where
possible. This may shorten the lifespan of
instruments and potentially leave metal
fragments in the surgical site. The use of Figure 18. Minnesota retractor.
elevators as retractors is discouraged. Again
damage to these instruments will impair
their efficiency and reduce their lifespan.
Damaged instruments are also harder to Tactile feedback is very different with this
clean and autoclave. instrument relative to the traditional slow-
speed. Care should therefore be taken by
Figure 19. Lindemann bone burr in Impact Air
the inexperienced operator. The use of
45.
Bone management coolant is mandatory and careful efforts
In many instances, bone removal should be maintained to ensure that this
(osteotomy) is important for the success is carefully directed to the cutting edge of
apically-repositioned flap.
of the procedure. Examples include crown the burr. Burr choice plays an important
Suture choice plays an important
lengthening surgery, endodontic surgery role in osteotomy. Diamond burrs have
role. The use of black silk in oral surgery
and third molar exodontia. Bone removal been shown to clog with bone particles and
is now regarded as being outmoded. This
may involve either the use of hand or rotary increase frictional heat5 and are therefore
material readily wicks (soaks-up) tissue
instruments. The mainstay of osteotomy not recommended. The use of round or
fluids and is rapidly colonized with bacteria
management is rotary instrumentation. fissure burrs with widely spaced flutes,
(Figure 20). Synthetic monofilament
Bone has been shown to such as the Lindemann bone cutting burr
materials have grown in popularity in
be particularly sensitive to changes in (Hu-Friedy Mfg Co, Inc, Leimen, Germany)
periodontal surgery. These materials do
temperature,3 with an increase of 10C are useful alternatives (Figure 19).
not wick tissue fluids and exhibit minimal
for 1 minute enough to induce necrosis Fine removal of bone is
bacterial colonization (Figure 21). They do
and impaired regeneration. Whilst sometimes required in crown lengthening
not, however, tie as well as silk and knots
this is particularly relevant for implant surgery where all attempts are made to
may loosen over time. Cut ends of sutures
surgery, operators should take care to avoid damage to adjacent root structure.
may be sharp and relatively irritating to the
avoid excessive heating of bone for any Initially, rotary instruments should be used
patient. Braided coated synthetic materials
periodontal surgery. Rotary instruments to leave a thin layer of bone overlying root
represent a marriage of handling properties
should therefore be used with minimal structure. The subsequent use of hand
of silk and biological compatibility of the
pressure and intermittent cutting strokes. instruments, such as fine chisels or sharp
synthetic materials. Resorbable materials
Cutting speed has been shown to be curettes, will then permit safe bone removal.
are useful where buried sutures have to
relevant in this regard, with high speed be placed, eg connective tissue grafting
cutting generally showing less temperature or where removal may be technically
increase than low speed.4 The main risk
Closure and compression
demanding or uncomfortable for the
of surgical emphysema from high speed Careful apposition of wound
patient. As a general principle, however,
turbine handpieces has been overcome margins is essential to fast healing by
these sutures should not be left in the
by newer back venting surgical turbines. primary intention and to maintain optimal
oral environment as they will be readily
An example includes the Impact Air 45 soft tissue aesthetics. The surgical site
colonized by bacteria and, where they have
(Sybron Dental Specialties, Orange, CA). should be debrided with sterile saline prior
been placed in accessible positions, should
This has been designed with a 45 head to definitive closure. It is helpful to position
be removed expediently.
angle to improve access for resection of the flap in an ideal position prior to closure.
Cutting-type needles will make
roots of third molar teeth. It is also, however, This is particularly helpful where changes
flap penetration easier but increase flap
very useful for apical root-end resection. in flap position are planned, for example an
damage and risks of pull-through. Reverse

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cutting needles will decrease the risk of through wide interdental embrasures, 34 mm from the knot. Sutures should be
suture pull-through. Non-cutting needles however, and 15 mm is probably a more tightened sufficiently to approximate the
are more resistant to tissue passage but appropriate length where posterior teeth edges of the flap without undue tension.
may be more suitable for very delicate are involved. In general, needle penetration should be
tissues, eg connective tissue graft or lingual It is good practice to compress a placed so that the wound edges meet at the
mucosa. flap with moistened gauze after closure for same level. This will minimize the possibility
Selection of suture size is around one minute to minimize dead tissue of mismatched wound edge heights.
important. 30 and 40 sutures are most space and potential haematoma formation. The application of a periodontal
suitable for closure of bleeding sockets, or Haematoma may encourage slow healing dressing is useful when bone or raw tissue
where healing by secondary intention is by secondary intention. surfaces are left exposed. A dressing may
expected. Meticulous flap closure, however, There are several different improve patient comfort and also prevent
relies on smaller diameter sutures from methods for suturing in the oral cavity and contamination of the surgical site (Figure
50 to 80. It is more difficult to close describing each method is beyond the 22). They are usually left in place for around
flaps under tension with fine diameter scope of this article. The most commonly one week.
materials as they will tend to snap. This is used and versatile technique for suturing in
advantageous as flap closure under tension dentistry is the simple interrupted suture.
will lead to bunching of tissues, ischaemic The needle is passed through the flap on Post-operative management
regions and impaired healing potentially one side and again through the flap on the Analgesia
with scar. It is more difficult to see small other side. The suture is tied so that the Currently, NSAIDS represent the
diameter suture materials. Magnification knot lies away from the incision and cut gold standard in relief of dentally related
is useful for 50 sutures and mandatory pain. In particular, a regime of Ibuprofen
for sutures finer than this. Needle length 800 mg TDS provides the most predictable
and shape are important in different areas. relief of discomfort. If this has not been
For fine aesthetic anterior work, a short given pre-operatively, this should be given
needle of 5 mm greatly simplifies tissue immediately post-operatively. Paracetamol
manipulation. Short needles will not pass 1000 mg QDS is an appropriate alternative
where this is contra-indicated. Opioid drugs
may be used where pain relief is inadequate
with NSAIDS. This would, however, be
relatively unusual.
It is good practice to infiltrate
post-surgically with a long-acting local
anaesthetic such as Bupivacaine (Marcain,
AstraZeneca, London, UK). This will give
the patient around 68 hours free from
discomfort, which may be enough to
provide a good nights sleep. A secondary
effect is the prevention of central
Figure 20. Poor healing response to black silk sensitization to post-operative nociceptor
sutures.
activation. This has been shown to decrease
post-op use of analgesics relative to
placebo long after the effects of anaesthesia
have disappeared.6 Bupivacaine is available
in ampoules for hypodermic administration
(Figure 23).
Figure 21. Healing response with 5.0 Prolene
(Johnson and Johnson, St-Stevens-Woluwe,
Belgium). Post operative instructions
Where incision has involved
gingival margins, toothbrushing will be
uncomfortable and potentially traumatic.
The patient should be prescribed a 0.2%
chlorhexidine gluconate mouthwash to
use until toothbrushing can be resumed
comfortably in the surgical site. The patient
should brush other sites as normal.
Figure 22. Coe-Pak dressing (GC, Tokyo, Japan). Figure 23. Bupivacaine. Trauma and tension to the

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surgical site should be discouraged and periodontal surgery has helped to simplify the bone growth chamber.
the patient should be asked to leave this management and allow for comfortable J Oral Maxillofac Surg 1984; 42:
alone as far as possible. This is particularly aesthetic healing in the majority of cases. 705711.
important for graft treatment where Simple changes to technique can be 4. Agren E, Arwill T. High-speed or
stability of the connective tissue graft is of inexpensive and will let the surgeon and conventional dental equipment
for the removal of bone in oral
primary importance. the patient enjoy a more pleasant and
surgery. 3. A histologic and
predictable operative experience.
microradiographic study on bone
Suture removal repair in the rabbit. Acta Odontol
Scand 1968; 26: 223246.
Where healing occurs by primary References
5. Moss RW. Histopathologic reaction
intention, sutures may be removed as early 1. Patterson TJ. The survival of skin flaps of bone to surgical cutting. Oral
as 48 hours but no later than 45 days. After in the pig. Br J Plast Surg 1968; 21: Surg Oral Med Oral Pathol 1964; 17:
this time, sutures serve to act only as an 113117. 405414.
irritant to the tissues.7 2. Velvart P. Papilla base incision: a new 6. Hargreaves KM, Keiser K.
approach to recession-free healing of Development of new pain
the interdental papilla after endodontic management strategies. J Dent Educ
Conclusions surgery. Int Endod J 2002; 35: 453460. 2002; 66: 113121.
3. Eriksson RA, Albrektsson T. The effect 7. Selvig KA, Torabinejad M. Wound
The introduction of modern of heat on bone regeneration: an healing after mucoperiosteal surgery
techniques and an evidence base to experimental study in the rabbit using in the cat. J Endod 1996; 22: 507515.

BookReview
Managing Orofacial Pain in Practice. dealt with separately in the
By Eamonn Murphy, Quintessence chapters dealing with TMJ
Publishing Co Ltd, 2008 (170pp, 28.00). disorders, muscle-related
ISBN: 978-1-85097-130-6. problems and neuropathic
pain. Perhaps one chapter at
the beginning would have
Managing Orofacial Pain in Practice is been a neater approach.
undoubtedly a useful addition to the Furthermore, each chapter
QuintEssentials of Dental Practice series. It begins with Aims and
will be helpful not only to general dental Outcomes sections which, as
practitioners, but to undergraduates and far as I could see, amounted to
those in early postgraduate training. It the same thing.
deals with a subject that is often not well Some of the
taught and with a group of patients with illustrations are non-
whom it is difficult to gain a lot of clinical contributary, in particular the
management experience unless one spends cartoons which are somewhat
time in a specialist clinic. simplistic. Similarly, some
The book comprises ten of the colour plates may
chapters: an introduction, one on have been put to better use:
assessment, five on different types of for example, Figures 210,
orofacial pain, one each on psychological demonstrating the assessment
factors, complex pain and the ultimate of sensory disturbance,
comprising a series of case presentations. illustrate techniques that
The content of most of the should be familiar to every
chapters is informative with appropriate qualified dentist and therefore
tables clarifying the important points, add little to the text.
such as signs and symptoms and other In summary, this is
diagnostic criteria. Indeed, throughout a commendable book which
the clinical subject is presented clearly should appeal to a wide
and in an uncomplicated fashion. The text range of clinicians. It presents
supports the mantra quoted by the author a balanced approach to the
in the preface: No diagnosis no treatment! management of an often poorly managed
If there are weaknesses in the problem within dentistry, in a lively style, Mike Hahn
book they are of arrangement rather than making a sometimes tedious clinical subject University of Birmingham
content. The anatomy and physiology are very readable. School of Dentistry

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