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
careful tissue handling married with a
microsurgical armamentarium will provide
predictable and aesthetic healing in the
majority of cases. Magnification using
loupes is invaluable for periodontal
surgery. The limited field of the operating
microscope can make surgical management
taxing. Specific surgical techniques will be
applicable to particular flap designs and
procedures. The following therefore form
general guiding principles for operative
surgical management.
Geoffrey J Bateman, BDS, MFDS RCS(Ed),
MMedEd, MRD RCS(Eng), FDS (Rest
Dent) RCS(Ed), Consultant in Restorative
Dentistry, Shuva Saha, BDS, MFDS
RCS(Eng), MFDS RCS(Ed), Specialist
Registrar in Restorative Dentistry and
David Pearson, BDS, MFDS RCS(Ed),
Staff Grade in Oral Surgery, Birmingham
Dental Hospital, St Chads Queensway,
Birmingham, UK.
470 DentalUpdate
A myriad of flap designs
exist in periodontal surgery. In general,
however, these can be described as having
a horizontal and vertical component. The
horizontal component of the flap normally
involves an intrasulcular incision around
gingival margins of the teeth of interest.
The vertical component of the flap is also
known as a relieving incision and helps
to relieve tissue tension and allow greater
access to the periradicular tissues. It is
possible for a flap to involve solely an
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.
Where there is a need for greater access
or relief of tissue tension, vertical relieving
incisions are required. In general, two
relieving incisions (a three-sided flap)
provide optimal access to the surgical
site and reduce tissue tension (Figure 1).
One relieving incision (a two-sided flap),
however, may provide adequate access
and reduce suture numbers for closure
Figure 2. Two-sided flap.
(Figure 2).
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Figure 3. Gingival blood vessels.
Figure 6. Partial-thickness flap.
Figure 8. Relative blade sizes for gingival dissection.
Figure 9. Microsurgical blade and handle.
Animal research has
demonstrated that gingival blood vessels
tend to have a relatively vertical orientation
(Figure 3). Incisions therefore should
tend to remain as vertical as possible to
minimize bisecting these vessels (Figure
4). This will reduce operative bleeding
September 2008
pg470-478 Contemporary Perio 2.indd 2
Figure 4. Vertical orientation of incision.
Figure 7. Papilla-sparing flap.
and also maximize blood supply to tissue
surrounding the raised flap. Where there
is a relatively oblique incision, this may
compromise the blood supply to the bound
tissue underneath the flap. In general, the
significant collateral circulation present
in gingival tissues obviates any risks of
Periodontology
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
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
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
raised, the potential for papillary recession
and subsequent unaesthetic black triangles
is greatly reduced.
Incision
Sharp anatomic dissection is
critical to modern surgical management.
Microsurgical instruments and techniques
have made this goal achievable in the
technically demanding region of the
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 Periodontology

accurate dissection around gingival margins The corner of horizontal and

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

Figure 13. Blakes knives.
Figure 14. Howarths nasal rasparatory.
gingival margin.
The Swann-Morton fine range
(Swann Morton, Sheffield, UK) includes
microsurgical blades contoured to allow
472 DentalUpdate
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
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
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
small shape helps to minimize trauma to
these delicate tissues. A curved Warwick
James elevator is also very useful for Figure 16. Sharp-edged elevator.
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
elevators as retractors is discouraged. Again
damage to these instruments will impair
their efficiency and reduce their lifespan.
Damaged instruments are also harder to
clean and autoclave.
Bone management
In many instances, bone removal
(osteotomy) is important for the success
of the procedure. Examples include crown
lengthening surgery, endodontic surgery
and third molar exodontia. Bone removal
may involve either the use of hand or rotary
instruments. The mainstay of osteotomy
management is rotary instrumentation.
Bone has been shown to
be particularly sensitive to changes in
temperature,3 with an increase of 10C
for 1 minute enough to induce necrosis
and impaired regeneration. Whilst
this is particularly relevant for implant
surgery, operators should take care to
avoid excessive heating of bone for any
periodontal surgery. Rotary instruments
should therefore be used with minimal
pressure and intermittent cutting strokes.
Cutting speed has been shown to be
relevant in this regard, with high speed
cutting generally showing less temperature
increase than low speed.4 The main risk
of surgical emphysema from high speed
turbine handpieces has been overcome
by newer back venting surgical turbines.
An example includes the Impact Air 45
(Sybron Dental Specialties, Orange, CA).
This has been designed with a 45 head
angle to improve access for resection of
roots of third molar teeth. It is also, however,
very useful for apical root-end resection.
September 2008
pg470-478 Contemporary Perio 2.indd 6
Periodontology
Figure 18. Minnesota retractor.
Tactile feedback is very different with this
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.
coolant is mandatory and careful efforts
should be maintained to ensure that this
is carefully directed to the cutting edge of
apically-repositioned flap.
the burr. Burr choice plays an important
Suture choice plays an important
role in osteotomy. Diamond burrs have
role. The use of black silk in oral surgery
been shown to clog with bone particles and
is now regarded as being outmoded. This
increase frictional heat5 and are therefore
material readily wicks (soaks-up) tissue
not recommended. The use of round or
fluids and is rapidly colonized with bacteria
fissure burrs with widely spaced flutes,
(Figure 20). Synthetic monofilament
such as the Lindemann bone cutting burr
materials have grown in popularity in
(Hu-Friedy Mfg Co, Inc, Leimen, Germany)
periodontal surgery. These materials do
are useful alternatives (Figure 19).
not wick tissue fluids and exhibit minimal
Fine removal of bone is
bacterial colonization (Figure 21). They do
sometimes required in crown lengthening
not, however, tie as well as silk and knots
surgery where all attempts are made to
may loosen over time. Cut ends of sutures
avoid damage to adjacent root structure.
may be sharp and relatively irritating to the
Initially, rotary instruments should be used
patient. Braided coated synthetic materials
to leave a thin layer of bone overlying root
represent a marriage of handling properties
structure. The subsequent use of hand
of silk and biological compatibility of the
instruments, such as fine chisels or sharp
synthetic materials. Resorbable materials
curettes, will then permit safe bone removal.
are useful where buried sutures have to
be placed, eg connective tissue grafting
or where removal may be technically
Closure and compression
demanding or uncomfortable for the
Careful apposition of wound
patient. As a general principle, however,
margins is essential to fast healing by
these sutures should not be left in the
primary intention and to maintain optimal
oral environment as they will be readily
soft tissue aesthetics. The surgical site
colonized by bacteria and, where they have
should be debrided with sterile saline prior
been placed in accessible positions, should
to definitive closure. It is helpful to position
be removed expediently.
the flap in an ideal position prior to closure.
Cutting-type needles will make
This is particularly helpful where changes
flap penetration easier but increase flap
in flap position are planned, for example an
damage and risks of pull-through. Reverse
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5/9/08 12:05:35
 Periodontology
cutting needles will decrease the risk of
suture pull-through. Non-cutting needles
are more resistant to tissue passage but
may be more suitable for very delicate
tissues, eg connective tissue graft or lingual
mucosa.
Selection of suture size is
important. 30 and 40 sutures are most
suitable for closure of bleeding sockets, or
where healing by secondary intention is
expected. Meticulous flap closure, however,
relies on smaller diameter sutures from
50 to 80. It is more difficult to close
flaps under tension with fine diameter
materials as they will tend to snap. This is
advantageous as flap closure under tension
will lead to bunching of tissues, ischaemic
regions and impaired healing potentially
with scar. It is more difficult to see small
diameter suture materials. Magnification
is useful for 50 sutures and mandatory
for sutures finer than this. Needle length
and shape are important in different areas.
For fine aesthetic anterior work, a short
needle of 5 mm greatly simplifies tissue
manipulation. Short needles will not pass
Figure 20. Poor healing response to black silk
sutures.
Figure 21. Healing response with 5.0 Prolene
(Johnson and Johnson, St-Stevens-Woluwe,
Belgium).
Figure 22. Coe-Pak dressing (GC, Tokyo, Japan).
476 DentalUpdate
pg470-478 Contemporary Perio 2.indd 7
through wide interdental embrasures,
however, and 15 mm is probably a more
appropriate length where posterior teeth
are involved.
It is good practice to compress a
flap with moistened gauze after closure for
around one minute to minimize dead tissue
space and potential haematoma formation.
Haematoma may encourage slow healing
by secondary intention.
There are several different
methods for suturing in the oral cavity and
describing each method is beyond the
scope of this article. The most commonly
used and versatile technique for suturing in
dentistry is the simple interrupted suture.
The needle is passed through the flap on
one side and again through the flap on the
other side. The suture is tied so that the
knot lies away from the incision and cut
Figure 23. Bupivacaine.
34 mm from the knot. Sutures should be
tightened sufficiently to approximate the
edges of the flap without undue tension.
In general, needle penetration should be
placed so that the wound edges meet at the
same level. This will minimize the possibility
of mismatched wound edge heights.
The application of a periodontal
dressing is useful when bone or raw tissue
surfaces are left exposed. A dressing may
improve patient comfort and also prevent
contamination of the surgical site (Figure
22). They are usually left in place for around
one week.
Post-operative management
Analgesia
Currently, NSAIDS represent the
gold standard in relief of dentally related
pain. In particular, a regime of Ibuprofen
800 mg TDS provides the most predictable
relief of discomfort. If this has not been
given pre-operatively, this should be given
immediately post-operatively. Paracetamol
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
sensitization to post-operative nociceptor
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).
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.
Trauma and tension to the
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5/9/08 12:05:52
 Periodontology

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

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

478 DentalUpdate September 2008

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