Principles and Practice of Periodontal Surgery 1: Case Selection and Planning
The aim of this chapter is to provide the reader with a philosophy for case selection and treatment planning in periodontal surgery. Treatment objectives for predictable surgical management will be detailed alongside the principles common to different surgical procedures.
Having read this chapter the reader will be able to carefully plan a surgical case and identify potential pitfalls on a case-by-case basis. The standardised evidence-based protocols described will help to enhance the operator’s existing surgical preparation, irrespective of the type of surgery planned.
Periodontal surgery is both a science and an art. The periodontal surgeon should be both knowledgeable and ready to adapt their practice in line with the best research evidence. They should be able to critically appraise this evidence in an objective manner. In addition, the technical aspects of surgery require fine motor skills, gentle tissue handling and the visual anticipation of how a flap will close: this is the art of surgery. Surgical management requires a marriage of both of these facets, if excellence is to be achieved. Surgical skill comes through both didactic and observational learning, thorough experience and, to a lesser extent, the surgeon’s innate dexterity. The importance of education, therefore, cannot be overstated.
The other key aspect of good surgical management is regular practice to guard against de-skilling. The practitioner should be ready to appraise their own abilities and not undertake cases beyond their limits of competence; these may change throughout the course of their career.
The archetypical Renaissance man, Leonardo da Vinci, was an example to modern-day surgeons. In his era, science and art were not regarded as mutually exclusive entities. His studies in science and engineering were as accomplished as his drawing and painting. Leonardo’s drawing skills developed through his study of anatomy. A reproduction of one of his head and neck dissections may be found on the front cover of this text.
It is axiomatic that careful diagnosis and prescription of the right procedure are a sine qua non of surgical management. Future chapters will explore a selection of more popular surgical techniques and their indications in greater depth. The dental surgeon should be aware, however, of the nature and sequelae of the proposed treatment and be competent to carry out that treatment where appropriate. It follows that a full and frank discussion with the patient is necessary to gain informed consent. Informed consent should detail benefits, risks, other treatment options to be considered and what will happen if treatment is not carried out. Under common law, a conscious and competent patient needs to provide verbal consent to any operative procedure, although where sedation or deeper anaesthesia is employed, written consent is mandatory. Patients should also be provided with a written treatment plan and an estimate of costs.
Appropriate patient selection is important if high success rates are to be achieved and maintained with surgery. There are few absolute contraindications to surgery in general dental practice.
Common contraindications include:
severe bleeding diatheses
congenital, e.g. haemophilia and von Willebrand’s disease
acquired, e.g. warfarinised patient with a high INR (international normalised ratio ≥ 3.5)
significantly immunocompromised patients, e.g. acute leukaemia
poorly controlled diabetes
With few exceptions, periodontal surgical procedures are elective in nature. All attempts should be made, therefore, to postpone surgery for medically compromised patients until such time as systemic complications are stabilised.
Those patients with relative contraindications require careful consideration. These include medical, social and compliance-related factors.
In the United Kingdom, management of patients who require antibiotic prophylaxis for endocarditis has been greatly simplified through the introduction of new guidelines from the British Society of Antimicrobial Chemotherapy (BSAC) (Gould et al., 2006). These guidelines have not, however, been universally accepted at the time of this book going to press.
Patient groups requiring antibiotic prophylaxis have been reduced to three:
those with previous endocarditis
those with heart valve replacement
those with surgically constructed systemic or pulmonary shunts.
All dentogingival manipulations for these patients require antibiotic cover. There is no longer a need to provide intravenous antibiotic cover; oral antibiotic cover is now considered sufficient. Older BSAC guidelines are still published in the British National Formulary (BNF), and medicolegally either is acceptable as the guidance and advice of a recognised and properly constituted expert group.
Other relative medical contraindications should be considered practically on a case-by-case basis and treatment provided following careful appraisal of risks and assessment of response to previous surgical intervention.
Addiction poses particular problems in the management of surgical patients. Smoking is a significant risk factor for periodontal surgical failure and failure of implant placement. Alcohol dependence will predispose to excess bleeding where liver function has been impaired. It is important to consider that patients with liver disease may be thrombocytopenic as well as having abnormal clotting factor levels. In such cases, a full blood count must be taken in addition to an INR (prothrombin time). Platelet levels below 60,000/ml of whole blood represent a risk for surgical intervention. The disordered lifestyle led by some alcoholics may compromise the delivery of the planned regular care necessary for surgical success. It may be sensible to suggest other treatment approaches for these patients.
Phobic patients or those with poor compliance are generally less suitable for periodontal surgery than others. Often these procedures may be relatively time-consuming and technically demanding for the operator. Whilst conscious sedation techniques may render treatment possible for these patients, anxiety and poor coping skills may render the post-surgical phase relatively stormy and future management more difficult. Again, simpler, nonsurgical treatment options may be more appropriate for such patients.
Careful preoperative management and planning will often simplify surgery itself and allow a more predictable post-operative healing phase. Meticulous record-keeping and the use of evidence-based practice should be observed in this regard.
As discussed previously, the informed consent process is vital and should be well documented. General risks are involved in any surgical procedure and should be discussed with the patient. These include pain, swelling, bruising and bleeding. Many of these can be minimised with careful technique. Ri/>