Chapter #52

Hisham AlShorman
Bayan Qawabah
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 Treatment of periodontal disease (ch52)
The surgical phase of periodontal therapy has the following main objectives:
1. Improvement of the prognosis of teeth and their replacement

2. Improvement of esthetic (correction of anatomic morphologic defects that may favor

plaque accumulation and pocket recurrence or impair esthetics.)

The surgical phase consists of techniques performed for pocket therapy and for the
correction of related morphologic problems, namely, mucogingival defects.

The purpose of surgical pocket therapy is to eliminate the pathologic changes in the pocket
walls; to create a stable, easily maintainable state, and if possible to promote periodontal
regeneration.

To fulfill these objectives, surgical techniques

(1) increase accessibility to the root surface , making it possible to remove all irritant
(2) reduce or eliminate pocket depth, making it possible for the patient to maintain the root
surfaces free of plaque
(3) reshape soft and hard tissues to attain a harmonious topography

Pocket reduction surgery seeks to reduce pocket depth by either resective or regenerative
means or often by a combination of both methods

Three types of techniques fall into this category, as follows :

1) Plastic surgery techniques are used to create or widen the attached gingiva by placing
grafts of various types.

2) Esthetic surgery techniques are used to cover denuded roots and to recreate lost papillae.

3) Preprosthetic techniques are used to adapt the periodontal and neighboring tissues to
receive prosthetic replacements; these include crown lengthening, ridge augmentation, and
vestibular deepening.

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These involve not only the implant placement techniques but also a variety of surgical
procedures to adapt the neighboring tissues, such as the sinus floor or the mandibular nerve
canal, for subsequent placement of the implant

Surgical Pocket Therapy

Surgical pocket therapy can be directed toward:

(1) access surgery to ensure the removal of irritants from the tooth surface or
(2) elimination or reduction of the depth of the periodontal pocket.

The effectiveness of periodontal therapy is predicated on success in completely eliminating

calculus, plaque, and diseased cementum from the tooth surface.

The presence of irregularities on the root surface also increase the difficulty of the
procedure. As the pocket becomes deeper, the surface to be scaled increases, more
irregularities appear on the root surface, and accessibility is impaired. The presence of
furcation will also create insurmountable problems for scaling the root surface.

These problems can be reduced by resecting or displacing

the soft tissue wall of the pocket, thereby increasing the
visibility and accessibility of the root surface.

Pocket elimination consists of reducing the depth of periodontal pockets to that of a

physiologic sulcus to enable cleansing by the patient.

The presence of a pocket produces areas that are impossible for the patient to keep clean,
which establishes the vicious cycle

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 Results of Pocket Therapy

A periodontal pocket can be in an active state or a period of inactivity or quiescence.

In an active pocket : underlying bone is being lost , can be diagnosed clinically by

bleeding either spontaneously or on probing.
After Phase I therapy the inflammatory changes in the pocket wall subside, rendering the
pocket inactive and reducing its depth, The extent of this reduction depends on the depth
before treatment and the degree to which the depth is the result of the edematous and
inflammatory component of the pocket wall.

Whether the pocket remains inactive depends on the depth, the individual characteristics
of the plaque components and the host response. Recurrence of the initial activity is likely.

Inactive pockets : can sometimes heal with a long junctional epithelium , this
condition also may be unstable, and the chance of recurrence and re-formation of
the original pocket is always present because the epithelial union to the tooth is
weak.

A more reliable and stable result is

obtained, however, by transforming the
pocket into a healthy sulcus. The bottom
of the healthy sulcus can be located
either where the bottom of the pocket
was localized or coronal to it. In the first
case, there is no gain of attachment ,and
the area of the root that was previously
the tooth wall of the pocket becomes
exposed. This does not mean that the
periodontal treatment has caused
recession but rather that it has
uncovered the recession previously
induced by the disease.

The healthy sulcus can also be located coronal to the bottom of

the preexisting pocket This is conducive to a restored marginal
periodontium; the result is a
sulcus of normal depth with gain of attachment. The creation
of a healthy sulcus and a restored periodontium entails a total
restoration of the status that existed before periodontal disease
began, which is the ideal result of treatment.

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 POCKET ELIMINATION VERSUS POCKE
MAINTENANCE

Pocket elimination (depth reduction to gingival sulcus levels) has traditionally been
considered one of the main goals of periodontal therapy and it was considered vital because
of the need to improve accessibility to root surfaces for the therapist during treatment and
for the patient after healing.

The prevalent opinion is the presence of deep pockets after therapy represents a greater
risk of disease progression than shallow sites.

In general, after surgical therapy, pockets that rebound to a shallow or moderate depth can
be maintained in a healthy state and without radiographic evidence of advancing bone loss
by maintenance visits consisting of scaling and root planning, with oral hygiene
reinforcement performed at regular intervals of 3 months or less.

In these patients, the residual pocket can be examined with a thin periodontal probe, but no
pain, exudate, or bleeding results. This appears to indicate that no plaque has formed on the
subgingival root surfaces , and these findings emphasize the importance of the maintenance
phase and the close monitoring of both level of attachment and pocket depth, together with
the other clinical variables (bleeding, exudation, or tooth mobility).

The most important variable for evaluating whether a pocket (or deep sulcus) is
progressive is the level of attachment which is measured in millimeters from the
cementoenamel junction.

Pocket depth remains an important clinical variable that contributes to decisions

about treatment selection.

Furthermore, probing depths established after active therapy and healing (approximately 6
months after treatment) can be maintained unchanged or reduced even further during a
maintenance period involving careful prophylaxis once every 3 months.

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 REEVALUATION AFTER PHASE I THERAPY

Longitudinal studies have noted that all patients should be treated initially with scaling and
root planning and that a final decision on the need for periodontal surgery should be made
only after a thorough evaluation of the effects of Phase I therapy. The assessment is
generally made no less than 1 to 3 months and sometimes as much as 9 months after the
completion of Phase I therapy. This reevaluation of the periodontal condition should
include re-probing the entire mouth. The presence of calculus, root caries, defective
restorations, and signs of persistent inflammation should also be evaluated.

CRITICAL ZONES IN POCKET SURGERY

Criteria for the selection of one of the different surgical techniques for pocket therapy are
based on clinical findings in the soft tissue pocket wall, tooth surface, underlying bone, and
attached gingiva.

Zone 1: Soft Tissue Pocket Wall

The clinician should determine the morphologic features, thickness, and topography of the
soft tissue pocket wall and persistence of inflammatory changes in the wall.

Zone 2: Tooth Surface

The clinician should identify the presence of deposits and alterations on the cementum
surface and determine the accessibility of the root surface to instrumentation. Phase I
therapy should have solved many, if not all, of the problems on the tooth surface. Evaluation
of the results of Phase I therapy should determine the need
for further therapy and the method to be used.

Zone 3: Underlying Bone

The clinician should establish the shape and height of the alveolar bone next to the pocket
wall through careful probing and clinical and radiographic examinations. Bony craters,
horizontal or angular bone losses, and other bone deformities are important criteria in
selection of the treatment technique.

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Zone 4: Attached Gingiva
an adequate band of attached gingiva is very important when selecting the pocket treatment
method. inadequate attached gingiva may be caused by a high frenum attachment, marked
gingival recession, or a deep pocket that reaches the level of the mucogingival junction.

INDICATIONS FOR PERIODONTAL SURGERY

1. Areas with irregular bony contours, deep craters.

2. Pockets on teeth in which a complete removal of root irritants is not considered
clinically possible may call for surgery. This occurs frequently in molar and
premolar areas.
3. In cases of furcation involvement of grade II or III
4. Intrabony pockets on distal areas of last molars, frequently complicated by
mucogingival problems, are usually unresponsive to nonsurgical methods.
5. Persistent inflammation in areas with moderate to deep pockets may require a
surgical approach. In areas with shallow pockets or normal sulci, persistent
inflammation may point to the presence of a mucogingival problem that needs a
surgical solution.

1. New attachment techniques : ideal result, because they eliminate pocket depth ; by
reuniting the gingiva to the tooth at a position coronal to the bottom of the
preexisting pocket
2. Removal of the pocket wall : (the most common method) It can be removed by the
following:
a- Retraction or shrinkage, in which scaling and root-planing procedures resolve
the inflammatory process, and the gingiva therefore shrinks, reducing the pocket
depth
B- Surgical removal performed by the gingivectomy technique or by means of an
undisplaced flap.
c- Apical displacement with an apically displaced flap.

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 3. Removal of the tooth side of the pocket : accomplished by tooth extraction or by
partial tooth extraction (hemisection or root resection).

Criteria for Method Selection

Clinical experience has suggested the criteria for selecting the method to treat the
pocket ,the selection of a technique for treatment of a particular periodontal lesion
is based on the following considerations :

1. Characteristics of the pocket: depth, relation to bone, and configuration.

2. Accessibility to instrumentation, including presence of furcation involvements.
3. Existence of mucogingival problems.
4. Response to Phase I therapy.
5. Patient cooperation.
6. Age and general health of the patient.
7. Overall diagnosis of the case.
8. Esthetic considerations.
9. Previous periodontal treatments.
Approaches to Specific Pocket Problems

Therapy for Gingival Pockets

Two factors are taken into consideration:
(1) the character of the pocket wall and
(2) the accessibility of the pocket. The pocket wall can be either edematous or
fibrotic.
Edematous tissue shrinks after the elimination of local factors, thereby reducing or
totally eliminating pocket depth. Therefore scaling and root planing are the
technique of choice in these cases. Pockets with a fibrotic wall are not appreciably
reduced in depth after scaling and root planing; therefore they are eliminated
surgically. Until recently, gingivectomy was the only technique available; it solves
the problem successfully, but in cases of marked gingival enlargement ,it may leave
a large wound that goes through a painful and prolonged healing process. In these
patients, a modified flap technique can adequately solve the problem with fewer
postoperative problems .

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Therapy for Slight Periodontitis.
In slight or incipient periodontitis a small amount of bone loss has occurred, and
pockets are shallow to moderate. In these patients, the conservative approach with
good oral hygiene will generally suffice to control the disease. Incipient
periodontitis that recurs in previously treated sites may require a thorough analysis
of the causes for the recurrence. Occasionally, a surgical approach may be required
to correct the problem.

Therapy for Moderate-to-Severe Periodontitis in Anterior Sector.

Anterior teeth offer two main advantages to a conservative approach:
(1) they are all single rooted and easily accessible
(2) patient compliance and thoroughness in plaque control are easier to attain.
Therefore scaling and root planing are the technique of choice for the anterior
teeth.
surgical technique may be necessary because of the need for improved accessibility
for root planing or regenerative surgery of osseous defects.
1- The papilla preservation flap is the first choice when a surgical approach is
needed. When the teeth are too close interproximally, the papilla preservation
technique may not be feasible.
2- The sulcular incision flap offers good esthetic results and is the next choice.
3- the modified Widman flap can be chosen when esthetics are not the primary
consideration. This technique uses an internal bevel incision about 1 to 2 mm
from the gingival margin without thinning the flap and may result in some
minor recession. Infrequently, bone contouring may be needed despite the
resultant root exposure.
4- the apically displaced flap is a treatment of choice with bone contouring

Therapy for Moderate-to-Severe Periodontitis in Posterior

Area.
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No esthetic problem but difficult accessibility.
Bone defects occur more often in the posterior than the anterior sector, and root
morphologic features, particularly in relation to furcations, Therefore surgery is
frequently indicated in the posterior region.
The purpose of surgery in the posterior area :
1- enhanced accessibility : can be obtained by either :
- undisplaced or the apically displaced flap
- the papilla preservation flap When osseous defects amenable to
reconstruction are present, because it better protects the interproximal
areas where defects are frequently present.
- 2nd choice the sulcular flap
- 3rd choice the modified Widman flap, maintaining as much of the
papilla as possible.
- flap with osseous contouring ; When osseous defects with no possibility
of reconstruction are present, such as interdental craters, the technique
of choice is the
2- the need for definitive pocket reduction requiring osseous surgery

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