Periodontology 2000, Vol.
25, 2001, 89–99
Printed in Denmark ¡ All rights reserved
Surgical periodontal therapy
H OM- L AY W ANG & H ENRY G REENWELL
Periodontal surgery in the
21st century
Periodontal therapy is directed at disease preven-
tion, slowing or arresting disease progression, re-
generating lost periodontium, and maintaining
achieved therapeutic objectives. A variety of differ-
ent treatment techniques have been used includ-
ing subgingival curettage, gingivectomy, modified
Widman flap, and full- or split-thickness flap pro-
cedures with or without osseous recontouring. The
best surgical approach remains controversial, al-
though the results of longitudinal clinical trials has
highlighted the advantages and disadvantages of
each technique.
More than 30 years have passed since the first re-
port of a long-term comparison of periodontal treat-
ments. Prior to that time, treatment was based on
deductive reasoning and empirical observations.
Ramfjord et al. sought to change the rationale for
periodontal therapy to one that was inductively de-
rived and scientifically founded on prospective,
long-term data (10, 27, 28, 50, 51, 54). As a pioneer,
Ramfjord challenged many long-held dogmas and
introduced new concepts into clinical periodontal
research.
Ramfjord et al. proposed attachment level change
as the primary outcome variable to assess and com-
pare the effect of periodontal treatments (10, 27, 28,
50, 51, 54). Loss of attachment was considered the
best measure of disease progression. How well
attachment change has served as a primary outcome
variable will be discussed in more detail later in this
chapter.
The longitudinal studies comparing surgical treat-
ments undoubtedly represent some of the most im-
portant clinical research ever performed in peri-
odontics. They have direct clinical relevance and af-
fect the way we practice on a daily basis. There are
seven main centers that have conducted these
studies: Michigan, Göteborg, Minnesota, Wash-
ington, Aarhus, Tucson and Nebraska. Each group of
studies has made its own unique contribution and
Copyright C Munksgaard 2001
PERIODONTOLOGY 2000
ISSN 0906-6713
provided the data on which our current knowledge
base is built. The more sophisticated studies of the
future will derive their improved designs from the
context of this information.
The Michigan studies began as a comparison of
curettage and pocket elimination procedures (54).
Pocket elimination was defined as gingivectomy or a
flap procedure with or without osseous recon-
touring. Over the years the comparison expanded to
include modified Widman flap and scaling and root
planing. Initially the treatments were compared in
groups, but this quickly evolved to a split-mouth de-
sign, which afforded better control over the many
variables that can affect treatment outcome.
Another feature of the Michigan studies was data
stratification based on the probing depth at initial
examination: 1 to 3 mm, 4 to 6 mm, and 7 mm or
greater. Results were also compared based on tooth
type: maxillary molars, mandibular molars, maxillary
premolars, mandibular premolars, maxillary an-
teriors and mandibular anteriors. Data were re-
ported as means, which were either full mouth or
stratified by initial probing depth. In general small
differences were found between treatments, between
initial probing depth strata or between tooth types.
From a clinical standpoint the differences were in-
significant, however, the trends did reveal some dis-
tinctions.
Curettage, scaling and root planing and modified
Widman flap produced slightly better attachment
level results, while pocket elimination procedures
gave the greatest probing depth reduction. Different
tooth types responded similarly to the treatments;
however, molars showed slightly less favorable re-
sults. Teeth with initially shallow probing depths
tended to lose a small amount of attachment due
to treatment, while teeth with initially deep probing
depths showed the greatest attachment gain and
probing depth reduction.
The Göteborg studies incorporated different de-
sign features than the Michigan studies and conse-
quently reported slightly different results (29–35, 42–
44, 55, 59). Lindhe & Nyman hypothesized that even
89
Wang & Greenwell
advanced cases of periodontitis could be cured if op-
timum plaque control was achieved (29). This meant
patients unable to maintain a plaque-free dentition
were not included in the study and that frequent
professional toothcleaning, often every 2 weeks, was
provided. In the early studies treatments were tested
in separate groups.
Surgical techniques tested included: gingivectomy,
modified Widman flap with and without osseous re-
contouring, and apically positioned flap with and
without osseous recontouring. All techniques halted
loss of attachment, but the greatest gain of attach-
ment was achieved when osseous resection was
avoided and soft tissue was sutured to completely
cover alveolar bone (29, 43, 44, 55). No study to date
has shown that plaque is the cause of periodontitis,
but these studies certainly demonstrated that with
no plaque there is no disease progression.
Later Göteborg studies utilized a split-mouth de-
sign and limited the comparison to scaling and
root planing and modified Widman flap (33–35).
These studies reported attachment level changes
and probing depth reductions similar to that found
by Ramfjord et al. Critical probing depths for scal-
ing and root planing and modified Widman flap
were identified (33). Values above the critical prob-
ing depth responded with gain of attachment
while values below tended to lose attachment. The
critical probing depth was 2.9 mm for scaling and
root planing and 4.2 mm for modified Widman
flap. This finding refined the concept that the
magnitude of the treatment response was depend-
ent on the initial probing depth and showed: 1)
that the response was treatment specific; and 2)
the precise point at which attachment gain could
be expected. This was a more defined guideline
than the nonspecific indication that certain prob-
ing strata tended to respond with gain or loss of
attachment.
The Minnesota studies focused on comparisons of
scaling and root planing and modified Widman flap
(47–49). Over the 6.5 years of the study, little differ-
ence between attachment level results for the two
treatments was found. Also minimal differences be-
tween treatments were found for attachment level
and tooth loss data for molar and nonmolar teeth.
The Aarhus studies compared apically positioned
flap to modified Widman flap and scaling and root
planing (11–13). Again little difference was found be-
tween treatments. Both the Minnesota and the
Aarhus studies were well designed and served to
confirm the findings of the Michigan and Göteborg
studies.
90
The Washington studies were unique in strictly
defining osseous surgery as designed to establish
positive, scalloped architecture (45, 56). Apically po-
sitioned flap without osseous recontouring, termed
flap curettage, was compared to apically positioned
flap with osseous recontouring. Osseous recon-
touring led to slightly more attachment loss, but
greater probing depth reduction, than flap curettage.
The authors concluded that the osseous recon-
touring was more effective in reducing pockets and,
therefore, in controlling inflammation than flap
curettage.
The Tucson studies differed from previous re-
ports in that they were conducted in a private
practice, rather than a university, setting (4, 5, 26).
Becker et al. compared scaling and root planing,
modified Widman flap and, again, utilized a
strictly designed protocol for osseous surgery. Over
the term of the study minimal differences were
found between procedures. This confirmed the
findings of the university studies and demon-
strated that similar results could be achieved in a
private practice setting.
The Nebraska studies are the most recent long-
term reports and include numerous distinctive de-
sign features (1, 15–25). Firstly, a coronal scaling
group was included. So many of the teeth in this
group had to be exited that it was clear that this was
not an acceptable form of therapy for periodontitis.
Secondly, the furcation response was analyzed using
horizontal attachment level data. Although interpre-
tation of this data was complicated by virtue of the
different therapeutic options utilized, the sites
treated by osseous surgery had the lowest incidence
of recurrence. Thirdly, sites were stratified by post-
surgical probing depths and not just initial probing
depths. Thus treatment effect was evaluated based
on the probing depths actually present during main-
tenance therapy. Breakdown incidences were greater
with increasing postsurgical probing depth. Fourthly,
the annual incidence of sites breaking down was de-
termined. The recurrence rate was greatest for sites
treated with scaling and root planing, which was
similar to modified Widman flap, and least for sites
that received osseous surgery. Finally, the effect of
smoking on treatment outcome was assessed and
found to profoundly influence disease recurrence.
While the effect was pervasive and included all out-
come variables it diminished, but did not prevent
the response to therapy. Thus smokers responded to
treatment but the response was less pronounced,
and the recurrence rate was higher, than in non-
smokers.

Interpretation of
longitudinal studies
Wang found that treated periodontitis patients pro-
gressed at a rate of 0.03 mm/year, Westfelt et al. re-
ported 0.04 mm/year, and Löe et al. reported 0.06
mm/year (36–40, 58, 60). Using 0.06 mm/year as an
example would give 0.3 mm progression in 5 years
and 0.6 mm in 10 years. Untreated periodontitis, on
the other hand, progresses at a more rapid rate. Craft
found 0.1 mm/year, while Axelsson & Lindhe re-
ported 0.2 mm/year and Löe et al. also found 0.2
mm/year (2, 3, 8, 36–40). If we select the 0.2 mm/
year this means 1 mm progression in 5 years and 2
mm in 10 years. The difference between the pro-
gression of treated and untreated disease at 5 years is
0.7 mm and 1.4 mm at 10 years. The small difference
between treated and untreated disease is difficult to
reliably detect using current instrumentation. This is
even more true for the difference between two forms
of treatment, where the annual progression means
are in hundredths of a millimeter. Since most of the
longitudinal studies are 5 years or less, and all are
less than 10 years duration, this means that the
limited amount of progression actually occurring
makes it difficult to discern differences between
treatments using mean values.
Jeffcoat & Reddy showed that the resolution of the
probing instrument can have a profound influence
on the interpretation of disease progression (14).
Using the Alabama cementoenamel junction probe,
with a resolution of 0.1 mm, they found that the pre-
dominant mode of progression was continuous
while using a manual probe, with a resolution of 1
mm, progression appeared to be in episodic bursts
of disease activity. Higher-resolution instrumen-
tation would afford better data for comparison of
treatment effect.
The use of full-mouth means is an important
method of data analysis. It is a particularly good way
to show trends and patient effects. Full-mouth
means can also obscure important individual site ef-
fects. Frequency data, incidence (rate) of recurrence
and rate of disease progression are methods of
analysis that will identify site specific effects. Thus,
there is a clear distinction between patient-based
and site-based data, and both types of analysis are
necessary to elucidate actual treatment outcome.
Many of the longitudinal studies have failed to use
both forms of analysis and thus have left many ques-
tions unanswered.
Machtei et al. reported that the rate of untreated
disease progression over a 9-month period was
Surgical periodontal therapy
much greater in deep pockets than in shallow ones
(41). This study used 12 individualized thresholds for
progression for each patient based on the probing
depth, tooth type, and buccal or lingual probing site.
The sophisticated data analysis used permitted
greater insight into the rate of disease progression
at individual sites because individualized thresholds
allowed more accurate selection of progressing sites
for study.
The initial findings of longitudinal studies, using
full-mouth means, were that there was little differ-
ence between treatments whether surgical or non-
surgical scaling and root planing. As study designs
have evolved and methods of data analysis become
more sophisticated a different picture may be
emerging. Shallower probing depths may gain
greater therapeutic emphasis due to the decreased
incidence of periodontal breakdown.
Initially the choice of primary outcome variable
for longitudinal studies was mean attachment level.
Thirty years later the choice of a primary outcome
variable is changing. Future studies should include
frequency data to help discern individual site effects,
annual and cumulative recurrence rate are needed
to distinguish between treatments, and the rate of
disease progression at individual sites is needed to
further analyze treatment outcome. Higher resol-
ution instrumentation is needed to provide better
techniques of measuring probing values. Improved
techniques of identifying progressing sites are also
needed.
While much has been learned with long-term
studies of periodontal therapy, there is much yet to
learn. The ultimate goal is to provide treatments that
will predictably arrest disease progression and give a
stable long-term result. Thirty years of excellent clin-
ical research has furthered this goal but additional
study is needed to more precisely define the role of
each therapeutic modality. Good clinical judgment
and treatment individually tailored to suit the pa-
tient’s needs is the best approach based on current
data.
Indications for periodontal surgery
Nonsurgical therapy is performed prior to surgical
treatment for periodontitis. Surgery is indicated
where nonsurgical methods fail. In general, the suc-
cess of nonsurgical treatment should be assessed fol-
lowing scaling and root planing but prior to the ad-
ministration of antimicrobial agents or antibiotics.
These medications tend to reduce inflammation and
91
Wang & Greenwell

obscure sites where scaling and root planing has

root planing
Scaling and
failed to resolve disease. Pocket reduction or elimin-
Table 1. Comparison of mean attachment level change and probing depth reduction values from long-term studies of surgical periodontal therapy
ation per se is not required in sites that respond to

1.33
1.32
1.30
0.59
0.83
3.20
0.79
1.27
nonsurgical therapy and remain stable during main-
tenance. When surgery is required, however, shal-
lower probing depths may be an appropriate goal to
Modified
Widman

facilitate maintenance therapy and reduce the inci-

1.63
1.89
1.61
1.70
0.91
1.17
2.90
1.39
1.48
flap

dence of recurrence (1, 15–25). The advantages of

surgical therapy are listed in Table 2.
Preparation prior to periodontal surgery should
elimination
Probing depth reduction

include a thorough examination and diagnosis and

surgery
Pocket

a complete assessment of risk factors. All patients

1.77
0.80
1.37
1.77
1.73

3.30
1.60
1.84
should have at least 80% plaque-free surfaces and
sufficient time should be allowed for tissue re-
Currettage

sponse following scaling and root planing. A dis-

cussion of the risks and benefits of surgery is ap-
0.99
0.50
0.71
1.26
1.50

propriate, and the patient should sign an informed

consent. Medications needed for anxiety control
root planing

and endocarditis prophylaxis should be prescribed

Scaling and

if indicated.
0.45
ª0.04
0.00
0.41
0.83
0.90
0.28
0.79

Appropriate postoperative instructions should be

given to the patient including an explanation con-
cerning: 1) discomfort and potential complications;
Modified

2) all medications, especially analgesics and anti-

Widman

0.26
0.20
ª0.16
0.30
0.20
0.33
0.60
ª0.07
0.70

biotics; 3) diet modification including avoidance of

flap
elimination
Attachment level change

Table 2. Advantages of periodontal surgery

surgery
Pocket

ª0.05
0.10
ª0.73
ª0.18
ª0.31

0.30
0.05
0.45

O Improved visualization of the root surface

O More accurate determination of prognosis
Currettage

O Improved pocket reduction or elimination

O Improved regeneration of lost periodontal structures
ª0.06
0.20
ª0.52
0.04
0.03

O An improved environment for restorative dentistry

O Improved access for oral hygiene and supportive
periodontal treatment
Years

3.65
6.5
3
6
5
2
2
4

5
1
2
12 to 58
21 to 59

10 to 17
10 to 17

Table 3. Postsurgical management

32

90
15

16
16
82

Analgesics, cold packs, moist gauze locally

n

Day 1:
as needed, total avoidance of wound
disturbance
Reference

After day 1: Pain, swelling, bleeding should

diminish or disappear
Begin light activity
54
51
50
10
14
21
22
25
28
31

Warm packs as needed

Chemical plaque control recommended
After 5–10 Remove dressing and sutures
Pihlstrom et al.
Pihlstrom et al.

days: Professionally de-plaque supragingivally

Ramfjord et al.
Ramfjord et al.
Ramfjord et al.

Kaldahl et al.

Begin light oral hygiene

Lindhe et al.

Becker et al.
Isidor et al.

After 4 to 6 Weekly or biweekly visits for professional

Hill et al.

weeks: de-plaqing and oral hygiene instruction

Mean
Author

The dentogingival junction should not be probed or

instrumented for 6 to 8 weeks following surgery

92

Fig. 1. A gingivectomy and gingivoplasty was used to cor-
rect gingival aberrations. A. Preoperative. B. Gingivectomy
hot or spicy food and liquids; 4) smoking reduction,
especially during the healing period; 5) home care
instructions; and 6) where to call if adverse events
occur or questions arise. A brief discussion of post-
surgical management is listed in Table 3.
Role of the general practitioner
The general dentist plays a prominent role in peri-
odontal diagnosis and therapy. Most periodontitis is
initially diagnosed in the general dental office.
Whether or not the patient is referred depends on
numerous factors including the patient’s wishes and
the dentist’s inclination to treat or refer. Scaling and
root planing and surgical treatment is appropriate
in general practices. Many general practitioners limit
surgical treatment to areas of horizontal bone loss
where probing depths are less than 5 millimeters.
Vertical osseous defects and furcation involvements
of class II or greater are often referred to the peri-
odontist due to the wide array of treatment options
and the difficulty associated with some of these sur-
gical procedures used to treat these conditions. Dis-
Surgical periodontal therapy
based upon aesthetic profile ratio. C. Gingivoplasty.
D. 8 weeks postsurgically.
tal wedges, especially distal to second molars are
often referred for the same reasons. The following
surgical techniques are appropriate for use in gen-
eral practice:
Gingivectomy (Fig. 1)
This procedure is used to excise suprabony pockets
if there is sufficient attached gingiva, to reduce gingi-
val overgrowth/hyperplasia, and for aesthetic crown
lengthening in certain situations. Generally, this pro-
cedure should not be used when: 1) infrabony
pockets/defects are present; 2) osseous surgery is re-
quired; 3) there is inadequate attached gingiva; 4)
frena/muscle attachments interfere; and 5) long clin-
ical crowns will compromise aesthetics.
Modified Widman flap (Fig. 2)
This procedure, introduced by Ramfjord & Nissle,
was designed to remove the inflamed pocket wall,
provide access for root debridement, and preserve
the maximum amount of periodontal tissue (53). It
is indicated where aesthetics is a primary concern,
93
Wang & Greenwell

94

Fig. 2. A modified Widman flap was used to reduce peri-
odontal pockets around teeth .12–15 (buccal and palatal
view). A, B. Preoperative. C, D. Incision. E, F. Flap reflec-
especially in the maxillary anterior sextant. The
drawbacks include the inability to achieve pocket
elimination and healing with a long junctional epi-
thelium.
Open flap debridement
The objectives of this technique are to provide ac-
cess for root debridement, to achieve pocket reduc-
tion, and to permit maximum flap coverage of de-
vices used for regenerative procedures. A sulcular in-
cision is used instead of an inverse bevel incision.
Apically positioned flap without osseous
recontouring
The objectives of this procedure are to reduce
pockets by repositioning the flap apically, to provide
access for root preparation, and to preserve or in-
crease the zone of attached gingiva. An inverse bevel
incision is used.
Surgical periodontal therapy
tion. G, H. Suture. I, J. 1 week of healing. K, L. 8 weeks’
follow-up.
Crown lengthening (Fig. 3 and 4)
Surgical crown lengthening is an appropriate pro-
cedure to: 1) facilitate caries removal; 2) provide ad-
ditional restorative retention; 3) establish biological
width; 4) improve aesthetics in cases of altered pass-
ive eruption. This procedure should only be con-
sidered when the remaining root is supported by a
healthy periodontium and the post-surgery crown/
root ratio will be favorable.
Lateral pedicle flap for one tooth
This procedure was developed to cover exposed
roots, prevent root sensitivity and root caries. It
should be performed when there is: 1) isolated re-
cession; 2) an adequate band of keratinized gingiva
on the adjacent donor tooth; and 3) adequate ves-
tibular depth. Areas with multiple adjacent recession
sites or secondary frenal pull at the donor site should
be avoided.
95
Wang & Greenwell
Histological studies have shown the flap pro-
cedures described above tend to heal with a long
junctional epithelium and not a new connective
tissue attachment. Long junctional epithelium, how-
ever, has been shown to provide a stable therapeutic
outcome (6, 7, 57, 61).
Principles of periodontal surgery
Historically the aims of periodontal surgery were to
remove the soft tissue pocket wall and infected bone
and to eliminate the periodontal pocket. Currently,
96
Fig. 3. A crown-lengthening procedure (an apically posi-
tioned flap with osseous recontouring) was used to estab-
lish biological width and increase the retention for the
fractured tooth .3 palatal side. A. Presurgically. B. In-
cision. C. After osseous. D. Suture. E. 8 weeks of healing.
the goals of surgery are to: 1) gain access for root
preparation when nonsurgical methods are ineffec-
tive; 2) establish favorable gingival contours; 3) fa-
cilitate oral hygiene; 4) lengthen the clinical crown
to facilitating adequate restorative procedures; and
5) regain lost periodontium using regenerative ap-
proaches. To ensure proper healing atraumatic surgi-
cal principles should be followed including: 1) ade-
quate anesthesia; 2) surface disinfection; 3) sharp in-
strumentation; 4) minimal, atraumatic tissue
handling; 5) short operating time; 6) preventing un-
necessary contamination; and 7) proper suturing
and dressing, if indicated.

Fig. 4. A crown-lengthening procedure, utilizing the prin-
ciple of apically positioned flap, was performed from .7
to 10 to facilitate crown placement and aesthetic require-
Postsurgical complications
The risks of surgery include pain, swelling, blood
loss, reaction to medications, and infection. Other
potential risks include root sensitivity, flap slough-
ing, root resorption or ankylosis, some loss of al-
veolar crest, flap perforation, abscess formation, and
irregular gingival contours. The incidence of these
complications is low (1%) as reported by Pack &
Haber (46). They found only 8 infections in 884 oper-
Surgical periodontal therapy
ments. A–D. Surgical procedure. E. 4 weeks of postopera-
tive healing. F. Final restoration.
ations performed without antibiotics, while 1 infec-
tion was noted in 43 operations with antibiotic
coverage. Curtis et al. also compared the incidence
and severity of postoperative complications and
pain among flap surgery, osseous surgery and muco-
gingival surgery (9). They reported only 5.5% of 304
treated cases had experienced moderate to severe
pain. Moreover, they showed that osseous surgery
was three times more likely to cause bleeding, infec-
tion, swelling or adverse tissue changes than mucog-
97
Wang & Greenwell
ingival surgery. Mucogingival surgery was 3.5 times
more likely to cause pain than osseous surgery and
six times more likely than soft tissue surgery. If post-
operative complications occur, they should be man-
aged by prompt and appropriate treatment, which
may include control of bleeding, adequate anal-
gesics or antibiotics.
Future trends in periodontal surgery
Periodontal therapy has evolved from the days of
scaling and root planing and/or gingivectomy to cur-
rently include a wide array of sophisticated plastic
and regenerative procedures. Regeneration of oss-
eous and furcation defects became possible with the
advent of guided tissue regeneration techniques but
have not yet become predictable. As growth factor
therapy develops, regeneration will become predict-
able, and resection will likely disappear as a mode of
periodontal treatment. Root coverage, not possible
20 years ago, is now routine. The development of
new materials to eliminate the need for palatal do-
nor tissue will increase the frequency of these pro-
cedures and reduce the prevalence of recession in
aging patients. Thus, in the near future, periodontal
surgery will probably increase as a modality of ther-
apy; however, the goal of the procedures will be al-
most totally regenerative.
References
1. Ah MK, Johnson GK, Kaldahl WB, Patil KD, Kalkwarf KL.
The effect of smoking on the response to periodontal ther-
apy. J Clin Periodontol 1994: 21: 91–97.
2. Axelsson P, Lindhe J. Effect of controlled oral hygiene pro-
cedures on caries and periodontal disease in adults: results
after 6 years. J Clin Periodontol 1981: 8: 239–248.
3. Axelsson P, Lindhe J. The significance of maintenance care
in the treatment of periodontal disease. J Clin Periodontol
1981: 8: 281–294.
4. Becker BE, Becker W, Caffesse RG, Kerry GJ, Ochsenbein C,
Morrison EC. Three modalities of periodontal therapy. II. 5
year final results. J Dent Res 1990: 69(spec issue): 219.
5. Becker W, Becker BE, Ochsenbein C, Kerry G, Caffesse R,
Morrison EC, Prichard J. A longitudinal study comparing
scaling, osseous surgery and modified Widman procedures.
Results after one year. J Periodontol 1988: 59: 351–365.
6. Caton J, Nyman S. Histometric evaluation of periodontal
surgery. I. The modified Widman flap procedure. J Clin
Periodontol 1980: 7: 212–223.
7. Caton J, Zander HA. Osseous repair of an infrabony pocket
without new attachment of connective tissue. J Clin Peri-
odontol 1976: 3: 54–58.
8. Craft G. Predicting future bone loss using a new pro-
98
gression rate index for the diagnosis and monitoring of un-
treated periodontitis. Thesis. Louisville, KY: University of
Louisville, 1996.
9. Curtis JW, McLain JB, Hutchinson RA. The incidence and
severity of complications and pain following periodontal
surgery. J Periodontol 1985: 56: 597–601.
10. Hill RW, Ramfjord SP, Morrison EC, Appleberry EA, Caffesse
RG, Kerry GJ, Nissle RR. Four types of periodontal treat-
ment compared over two years. J Periodontol 1981: 52:
655–662.
11. Isidor F, Attström R, Karring T. Regeneration of alveolar
bone following surgical and nonsurgical periodontal treat-
ment. J Clin Periodontol 1985: 12: 687–696.
12. Isidor F, Karring T. Long term effect of surgical and nonsur-
gical periodontal treatment. A 5 year clinical study. J Peri-
odontal Res 1986: 21: 462–472.
13. Isidor F, Karring T, Attström R. The effect of root planing as
compared to that of surgical treatment. J Clin Periodontol
1984: 11: 669–681.
14. Jeffcoat M, Reddy M. Progression of probing attachment
loss in adult periodontitis. J Periodontol 1991: 62: 185–189.
15. Kaldahl WB, Johnson GK, Patil KD, Kalkwarf KL. Levels of
cigarette consumption and response to periodontal ther-
apy. J Periodontol 1996: 67: 675–681.
16. Kaldahl WB, Kalkwarf KL, Patil KD. A review of longitudinal
studies that compared periodontal therapies. J Periodontol
1993: 64: 243–253.
17. Kaldahl WB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE Jr.
Evaluation of four modalities of periodontal therapy. J Peri-
odontol 1988: 59: 783–793.
18. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP. Evaluation
of gingival suppuration and supragingival plaque following
4 modalities of periodontal therapy. J Clin Periodontol
1990: 17: 642–649.
19. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP. Responses
of four tooth and site groupings to periodontal therapy. J
Periodontol 1990: 61: 173–179.
20. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP. Relationship
of gingival bleeding, gingival suppuration, and supragin-
gival plaque to attachment loss. J Periodontol 1990: 61:
347–351.
21. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK.
Long-term evaluation of periodontal therapy. II. Incidence
of sites breaking down. J Periodontol 1996: 67: 103–108.
22. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK.
Long-term evaluation of periodontal therapy. I. Response
to 4 therapeutic modalities. J Periodontol 1996: 67: 93–102.
23. Kalkwarf KL, Kaldahl WB, Patil KD. Evaluation of furcation
region response to periodontal therapy. J Periodontol 1988:
59: 794–804.
24. Kalkwarf KL, Kaldahl WB, Patil KD. Patient preference re-
garding 4 types of periodontal therapy following 3 years of
maintenance follow-up. J Clin Periodontol 1992: 19: 788–
793.
25. Kalkwarf KL, Kaldahl WB, Patil KD, Molvar MP. Evaluation
of gingival bleeding following 4 types of periodontal ther-
apy. J Clin Periodontol 1989: 16: 601–608.
26. Kerry G, Becker W, Morrison E, Ochsenbein B, Becker B,
Caffesse R. Three modalities of periodontal therapy. I. 5
year final results. J Dent Res 1990: 69(spec issue): 246.
27. Knowles JW, Burgett F, Morrison E, Nissle R, Ramfjord S.
Comparison of results following three modalities of peri-
odontal therapy related to tooth type and initial pocket
depth. J Clin Periodontol 1980: 7: 32–47.

28. Knowles JW, Burgett FG, Nissle RR, Shick RA, Morrison EC,
Ramfjord SP. Results of periodontal treatment related to
pocket depth and attachment level. Eight years. J Peri-
odontol 1979: 50: 225–233.
29. Lindhe J, Nyman S. The effect of plaque control and surgi-
cal pocket elimination on the establishment and mainten-
ance of periodontal health: a longitudinal study in cases of
advanced disease. J Clin Periodontol 1975: 2: 67–79.
30. Lindhe J, Nyman S. Alterations of the position of the mar-
ginal soft tissue following periodontal surgery. J Clin Peri-
odontol 1980: 7: 525–530.
31. Lindhe J, Nyman S. Long-term maintenance of patients
treated for advanced periodontal disease. J Clin Peri-
odontol 1984: 11: 504–514.
32. Lindhe J, Socransky S, Nyman S, Westfelt E, Haffajee A. Ef-
fect of age on healing following periodontal surgery. J Clin
Periodontol 1985: 12: 774–787.
33. Lindhe J, Socransky SS, Nyman S, Haffajee A, Westfelt E.
‘‘Critical probing depths’’ in periodontal therapy. J Clin
Periodontol 1982: 9: 323–336.
34. Lindhe J, Westfelt E, Nyman S, Socransky S, Haffajee A.
Long term effect of surgical/non-surgical treatment of peri-
odontal disease. J Clin Periodontol 1984: 11: 448–458.
35. Lindhe J, Westfelt E, Nyman S, Socransky S, Heijl L, Brat-
thall G. Healing following surgical/non-surgical treatment
of periodontal disease. A clinical study. J Clin Periodontol
1982: 9: 115–128.
36. Löe H, Anerud A, Boysen H. The natural history of peri-
odontal disease in man: prevalence, severity, and extent of
gingival recession. J Periodontol 1992: 63: 489–495.
37. Löe H, Anerud A, Boysen H, Morrison E. Natural history of
periodontal disease in man. Rapid, moderate and no loss
of attachment in Sri Lankan laborers 14 to 46 years of age.
J Clin Periodontol 1986: 13: 431–440.
38. Löe H, Anerud A, Boysen H, Smith M. The natural history
of periodontal disease in man. Study design and baseline
data. J Periodontal Res 1978: 13: 550–562.
39. Löe H, Anerud A, Boysen H, Smith M. The natural history
of periodontal disease in man. The rate of periodontal de-
struction before 40 years of age. J Periodontol 1978: 49:
607–620.
40. Löe H, Anerud A, Boysen H, Smith M. The natural history
of periodontal disease in man: Tooth mortality rates before
40 years of age. J Periodontal Res 1978: 13: 563–572.
41. Machtei E, Norderyd J, Koch G, Dunford R, Grossi S, Genco
R. The rate of periodontal attachment loss in subjects with
established periodontitis. J Periodontol 1993: 64: 713–718.
42. Nyman S, Lindhe J. A longitudinal study of combined peri-
odontal and prosthodontic treatment of patients with ad-
vanced periodontal disease. J Periodontol 1979: 50: 163–169.
43. Nyman S, Lindhe J, Rosling B. Periodontal surgery in plaque
infected dentitions. J Clin Periodontol 1977: 4: 240–249.
44. Nyman S, Rosling B, Lindhe J. Effect of professional tooth
cleaning on healing after periodontal surgery. J Clin Peri-
odontol 1975: 2: 80–86.
45. Olsen CT, Ammons WF, van Belle G. A longitudinal study
comparing apically repositioned flaps with and without
Surgical periodontal therapy
osseous surgery. Int J Periodontics Restorative Dent 1985:
5: 10–33.
46. Pack PD, Haber J. The incidence of clinical infection after
periodontal surgery. A retrospective study. J Periodontol
1983: 54: 441–443.
47. Pihlstrom BL, McHugh RB, Oliphant TH, Ortiz-Campos C.
Comparison of surgical and nonsurgical treatment of peri-
odontal disease. A review of current studies and additional
results after 61⁄2 years. J Clin Periodontol 1983: 10: 524–541.
48. Pihlstrom BL, Oliphant TH, McHugh RB. Molar and non-
molar teeth compared over 61⁄2 years following two
methods of periodontal therapy. J Periodontol 1984: 55:
499–504.
49. Pihlstrom BL, Ortiz-Campos C, McHugh RB. A randomized
four year study of periodontal therapy. J Periodontol 1981:
52: 227–242.
50. Ramfjord SP, Knowles JW, Nissle RR, Burgett FG, Shick RA.
Results following three modalities of periodontal therapy. J
Periodontol 1975: 46: 522–526.
51. Ramfjord SP, Knowles JW, Nissle RR, Shick RA, Burgett FG.
Longitudinal study of periodontal therapy. J Periodontol
1973: 44: 66–77.
52. Ramfjord SP, Morrison EC, Burgett FG, Nissle RR, Shick RA,
Zann GJ, Knowles JW. Oral hygiene and maintenance of
periodontal support. J Periodontol 1982: 53: 26–30.
53. Ramfjord SP, Nissle RR. The modified Widman flap. J Peri-
odontol 1974: 45: 601–607.
54. Ramfjord SP, Nissle RR, Shick RA, Cooper H Jr. Subgingival
curettage versus surgical elimination of periodontal
pockets. J Periodontol 1968: 39: 167–175.
55. Rosling B, Nyman S, Lindhe J, Jern B. The healing potential
of the periodontal tissues following different techniques of
periodontal surgery in plaque-free dentitions. A 2-year
clinical study. J Clin Periodontol 1976: 3: 233–250.
56. Smith DH, Ammons WF Jr, Van Belle G. A longitudinal
study of periodontal status comparing osseous recon-
touring with flap curettage. I. Results after 6 months. J Peri-
odontol 1980: 51: 367–375.
57. Steiner SS, Crigger M, Egelberg J. Connective tissue re-
generation to periodontally diseased teeth. II. Histologic
observations of cases following replaced flap surgery. J Peri-
odontal Res 1981: 16: 109–116.
58. Wang A. Predicting future bone loss using a new pro-
gression rate index for the diagnosis and monitoring of
treated periodontitis. Thesis. Louisville, KY: University of
Louisville, 1996: 140.
59. Westfelt E, Nyman S, Socransky S, Lindhe J. Significance of
frequency of professional toothcleaning for healing follow-
ing periodontal surgery. J Clin Periodontol 1983: 10: 148–
156.
60. Westfelt E, Nyman S, Socransky S, Lindhe J. Significance of
frequency of professional tooth cleaning for healing follow-
ing periodontal surgery. J Clin Periodontol 1983: 10: 148–
156.
61. Yukna RA. A clinical and histologic study of healing follow-
ing the excisional new attachment procedure in rhesus
monkeys. J Periodontol 1976: 47: 701–709.
99