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Periodontology *4*

DR. RAWAND SAMY MOHAMED ABU NAHLA

ORAL MEDICINE, PERIODONTOLOGY&ORAL
RADIOLOGY DEPARTMENT.
DR. HAYDAR.A.SHAFY FACULTY OF DENTISTRY.
EL AZHAR UNIVERSITY.
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Lecture 4
Phase II Periodontal
Therapy
Introduction 3

 Although advances in root instrumentation techniques and

antibiotic therapy have improved the available treatments
for periodontal infections, periodontal surgery will
continue to be a necessary procedure in the foreseeable
future.
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Rationale for Periodontal Surgery
 Periodontal surgery is indicated to control the progression of
periodontal destruction and attachment loss when more
conservative nonsurgical treatments are not sufficient.

 Periodontal surgery involves techniques that intentionally cut

into soft tissues to control disease or change the size and
shape of tissues.
Indications for periodontal surgery:
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1. Areas with irregular bony contours or deep craters.

2. Pockets on teeth in which a complete removal of
root irritants is not considered clinically possible.
(molars).
3. In cases of grade II or III furcation involvement.
4. Infrabony pockets in distal areas of last molars.
5. Persistent inflammation in areas with moderate to
deep pockets may require a surgical approach.
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Contraindications: 9
1. Patients who do not exhibit good plaque control.
2. Uncontrolled or progressive systemic disease
(uncontrolled diabetics, leukemia ect.).
3. Patients taking large doses of corticosteriods may
have reduced resistance to stress associated with
surgery ..
4. Patients with imminent terminal disease who are
debilitated are not candidates for surgery.
Advantages of Periodontal Surgery:10
1. The major benefit and indication for periodontal surgery is
to gain access to root surfaces for scaling and root
planning.
2. Surgery also improves access for patient control of plaque
biofilm.
3. Improving access to periodontal abscesses
4. Exposing root surfaces for restorative dentistry
5. Altering the position of the gingival margin to improve
patient esthetics
Disadvantages of Periodontal Surgery:
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1. A number of disadvantages and contraindications to
periodontal surgery exist:
 Health status or age of the patient

 Specific limitations for each of the periodontal surgical

procedures

2. From the patient’s perspective, the disadvantages of

surgery are time, cost, esthetics, and discomfort.
General Considerations 12for
Periodontal Surgery:
Probing pocket depth
Amount of bone loss
Importance of the tooth to function
Esthetics
Patient’s level of plaque biofilm control
Patient’s general health
1-Probing Pocket Depth 13

 The pocket is coronally bound by the gingival margin on

one side by the root surface, on the other side
by the epithelial surface, and at the base by the junctional
epithelium.

 Scaling and root planning are effective in controlling

periodontal disease to probing depths of approximately 4
mm.
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 Pockets deeper than 5 mm are difficult to
instrument and often remain infected after the
best dental hygiene care.

 Pockets with probing depths greater than 9

mm suggest extreme loss of attachment, which
makes the long-term prognosis for retaining
the affected teeth poor.
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Probing pocket depth is not always equal to clinical
attachment loss.

 The probing depth is the measurement from the crest of the

gingival margin to the base of the pocket.

 Attachment loss is measured from the cementoenamel

junction to the base of the pocket.
 If the gingival margin is on the root surface, as 16
when
recession has occurred, then the attachment loss is greater
than the probing depth.

 If the gingival margin is on the enamel surface of

the crown, as in gingival hypertrophy, then the attachment
loss is less than the probing depth.

 Attachment loss represents bone destruction, which in

turn affects the long-term prognosis of the tooth.
2-Bone Loss 17

 The base of the periodontal pocket is not at the level of the

crest of the alveolar bone.

 Usually, 1 to 2 mm of connective tissue attachment

covered by epithelium is between the probing depth and
the alveolar bone.

 This area is termed the biologic width and must

be considered when estimating the amount of attachment
remaining on a periodontally involved tooth.
 Bone loss caused by periodontal disease results in
osseous defects. 18
 These defects may occur in either a horizontal
dimension or a vertical dimension.
 A defect in the horizontal dimension occurs when
bone resorption is equal on the mesial and distal
surfaces of the teeth.
 A defect in the vertical dimension occurs when bone
resorption is unequal around the teeth.
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Horizontal bone loss is demonstrated in the
following figure.
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Vertical bone loss is demonstrated in the following figure.
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Pockets that are coronal to horizontal bone loss are
often called suprabony pockets.

 Pockets that extend apically beyond the crest of the

bone are called infrabony pockets.

 Vertical bone loss may also occur in a variety of

configurations that are usually described by the
number of bony walls remaining.

 When all of the walls of the osseous defect are within

the bone housing, the term is intrabony pocket.
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The amount of bone remaining around a tooth is an important
consideration in the decision to perform periodontal surgery.

 Large amounts of bone supporting a tooth may allow the

clinician to take a wait-and-see approach to postpone or avoid
periodontal surgery.

 If the amount of bone is already reduced, then delaying

periodontal surgery may radically decrease the prognosis for
the tooth.
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 Periodontal surgery that includes modification of 28
the
bone level or shape is called osseous surgery.

 Generally, osseous surgery is indicated when at least

one half of the bone support remains.

 If too much bone has been lost, then osseous surgery

becomes a less-attractive option.
Bone loss is demonstrated in the following 29
figure.
3-Value of the Tooth 30

 Not all teeth have equal value when periodontal surgery is

considered.
 Some teeth cannot be saved, and others are not worth
saving.
 Third molars, for example, may be extracted without
altering the patient’s chewing pattern.
 In contrast, an abutment tooth for a bridge is important to
the patient, and every attempt is made to save that
particular tooth.
4-Personal Plaque Biofilm Control
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of the Patient
 Every patient should have established the best possible
supragingival plaque biofilm control before surgical therapy
is initiated.

 If plaque biofilm control is poor, then surgical intervention

should be postponed or abandoned because it will not
prevent the recurrence of periodontal infection and the
possible loss of teeth.
5-Age and Health of the Patient 32

 Patients who are in poor health are not good candidates

for periodontal surgery.

 However, the periodontal disease may contribute

to the poor general physical condition, and the
periodontist may decide, in concert with the patient’s
physician, that periodontal surgery is appropriate.
Age, in itself, is not a contraindication to surgery. 33
 Patients with pocket depths exceeding 5 mm and
one half their supporting bone lost who are relatively
young (younger than 30 years of age) have an
aggressive form of periodontal disease—
 Surgery is strongly indicated.
 Older patients (older than 60 years of age) with the
same clinical conditions usually have a more slowly
progressing disease—
 Surgery may be less critical for these patients.
6-Patient Preference 34

 Some patients are reluctant to have periodontal surgery.

 These patients need to know the ramifications of delaying

periodontal surgery and the possible effects on the long-
term prognosis of their teeth.

 Patients who decide not to have surgery must be willing to

undergo more frequent periodontal maintenance
procedures and perform more complex subgingival plaque
control in an effort to slow the progression of their disease.
Types of Periodontal Surgery 35

 Lang and Löe classified periodontal surgical

procedures into five basic categories—procedures
for:
1. Pocket reduction or elimination

2. Access to the root surface

3. Treatment of osseous defects

4. Correcting mucogingival defects

5. New attachment
Classification of periodontal 36

surgeries:
I- Gingival surgical procedures:
A-Curettage:

1- Open curettage and root planning.

2- Subgingival curettage(closed curettage).

3- Excisional new attachment procedures(ENAP)

4-Chemical curettage.
B-Gingivectomy. 37

C-Gingivoplasty.

D-Tuberosity and retromolar reduction.

1-Wedges.

2-Gingival resection.
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II-Periodontal flaps and alveolar osseous surgical
procedures:
A-Modified Widman flap.

B-Repositioned Flap:

1- Apically.

2-Laterally.

3-Coronally.
C-Osseous surgery: 39
1-Osteoplasty.
2-Osteotomy.
3-Grafting (regeneration Procedures).
III-Mucogingival surgical Procedures:
A-Frenotomy and frenectomy.
B-Vestioplasty.
C-Grafts:
1-Free gingival grafts.
2-Coronal repositioning after gingival graft.
3-subepithelial connective tissue graft.
IV-Furcation treatment: 40
A-Odontoplasty.
B-Root tunneling.
C-Root resection and hemisection.
D- Regenerative procedures.
V-Combined surgical procedures:
A-Flap and osseous surgery.
B-Flap and bone graft.
C-Flap and regenerative procedures.
D-Flap and wedge
1-Procedures for Pocket Reduction or
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Elimination
 The goal of pocket reduction surgery is to reduce
periodontal pocket depth by removing soft tissues
to a level at which plaque biofilm control and maintenance
procedures are effective.
 This level does not usually exceed 3 to 4 mm in depth.

 Methods for pocket reduction include:

1. Excisional periodontal surgery (gingivectomy)
2. Incisional periodontal surgery (flap)
1-Excisional Periodontal Surgery42
 Excisional periodontal surgery removes the excess tissue from
the wall of the periodontal pocket.
 This procedure is useful for the rapid reduction of gingival
pockets.
 The most basic excisional surgical procedures are termed:
1. Gingivectomy—excision of the gingiva
2. Gingivoplasty—surgical reshaping of the gingival tissues
 Gingivectomy,Gingivoplasty 43

 Gingivectomy: Excision of soft tissue wall of periodontal

pocket.

 Gingivoplasty: To restore gingival contours.

 Basic rational is pocket elimination to allow access for root

instrumentation.

 External bevel incision is done to remove excess gingiva and

healing is by secondary intention.
Indications for Excisional Periodontal 44
Surgery
 The presence of deep periodontal pockets with
thick fibrous tissue is the major indication for
gingivectomy.
 Drug-induced gingival hyperplasia is treated by
this form of excisional surgery.
Other indications include:
 Familial gingival hyperplasia
 Localized crown lengthening for restorative
dentistry
Procedure for Excisional Periodontal Surgery
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1. During gingivectomy, the surgeon marks the bottom of the
pockets with a periodontal probe or Krane Kaplen pocket
markting forceps.

2. Primary incision the gingiva is excised with Kirkland knives

at a 45-degree angle to the gingival surface, keeping the
incision within the keratinized gingiva.
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3. Secondry incision to separate interproximal soft tissues by
Orban Knife or Buck Knife.
4. After the removal of a majority of the gingival tissues, the
underlying exposed connective tissue is refined and trimmed
with knives, burs, or other instruments
5. Exposed root surfaces are cleaned and smoothed as necessary
with curettes.
6. The surgical area is packed with a periodontal dressing to
reduce postoperative discomfort and to protect the underlying
connective tissue.
7. The gingival epithelium is reestablished approximately 2 weeks
after surgery.
Excisional Periodontal 47

Surgery
 The gingivectomy
procedure is
demonstrated in the
following figure.
Sli
de
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 Sli
de
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1-befor surgery 2-Bleeding pointsmarks

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de
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1-Befor surgery 2-Bleeding marks

3-gingivectomy
 Sli
de
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4-periodontal pack

5-After healing.
Contraindications for Excisional Periodontal Surgery
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 The procedure does not permit access to infrabony pockets.

 Healing is relatively slow.

 Postoperative discomfort is significant.

 The anatomy may prevent incising the tissues at the proper

angle.
 Minimal width of attached gingiva may prevent keeping the
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incision within the keratinized tissue.

 The procedure exposes root surfaces, which may:

 Result in unacceptable esthetics

 Leave the teeth sensitive to heat and cold

 Leave the teeth susceptible to root caries

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2-Incisional Periodontal Surgery55

 Incisional surgery is called periodontal flap surgery

or simply flap surgery.
 The tissues are pushed away from the underlying tooth
roots and alveolar bone.
 The alveolar bone may be resected or modified during
the surgical procedure.
 The incisional technique for pocket reduction with flap
surgery is called the apically positioned flap.
Indications for Incisional Periodontal 56
Surgery
 Deepened periodontal pockets, which are
contraindicated for gingivectomy, are the
primary indication for incisional surgery.
 Suprabony pockets are often best treated
by flap surgery.
Procedure for Incisional 57
Periodontal
Surgery
1. After the anesthesia is administered, the pockets are
probed to determine their depths, and the bony
contours are “sounded” by pushing the periodontal
probe through the tissues until the crest of the
alveolar bone is detected.
2. The surgeon uses this information to design the
incision around the necks of the teeth to retain as
much tissue as possible while allowing for pocket
reduction.
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Flaps of gingiva are pushed away from the alveolar bone and
teeth, usually on the buccal and lingual surfaces, with a
periosteal elevator.

 Infected epithelium, connective tissue, and granulation

tissues are removed with curettes, scalers, and ultrasonic
instruments.

 Residual calculus is cleaned, and roots are smoothed as

necessary.

 The flaps are then readapted at a more apical level to reduce

the pockets.
 The surgeon may reduce the bony ledges or
59may
further elevate the flaps past the mucogingival
junction to position it for proper adaptation.

 The surgical wound is closed by suturing the

flaps together in the interproximal papillae.

A periodontal dressing may be applied to help

adapt the gingiva to the alveolar bone.
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Contraindications for Incisional 62
Periodontal
Surgery
1. The gingival tissues must be wide and thick
enough to allow for proper incision.
2. Apically positioned gingival flaps expose root
surfaces.
3. Positioning may have to be altered for esthetics or
for patients who are prone to caries.
 Fluoride mouth rinses should be recommended to
reduce the potential for root caries.
 Special 63
modifications of pocket reduction
surgery include combinations of incisional and
excisional techniques, such as distal wedge
surgery and internal beveled gingivectomy.

 These techniques are indicated in specific areas,

such as the palatal tuberosity region or where
tissues are thick and not easily managed by one
method alone.
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 The distal wedge procedure is demonstrated in the
following figure. 69
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Figure .A typical series of periodontal surgical instruments, divided
into two cassettes. A, From left, Mirrors, explorer, probe, series 71
of curettes, needle holder, rongeurs, and scissors.

A
B, From left, Series of chisels, Kirkland knife, Orban knife, scalpel handles
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with surgical blades (nos. 15C, 15, and 12D), periosteal elevators, spatula,
tissue forceps, cheek retractors, mallet, and sharpening stone.

B
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Figure . Gingivectomy knives. A,

Kirkland knife. B, Orban
interdental knife.
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Figure .Surgical blades. Top to

bottom, Nos. 15, 12D, and
15C. These blades are disposable.
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A B

C D

Figure . Preparing the surgical pack (Coe-Pak). A, Equal lengths of the two pastes are placed on a
paper pad. B, The pastes are mixed with a wooden tongue depressor for 2 or 3 minutes until, C,
the paste loses its tackiness. D, The mixed paste is placed in a paper cup of water at room
temperature. With lubricated fingers, is then rolled into cylinders and placed on the surgical
wound.
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Thank you