The Surgical Phase of Therapy

CARRANZA’S CLINICAL PERIODONTOLOGY 11th edition

Ch 52( pages 511-515)
 Objective

 To understand what are the indications of periodontal surgery

 To identify the criteria for selection of different surgical procedures

 Explain the different results of pocket therapy

 Mention therapotic modalities for

Start to plan I.

II.

III.

IV.
 Main objectives of the Surgical Phase:

Improvement of the prognosis of the teeth and their

replacement.
Improvement esthetics
 Periodontal Surgery

Correction of Anatomic/Morphologic
Pocket Reduction Surgery Defects

Resective Plastic surgery techniques

Regenerative Esthetic surgery

Preprosthetic techniques

Placement of dental implants

1
1.Pocket reduction surgery
Resective (Gingivectomy, apically displaced flap and undisplaced flap with
or without osseous resection)
Regenerative (flaps with grafts, membranes, etc.)

2
 Pocket reduction surgery

To Eliminate of the pathologic changes in the pocket walls

To create a stable, easily maintainable state;
To promote periodontal regeneration
2.Correction of anatomic/morphologic defects
Plastic surgery )widen attached gingiva, free gingival grafts, and other techniques, etc.)
Esthetic surgery (root coverage, re-creation of gingival papillae)
Preprosthetic techniques (crown lengthening, ridge augmentation, vestibular deepening)
3
Placement of Implants (guided bone regeneration, sinus grafts)
Periodontal pocket
 Difficulties

• Increased pocket depth

• The presence of irregularities on the root surface
• The presence of furcation involvements.
• Unaccessible tooth (molar, premolar)
 Results of Pocket Therapy
•Active pocket
•Underlying bone is being lost, loss of attachment, clinically (bleeding spon. Or BOP),
pain.
•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 reduces, is the result of the edematous and inflammatory
component of the pocket wall.
•Inactive pocket:
•inactive pockets can heal with a long junctional epithelium, However, the chance of
recurrence and reformation of the original pocket is always present because the
epithelial union to the tooth is weak.
Results of Pocket Therapy

4
 Pocket Elimination Vs Pocket Maintenance

after surgical therapy, pockets can be maintained in a healthy state and without

radiographic evidence of advancing bone loss by maintenance visits consisting of SRP

with OH reinforcement performed at regular intervals of 3 months or less.

Maintenance phase (close monitoring of both level of attachment and pocket depth,

together with the other clinical variables (bleeding, exudation, or tooth mobility)
Which is important, CAL or PD? Why?
Scaling and root-planing procedures alone

<2.9 mm pocket > 2.9 mm pocket

loss of attachment gain of attachment

modified Widman flap

<4.2 mm pocket > 4.2 mm pocket

loss of attachment gain of attachment

 Reevaluation After Phase I Therapy

Phase I therapy should have solved many, if not all, of the problems on the tooth surface

All patients should be treated initially with SRP and the final decision on the need for periodontal surgery
should be made only after thorough evaluation of the effects of the phase I therapy

No less than 1 to 3 months and sometimes as much as 9 months after the completion
of Phase I therapy.

Reevaluation visit )reprobing of the depth, presence of calculus, root caries, defective
restorations, signs of persistent inflammation (
Surgical pocket therapy
Criteria for selection of surgical technique: based on the clinical
findings
1. Soft tissue pocket wall
2. Tooth surface
3. Underlying bone
4. Attached gingiva
Zone 1: The Soft Tissue Wall
The morphologic features, thickness, and topography of the soft tissue pocket wall and
persistence of inflammatory changes in it should be determined.

Zone 2: The Tooth Surface

The presence of deposits and alteration on the cementum surface and the accessibility
of root surface to instrumentation* should be identified .
• Zone 3: The underlying Bone
• The shape and height of the alveolar bone should be established by careful probing and
clinical and radiographic examination. Bony craters, horizontal or angular bone losses,
and other bone deformities are important criteria for the selection of the treatment
technique.

• Zone 4: The Attached Gingiva

The presence or absence of an adequate band of attached gingiva is a factor to be
considered when selecting the pocket treatment method. An inadequate attached gingiva
may be due to a high frenal 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

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
 Methods of pocket therapy
i. New attachment techniques (regenerative procedures)*, GTR,GBR, Membrane

ii. Removal of the pocket wall

• Retraction or shrinkage, after SRP
• Surgical remove (modified Widman Flap, Gingivectomy, undisplaced flap, apically displaced flap)

iii. Removal of the tooth side of the pocket(hemisection and root resection
 Criteria for Method Selection
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.
 Criteria for Method Selection

5. Patient cooperation, including ability to perform effective oral hygiene. Smokers must be willing to stop
their habit

6. Age and general health of the patient.

7. Overall diagnosis of the case: various types of gingival enlargement and types of periodontitis (e.g.,
chronic periodontitis, localized aggressive periodontitis, generalized aggressive periodontitis).

8. Esthetic considerations.

9. Previous periodontal treatments.

 Therapy for Gingival Pockets
Two factors are taken into consideration
Character of the pocket wall
Pocket accessibility

Edematous SRP

Pocket Wall

-Gingivectomy= small defect

Fibrotic -Flap technique =sever large
enlargement
 Therapy for Slight (mild )Periodontitis
 Pockets are shallow to moderate

 Usually SRP is sufficient

 Recurrence of incipient periodontitis may require a surgical

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

The anterior teeth are important esthetically- hazard to root exposure

Anterior teeth offer two main advantages to a conservative approach:

(1) they are all single rooted and easily accessible

(2) patient compliance and care in plaque control are easier to attain

Scaling and root planing are the technique of choice

• When surgical technique may be necessary because of the need for
Improved accessibility for root planing or regenerative surgery of
osseous defects

The papilla preservation flap is the first choice when a surgical approach
is needed
In the case ( too close interproximally) sulcular incision flap
Therapy for Moderate-to-Severe Periodontitis in Posterior Area

• Tx in posterior usually show no esthetic problem but frequently involves

difficult accessibility.
• Papilla preservation flap is the technique of choice
• 2nd and 3rd choices are the sulcular flap and the modified Widman flap
 Summary

 The surgical phase consists of techniques performed for pocket therapy and for the correction of
related morphologic problems.

 Surgical phase are not directed to treat disease but aim to alter the gingival and mucosal tissues to
correct defects that may predispose to disease.

 Prior to any surgical procedure, every patient must undergo the initial phase (nonsurgical) of therapy
including SRP and reevaluation phase

 Phase II therapy is used to treat residual periodontal pockets and bone defects remaining after Phase I
therapy

 When esthetics are the primary consideration, papilla preservation flap is technique of choice in the
case when esthetics are not the primary consideration, the modified Widman flap can be chosen
 Quiz

1. Scaling and root-planning procedures can lead to attachment loss when the
probing depth is:
a) Greater than 4.2
b) Greater than 2.9
c) Less than 2.9
d) Equals to 4.2

2. in cases of marked gingival enlargement (e.g., severe phenytoin enlargement) what is

the surgical method you will use?

Gingivectomy or flap surgery

Any question?

Thank You!!