6 Surgical Periodontal Therapy

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Lecturer: Levkiv Mariana O.

Department of Therapeutic Dentistry

TSMU


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Periodontal therapy is directed at disease prevention,slowing or arresting disease progression, regenerating lost of

periodontium, and maintaining achieved therapeutic objectives.A variety of different treatment techniques have been used

including subgingival curettage, gingivectomy, modifiedWidman flap, and full- or split-thickness flap procedureswith or without osseous recontouring. The best surgical

approach remains controversial, although the results oflongitudinal clinical trials has highlighted the advantages and

disadvantages of each technique.


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Curettage, scaling and root planing and modifiedWidman flap

produced slightly better attachment level results, while pocket

elimination procedures gave the greatest probing depthreduction.

Surgical techniques included: gingivectomy, modified Widman

flap with and without osseous recontouring, and apically

positioned flap with and without osseous recontouring. Alltechniques halted loss of attachment, but the greatest gain of

attachment was achieved when osseous resection was avoided

and soft tissue was sutured to completely cover alveolar bone.

No study to date has shown that plaque is the cause of

periodontitis, but these studies certainly demonstrated thatwith no plaque there is no disease progression.


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Indications for periodontal surgery

Nonsurgical therapy is performed prior to surgical treatment for

periodontitis. Surgery is indicated where nonsurgical methods fail.

In general, the success of nonsurgical treatment should be

assessed following scaling and root planing but prior to the

administration of antimicrobial agents or antibiotics.

These medications tend to reduce inflammation and obscure sites

where scaling and root planing has failed to resolve disease.

Pocket reduction or elimination is not required in sites that

respond to nonsurgical therapy and remain stable during

maintenance. When surgery is required, however, shallower

probing depths may be an appropriate goal to facilitatemaintenance therapy and reduce the incidence of recurrence.


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*Improved visualization of the root surface;

*More accurate determination of prognosis;

*Improved pocket reduction or elimination;

*Improved regeneration of lost periodontalstructures;

*An improved environment for restorative

dentistry;

*Improved access for oral hygiene and supportive

periodontal treatment.


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This procedure is used to excise suprabony pockets if there is sufficient

attached gingiva, to reduce gingival overgrowth/hyperplasia, and for

aesthetic crown lengthening in certain situations. Generally, this procedure

should not be used when:

1) Infrabony pockets/defects are present;

2) osseous surgery is required;

3) there is inadequate attached gingiva;

4) frena/muscle attachments interfere;

5) and long clinical crowns will compromise aesthetics.


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A gingivectomy and gingivoplasty was used to correct

gingival aberrations

A. Preoperative. B. Gingivectomy based upon aesthetic profile ratio.


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C. Gingivoplasty. D. 8 weeks postsurgically.


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*

*The word curettage is used in periodontics to mean scrapingof the gingival wall of a periodontal pocket to removeinflamed soft tissues.

*Curettage removes the soft tissue lining of the periodontalpockets in order to completely eliminate bacteria and

diseased tissue. It may be used along with scaling and rootplaning, but achieves a deeper and more completecleaning. Evidence indicates, however, that it does notcontribute any additional benefits beyond simple scalingand planing.

*Inadvertant curettage:Some degree of curettage doneunintentionally when scaling and root planing is performed.


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Presurgical curettage: used in patients whose treatment plans

include strong evidence that a surgical phase will be used.

Definitive curettage: No other therapy will be required or used.

Gracey Curettes: Used for eliminating

the Soft Tissue Wall of the

Periodontal PocketRATIONALE

Accomplishes removal of chronically inflamed granulation tissue

in the lateral wall of periodontal pocket.

Apart from the usual components of angioblastic and fibroblasticproliferation in granulation tissue, may also contain pieces of

dislodged calculus and bacterial colonies.


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INDICATIONS

*Curettage can be performed in moderately deep infrabonypockets located in accessible areas where a type of closedsurgery is deemed advisable.

*Done to reduce inflammation prior to pocket elimination usingother methods or in patients in whom surgical techniques arecontraindicated

*Shrinkage of localized areas of gingiva, particularly interdentalpapillae which are bulbous and lead to plaque retention and

accumulation

*Curettage is frequently performed on recall visits as a method ofmaintenance treatment for areas of recurrent infection.

CONTRAINDICATIONS

*Presence of acute infection

*Fibrous epithelial enlargement of gingiva as in phenytoinhyperplasia

*Frenal pull on gingival margin

*Extension of base of pocket apical to mucogingival junction.


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PROCEDURE

*Basic technique-curette is selected so that the cutting edge

will be against the tissue.

*Instrument is inserted so as to engage the inner lining of

pocket wall and is carried along the soft tissue

*Pocket wall maybe supported by gentle finger pressure on

the external surface.


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Also it is recommended while conducting closed curettage, torinse the periodontal pocket with antiseptic solutions. Such

procedure is called one-time curettage. Antiseptics thatcan be used:Chlorhecsidine 0,2%, peroxide hydrogeny 0,3%,Chloramini 0,5%.


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*Caustic Drugs: To induce a chemical curettage of thelateral wall of the pocket

*Drugs such as sodium sulfide, alkaline sodium hypochloritesolution(antiformin) and phenol were used.

*The extent of tissue destruction with these drugs cannotbe controlled and they may be increase rather thanreduce the amount of tissue to be removed by enzymes

and phagocytes.*LASERSLaser curettage in suprabony pockets where

osseous surgery is not required.

*When performed with mechanical root instrumentation, itis considerably less invasive than traditional flap surgery.

*Due to small size of fiber(ie)tip diameter,Nd:YAG laser hasbeen suggested as a good candidate for gingivalcurettage.


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TISSUE RESPONSE TO CURETTAGE

*Reversal of all signs of gingival inflammation.

*Shrinkage, resolution of oedema and exudation.

*Morphologic features in gingiva and mucosa are delineated

more clearly after inflammation has been resolved.

*Exuberant granulation tissue rarely present postoperatively.

*Gingiva is firm to the scalpel and is of good texture to bebeveled or split as required.


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HEALING AFTER CURETTAGE

*Blood clot fills the gingival sulcus which is totally or

partially devoid of epithelal lining.

*Hemorrhage present in tissues, abundant PMNLs apper

shortly on wound surface.

*Restoration and epithelialisation of sulcus generally

requires from 2-7days.

*Immature collagen fibres appear in 21days.

*Zander and Waerhaug et al reported that resulted in

formation of long junctional epithileum.


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CLINICAL APPEARANCE

*Gingiva appears haemorrhage and bright red.

*After 1 week, gingiva appears reduced in height owing to an apical

shift in positon of gingival margin*After 2 weeks,with proper oral hygiene by patient, normal

consistency and color of gingiva are attained and gingival margin welladapted to the tooth.

*GINGIVAL CURETTAGE RELEVANCE

*Gingival curettage and debridement of soft tissue wall of the pocketas an adjunct to SRP seems to offer no advantage in the initialhealing response over SRP alone.

*Removal vs non removal of granulation tissue during flap surgery andnon surgical therapy (SRP) was studied by Lindhe & Nyman (1985).There results failed to show an advantage of granulation tissueremoval.

*Studies provide convincing evidence that SRP alone produce resultsclinically equivalent to curettage plus SRP.


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*The various methods used for epithelial removal show that

they have no advantage over mechanical instrumentation

with curette.

*Therefore gingival curettage by whatever method performedshould be considered as a procedure that has no additional

benefit to SRP alone in treatment of chronic periodontitis.


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Comparison between the results obtained in the initial

preparation of the periodontal treatment such as oral

hygiene and scaling and root planing and that of same

procedure supplement by curettage, are made to assess thejustification of using curettage to eliminate gingival

inflammation and accomplish retraction of the gingiva.

One-time curettage: X-ray study


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Due to the histological and clinical healing response

investigated by current studies, the advantages of curettage in

the shallow pocket are debatable. Curettage are now to be

done in deep pocket, especially in the aggressive lesion such asthat of the localized junvenile periodontitis. Nevertheless,

there is insignificant difference between the result of the

scaling and root planing alone and scaling and root planing

with the tissue curettage.

One-time curettage: X-ray study


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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. It is indicated where aesthetics is a primary

concern, especially in the maxillary anterior sextant. The

drawbacks include the inability to achieve pocket elimination

and healing with a long junctional epithelium. (Open

curettage)


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After completing scalloped section, parallel to the

gingival margin, and additional sections, partly

movable muco-periosteal flap is shifted to the level of

the alveolar ridge.

Treatment of the teeth roots is carried out under

visual control by curettes or ultrasonic instruments.

Then the flap is adapted to the underlying tissues and

stitched in the interdental spaces.


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A modified Widman flap was used to reduce periodontal pockets aroundteeth # 1215 (buccal and palatal view)

A, B. Preoperative. C, D. Incision


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E, F. Flap reflection. G, H. Suture.


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I, J. 1 week of healing. K, L. 8 weeks follow-up.


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Histological studies have shown the flap procedures describedabove tend to heal with a long junctional epithelium and not a

new connective tissue attachment. Long junctional epithelium,

however, has been shown to provide a stable therapeutic

outcome.


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Historically the aims of periodontal surgery were to remove the

soft tissue pocket wall and infected bone and to eliminate the

periodontal pocket.Currently, the goals of surgery are to: 1) gain access for root

preparation when nonsurgical methods are ineffective; 2)

establish favorable gingival contours; 3) facilitate oral hygiene;

4) lengthen the clinical crown to facilitating adequate

restorative procedures; and 5) regain lost periodontium using

regenerative approaches.

To ensure proper healing atraumatic surgical principles should

be followed including: 1) adequate anesthesia; 2) surface

disinfection; 3) sharp instrumentation; 4) minimal, atraumatictissue handling; 5) short operating time; 6) preventing

unnecessary contamination; and 7) proper suturing and dressing,

if indicated.


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Flap operations

The formation of the flap and the types of sections

Throwing soft tissue flap starts with the precise cuts. The

location and direction of the cuts depends on the type of

periodontal defect, purpose of surgical intervention and

the desired result.

The horizontal incision is made in all cases. itcan be intrasulcular (within the gingival sulcus) or

paramarginal (parallel to the gingival margin, at some

distance from it). In paramarginal section, connecting

epithelium is excised, and gingival margin shifted in the

apical direction. In this type of incision is the so-calledlatent gingivectomy. When viewed from the vestibular or

lingual side, the paramarginal section has scalloped

shape, close to the ideal form of the gingival margin.


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If it is a wide interdental spaces, it is recommended a special

flap that preserves gingival papillae (Takei et al, 1985). There

is also a modification of this flap for narrow interdental spaces

(Cortellini et al., 1995).

Vertical sections are not always necessary or desirable,

because they lead to the appearance of scars on the mucous

membrane. If a vertical incision is required, it should be done

in order to prevent gingival recession or loss of interdentalpapilla.


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Horizontal sections

A. traditional horizontal sections are performed fromvestibular (red line) and the oral side (blue line). In

interdental spaces, the surface of the tissue sections arearranged parallel or diagonally.

B. Intrasulcular section at which epithelium of the pocket isnot excised, but the maximum amount of soft tissue issaved.

C. Paramarginal sections is performed at differentdistance from the gingival edge. Part of the tissue isexcised by means of gingivectomy.


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The flap that preserves thegingival papillae.

When suturing the wound after the operation, the soft tissue

cover interdental spaces. However, this flap can be formedonly at relatively wide interdental gaps.

D. Papilla are displaced in the vestibular direction during the

flap formation.

E. Papilla are displaced in the oral direction.


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Vertical sections and

relaxing sections

Unfavorable location:

A. If the cut goes throughthe papilla, there is risk

of recession and loss of

interdental papilla.B. The middle section is

undesirable

in the presence of

vestibular pocket, as it

increases the probabilityof gum recession.


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The favorable location:

C. The section at the side of

midline does notleads to significant shrinkage

and is better for healing.

D. For the treatment of local

defects it is

recommended a triangular

flap, to unfold it ,

two paramedial sections is

conducted.


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*Guided Tissue Regeneration.A more advanced technique,

called guided tissue regeneration, is used to stimulate

bone and gum tissue growth:

*First, the root surfaces and diseased bone are meticulously

cleaned out. Preventing bacterial contamination is very

important. The more residual bacteria, the greater the

chance that the treatment will fail.

*A specialized piece of fabric is sewn around the tooth tocover the crater in the bone left after the cleaning. It is

either absorbable or nonabsorbable. (Some studies report

highly beneficial results with new absorbable materials,

including those coated with the antibiotic doxycycline.)


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*Bone Grafting. In some cases of severe bone loss, the surgeon mayattempt to encourage regrowth and restoration of bone tissue thathas been lost through the disease process. This involves bone

grafting:*The surgeon places bone graft material into the defect.

*The material may be either bone from the same patient or asubstance called decalcified freeze-dried bone allografts (DFDBA)which is obtained from a donor.

*This material then stimulates new bone growth in the area.

*Enamel Matrix Protein Derivative.Amelogenin is a derivative of amajor protein in the structure (the matrix) of enamel that helpsstimulate gum tissue growth. A gel containing amelogenin(Emdogain) is applied during surgery and forms a coat over theroots of the teeth. The gel itself dissolves after 2 days, leaving theactive substance behind. Studies report that it is safe and maysignificantly reduce the effects of periodontal disease. A 2001study suggested that the benefits, as indicated by boneattachment, can persist for at least 4 years. (Results were similarto guided tissue regeneration.)


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The risks of surgery include pain, swelling, blood loss, reaction

to medications, and infection. Other potential risks include root

sensitivity, flap sloughing, root resorption or ankylosis, someloss of alveolar crest, flap perforation, abscess formation, and

irregular gingival contours. If post-operative complications

occur, they should be managed by prompt and appropriate

treatment, which may include control of bleeding, adequate

analgesics or antibiotics.Post-surgery discomfort is usually managed easily with over-

the-counter medications such as ibuprofen. If discomfort is

severe, stronger analgesics may be prescribed. Some patients

experience sensitivity to hot or cold temperatures from

exposed roots. These problems can be managed with topicalfluoride treatments or, in severe cases, with dental restoration.


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6 Surgical Periodontal Therapy

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