10: Surgical treatment of periodontal pocketing

Chapter 10

Surgical treatment of periodontal pocketing

Introduction

In < ?xml:namespace prefix = "mbp" />Chapter 9, reassessment of the patient following completion of initial periodontal therapy was discussed. It was noted that in cases in which deep pockets persist, it may be necessary to carry out further root surface debridement either by repeating the nonsurgical treatment or considering a surgical approach to debridement of the periodontal defect. This chapter explains the indications for surgery for the treatment of periodontal pocketing and discusses the basic techniques that are used to carry out this treatment. Periodontal surgery is often regarded as within the particular domain of the periodontal specialist, and it is described in considerable detail in a number of comprehensive periodontal textbooks and surgical atlases. Therefore, here we have placed the emphasis on understanding the decision-making processes involved in electing for surgical treatment, and the basic procedures involved, rather than providing a detailed manual of surgical procedures.

Indications for surgery

Further active periodontal treatment is generally indicated when deep pockets persist following initial therapy. Often, the persistence of deep pocketing may be the result of difficulty in completely debriding the root surface nonsurgically, and in these cases either more nonsurgical treatment or surgery may be chosen. There are no absolute guidelines in deciding which cases should be treated surgically, and in making the decision, the clinician needs to consider the likely reasons for persistence of pocketing, the appropriate remedies, the potential advantages of surgical treatment, the likely outcomes, and the patient’s wishes and best interests. The potential advantages and disadvantages of surgical treatment of pockets compared to nonsurgical therapy are listed in Table 10.1.

Table 10.1 Advantages and disadvantages of periodontal surgery compared to nonsurgical treatment

Advantages of surgery Disadvantages of surgery
Provides direct visualization of defect More traumatic for the patient
Improves access to the defect Causes more postoperative recession than nonsurgical treatments
Allows correction of root surface anomalies such as root grooves Requires operator with specific surgical skills and experience
Allows direct exploration of a defect and detection of unexpected anomalies (e.g., lateral perforation of a post) Not suitable in some medically compromised cases, particularly those with bleeding disorders
Allows recontouring/repositioning of soft tissues to facilitate plaque control/improve aesthetics  
Allows surgical elimination of pocket, including bone recontouring of infrabony defects  
Allows use of regenerative techniques on some occasions  

In particular, surgery allows direct access for root surface debridement so that the root surface can be directly visualized, along with its possible anatomical anomalies (e.g., grooves and furcations) and calculus deposits, enabling accurate debridement to be achieved by direct vision. Therefore, despite the many varieties of surgical techniques that have been described, direct access to the periodontal defect remains the main indication for periodontal surgery. A surgical approach does allow the alteration of the soft tissue to facilitate oral hygiene through gingival recontouring and/or pocket elimination. It is also possible to modify the contour of the bone and alter osseous defects and to re-establish the anatomical architecture of the bone.

Periodontal surgery may therefore be indicated when there are persisting deep pockets in the presence of good plaque control. Choosing a surgical approach in these circumstances is more likely for treatment of posterior sites, in deeper pockets, where there are infrabony pockets, where there are complicating root surface anomalies, and where there are soft tissue anomalies. Choosing a surgical approach (rather than a nonsurgical approach) is less likely for less deep pockets, suprabony sites, anterior teeth, and where there are obvious residual calculus deposits that can be readily detected and removed by further nonsurgical root surface debridement. The clinician needs to weigh these different factors when making a decision (with the most important aspect being that an active decision is made based on the available evidence rather than simply repeating the nonsurgical treatment as a default position).

Contraindications for surgery

The major contraindication for surgery is poor oral hygiene. This should be regarded as an absolute contraindication for surgery. Surgery is far more likely to fail in the plaque-infected dentition, and consequently surgery is not advised in these circumstances. Studies suggest that in the presence of poor plaque control, the outcome of surgery may be worse than if nothing is done. Probably the only other absolute contraindication for surgery is lack of patient consent.

There are also a number of relative contraindications for surgery—that is, those that do not absolutely rule out surgery but indicate that surgery should only be carried out with caution, recognizing the risks involved. These include the following:

Smoking

Medical issues

When postoperative recession is likely to be problematic aesthetically

When the patient shows an overall lack of response to nonsurgical therapy (where antimicrobials might be used; discussed in Chapter 13)

Patient preference

Surgery is more likely to fail in smokers than in nonsmokers, so careful informed consent must be established if surgery is performed in a smoker, such that the risks are fully explained. Uncontrolled medical conditions such as angina, hypertension, diabetes, or recent stroke or infarct may also tend to contraindicate surgery. Patients with bleeding disorders may require special management and represent a serious contraindication if no/>

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Jan 5, 2015 | Posted by in Implantology | Comments Off on 10: Surgical treatment of periodontal pocketing
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