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

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).