Surgical treatment of periodontal pocketing
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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
|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).
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:
• When the patient shows an overall lack of response to nonsurgical therapy (where antimicrobials might be used; discussed in
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/>