Since the early twentieth century, periodontal surgery has been used to help dentists control the progression of periodontal disease. Although advances in root instrumentation techniques and antibiotic therapy have improved the available treatments for periodontal infections, periodontal surgery will continue to be a necessary procedure in the foreseeable future. It is important for the dental hygienist to understand the indications for and contraindications to basic periodontal surgical procedures and to advise patients of the potential therapies available. In many situations, the dental hygienist is the best person to discuss the options for periodontal surgery with the patient and to alert the dentist to the possible need for surgical intervention.
Periodontal surgery is indicated to control the progress of periodontal destruction and attachment loss when more conservative nonsurgical treatment is insufficient. The definition of nonsurgical treatment in dentistry is perhaps a misnomer. Surgery is often defined as the practice of treating diseases by instrumentation or manual operations. By this definition, almost all dental procedures would be considered surgery. Dentists often limit the definition of surgery to cutting procedures with sharp instruments, especially scalpels or knives. Even by this definition, most periodontal therapy qualifies as surgery because sharp scalers and curettes cut both hard and soft tissues in the periodontal environment. Scaling and root planing result in intentional cutting of the root surfaces and inadvertent cutting of the surrounding soft tissues. However, they are considered part of nonsurgical periodontal therapy. This chapter limits the definition of periodontal surgery to techniques that intentionally cut into soft tissues to control disease or change the size and shape of tissues.
Periodontal educators have identified a number of goals for periodontal surgery.1 These goals are defined in Box 14-1. All these goals are valid reasons for recommending periodontal surgery.
The major benefit and indication for periodontal surgery as an adjunct to nonsurgical periodontal treatment is to gain access to the root surface for scaling and root planing. It also improves access for plaque biofilm control. Periodontal surgery results in better access to furcations, complex root surfaces, and infrabony pockets (those apical to the crest of bone, surrounded by bone on one or more sides), areas that are the most difficult to treat by scaling and root planing. Improving access for plaque biofilm control by the patient may require removing tissues or bony forms that block the patient from adequately removing as much biofilm as necessary to control the disease. Other advantages of periodontal surgery include improved access to periodontal abscesses to obtain drainage and the ability to expose root surfaces for restorative dentistry. In addition, numerous new techniques are being used to improve patient aesthetics by altering the position of the gingival margin.2
There are a number of disadvantages and contraindications to periodontal surgery. These include the health status or age of the patient and the specific limitations of each procedure.2 From the patient’s perspective, the disadvantages of surgery are usually limited to time, cost, aesthetics, and discomfort.
The dental hygienist is in the unique position to discuss all these concerns with the patient before periodontal surgery is performed. The hygienist is often involved with continuing maintenance procedures, is well known to the patient, or has developed a good rapport with the patient while performing nonsurgical periodontal procedures. By being involved in the patient’s decision making process, the hygienist contributes to the patient’s understanding and acceptance of the proposed surgical procedure. This contribution may be helpful to the patient in maintaining the teeth.
Several things must be considered when periodontal surgical therapy is prescribed. The periodontist usually makes a final decision to proceed with periodontal surgery after sufficient time is allowed for healing after nonsurgical procedures, at least 4 weeks. The amount of pocket reduction observed after these procedures indicates the extent of surgical procedures still required. The patient’s concerns and fears must also be considered, and the patient must be fully informed of all factors related to the surgical treatment plan, including what to expect during the procedure and healing process. In prescribing periodontal surgery, the periodontist carefully considers the following:
A periodontal pocket is a deepened gingival sulcus with an infected root surface covered by an ulcerated epithelial surface, with underlying inflamed connective tissue. The pocket is bound coronally by the gingival margin on one side by the root surface, on the other side by the epithelial surface, and at the base by the junctional epithelium. Studies have shown that scaling and root planing is effective in controlling periodontal disease to probing depths of about 4 mm.4 Pockets deeper than 5 mm are difficult to instrument and therefore often remain infected, even after the best dental hygiene care. Pockets with probing depths greater than 9 mm suggest extreme loss of attachment, which makes the long-term prognosis for retaining the affected teeth poor.
Probing pocket depth is not always equal to clinical attachment loss. The probing depth is the measurement from the crest of the gingival margin to the base of the pocket. The deeper the probing depth, the more difficult is the complete removal of calculus. Therefore, the indication for periodontal surgery is stronger. Attachment loss, rather than probing depth, is measured from the cementoenamel junction to the base of the pocket. If the gingival margin is on the root surface, as when there has been recession, the attachment loss is greater than the probing depth. If the gingival margin is on the enamel surface of the crown, as in gingival hypertrophy, then the attachment loss is less than the probing depth. Attachment loss represents bone destruction, which in turn affects the long-term prognosis of the tooth. The concepts of probing depth and clinical attachment loss are discussed in Chapter 8.
Although surgery may be needed to treat pockets deeper than 5 mm, not all pockets of this depth require surgery. The 5-mm guideline is only the first step in identifying patients who may be helped by periodontal surgery. Patients with moderate pocket depths of 5 to 6 mm may be monitored with a wait-and-see approach to determine whether nonsurgical periodontal therapy and careful maintenance are adequate. If there is no progression of the periodontal disease in these cases, then periodontal surgery is not necessary. However, it is not always safe to wait and see. If the periodontal disease progresses and more attachment loss results, the prognosis for a tooth may worsen. Also, probing measurements are inexact. Measurements may differ by as much as 1 mm because of variations in probing technique. Therefore, to know that the disease is definitely progressing, a 2-mm increase in probing depth (and thus bone loss) must be observed over time. If surgery is postponed, the dentist (and patient) must be willing to risk this 2-mm bone loss.5
The base of the periodontal pocket is not at the level of the crest of the alveolar bone. There is usually 1 to 2 mm of connective tissue attachment covered by epithelium between the probing depth and the alveolar bone. This area is termed the biologic width6 and must be considered when estimating the amount of attachment remaining on a periodontally involved tooth.
Bone loss caused by periodontal disease results in osseous defects. These may occur in either a horizontal dimension, where the bone resorbs equally on the mesial and distal surfaces of the teeth, as seen in Figure 14-1, or a vertical dimension, where the resorption is unequal around the teeth, as illustrated in Figure 14-2. Pockets that are coronal to horizontal bone loss are often called suprabony pockets, whereas those that extend apically beyond the crest of the bone are called infrabony pockets.
Vertical bone loss may also occur in a variety of configurations that are usually described by the number of bony walls remaining. When all the walls of the osseous defect are within the bone housing, they may be termed intrabony pockets. These types of bony defects are shown in Figure 14-3.
The amount of bone remaining around a tooth is an important consideration in the decision to perform periodontal surgery. Large amounts of bone supporting a tooth may allow the clinician to take a wait-and-see approach to postpone or avoid periodontal surgery. However, if the amount of bone is already reduced, delaying periodontal surgery may radically decrease the prognosis for the tooth. This rationale is illustrated in Figure 14-4.
Periodontal surgery that includes modification of the bone level or shape is called osseous surgery. The amount of bone remaining is important in determining whether periodontal surgery will be beneficial. If too much bone has been lost through disease or so much bone must be removed during surgery that the tooth will be weakened, osseous surgery becomes a less attractive option for treatment. Other procedures, such as grafting or regeneration techniques, may be required. Generally, osseous surgery performed to correct irregularly shaped defects of the bony support around the tooth is indicated when at least half of the bone support remains, as shown in Figure 14-5.
Not all teeth have equal value when considering periodontal surgery. Some periodontally involved teeth cannot be saved, and others are not worth making heroic attempts to treat. Third molars, for example, may not be in a good position for mastication, and they may be extracted without altering the patient’s chewing pattern. An abutment tooth for a functioning fixed bridge, however, can be important to the patient, and often every attempt to salvage a particular tooth through periodontal surgery is strongly indicated.
The progression of periodontal disease may increase after periodontal surgery if plaque biofilm is not adequately controlled.7 Therefore, every patient should establish the best possible supragingival plaque biofilm control before surgical therapy is initiated. If plaque biofilm control is poor, surgical intervention should be postponed or abandoned because it will not prevent the recurrence of periodontal infection and the possible loss of teeth.
Patients who are in poor health are not good candidates for periodontal surgery. However, periodontal disease may contribute to poor general physical condition, and periodontists may decide, in concert with the patients’ physicians, that periodontal surgery is appropriate. Older patients usually heal as well as younger patients after periodontal surgery, so age in itself is not a contraindication to surgery. The patient’s age is an important factor when considering the progress of the periodontal disease. Patients with pocket depths exceeding 5 mm and half their supporting bone lost who are relatively young (younger than 30 years) have an aggressive form of periodontal disease. Surgery is strongly indicated to control this infection. However, older patients (older than 60 years) with the same clinical conditions usually have a more slowly progressing form of the disease. Surgery may be less critical for these patients. It is important to remember that the human life span is increasing. Periodontal surgery, if strongly indicated, should not be denied a patient just because of advanced age. The quality of life of older patients may be significantly improved by controlling periodontal disease and retaining the dentition.
Some patients are reluctant to have periodontal surgery, no matter how strong the indications may be. It is important for patients to know all the ramifications of delaying recommended periodontal surgery and the possible effects on the long-term prognosis of the teeth. All patients must be informed of the alternatives, risks, and benefits of every dental procedure before deciding whether to undergo periodontal surgery. The architecture of gingival tissues resulting after periodontal surgery is more conducive to plaque biofilm control and maintenance. Patients who decide not to have surgery must be willing to undergo more frequent periodontal maintenance procedures and perform more complex subgingival plaque control in an effort to slow the progress of their disease. Even with these additional procedures, patients who decline to have periodontal surgery must understand that their disease will most likely progress and be willing to accept the risk of continued periodontal attachment and tooth loss.
Many methods of classifying periodontal surgery have been described. One approach is to name the procedure for the clinician who first described it—for example, the Widman flap. Another approach is to describe how the procedure is performed, as with gingivectomy, which means to remove the gingiva. Lang and Löe proposed a convenient classification of periodontal surgical procedures into five basic categories8:
The goal of pocket reduction surgery is to reduce periodontal pocket depth by removing soft tissues to a level at which plaque biofilm control and maintenance procedures are effective, usually not exceeding 3 to 4 mm in depth. Methods for pocket reduction include excisional periodontal surgery (gingivectomy) and incisional periodontal surgery (flap).
Excisional periodontal surgery removes the excess tissue from the wall of the periodontal pocket. It is useful for the rapid reduction of gingival pockets. The most basic excisional surgical procedures are termed gingivectomy, meaning excision of the gingiva, or gingivoplasty, meaning surgical reshaping of the gingival tissues. In practice, both procedures are often performed in combination. Gingivectomy is a reasonably simple surgical procedure that is usually the first consideration for pocket reduction. However, contraindications to gingivectomy are numerous, and there are relatively few cases in which it is the sole therapy required. It is often performed with a special set of surgical instruments, although standard scalpel blades, electrosurgical devices, and dental lasers may also be used.
The presence of deep periodontal pockets with thick fibrous tissue is the major indication for gingivectomy. Drug-induced gingival hyperplasia is ideally treated by this form of excisional surgery. This condition is often caused by antiseizure medication (e.g., phenytoin), calcium channel blockers to control blood pressure (e.g., nifedipine), or immunosuppressive drugs (e.g., cyclosporine). Other indications include familial gingival hyperplasia and localized crown lengthening for restorative dentistry. Periodontal scaling and root planing, complemented by adequate plaque biofilm control procedures, should be completed 4 to 6 weeks before the surgery to allow tissues to heal. Often, the need for gingivectomy cannot be determined until tissue shrinkage after scaling and root planing has occurred.
During gingivectomy, the surgeon marks the bottom of the pockets with a periodontal probe or forceps. The gingiva is excised with knives at a 45-degree angle to the gingival surface, keeping the incision within the keratinized gingiva. This practice results in a thin tissue margin at the dentogingival junction. After removal of the majority of the gingival tissues, the underlying exposed connective tissue is refined and trimmed with knives, burs, or other instruments. Exposed root surfaces are carefully examined for residual calculus and roughness and they are cleaned and smoothed as necessary with curettes. Bleeding after surgery is controlled with gauze pads dampened with saline solution, and the surgical area is packed with a periodontal dressing to reduce postoperative discomfort and protect the sensitive underlying connective tissue. Healing is usually uneventful and the gingival epithelium is reestablished 2 weeks after surgery.9 An example of a gingivectomy procedure is presented in Figure 14-6.
There are many contraindications to excisional surgery, which is why it is rarely used for periodontal pocket reduction. Concerns about this procedure, which are illustrated in Figure 14-7, include the following:
Incisional surgery, commonly called periodontal flap surgery or simply flap surgery, is the procedure of choice when excisional periodontal surgery cannot be performed for pocket reduction. This procedure is called flap surgery because the tissues are pushed away from the underlying tooth roots and alveolar bone, much like the flap of an envelope. Flap surgery includes a variety of techniques for pocket depth reduction. Depending on the clinical circumstances and the preference of the surgeon, the alveolar bone may be resected or modified during the surgical procedure. The usual incisional technique for pocket reduction with flap surgery is called the apically positioned flap because the flap is sutured at a more apical location on the tooth roots to reduce pocket depth.9
Deepened periodontal pockets, which are contraindicated for gingivectomy, are the primary indication for incisional surgery. Suprabony pockets are often best treated by flap surgery. However, flap surgery also allows access to infrabony pockets, so the procedure is often combined with other osseous surgical procedures to treat existing bony defects.
After anesthesia is given, pockets are probed to determine their depths and the bony contours are “sounded” by pushing the periodontal probe through the tissues until the crest of the alveolar bone is detected. The surgeon uses this information to design the incision around the necks of the teeth to retain as much tissue as possible while allowing for pocket reduction. In thick tissues, this incision may be several millimeters away from the root surfaces. Flaps of gingiva are created that are pushed away from the alveolar bone and teeth, usually on the buccal and lingual surfaces, with a periosteal elevator. In this way, the infected epithelium, connective tissue, and granulation tissues can be removed with curettes, scalers, and ultrasonic instruments. The roots are examined for residual calculus and cleaned and smoothed as necessary. The flaps are then readapted at a more apical level to reduce the pockets. At this stage, the surgeon may reduce the bony ledges or may further elevate the flaps past the mucogingival junction to position it for proper adaptation. The surgical wound is closed by suturing the flaps together in the interproximal papillae and closely adapting them around the root surfaces. A periodontal dressing may be applied to help adapt the gingiva to the alveolar bone and assist with pocket reduction by applying pressure to the healing flap. This procedure is illustrated in Figure 14-8.
There are few contraindications to periodontal flap surgery beyond those that preclude any periodontal surgical intervention. The gingival tissues must be wide and thick enough to allow proper incision. Often, the incision must be modified to preserve as much keratinized tissue as possible. Like excisional surgery, apically positioning the gingival flaps exposes the root surfaces. The positioning may have to be altered or compromised for esthetics or in caries-prone patients. Fluoride mouth rinses should be recommended to reduce the potential for root caries.
Special modifications of pocket reduction surgery include combinations of incisional and excisional techniques, such as distal wedge surgery and internal beveled gingivectomy. These techniques are indicated in specific areas, such as the palatal tuberosity region, or where tissues are thick and not easily managed by one method alone.9 The distal wedge procedure is shown in Figure 14-9. It permits adequate plaque control on the distal surface of the last tooth in the mandibular arch.
The goal of access flap procedures is to provide access to the root surfaces for debridement and to create conditions for reattachment of the gingival tissues to the root. These access procedures include the modified Widman flap,9,10 the excisional new attachment procedure,11 and open flap curettage.12 Most of these procedures are similar and differ only in the details of the technique. The modified Widman flap, for example, uses three incisions to separate the pocket lining from the tooth in a controlled manner, whereas the excisional new attachment procedure usually does not involve elevating the flap past the mucogingival junction. The goal of all these procedures is the same—to gain access to the root surface for plaque biofilm and calculus removal, including scaling and root planing. Pocket reduction by apical positioning is not the goal of access flap procedures.
Access flap procedures are used to treat periodontal pockets in aesthetically sensitive areas or where pocket reduction is not desired or indicated. Many periodontists perform access flap procedures instead of pocket reduction procedures because there are few long-term d/>