3.1 Introduction

Upon completion of initial periodontal therapy, when inflammation of the gingiva has been reduced and the patient has shown improved compliance with oral hygiene, surgical intervention might be necessary. Periodontal surgery may become important to facilitate the access to the root surfaces for proper debridement as well as access to the alveolar bone to reestablish a more desirable bony architecture.

To date, the rationale for surgery includes access for scaling and root planing and access for restorative procedures, soft tissue biopsy, and periodontal regeneration procedures. The goal for this chapter is to exclusively discuss the periodontal flap designs for access and osseous surgery. The objectives described here have been established for several decades, but the techniques have evolved to reflect new knowledge and preferences.

Broadly speaking, periodontal surgery can be divided into resective and non-resective techniques as depicted in Fig. 3.1.

3.1.1 Periodontal Resective Surgery

Soft Tissue

Periodontal resective surgery can be categorized into soft tissue or hard tissue procedures. Soft tissue focused surgeries include gingivectomy, gingivoplasty, and distal wedge procedures.

Gingivectomy

Gingivectomy is among the oldest surgical periodontal procedure documented in the literature. In [2], Kronfeld revitalized and reimagined the original surgical technique described by Robicsek in 1884 in a more conservative manner. For review, Orban [3] described the surgical technique aimed at treating a pyorrhea pocket that did not resolve after nonsurgical therapy. By surgically removing the free gingival margin of tissue to the bottom of the gingival pocket, the clinician would physically eliminate the pocket and thus “cure” periodontal disease.

Gingivoplasty

Goldman [4] described gingivoplasty with the intention to reestablish a physiological gingival contour. By creating a bevel margin and festooning into the interdental spaces, the gingivoplasty procedure created a more esthetic and physiologic contour to the soft tissue after these soft tissue resective surgeries. Figure 3.2 shows a case of gingivectomy and gingivoplasty before treatment and 7 months after completion of surgeries.

Distal Wedge

In [5], Robinson devised a technique to eliminate the periodontal pocket on the distal of maxillary or mandibular second or third molars. The technique was introduced with three options for incision design described as triangular, square, and linear. The anatomy of this area typically presents with an excessive soft tissue volume, which makes plaque control more challenging. Pocket elimination in this area of the mouth will likely result in more favorable long-term periodontal outcomes.

Hard Tissue

Osseous Surgery

The rationale for osseous surgery, alveolar bone recontouring, arose from the need to further assist cases of gingivectomy that did not have satisfactory outcomes [6]. A flap technique that involved access to and reshaping of alveolar bone leading to a more favorable topography (physiologic architecture) would result in shallower pockets that were easier to maintain after surgery. Historically, these resective procedures required significant removal of supporting alveolar bone. When reviewing the longitudinal studies comparing different periodontal therapies, Kaldahl et al. [7] concluded that osseous surgery often resulted in greater short-term reduction of probing depths than surgery without osseous resection. In regard to attachment levels, osseous resection showed no additional gain compared to non-resective flap surgeries. In fact, flap surgeries without osseous resection showed greater short- and long-term gains in attachment. Figure 3.3 documents intra-surgical views of a case before and immediately after ostectomy and osteoplasty.

Soft and Hard Tissue

Crown Lengthening

The intersection of soft and hard tissue resective surgeries is seen in crown lengthening procedures. Utilizing any combination of the surgical techniques described above, crown lengthening surgery aims to gain access to the tooth surface for restorative purposes [8]. This topic is discussed with details in the chapter by Karateew et al., in this volume. Figure 3.4 gives a depiction of a crown lengthening procedure before and after surgery.

Biologic Shaping

One of the main challenges of the profession is to have full access to the furcation area for proper debridement. Biologic shaping, as part of periodontal surgery, has been proposed by Melker and Richardson [9] as a means of addressing furcation-involved teeth (decreasing or eliminating class I and II furcation lesions), root grooves, concavities, and projections of the cemento-enamel junction. The authors proposed that by establishing smooth root surfaces, a more biocompatible anatomy would be present for soft tissue attachment and long-term care. Biologic shaping is discussed in the chapter 4 in this volume.

3.1.2 Periodontal Minimally Resective Surgery

The aim of minimally resective periodontal surgeries is to gain access for thorough debridement while being conservative in the amount of soft or hard tissue removal.

Widman Flap

One of the first techniques described, the Widman Flap, was introduced in 1918. This type of flap included a scalloped gingival incision 1 mm apical to the free gingival margin, a full-thickness flap elevation past the mucogingival junction, curette of the collar of tissue surrounding teeth, planing of root surfaces, minimal resection of bone, and re-approximation of the flaps with interrupted sutures [10, 11]. By attempting to obtain primary closure with an intimate contact between the flap and tooth, the desired outcome of the Widman Flap was to obtain reattachment.

Modified Widman Flap (MWF)

As a modification to the Widman Flap, Ramfjord and Nissle described a new flap design in 1974. The Modified Widman Flap became a more precise surgical technique to eliminate some of the unpredictability of the Widman Flap. As a series of incisions and a minimal flap elevation, the Modified Widman Flap includes an initial incision parallel to the long access of the tooth. The location of this initial incision is dictated by either the buccal or the lingual pocket probing depth. If a pocket is present, deeper than 2 mm, this initial incision is made 0.5–1 mm apical to gingival margin in a scalloped pattern. If the pocket is minimal, a sulcular incision is made. Additionally, the scalloping is exaggerated on the palatal aspect to thin the palatal flap for improved adaptation of the re-approximated tissue. The second incision is made in the sulcus until alveolar bone is contacted with the blade. The last incision is made supracrestal with a narrow interproximal knife perpendicular to the long access of the tooth. Again, the collar of tissue is removed with curettes; the flap is minimally (2–3 mm) reflected to gain access to the tooth surface for scaling and root planing. Finger pressure is applied to the flaps and interrupted sutures are placed.

Laser-Assisted MWF

Current alterations to the Modified Widman Flap include the use of diode laser to aid in the removal of the epithelial lining of pockets and improve clinical outcomes of flap surgery. Treatment protocols include the abovementioned steps of incision and reflection of the Modified Widman Flap. In addition, the application of an 810-nm diode laser to all surfaces of the flap, the exposed bone, and the tooth surface takes place [12]. While this study included only a small sample size over a relatively short follow-up period, they show promising results in decreasing postoperative pain while improving clinical measurements of probing depth and attachment level [13].

Excisional New Attachment Procedure (ENAP)

Approximately, at the same time as the Modified Widman Flap, the excisional new attachment procedure (ENAP) was introduced in 1976 as a “definitive subgingival curettage performed with a knife” [14]. Pockets are marked with an explorer, an internally beveled incision is made from the free gingival margin to the base of the pocket to remove the pocket epithelium, and this tissue is removed with a curette. The fresh connective tissue of the pocket lining is repositioned against the tooth, and digital pressure is applied. Interrupted sutures maintain the flap in place. In order to gain access and improve healing after flap surgery, the ENAP showed improved clinical attachment during long-term follow-up (5 years) [15].

Laser-Assisted New Attachment Procedure (LANAP)

More recent modifications to the ENAP include the application of laser therapy in the laser-assisted new attachment procedure (LANAP). It became popular among periodontists and general dentists over the last two decades as a minimally invasive procedure with favorable outcomes. In a case series, Martin and David [16] demonstrated that a majority of treated sites had clinical improvement after LANAP therapy. To date, there is still limited evidence that laser therapy is a superior technique to other modalities of periodontal treatment [17]. LANAP is discussed in depth in the chapter by Honigman and Sulewski, in this volume.

3.1.3 Periodontal Non-resective Surgery

When treating periodontitis, one of the most conservative ways to access root surfaces, for debridement, is through a simple flap that preserves periodontal structures. For moderate to severe pockets, these procedures facilitate full access and promote superior calculus removal versus nonsurgical (closed) scaling and root planing [18].

Open Flap Debridement (OFD)

In [19], Kirkland published the technique to treat periodontal pockets. Prior to surgery, nonsurgical scaling and root planing and occlusal adjustment were performed as part of the protocol. Procedure-specific curettes were introduced in this publication for use during this flap procedure. After mechanically cleaning the root surface, a chlorinated soda was applied for further debridement. Flaps were then re-approximated and sutured by primary closure and covered with a wax dressing. The author claimed that this procedure was minimally traumatic resulting in no swelling and no postoperative pain, when compared to minimally resective procedures.

Intrabony Defects

Becker et al. [20] studied the value of open flap debridement. A small group of patients with moderate to severe three-walled intrabony defects were monitored after surgery with a reentry procedure. The authors noticed a 61% bone defect fill and approximately 10% crestal resorption after open flap debridement. This underlines the value of flap access per se, without adding grafting materials (membrane, bone, or biologic agents) for regeneration.

In addition to vertical bony defects, OFD for access to furcation-involved teeth is valuable. In a systematic review and meta-analysis of randomized clinical trials, Graziani et al. [21] concluded that teeth with mandibular class II furcation involvement treated with OFD had significant clinical improvements 6 months after surgery.

Apically Positioned Flap

Building on the surgical techniques described for an open flap debridement, the apically positioned flap was introduced by Friedman in [22] to further reduce pocketing. The author aimed to reposition the attached gingiva more apically after thorough debridement of the root surfaces. By performing vertical incisions and suturing to precisely place the free gingival margin at the level of the alveolar crest, pocket elimination was achieved.

Single-Flap Approach

Trombelli and collaborators published a case series, in [23], where they described a conservative approach called the single-flap approach. This procedure involved the reflection of a buccal flap while preserving the lingual flap. The original technique was aimed at gaining access to the root surface, and over time this procedure was also adopted for use in regeneration procedures.

Papilla Preservation

The papilla preservation technique, introduced by Takei and collaborators in [24], described a very conservative approach of flap design and elevation for primary closure of the wound. The original application of this technique was in regeneration procedures. However, this technique can be utilized for access for debridement without a reconstructive goal. More recent evolutions of this flap design include the simplified papilla preservation, minimally invasive techniques, etc. From an operator point of view, the simplified procedures require limited equipment, fast learning curve, and potentially improved healing. In addition, for the patient these procedures appear to reduce pain, discomfort, and faster resumption of daily activities. For both patient and provider, these procedures minimize chair time and office visits [25]. For in-depth review of flap design for regeneration purposes, please refer to the chapter by Narvekar in this volume.

Regardless of which flap design variation is chosen for non-resective surgery, the benefits of conservative surgery have been notable. In a systematic review by Graziani et al. [26], it was determined that the clinical performance of conservative surgery for the treatment of intrabony defects resulted in high tooth retention and improvement in periodontal clinical parameters.

3.1.4 Smoking and Healing After Periodontal Surgery

As a modifying risk factor for periodontitis, tobacco smoking has major adverse effects on periodontal tissues. Pathologic mechanisms involved with cigarette smoking and impaired healing include reduced neutrophil function, decreased production of IgA and IgG in both saliva and serum, increased presence of select periodontal pathogens, and impaired fibroblast function and proliferation [27].

When treating a periodontitis patient who smokes, clinical outcomes of both nonsurgical and surgical therapy may be hindered compared to non-smokers. It is important for both clinicians and patients to discuss expectations and understand long-term benefits to surgical intervention. While smoking is not a contraindication to surgery, the benefits of periodontal surgery may be reduced.

In a prospective controlled human clinical trial, Bunæs et al. [28] compared treatment outcomes after nonsurgical and surgical periodontal therapy in smokers and non-smokers. Overall, smokers and sites positive for bacterial biofilm showed less improvement from therapy. In particular, probing depths associated with deeper pockets (≥7 mm) and posterior maxillary sites showed the least favorable outcomes, with likely need for additional therapy. In a review by Kotsakis et al. [27], reductions in probing depth and gain in clinical attachment were diminished by 0.4 mm and 0.3 mm, respectively, in smokers.

3.1.5 Oral Hygiene, Periodontal Maintenance, and Compliance

It is well established that bacterial biofilm is a main etiologic factor for periodontal diseases. Control of bacterial biofilm, after periodontal surgery, is critical for the long-term success of these interventions. In fact, longitudinal studies have shown that when comparing different surgical modalities, regardless of the type of surgery, periodontal maintenance was the most important variable for the long-term retention of the dentition. A classical study by Nyman et al., in [29], demonstrated that patients receiving professional plaque control once every 2 weeks exhibited less inflammation, reduced probing depth, and improved gain of attachment, when compared to a control group who was recalled every 6 months only. In a subsequent study by [30], patients treated with periodontal surgery, who did not receive periodontal maintenance, for an average of 5.25 years, demonstrated higher average tooth loss when compared to treated and maintained patients.

When determining the appropriate frequency for periodontal maintenance, after surgery, there is a paucity of randomized, controlled clinical trials to support a predetermined interval. To date, a preestablished 3-month periodontal recall has no robust data to support its implementation. Risk assessment algorithms may provide a more tailored and patient-specific protocol [31].

3.2 Conclusion

Surgical techniques utilized for improved access to scaling and root planing and osseous surgery have evolved and solidified their place as very reliable and predictable for specific clinical situations. These techniques are invaluable for the care of periodontal patients and for the goal to arrest disease progression, achieving long-term periodontal stability.