For patients with more significant periodontal disease, there typically are residual deep pockets remaining after nonsurgical periodontal treatment. While it is possible that repeat scaling and root planing and other nonsurgical methods will further reduce pocketing, for most of these patients, surgical pocket reduction is needed. This chapter will describe why pocketing can persist after quality nonsurgical treatment, and how to prepare a treatment plan and perform these surgeries. The same techniques are also used for crown-lengthening surgery, which is used to prevent complications from restorations impinging on supracrestal attached tissues.
Case
A 63-year old South Asian male presented to us asking for a “tooth cleaning” since he has not received dental care for about 10 years. He had a history of hypertension, but that abated with diet change and relaxation techniques, and a history of type 2 diabetes mellitus, which is controlled with 5-mg Glucotrol XL (Glipizide) once daily. He reported that he is not required by his physician to measure his glucose at home, but gets it tested regularly through his physician’s office. He also brought in a printout showing the values measured last month: serum glucose 102 mg/dL; HbA1c 6.2%.
Although he had not seen a dentist for many years, he does not have any specific tooth-related complaint other than “feeling the need for a cleaning.” He brushes his teeth twice a day with a hard brush and flosses twice a day. When asked about the tooth wear and suspected parafunctional habit, he replied that his previous dentist thought he grinds his teeth at night.
Extraoral exam findings revealed no abnormal findings for the facial skin, lymph nodes, thyroid gland, cranial nerves, salivary glands, masticatory muscles, and temporomandibular joint other than reduced hearing on the left side. Intraorally, no mucosal pathology was apparent other than periodontal disease and a small, 2-mm diameter white round nodule at the height of the occlusal plane on the left lateral border of the tongue. Teeth had worn occlusal surfaces and small abfraction lesions, but were otherwise in good repair.
Blood pressure was 124/83 mm Hg and pulse 70/min.
Initial findings in the periodontal chart were as follows (see Fig. 6.1 for clinical presentation and Fig. 6.2 for radiographs).
Teeth nos. 1, 3, and 14 were considered hopeless and removed soon after the initial exam. The patient received scaling and root planing (SRP) in all quadrants and was instructed to use a gentle brushing technique using a soft brush. In addition, the patient was instructed on how to use interproximal brushes. This resulted in some pocket reduction, but there were still residual deep pockets between mandibular molars.
Pocket depths after SRP are as follows:
Partial osseous resective surgery, with bone grafting of the deeper bone defects, was performed for the mandibular quadrants, and the patient seen every 3 to 4 months for periodontal maintenance. This surgical treatment reduced pocketing to low levels, and they were maintained at that level 2 years after the surgery by periodic periodontal maintenance.
Pocket depths 2 years after surgery are as follows:
What can be learned from this case?
This case illustrates that successful pocket reduction may require both nonsurgical and surgical treatments. The case benefited from a patient who is reasonably healthy and is committed to improving his health as shown by his effective, although abrasive oral hygiene technique, apparent compliance with medical treatment, and his apparent ability to reduce his blood pressure with lifestyle changes. Unlike Chapter 5 case, this patient has more bony irregularities and these likely explain the need for surgery in this case. The bony defects probably harbor deep subgingival plaque and calculus accretions on the root surfaces adjacent to these defects, and the shape of the bone defect with surrounding tissue made it impossible to remove all deposits. When these were exposed and removed surgically, this allowed proper healing and reduced pocket depths. Patients with low probing depths can be predictably maintained, and this is the reason for the observed periodontal stability.
Recognize Indications for Pocket-reduction Surgery
Generally, the indications for pocket-reduction surgery are residual deep pockets after high-quality nonsurgical periodontal treatment in a compliant patient.
Risks Associated with Residual Deep Pocketing
Residual deep pocketing poses the following risks:
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Increased risk of further attachment loss and eventual tooth loss.
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Continues active disease and possible systemic risks of periodontal disease.
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Deep pocketing and gingival bleeding may cause inaccurate impressions, resulting in poor restorations and premature treatment failure.
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Increased risk of periodontal abscesses and associated pain.
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Less predictable orthodontic tooth movement and risk of tooth loss during therapy.
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Longer and more difficult periodontal maintenance, which also may not be effective.
Consequently, deep pocketing needs to be eliminated prior to orthodontics and complex restorative procedures such as implant therapy, crown fabrication, and fixed and removable partial denture therapy.
Causes of Residual Deep Pocketing
Residual deep pocketing is usually caused by residual subgingival plaque or calculus left after nonsurgical therapy. Besides operator error or lack of experience, the following factors may prevent complete calculus removal:
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Deep pockets: In pockets deeper than 5 mm, complete calculus removal is unlikely.
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Pocket anatomy: Some pockets have curved anatomy, and pocket gingiva prevents visualization of calculus and instrumentation access.
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Bone defects: Narrow entrances to bone defects covered with pocket tissue prevent access.
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Furcation entrances: For molars, this is the typical cause of residual pockets.
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Root surface abnormalities such as developmental grooves, enamel projections, ridges, root concavities, and enamel pearls are associated with residual pockets. Failing to remove these abnormalities is a common reason for residual pockets after periodontal surgery. Common sites are as follows:
Residual pocketing may also be caused by persistent inflammation caused by caries, defective restorations, biologic width invasion, occlusal trauma, and endodontic infections.
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