Ch. 30 Perio Surgery Pt. 1

Primary Goals of Periodontal Surgery:

1. To eliminate the pathologic changes in the pocket

2. To create a stable and easily maintainable healthy state of the periodontium throughout the life of the patient

***Surgery is necessary when the periodontitis cannot be controlled with nonsurgical periodontal therapy alone.

Historical Perspective for Periodontal Surgery:

• Until the middle of the 20th century perio surgery procedures were resective

• Recommended for removal of what was thought to be dead or infected periodontal tissues

• Refers to those procedures that simply cut away and remove damaged tissues

• Today, resective procedures are not commonly used in periodontal care (Good for gingivectomy)

Modern Periodontal Surgical Techniques

• Basic sciences and regenerative medicine has advanced

• Emphasis has shifted from resective surgery to regenerative surgical techniques

• Regenerative- attempt to rebuild or regenerate lost periodontal tissues

• Most modern surgeries begin with a periodontal flap 

• Now we add regenerative products under the incision to regrow the tissue

Indications for Periodontal Surgery:

1. To provide access for improved instrumentation of root surfaces

2. To reduce pocket depths

3. To provide access to defects in the alveolar bone (AKA-osseous defect)

4. To resect or remove tissue

5. To regenerate the periodontium lost due to disease

6. To graft bone or bone-stimulating materials into osseous defects

7. To improve the appearance  of the periodontium

8. To enhance prosthetic dental care

9. To allow for the placement of a dental implant

1. Access for Periodontal Instrumentation

• Pockets increase, resulting in challenging to reach the base of the pocket

• Surgery allows for increased access and visualization of the root surfaces

• Nonsurgical (NSPT) is challenging with deep pockets. 

• Ex. Flap surgery

2. Reduction of Pocket Depths

• Biofilms thrive in deep pockets resulting in challenging control of periodontitis

• Surgical procedures reduce pocket depths so that a combination of self-care and professional care increases the chance of controlling periodontitis

3. Access to Osseous Defects

• An osseous defect is a deformity in the tooth supporting the alveolar bone- usually a result of periodontitis

• Alveolar bone loss modifies the normal contour and structure of the bone

• Bone defects can be managed by periodontal surgery

4. Resect or Remove Tissue

• Needed when there is overgrowth or enlargement of gingival tissue

• Overgrown tissue may interfere with normal eating

• Surgery can remove and reshape the gingiva

• “Gummy Smile”

5. Regenerate the Periodontium Lost due to Disease

• Defined: The reconstitution of new tissue= 

  • to grow back cementum, PDL, & alveolar bone

• Possible to achieve in some instances with sophisticated periodontal surgical techniques

• $$$ - Remember Emdogain from chapter 28? 

6. Graft Bone or Bone-Stimulating Materials

• Grafting of bone or bone-stimulating materials into an osseous defect

• Does not necessarily mean there will be regeneration of the lost cementum or the lost PDL

• Again $$$ but worth it!! 

7. To Improve Appearance of the Periodontium

• Some patients may have gingival levels or contours that result in an unattractive smile

• Periodontal surgery may improve the quality of a patient’s smile. 

8. Enhance Prosthetic Dental Care

• Modern periodontal surgery includes many procedures directed toward enhancing restorative dentistry

  • Altering alveolar ridge contours

  • Lengthening tooth crowns

  • Augmenting the amount of gingiva

  • Augmenting the bone prior to the implant placement

9. Allows for Placement of Dental Implants

• Periodontal surgery can be used to prepare sites for dental implants

• Dental implants must be surrounded by sound alveolar bone

Periodontal Surgery Contraindications:

• Most contraindications for periodontal surgery are relative contraindications

• Relative contraindications are conditions that may make surgery inadvisable for some patients when the conditions or situations are severe or extreme. Ex elevated BP

• An absolute contraindication is a situation that makes a particular treatment absolutely inadvisable. Ex. Patient with full blown AIDS

Relative Contraindications for Surgery:

Patients who:

• 1. Have certain systemic diseases 

• 2. Are totally noncompliant with self-care

• 3. Have a high risk for dental caries

• 4. Have unrealistic expectations for the outcomes of periodontal surgery

Systemic Diseases and Conditions:

• Recent history of heart attack

• Uncontrolled hypertension

• Uncontrolled diabetes

• Certain bleeding disorders

• Kidney dialysis

• History of radiation to the jaws

• HIV infection

Self-Care Noncompliance:

• Outcomes of many types of surgery depend on the level of the patient’s efforts with plaque control

• Poor self-care can cause a poor periodontal surgical outcome

High Risk for Dental Caries:

• Periodontal surgery can expose portions of the tooth root

• High risk caries patients may have rampant root caries

Unrealistic Expectations of Surgical Outcomes:

• Surgical correction of damage to diseased tissues does not always result in a perfectly restored periodontium

• For example, pocket reduction can result in portions of the tooth root being exposed in the oral cavity

• Patients have to develop realistic expectations for surgical outcomes

Outcomes of Modern Periodontal Surgery:

• Readaptation of soft tissue to the tooth root by formation of  a long junctional epithelium

• Resolution of inflammation associated with periodontal pockets 

• Regeneration – a restored periodontium; an expectation for periodontal regenerative surgery but not expected as the result of nonsurgical periodontal therapy alone. 

Terminology Used to Describe Surgical Wound Healing:

• 1. Healing by repair

• 2. Healing by reattachment

• 3. Healing by new attachment

• 4. Healing by regeneration

Healing by REPAIR

• healing of a wound by formation of tissues that do NOT precisely restore the original architecture or original function of the body part

• Example---formation of a scar during healing of a cut to a finger

 Healing the Periodontium by REPAIR:

• Healing after periodontal instrumentation results in a long junctional epithelium

• A long junctional epithelium does NOT precisely duplicate the original periodontal tissues

  • No formation of new bone

  • No formation of new cementum

  • No formation of periodontal ligament

Healing by REATTACHMENT:

• healing by the reunion of the periodontal connective tissue and tooth root where the two tissues have been separated by incision or injury, but NOT by disease

• Example---temporarily moving healthy tissue away from the tooth root or bone during crown lengthening.

Healing by NEW ATTACHMENT:

• New attachment---healing that occurs when epithelium and connective tissues are newly attached to a tooth root where periodontitis had previously destroyed this attachment

• New attachment occurs in an area damaged by disease

• Again, Reattachment occurs in the absence of disease, such as in a surgical procedure.

To qualify as new attachment, the tissues must be attached to the tooth surface in the area where on this picture?

B-area of attachment loss

Healing by REGENERATION:

• regrowth of the precise tissues that were present before the disease or damage to the tissues occurred

REGENERATION of the Periodontium:

• The healing would have to result in the reformation of the lost cementum, lost periodontal ligament, and lost alveolar bone

  • Regeneration of the periodontium is possible with modern surgical procedures

  • Unfortunately, the periodontium cannot be regenerated predictably in all sites with current surgical techniques

Terminology to Describe the Degree of Wound Closure:

• 1. Healing by primary intention

• 2. Healing by secondary intention

• 3. Healing by tertiary intention

1. Primary Intention:

• Occurs when the wound margins are closely adapted to each other

• Ideally, all wounds created by periodontal surgery would heal by primary intention, but often this is not possible 

• Difficult in periodontics since one edge of the surgical wound is the tooth root that cannot contribute any living cells to the wound healing

2. Secondary Intention:

• Margins or edges of the wound are not close in contact with each other

• Granulation tissue must form to close the space between the wound margins and then the epithelial cells grow over the surface of the wound

• Many wounds in periodontal surgery involve healing by secondary intention

3. Tertiary Intention:

• Tertiary intention---healing of a wound that is temporarily left open with the specific intent of surgically closing that wound at a later date

• Not normally a type of healing that applies to periodontal surgery

• “Needs to heal from within & could create abscess if closed too soon. 

  • Ex. A dog bite

Periodontal Flap:

Defined: is a periodontal surgical procedure in which incisions are made in the gingiva or mucosa to allow for separation of the epithelium and connective tissues from the underlying tooth roots and underlying alveolar bone 

Periodontal Flap Procedure:

• Incision made to allow for separation of the soft tissue from the roots and alveolar bone

• The soft tissue is lifted temporarily from the teeth and alveolar bone

• Improved visualization of both the tooth roots and alveolar bone contours 

Elevation or Reflection of Tissue:

• Elevation---separating the epithelium and connective tissues from the underlying tooth root and alveolar bone

• Once these tissues are elevated, they can be replaced at the original position or moved to different locations

Indications for a Periodontal Flap:

• To provide access to tooth root surfaces for completion of meticulous periodontal instrumentation that was begun as part of the nonsurgical periodontal therapy

• To provide access to reshape or treat alveolar bone defects resulting from periodontitis

Classification of Periodontal Flaps:

• Based on bone exposure

  • 1. Full-thickness flap

  • 2. Partial-thickness flap

• Based on location of the flap margin

  • 1. Nondisplaced flap

  • 2. Displaced flap

1. Full-Thickness Flap

• Also called a mucoperiosteal flap

• Lifting of the entire thickness of soft tissue

• Provides complete access to the underlying alveolar bone

• BLUNT instruments are used to elevate the flap in a manner quite similar to lifting the peel off an orange

2. Partial Thickness Flap:

• Elevation only of the epithelium and a thin layer of the underlying connective tissue

• Sharp instruments are used for a partial-thickness flap

Nondisplaced Flap:

• A flap that is sutured with the margin of the flap placed at its original relationship to the CEJ of the tooth

• Analogy:  the window shade goes up, window shade comes back down

Displaced Flap:

• A flap that is sutured with the margin of the flap placed at a position other than its original position in relation to the CEJ

• A displaced flap can be positioned apically, coronally, or laterally in relationship to its original position

Types of Incisions Used During Periodontal Flap Surgeries:

• Horizontal---run parallel to the gingival margin in a mesiodistal direction

  • •1. Inverse bevel incision- left photo-initial incision

  • •2. Crevicular incision –right photo-2^nd incision

  • 3. Vertical  Incision- runs perpendicular to the gingival margin in an apico-occlusal direction

    • Releases sides

Displaced Flap with a Photo:

• A flap that is sutured with the margin of the flap placed at a position other than its original position in relation to the CEJ

• A displaced flap can be positioned apically, coronally, or laterally in relationship to its original position

Types of Periodontal Surgery: Flap for Access

• Also called modified Widman flap surgery

• Provides access to tooth roots for improved root preparation

• Tissue is lifted long enough for the procedure

• After completion of the procedure, tissue is replaced at the original position

• Sutured in place (Shade up Shade down)

Special Considerations for the Dental Hygienist– Flap for Access 

• Difficult to remove all calculus deposits in pocket depths deeper than 6 mm in nonsurgical periodontal instrumentation

• Flap for access surgery allows more efficient and meticulous instrumentation of root surfaces

Types of Periodontal Surgery: Open Flap Debridement

• Similar to flap access except:

  • More extensive flap elevation

  • May displace flap margin to new location

Steps in Open Flap Debridement

1. Horizontal incisions being made to bone within the sulcus or pocket base

2. Elevation of full-thickness flap to expose tooth roots and alveolar bone

3. Periodontal instrumentation of tooth roots

Types of Periodontal Surgery: Osseous Resective Surgery

• Corrects deformities of the alveolar bone resulting from advanced periodontitis

• Main goal---to eliminate periodontal pockets

• Ostectomy---removal of the alveolar bone attached to the tooth

• Osteoplasty---reshaping the alveolar bone without removing the supporting bone

• Contraindicated in patients with severe periodontitis- may further compromise the support around the tooth

Boney Defects are…

harder to fix

Boney Defects Classification:

• 1 wall defect- 3 walls missing w/ 1 wall remaining

• 2 wall defect- 2 walls missing

• 3 wall defect- 1 wall missing w/ 3 walls remaining

  • This is the best one to have due it is the least damaged and easiest to fix!! 

Types of Periodontal Surgery:Apically Positioned Flap w/ Osseous Resective Surgery

• Combines displaced flap in the apical direction with the resective osseous surgery

• Gingival margin apical to CEJ

• Increased root exposure

• Reduced pocket depths

• Expect reasonable patient self-care and professional periodontal maintenance

• to purposefully remove gingiva to create a reduced pocket depth

Steps in Apically Positioned Flap w/ Osseous Resective Surgery:

1. Internal Bevel incision and vertical releasing incision

2. Removal of collar of soft tissue following flap elevation

3. ostectomy

4. Inspection of final bone contours after ostectomy and osteoplasty

5. Suturing

   Note that the flap margin is displaced in an apical position compared to its original position

6. Placement of periodontal dressing to stabilize the flap at its new position

Special Considerations for the Dental Hygienist:

• During surgery, it is common for the gingival margin to be positioned against the teeth in a more apical position than is originally occupied

• This exposes a portion of the root to the oral cavity

• Exposure of a portion of the root may be an esthetic concern for the patient

• Exposure of a portion of the root can lead to root caries

• Temporary dentinal sensitivity is a frequent postsurgical complaint

• Before surgery, the patient should be informed about anticipated changes in appearance and the potential for dentinal sensitivity