Definitions

 Attachment loss. It is the absolute measure of the loss of periodontal support. It is measured from the junctional epithelium to the C.E.J.

 Curettage. Cleaning of the inside surface of the free gingiva that forms the outer wall of the gingival sulcus.

 Root planing. Cleaning of the calculus and the infected cementum, within the gingival sulcus.

 Infrabony pocket. Periodontal pocket whose bottom is situated coronal to the crest of the surrounding alveolar bone.

 Pseudopocket. Pocket whose bottom is at the C.E.J., and whose increased depth is due to gingival hyperplasia rather than to loss of periodontium.

 Root planing. Cleaning of the root surface inside the gingival sulcus.

 Subgingival scaling. Combination of curettage and root planing.

 Suprabony pocket. Periodontal pocket whose bottom is situated apical to the crest of the surrounding alveolar bone.

Before performing any periodontal surgery be sure the client can carry out daily home care. If the client is unable or unwilling to do so, most of your procedures will fail or produce only temporary improvements. Periodontal surgery is performed only after a complete prophylactic cleaning. Always, always leave at least 2 mm of attached gingiva at the end of the procedure.

Basic Technique

Subgingival Scaling

This procedure is composed of two parts: root planing and curettage. Root planning is the removal of infected cementum on the surface of a root. It is performed using a sharp curette. Curettage is the removal of the inflamed connective tissue on the inside of the gingival sulcus. It is also performed using a curette. Both procedures are often referred to as curettage. These are the most common procedures used in periodontal therapy. They are most effective when dealing with pockets less than 5mm deep.

Techniques Involving Tissue Resection

Gingivectomy

(Def. elimination of gingival pockets by resection of gingival tissue from the inside of the pockets). The oldest method still in use.

External Bevel Gingivectomy

 Indications: 1. Shallow suprabony periodontal pockets. 2. Moderate gingival hyperplasia. 3. Asymmetrical gingival topography. 4. Soft tissue impaction causing a dental inclusion.

 Contraindications: 1. Infrabony pockets. 2. Pockets extending beyond the mucogingival junction, or in cases where there remain very little attached gingiva. 3. Inflamed tissues. 4. When the procedure compromises the esthetic.

 Technique: Measure the pocket with a probe, mark the outside of the gingiva with the point of the probe, align the scalpel blade at a 45% angle with the surface of the root, and cut. This leaves a pocket less than 2 mm deep.

 It is an easy operation, but used only in the presence of pseudopockets (gingival hyperplasia), in veterinary dentistry. Its major disadvantage is an important loss of gingiva.

Internal Bevel Gingivectomy

It is actually an incision that can be combined with other periodontal treatments.

 Indications: 1. Suprabony pockets. 2. To facilitate wound healing. 3. Moderate gingival hyperplasia. 4. Asymmetrical gingival topography. 5. Soft tissue impaction causing a dental inclusion.

 Contraindications: 1. Infrabony pockets. 2. Pockets with little attached gingival left. 3. Very inflamed tissue. 4. Need to access bone support. 5. When it compromises the esthetics.

 Advantages: 1. Facilitates wound closure. 2. Diminishes post-op complications.

 Disadvantages: Harder procedure than the external bevel gingivectomy.

 Technique: Measure the pocket depth with a probe, mark the gingiva, align the scalpel blade to have it stop on the crestal bone, cut and remove the band of granulating connective tissue with the help of a curette.

Apically Positioned Flap without Osseous Reduction

This technique requires one or two vertical releasing cuts, past the mucogingival margin, with periosteal elevation of the flap.

 Indications: 1. Supra and infrabony pockets. 2. Subgingival root caries. 3. Crown lengthening. 4. Need to increase epithelial tissue coverage.

 Contraindications: May cause cosmetic problems.

 Advantages: 1. Decreases pocket depth. 2. Facilitate wound healing. 3. Allows access to bony support, to roots, to furcations, and to subgingival caries.

 Disadvantage: Limits the treatment of infrabony pockets.

 Technique: Same steps as before plus vertical releasing incisions and elevation of a flap. Cleaning of the granulating connective tissue with a curette. Apical repositioning of the flap with elimination of the pocket. Suturing to reattach the flap.

Apically Positioned Flap with Osseous Reduction

 Indications: 1. Moderate infrabony pockets. 2. Subgingival root caries. 3. Asymmetrical gingival topography. 4. To facilitate restorative processes. 5. To facilitate cleaning.

 Contraindications: 1. Roots too short for the size of the crown. 2. Esthetic considerations. 3. Furcation exposure. 4. Excessive mobility of the tooth. 5. Inadequate amount of gingiva. 6. Too important a loss of attachment.

 Advantages: 1. Reduces pocket depth. 2. Preserves gingiva. 3. Allows access to bony support, to roots, to furcations, and to subgingival caries. 4. Facilitates dental restorations. 5. Facilitates exposed root surfaces examination.

 Disadvantages: 1. Complex technique. 2. Possibility of removing too much periodontal attachment.

 Technique: Same steps as before except that when the flap has been elevated, an osteoplasty is performed to redefine the osseous margins.

Root Resection

 Indications: 1. Important bone loss around one or several roots. 2. Class II or III furcation exposures. 3. Adjacent tooth roots too close. 4. Fracture, perforation, caries, or resorption of one or several roots. 5. When endodontic treatment of a root seems impossible.

 Contraindications: 1. Insufficient bony support around the remaining roots. 2. Endodontic treatment of the remaining roots is impossible. 3. When the remaining roots are useless. 4. When the remaining roots cannot be restored.

 Advantages: 1. Preservation of part of the tooth. 2. Easy access for cleaning. 3. Decrease in the morbidity of the tooth.

 Disadvantages: 1. Complex technique. 2. Difficult case selection.

 Technique: Finish the endodontic treatment of the tooth before amputating the root. Make sure that you close the gingiva after extracting the root. Ensure that the area will be easy to keep clean.

Tissue Attachment

Definition of the terms used in this section.

 Reattachment: Union of connective tissue with the surface of the root on which live periodontal tissue is present.

 Repair: Healing of a wound without completely repairing architecture or function of the part in question (i.e., formation of long junctional epithelium).

 New attachment: Union of connective tissue with the surface of a denuded root. This can happen with or without the formation of new cementum.

 Regeneration: Reconstitution of a damaged or lost part.

Curettage (Removal of Pocket Epithelium)

It removes infiltrated granulating connective tissue, but causes of pronounced tissue shrinkage. It is adequate for 3 to 5 mm deep pockets. Deeper pockets are difficult to clean and require the creation of flaps. The flaps heal by way of long junctional epithelium formation. Curettage is not indicated if the goal of the procedure is to obtain a new attachment. Always combine this technique with root planning.

Modified Widman Flap

 Indications: 1. Moderate to deep periodontal pockets. 2. Preservation of esthetic. 3. Improved access to root surfaces and supporting bone.

 Contraindications: 1. Shallow pockets (less than 3 mm). 2. If in need of new attachment.

 Advantage: Yields a comfortable, functional, healthy dentition.

 Disadvantage: Heals by repair.

 Technique: First cut in an internal sharp bevel directed toward the crestal bone. Second cut, intrasulcular. Partially elevate the flap. Third cut, at right angle with the root surface, at the base of the sulcus.

As mentioned above, repair is done by the formation of a long junctional epithelium. Research done on animals where they use a ligature, around the base of the tooth, to create a periodontitis, shows no difference in the formation of pockets whether the attachment is long or short (normal) junctional epithelium.

Regenerative Methods

Autografts

They act via osteoproliferative, osteoconductive, and osteoinductive mechanisms. Autografts are the only ones to be osteoinductive. The results are good when dealing with infrabony defects (normally more than 50% filling of the defects), but they are less successful with crestal bone or furcation defects.

Freeze-Dried Allografts

Satisfactory for filling infrabony defects but have minimal success with furcation exposures. A mixture of autograft and freeze-dried allograft yields better results with furcation exposures.

Decalcified Freeze-Dried Allografts

Sometimes allows regeneration of periodontium during infrabony defects treatment. The material is inductive, conductive, resorbed, and replaced.

Implants

 Tri calcium phosphate (TCP. Ceros 82, Synthograft, and others). Resorbable, osteoproductive, good as filler but is of no use for regeneration work.

 Hydroxyapatite (HA, Alveograf, Bio-Oss, Calcitite, Ceros 80, Interpore 200, Osprovit, Periograf, and others). Not resorbable, otherwise similar to TCP.

Guided Tissue Regeneration

(GTR) it is a whole different story!