Surgical Periodontal
Therapy
By: Dr Haaris Scheeraz Khan
Introduction
Surgical therapy is considered when non-surgical therapies do not resolve the
issue. The flap technique is often used during surgery. After surgery, post-
operative plaque control is essential.
● Phase II Periodontal Surgery
● Regenerate lost tissues
● Correcting anatomic conditions that favor periodontal disease
● Esthetics
● Implant placement
Surgical Pocket Therapy
Surgical pocket therapy can be used to
● Gain access to the diseased root
surface to ensure calculus removal
located subgingivally
● Reduce and eliminate the depth of
periodontal pocket
Flap Design
● Wider base to ensure adequate
blood supply
● Incisions over intact bone, not
over bony defects or eminences
● Rounded corners
● Vertical releases at line angles
● Avoid vital structures
● Post-operative plaque control is
the most important procedure
after periodontal surgery
Flap Thickness
● Split or partial thickness (mucosal) flap
– Gingiva/mucosa, submucosa
– Used for mucogingival surgery because exposing the bone is unnecessary
● Full thickness (mucoperiosteal) flap
– Gingiva/mucosa, submucosa, periosteum
– Used for osseous surgery and periodontal regeneration to permit primary closure
as well as in apically repositioned flaps
• Whenever alveolar bone is exposed like in full thickness flaps, expect about 1mm of
bone resorption and remodeling
Flap Techniques
1. Modified Widman Flap
2. Un-displaced Flap
3. Apically displaced Flap
4. Papilla Preservation Flap
Modified Widman Flap
Offers the possibility of establishing an intimate postoperative adaptation of
healthy connective tissue to the tooth surface.
Provides access for adequate instrumentation of root surfaces.
Undisplaced Flap
Currently the undisplaced flap may be the most frequently performed type of
periodontal surgery.
Apically displaced flap
The apically displaced flap is selected for cases that present with a minimal
amount (< 3mm) of attached gingiva.
Papilla Preservation Flap
• Conventional flap= split the papilla
• Papilla preservation flap= preserve the
papilla
Distal Terminal Molar Flap
Pocket reduction distal to terminal molars
• Maxillary= full thickness flap with parallel incisions
• Mandibular= full thickness flap with V-shaped incisions
Full thickness flap
Involves three horizontal incisions:
– Internal or reverse bevel—about 1mm from the gingival
margin, removes pocket lining yet conserves outer gingiva
– Sulcular or crevicular—through base of pocket to alveolar
crest
– Interdental or interproximal—removes the collar of tissue
around the tooth you created with the first two incisions
• Modified Widman flap involves these three incisions and
provides access to subgingival areas for debridement with the
goal of new attachment
• Apically repositioned flap requires additional vertical releasing
incisions made beyond the mucogingival junction in order to
attain pocket reduction
Periodontal Pack
• Usually consists of ZOE
• Leave in place for 1 week
• Packs are placed to protect the surgical
wound, minimize discomfort, maintain tissue
placement, and help prevent post-op bleeding
• Packs do NOT enhance healing
Incisions
Horizontal Incisions Vertical Incisions
1. Internal Bevel 1. Single end
2. Crevicular 2. On both ends
3. Interdental
Horizontal Incisions
● Directed along gingiva mesially or distally
● Envelope flap created
Vertical Incisions
● Oblique releasing incisions
● Can be used on one or both ends of
horizontal incision depending on
design and purpose of flap
Gingival Surgery
• Gingivectomy= excision of gingiva to eliminate suprabony pockets or gingival
enlargements
• Gingivoplasty= excision of gingiva to reshape tissue deformities
• Healing is by secondary intention because there is no tissue to approximate
GINGIVECTOMY
INDICATIONS CONTRAINDICATIONS
Elimination of suprabony pockets Narrow zone of keratinized tissue
Infrabony pockets
Elimination of gingival enlargements When osseous surgery or inductive
techniques are recommended
Elimination of suprabony periodontal Systemic problems (e.g uncontrolled
abcess diabetes, blood dyscrasias etc)
Healing after Gingivectomy
The initial response after gingivectomy is the formation of a protective surface
blood clot. The clot is replaced by granulation tissue.
● In 24 hours, an increase occurs in new connective tissue cells.
● After 12 to 24 hours, epithelial cells at the margins of the wound begin to
migrate over granulation tissue, thereby separating it from the contaminated
surface layer of the clot. Epithelial activity at the margins reaches a peak after
24 to 36 hours.
● After 5 to 14 days, surface epithelialization is generally complete.
● Complete epithelial repair takes about 1 month. Complete repair of
connective tissue take about 7 weeks
Gingivoplasty
Recontouring the gingiva in the absence of
pockets
Mucogingival Surgery
• Free gingival graft= widen
band of keratinized tissue
• Connective tissue graft= root coverage
• Frenectomy= complete removal of frenum
• Frenotomy= incision of frenum
• Vestibuloplasty= deepen the vestibule
Free Gingival Graft
• No minimum width of attached gingiva has
been established, but 2 mm is a good amount
• Attached Gingiva Helps Enhance Plaque
Removal (less painful brushing), improves
esthetics, and reduces inflammation around
abutment teeth and implants
• Ideal thickness of graft is 1-1.5mm
• A “free” graft by definition is transplanted
without a nourishing blood supply so it must
undergo revascularization from the recipient bed
Connective Tissue Graft
Harvest the inner connective tissue only and not the epithelium so it is less painful
for patients during healing
• Donor sites should always have enough attached gingiva
• Palate is most common donor site for both FGG and CTG
Osseous Surgery
Visualization of bony architecture allows clinician
to determine the types of bony defects that are
present and the extent of those defects
• Positive architecture= interproximal bone is
coronal to radicular bone, normal ideal alveolar
bone morphology
• Flat architecture= interproximal and radicular
bone are at same height
• Negative architecture= interproximal bone is
apical to radicular bone
Osseous Surgery
• Ostectomy= removal of supporting bone
• Osteotomy= removal of non-supporting bone
• After ostectomy, peaks of bone often remain at the line angles called widow’s
peaks which predispose to periodontal pockets in these areas
Periodontal Regeneration
Regeneration= completely restore architecture and
function
• Repair= not completely restore architecture and
function, involving healing by scar or formation of
long JE
• Reattachment= reunion of epithelial and connective
tissue with root surface after incision or injury
• New attachment= embedding of new PDL fibers into
new cementum that has been previously deprived of
its original attachment
Bone Graft Materials
• Autograft= from yourself
• Allograft= from another human, usually
cadaver
• Xenograft= from another animal, usually cow
• Alloplast= synthetic or inorganic
• Osteoconductive= scaffold
• Osteoinductive= convert neighboring
progenitor cells into osteoblasts
• Osteogenic= make bone
Periodontal Surgery Summary
• Additive • Subtractive
– Periodontal – Resective osseous
regeneration surgery
– FGG – Gingivectomy
– CTG – Apically positioned flap
– Coronally advanced flap
REFERENCES
● Carranza’s Clinical Periodontology
● https://m.youtube.com/watch?v=ewjt-8MRbxY
● Slide Share
● Google Images
THANK YOU!
