Surgical therapy should be seen as an adjunct to cause related therapy (point is to improve ours and pts

access)
 To facilitate removal of subgingival deposits
 To facilitate plaque control
 Recontouring of gingival +/- bony contours to achieve positive architecture
 Pocket reduction/elimination
 Periodontal regeneration

Our Goal
 ENHANCE the long-term preservation of the periodontium

The decision to do periodontal surgery is normally made at the re-evaluation visit(s) (so we know about the
pts compliance, prognosis)
 Better assessment of the teeth and gums
 Gums are healthier (easier to manipulate surgically) and there has been a reduction in inflammation
and as much healing has occurred after non-surgical treatment.
 Patient compliance can be more accurately assessed
 Once the prognosis of teeth have been confirmed.

Indications for periodontal surgery

 Non responding sites
 Increasing depths of periodontal pockets
 Presence of root grooves, furcations, concavities.
 Good oral hygiene (if pt doesn’t have good OH, healing wont be good)
 Angular bony defect (Access would be bad)

Contraindicaionts
 Patient co-operation
 Uncontrolled cardiovascular disease
 Organ transplantation l
 Blood disorders
 Hormonal disorders
 Neurologic disorders
 Smoking

Gingivectomy (used to drug induced gingival

overgrowth) Eliminate
 Excess issue
 Suprabony pocketing
 Incision type
 External bevel or internal bevel
Access surgery and osseous surgery (tend to use more flap surgery more than gingivectomy)
 Advantages of flap surgery over gingivectomy
 Rapid healing by primary intention (less post-op discomfort)
 Maximised repair potential of periodontium
 Less post-op recession
 Preserve existing keratinised tissue
 Access to bone and furcations
 Higher flexibility in technique
 Possibility to use regenerative techniques

For periodontal lesion,

We have soft tissue component (PD) and hard tissue
component (intrabony defect?).
Are we coronally repositioned flap or apically reposition flap
For the bone defect, we have different ways as well.
EG, no treatment, regeneration or bone graft

 Surgical principles
 Anaesthesia
 Incision
 Flap elevation
 Debridement
 Management of bone or tooth structure
 Flap closure
 Post-op care
Access surgery
 Allows us to move the gingiva out the way to allow visual access to the area
 Check for anatomical defects
 Root grooves
 Root fractures
 Improved access for deep sites
 Improved access for furcations
 Improved access to remove overhangs
 Pic on the right, we now have good access and the amount of bone loss in the furcation area.
Osseous surgery
 Recontouring bone
 Osteoplasty(removal of supporting bone around the tooth) /ostectomy (reshaping bone)
 Eliminate infrabony defects
 Allows the gingiva to be replaced and provide positive gingival architecture
Flap design
 The original Widman Flap
 Aimed to remove (infected) pocket epithelium and inflamed connective tissue to facilitate
debridement of the root surfaces
 Bone recontouring was recommended to achieve more ideal bone contours

Krikland flap (just incision, no vertical releasing incisions)


The modified Widman Flap (just internal bevel incision

 Adv:
 Close adaptation of soft tissues to root surface
 Minimal trauma to alveolar bone and soft CT
 Less exposure of root surfaces/recession

Osteoplasty/Ostectomy
 Osteoplasty
 Recontouring of alveolar bone
 Purpose is to create a physiological bone contour with removing supporting bone
 Ostectomy
 Removal of bone which was supporting the tooth
 Often necessary for pocket elimination
Comparing surgical/non-surgical
 Surgical is good for higher PD (>5mm), but in a long term, there outcome for treatment become
smaller.
 Serino et al. (2001) reported that in patients with advanced periodontal disease, surgical therapy
provided better short and long-term reduction of pocket depth and may lead to fewer subjects
requiring adjunctive additional therapy
Biologic Width and Papillas
 Biological width
 Dimension of the soft tissue which is attached
to the portion of the tooth coronal to the crest
of the alveolar bone
 Need to anesthetize the pt
 Check the PD
 Then, push down through the CT
attachment to hit the bone
 This no. minus pocket PD.
 Usually we don’t have to do this, unless we are considering crown lengthen
 When we combine the biologic width with the pocket depth, we get an idea of the distance
required between the restorative margin and the alveolar crest
 For most patients this would mean a distance of around 3-5 mm between the restorative
margin and the bone crest
 There will be problems if the restorative margin placed sungingivally.
 Studies shown that pt with subgingival margins basically lost attachment over the 1 st
few years.
 Cuz the gingiva tissues are trying to move away from the restoration
 Might end up recession or PD
 Restoration is difficult
 Isolation (control of material during placement
 Moisture control (contamination of the cavity prep & decreased bonding and
microleakage)
 Laser might help for bleeding issues
 BUT there is potential risk to damage periodontal support

Surgical crown lengthening (usually for excessive gingival express)

 Indications
 Excessive gingival display and short clinical crowns
 Need for greater restorative height.
 Exposure of subgingival fracture lines.
 Exposure of subgingival caries.
 Contraindications
 Vertical maxillary excess and normal clinical crowns
 Where crown lengthening would compromise adjacent teeth functionally or aesthetically
 Unfavourable crown to root ratio after crown lengthening
 Aesthetics
 Issues
 Potentially we are creating a localized periodontal defect
 Infrabony defects may be difficult to clean
 Potential for increased localised disease in the area
  To overcome this, we can consider crown lengthening surgery by
 Recontouring bone and soft tissue to allow for equal or supragingival restorative margins
 Provide cleansable areas and positive gingival architecture
 RMB
 Surgical crown lengthening involves the removal of bones
 So, this equates to loss at attachment at the sites and adjacent sites as well

Papilla

 5 mm or less = the distance from CEJ and bone level, we get papilla present 100% of the time.
 ≤5mm – the papilla was present almost 100% of the time
 6mm – the papilla was present 56% of the time
 ≥7mm – the papilla was present 27% of the time or less

Implant and papillas

 For a single implant, the papilla height is generally determined by the crestal bone of the adjacent
tooth
 Even more difficult to reconstruct papilla between two implants
 We don’t have fibres from adjacent teeth to support the implant
 measured the height of soft tissue to crest of bone between two adjacent implants. The authors
found that the mean height of tissue of the papilla between two adjacent implants was 3.4mm, a
deficiency of 1 to 2mm of what is needed to duplicate the interproximal papillae of the adjacent
teeth

Management of papillas:
 Non-surgical
 prosthetic masking by apically lengthening the contact area between the teeth or use of gum
coloured acrylic/composite
 Surgical
 Several case reports have been published (Beagle 1992 and Azzi et al. 1998), however the
predictability and long-term data of these surgical techniques for reconstruction of deficient papillae
has not been documented
 PT can always consider a crown in the future after the perio condition is stable, but gaining a full
papilla height is hard