Surgical Periodontal Treatment
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Periodontal surgery aims to eliminate the cause of periodontal disease, restore proper function, and establish a periodontal environment that will promote the long-term maintenance of health. Hard and soft-tissue defects can be corrected and periodontal structures regenerated through various surgical techniques. Periodontal surgery is useful for allowing proper access in order to visualize the roots of teeth, facilitating adequate plaque and calculus removal. Surgery can often be avoided by focusing on scaling, root planing, and an improvement in oral hygiene.
A gingivectomy is a surgical procedure that focuses on the removal of gingival tissues coronal to the base of the pocket. This procedure can be used to eliminate suprabony pockets, gingival enlargements, or suprabony periodontal abscesses. A scalpel is used to make a beveled incision apical to the base of the pocket creating a bevel/contour at the coronal margin of the surgical wound. Alternatively, electrodes or lasers can be used. The area is debrided, and a surgical pack may be placed. Healing is by secondary intention. A gingivectomy procedure is not used in cases where:
- Bone shape or morphology needs to be modified.
- Aesthetics would be negatively affected (e.g. anterior maxilla).
- There is an inadequate amount of attached gingiva present.
- The base of the pocket is located apical to the muco-gingival junction.
Gingivoplasty involves the reshaping of the gingiva in order to fix defects and re-establish proper form and function. Gingivoplasty is performed to treat deformities such as gingival clefts/craters or gingival enlargements. Gingivoplasty differs slightly from gingivectomy as it only involves partial removal of the gingival tissues, and focuses on reshaping to provide a more physiological tissue contour. It is not performed to reduce or eliminate periodontal pockets.
Resective osseous surgery can be accomplished through:
- Osteoplasty – the reshaping and/or recontouring of non-supportive bone (no Sharpey’s fiber attachment). The removal of a bony prominence or spur is an example of osteoplasty.
- Ostectomy – the removal of supportive bone surrounding a tooth in an attempt to eliminate an adjacent periodontal pocket. The removal of alveolar bone may weaken the support of an adjacent tooth. Peaks of bone (Widow’s peaks) may remain at the line angles, and if left, will predispose the patient to recurrence of periodontal pockets.
Hemisection (bicuspidization) refers to the vertical sectioning of a tooth, often through the furcation. Root amputation refers to the separation of an individual root from the remaining tooth structure. The compromised part of the tooth is removed and the remaining tooth structure is recontoured and restored. Endodontic treatment is likely required before root removal. The teeth that are most frequently involved are maxillary first and second molars.
GINGIVAL GRAFT
Autogenous free gingival graft (FGG) utilizes donor attached gingiva harvested from an edentulous region of alveolar bone, tuberosity, or the palate. The graft is transplanted onto a viable connective tissue bed. The graft does not carry its own blood supply but instead relies on the tissue bed for nutrients. In order to permit diffusion and vascularity, the free gingival graft has to be defatted. The ideal thickness for the free gingival graft is 1 to 1.5 mm. Autogenous free gingival grafting can be used to prevent further recession, to widen the attached gingiva, or to cover non-pathologic defects such as dehiscences or fenestrations. Post-operatively shrinkage occurs, which is most pronounced in the first 4-6 weeks. The success of the graft is dependent on survival of the connective tissue.
Healing of a free gingival graft begins with the diffusion of nutritive fluids from the surrounding tissues (recipient bed, adjacent gingiva/mucosa). 2-3 days after surgery capillaries from the recipient bed migrate into the graft tissue (revascularization). The epithelium undergoes degeneration and dies (necrotic slough), replaced by new epithelium from the borders of the recipient site. The nature of the connective tissue bed determines the nature of the new epithelial tissue. Failure is most commonly due to vascular supply disruption or infection.
Autogenous free mucosal graft (subepithelial connective tissue graft (CTG)) uses subepithelial connective tissue (without an epithelial covering) to gain root coverage in cases of gingival recession. It is known that the connective tissues carry the genetic “messaging” required for overlying epithelium to differentiate into keratinized gingiva, which is why the donor site has to be a keratinized zone of epithelium. This procedure uses the same donor site (palate) as the free gingival graft but the gingival epithelium is not used. A connective tissue graft can be more predictable for root coverage when compared to a free gingival graft and may be able to improve aesthetics or treat hypersensitivity caused by gingival recession. The surgical procedure is more challenging compared to free gingival grafting, and is often utilized in the canine area since it produces a better aesthetic result and better root coverage when compared to free gingival graft.
A Pedicle graft remains attached to the donor site to maintain its own blood supply, making it superior from an aesthetic standpoint, but less versatile since it can only be moved a short distance. A pedicle graft allows for the predictable correction of gingival defects, with relatively minor postoperative discomfort. It is only useful for localized recession defects with adequate proximal donor sites. Optimally there would be an area of narrow gingival recession (or similar defect) adjacent to a wide band of attached gingiva that can be used as a donor site. Many gingival defects will not have an appropriate donor site adjacent.
Techniques for root coverage include:
- Free gingival autograft.
- Connective tissue autograft.
- Pedicle autografts.
- Guided tissue regeneration techniques.
- Laterally positioned (displaced) flap.
- Coronally displaced flap.
- Subepithelial connective tissue graft.
Techniques for widening the attached gingiva include:
- Free gingival autograft.
- Free connective tissue autograft.
- Apically positioned flap.
FRENOTOMY & FRENECTOMY
A frenulum (or frenum) is a small band of tissue that secures the motion of a mobile organ in the body. Frena located in the oral cavity include the labial frena, lingual frenum, and buccal frena. A frenotomy, also known as a frenulotomy or frenulectomy, is the procedure in which a frenum is cut. A frenectomy is a procedure to surgically remove a frenum. A frenotomy or frenectomy can be utilized for the following clinical cases:
- Midline diastema with a low frenum attachment.
- Localized gingival recession with high frenum attachment.
- Ankyloglossia (tongue tie).
- Interference with denture fabrication (dislodged dentures).
Most surgical sites are covered with a periodontal pack which is placed to protect the surgical site, improving patient discomfort and maintaining tissue position. It may also help to support any mobile teeth during healing. A surgical dressing is kept in place by interlocking in dental spaces. Coe-Pak is a widely used non-eugenol dressing that consists of Zinc oxide, gum (cohesion), lorothidol (antifungal), colophony resin, and chlorothymol (antibacterial). Zinc oxide-eugenol packs are also used. Mechanisms of healing seen following periodontal treatment include:
- Regeneration – growth and differentiation of the same tissue type.
- Repair – healing via scar formation.
- New attachment – embedding of new PDL fibers and the attachment of gingival epithelium to a previously diseased root surface.
Reflection of a full-thickness flap results in superficial bone necrosis. Immediately after periodontal flap is sutured a clot forms that connects the flap to the tooth and alveolar bone. The clot contains a fibrin network and various cells including PMNs and erythrocytes. 1-3 days after surgery osteoclastic resorption is active, reaching peak activity at 4-6 days. Epithelial cells begin to migrate over the margins of the flap and the clot is slowly replaced by granulation tissue. 1 week after surgery an epithelial attachment is established, consisting of hemidesmosomes and a basal lamina. Within 1 month, the gingival crevice is lined with epithelium.
MODIFIED WIDMAN FLAP
The modified Widman flap is a surgical variation of the replaced flap procedure. This full-thickness flap is used to facilitate open flap debridement by allowing access to the underlying bone and root surfaces. A modified Widman flap design is useful for pocket lining removal, but is not used for apical flap repositioning or pocket depth reduction.
Three incisions are made, the flap raised, excess tissue removed, and the surgical area cleaned and inspected before the flap is repositioned. There are no relieving incisions required. The flap is only reflected 1-2mm from the alveolar crest and is not reflected beyond the mucogingival line. The main advantage of the modified Widman flap surgery is the close postoperative adaptation of healthy tissues to all tooth surfaces which promotes healing. The clinical procedure as follows:
- Internal bevel incision:
- Parallel to the long axis of the tooth, aiming for the alveolar process.
- Starting 0.5mm to 1mm away from the gingival margin.
- A Bard Parker #11 scalpel is commonly used.
- Scalloping follows the gingival margin and should be exaggerated on the palatal aspect in order to improve flap adaptation.
- Crevicular incision (sulcular incision):
- Made around the neck of each tooth from the depths of the gingival pocket to the alveolar crest.
- Flap is elevated
- Interdental incision (super-crestal incision):
- Follows the contour of the alveolar crest and the interproximal septum as much as possible.
- The loose collar of gingival tissue is removed with a curette.
- Tissue tags, granulation tissue, and external buildup is cleaned. Scaling and root planing as necessary. Flaps are repositioned and secured with continuous, independent sling sutures in both the facial and palatal areas.
UNDISPLACED FLAP
The undisplaced flap (un-repositioned flap) is similar to a modified Widman in that it allows access for proper instrumentation, but also includes an internal bevel gingivectomy which removes the pocket wall and reduces/eliminates the pocket. The pockets are measured with the periodontal probe and depth of pockets are marked externally by “bleeding points”. Pocket marking forceps may be used. The clinical procedure as follows:
- Internal bevel incision
- Both the buccal and palatal side.
- Follows the scalloped outline of the bleeding marks on the gingiva.
- Usually extended to the point apical to the alveolar crest, depending on the thickness of the tissue. The thicker the tissue, the more apical the ending point.
- Crevicular incision (sulcular incision):
- Made around the neck of each tooth from the depths of the gingival pocket to the alveolar crest.
- Flap is elevated.
- Interdental incision (super-crestal incision):
- Follows the contour of the alveolar crest and the interproximal septum as much as possible.
- The loose collar of gingival tissues is removed with a curette.
- Tissue tags, granulation tissue, and external buildup is cleaned. Scaling and root planing as necessary. Flaps are repositioned and sutured with continuous, independent sling sutures in both the facial and palatal areas.
APICALLY POSITIONED FLAP
The Apically Positioned Flap (APF) is a full thickness mucoperiosteal flap procedure used to achieve pocket elimination and to widen the zone of attached gingiva. A split thickness (mucosal) flap can be used. APF maintains an adequate zone of keratinized tissue when compared to a technique where tissue is removed (gingivectomy). The advantages of APF technique include minimal postoperative bone loss and controlled postoperative position of the gingival margin. An APF is not recommended for patients who present with a thin gingival biotype, and may cause unaesthetic root exposure, hypersensitivity, furcation exposure and increase the risk of root caries. The clinical procedure as follows:
- Internal bevel incision:
- Parallel to the long axis of the tooth, aiming for the alveolar process.
- Starting 0.5 mm to 1 mm away from the gingival margin.
- A Bard Parker #11 scalpel is commonly used.
- Usually extended to the point apical to the alveolar crest, depending on the thickness of the tissue. The thicker the tissue, the more apical the ending point.
- Crevicular incision (sulcular incision):
- Made around the neck of each tooth from the depths of the gingival pocket to the alveolar crest.
- Flap is elevated.
- Interdental incision (super-crestal incision):
- Follows the contour of the alveolar crest and the interproximal septum as much as possible.
- The loose collar of gingival tissues is removed with a curette.
- Vertical incisions:
- Extend from the gingival margin past the mucogingival line.
- Palatal mucosa has no mucogingival junction so the flap cannot be displaced. Palatal flap margins need to be trimmed to the proper length to facilitate apical “placement”.
- A full thickness (mucoperiosteal) or split/partial thickness (mucosal) flap is elevated.
- Tissue tags, granulation tissue, and external buildup is cleaned. Scaling and root planing as necessary. Flaps are apically repositioned at the crest of bone to ensure no pocket remains following surgery, and secured with continuous, independent sling sutures in both the facial and palatal areas.
SURGICAL CROWN LENGTHENING
The Apically Positioned Flap (APF) is commonly selected for surgical crown lengthening. A crown lengthening procedure can be utilized when the clinical crown height needs to be increased. Surgically removing alveolar bone and gingiva leads to more coronal structure exposure. Crown-lengthening can involve:
- Gingivectomy.
- Gingivoplasty.
- Apically positioned flaps.
- Osseous resection.
Crown lengthening is most often implemented in cases where a tooth has been badly damaged by trauma or caries. Periodontal crown lengthening can be used to :
- Improve aesthetics in cases of delayed passive eruption.
- Re-establish proper biological width.
- Increase the amount of usable coronal structure.
- Facilitate the length required to produce a ferrule for prosthetic management.
DISTAL WEDGE PROCEDURE
The Distal Wedge Procedure (proximal wedge procedure) involves the removal of a “wedge” of excess tissue, most often distal to the last tooth in the maxillary tuberosity and mandibular retromolar triangle regions. Excessive, bulbous or movable soft tissue in these areas can frustrate proper oral hygiene. The distal wedge can be used independently or in combination with flap access for crown lengthening, apically positioned flap, osseous surgery, or regenerative periodontal therapy. There are many variations regarding incision outline and suturing technique, but three classic distal wedge incision designs are:
- Square
- Triangular
- Linear
Following surgery, the root surface can be treated with various substances, including citric acid, tetracycline, EDTA, fibronectin, and growth factors. Sometimes referred to as “biomodification”, these treatments aim to improve the healing of attached gingival tissues. Growth factors that can be used include:
- Platelet-derived growth factor (PDGF).
- Insulin-like growth factor (IGF).
- Basic fibroblast growth factor (bFGF).
- Bone morphogenetic proteins (BMPs).
- Transforming growth factor, aka tumor growth factor (TGF).
GUIDED TISSUE REGENERATION
Guided Tissue Regeneration (GTR) is used to facilitate wound healing while simultaneously preventing non-desirable, faster tissues from migrating into a wound. A nonresorbable or resorbable membrane barrier inhibits invasion of long junctional epithelium and gingival connective tissue, allowing cells from the periodontal ligament and bone to repopulate the periodontal defect. Vertical or intra-bony defects are good candidates for GTR. The prognosis for the procedure is poor in cases with poor oral hygiene, excessive mobility, or horizontal bone loss. GTR uses a variety of barrier membranes to cover the bone and periodontal ligament prior to flap replacement, including:
- Expanded polytetrafluoroethylene (ePTFE) membrane (e.g. Gore-TEX).
- Collagen – Type I and III collagens derived from porcine, bovine, and human sources.
- Silk fibroin membrane – a structural protein of silk material.
- Synthetic polymers – aliphatic polyesters such as polylactic acid (PLA) and polyglycolic acid (PGA). Synthetic polymers degrade by enzymatic hydrolysis.
Collagen membranes tend to be the most widely used, but are expensive, exhibit weak tensile strength in wet conditions, and are prone to rapid degradation. Most synthetic polymers are poorly biodegradable and require removal after bone regeneration.