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Periodontology 2000, Vol.

25, 2001, 89–99 Copyright C Munksgaard 2001


Printed in Denmark ¡ All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

Surgical periodontal therapy


H OM- L AY W ANG & H ENRY G REENWELL

Periodontal surgery in the provided the data on which our current knowledge
21st century base is built. The more sophisticated studies of the
future will derive their improved designs from the
Periodontal therapy is directed at disease preven- context of this information.
tion, slowing or arresting disease progression, re- The Michigan studies began as a comparison of
generating lost periodontium, and maintaining curettage and pocket elimination procedures (54).
achieved therapeutic objectives. A variety of differ- Pocket elimination was defined as gingivectomy or a
ent treatment techniques have been used includ- flap procedure with or without osseous recon-
ing subgingival curettage, gingivectomy, modified touring. Over the years the comparison expanded to
Widman flap, and full- or split-thickness flap pro- include modified Widman flap and scaling and root
cedures with or without osseous recontouring. The planing. Initially the treatments were compared in
best surgical approach remains controversial, al- groups, but this quickly evolved to a split-mouth de-
though the results of longitudinal clinical trials has sign, which afforded better control over the many
highlighted the advantages and disadvantages of variables that can affect treatment outcome.
each technique. Another feature of the Michigan studies was data
More than 30 years have passed since the first re- stratification based on the probing depth at initial
port of a long-term comparison of periodontal treat- examination: 1 to 3 mm, 4 to 6 mm, and 7 mm or
ments. Prior to that time, treatment was based on greater. Results were also compared based on tooth
deductive reasoning and empirical observations. type: maxillary molars, mandibular molars, maxillary
Ramfjord et al. sought to change the rationale for premolars, mandibular premolars, maxillary an-
periodontal therapy to one that was inductively de- teriors and mandibular anteriors. Data were re-
rived and scientifically founded on prospective, ported as means, which were either full mouth or
long-term data (10, 27, 28, 50, 51, 54). As a pioneer, stratified by initial probing depth. In general small
Ramfjord challenged many long-held dogmas and differences were found between treatments, between
introduced new concepts into clinical periodontal initial probing depth strata or between tooth types.
research. From a clinical standpoint the differences were in-
Ramfjord et al. proposed attachment level change significant, however, the trends did reveal some dis-
as the primary outcome variable to assess and com- tinctions.
pare the effect of periodontal treatments (10, 27, 28, Curettage, scaling and root planing and modified
50, 51, 54). Loss of attachment was considered the Widman flap produced slightly better attachment
best measure of disease progression. How well level results, while pocket elimination procedures
attachment change has served as a primary outcome gave the greatest probing depth reduction. Different
variable will be discussed in more detail later in this tooth types responded similarly to the treatments;
chapter. however, molars showed slightly less favorable re-
The longitudinal studies comparing surgical treat- sults. Teeth with initially shallow probing depths
ments undoubtedly represent some of the most im- tended to lose a small amount of attachment due
portant clinical research ever performed in peri- to treatment, while teeth with initially deep probing
odontics. They have direct clinical relevance and af- depths showed the greatest attachment gain and
fect the way we practice on a daily basis. There are probing depth reduction.
seven main centers that have conducted these The Göteborg studies incorporated different de-
studies: Michigan, Göteborg, Minnesota, Wash- sign features than the Michigan studies and conse-
ington, Aarhus, Tucson and Nebraska. Each group of quently reported slightly different results (29–35, 42–
studies has made its own unique contribution and 44, 55, 59). Lindhe & Nyman hypothesized that even

89
Wang & Greenwell

advanced cases of periodontitis could be cured if op- The Washington studies were unique in strictly
timum plaque control was achieved (29). This meant defining osseous surgery as designed to establish
patients unable to maintain a plaque-free dentition positive, scalloped architecture (45, 56). Apically po-
were not included in the study and that frequent sitioned flap without osseous recontouring, termed
professional toothcleaning, often every 2 weeks, was flap curettage, was compared to apically positioned
provided. In the early studies treatments were tested flap with osseous recontouring. Osseous recon-
in separate groups. touring led to slightly more attachment loss, but
Surgical techniques tested included: gingivectomy, greater probing depth reduction, than flap curettage.
modified Widman flap with and without osseous re- The authors concluded that the osseous recon-
contouring, and apically positioned flap with and touring was more effective in reducing pockets and,
without osseous recontouring. All techniques halted therefore, in controlling inflammation than flap
loss of attachment, but the greatest gain of attach- curettage.
ment was achieved when osseous resection was The Tucson studies differed from previous re-
avoided and soft tissue was sutured to completely ports in that they were conducted in a private
cover alveolar bone (29, 43, 44, 55). No study to date practice, rather than a university, setting (4, 5, 26).
has shown that plaque is the cause of periodontitis, Becker et al. compared scaling and root planing,
but these studies certainly demonstrated that with modified Widman flap and, again, utilized a
no plaque there is no disease progression. strictly designed protocol for osseous surgery. Over
Later Göteborg studies utilized a split-mouth de- the term of the study minimal differences were
sign and limited the comparison to scaling and found between procedures. This confirmed the
root planing and modified Widman flap (33–35). findings of the university studies and demon-
These studies reported attachment level changes strated that similar results could be achieved in a
and probing depth reductions similar to that found private practice setting.
by Ramfjord et al. Critical probing depths for scal- The Nebraska studies are the most recent long-
ing and root planing and modified Widman flap term reports and include numerous distinctive de-
were identified (33). Values above the critical prob- sign features (1, 15–25). Firstly, a coronal scaling
ing depth responded with gain of attachment group was included. So many of the teeth in this
while values below tended to lose attachment. The group had to be exited that it was clear that this was
critical probing depth was 2.9 mm for scaling and not an acceptable form of therapy for periodontitis.
root planing and 4.2 mm for modified Widman Secondly, the furcation response was analyzed using
flap. This finding refined the concept that the horizontal attachment level data. Although interpre-
magnitude of the treatment response was depend- tation of this data was complicated by virtue of the
ent on the initial probing depth and showed: 1) different therapeutic options utilized, the sites
that the response was treatment specific; and 2) treated by osseous surgery had the lowest incidence
the precise point at which attachment gain could of recurrence. Thirdly, sites were stratified by post-
be expected. This was a more defined guideline surgical probing depths and not just initial probing
than the nonspecific indication that certain prob- depths. Thus treatment effect was evaluated based
ing strata tended to respond with gain or loss of on the probing depths actually present during main-
attachment. tenance therapy. Breakdown incidences were greater
The Minnesota studies focused on comparisons of with increasing postsurgical probing depth. Fourthly,
scaling and root planing and modified Widman flap the annual incidence of sites breaking down was de-
(47–49). Over the 6.5 years of the study, little differ- termined. The recurrence rate was greatest for sites
ence between attachment level results for the two treated with scaling and root planing, which was
treatments was found. Also minimal differences be- similar to modified Widman flap, and least for sites
tween treatments were found for attachment level that received osseous surgery. Finally, the effect of
and tooth loss data for molar and nonmolar teeth. smoking on treatment outcome was assessed and
The Aarhus studies compared apically positioned found to profoundly influence disease recurrence.
flap to modified Widman flap and scaling and root While the effect was pervasive and included all out-
planing (11–13). Again little difference was found be- come variables it diminished, but did not prevent
tween treatments. Both the Minnesota and the the response to therapy. Thus smokers responded to
Aarhus studies were well designed and served to treatment but the response was less pronounced,
confirm the findings of the Michigan and Göteborg and the recurrence rate was higher, than in non-
studies. smokers.

90
Surgical periodontal therapy

Interpretation of much greater in deep pockets than in shallow ones


longitudinal studies (41). This study used 12 individualized thresholds for
progression for each patient based on the probing
Wang found that treated periodontitis patients pro- depth, tooth type, and buccal or lingual probing site.
gressed at a rate of 0.03 mm/year, Westfelt et al. re- The sophisticated data analysis used permitted
ported 0.04 mm/year, and Löe et al. reported 0.06 greater insight into the rate of disease progression
mm/year (36–40, 58, 60). Using 0.06 mm/year as an at individual sites because individualized thresholds
example would give 0.3 mm progression in 5 years allowed more accurate selection of progressing sites
and 0.6 mm in 10 years. Untreated periodontitis, on for study.
the other hand, progresses at a more rapid rate. Craft The initial findings of longitudinal studies, using
found 0.1 mm/year, while Axelsson & Lindhe re- full-mouth means, were that there was little differ-
ported 0.2 mm/year and Löe et al. also found 0.2 ence between treatments whether surgical or non-
mm/year (2, 3, 8, 36–40). If we select the 0.2 mm/ surgical scaling and root planing. As study designs
year this means 1 mm progression in 5 years and 2 have evolved and methods of data analysis become
mm in 10 years. The difference between the pro- more sophisticated a different picture may be
gression of treated and untreated disease at 5 years is emerging. Shallower probing depths may gain
0.7 mm and 1.4 mm at 10 years. The small difference greater therapeutic emphasis due to the decreased
between treated and untreated disease is difficult to incidence of periodontal breakdown.
reliably detect using current instrumentation. This is Initially the choice of primary outcome variable
even more true for the difference between two forms for longitudinal studies was mean attachment level.
of treatment, where the annual progression means Thirty years later the choice of a primary outcome
are in hundredths of a millimeter. Since most of the variable is changing. Future studies should include
longitudinal studies are 5 years or less, and all are frequency data to help discern individual site effects,
less than 10 years duration, this means that the annual and cumulative recurrence rate are needed
limited amount of progression actually occurring to distinguish between treatments, and the rate of
makes it difficult to discern differences between disease progression at individual sites is needed to
treatments using mean values. further analyze treatment outcome. Higher resol-
Jeffcoat & Reddy showed that the resolution of the ution instrumentation is needed to provide better
probing instrument can have a profound influence techniques of measuring probing values. Improved
on the interpretation of disease progression (14). techniques of identifying progressing sites are also
Using the Alabama cementoenamel junction probe, needed.
with a resolution of 0.1 mm, they found that the pre- While much has been learned with long-term
dominant mode of progression was continuous studies of periodontal therapy, there is much yet to
while using a manual probe, with a resolution of 1 learn. The ultimate goal is to provide treatments that
mm, progression appeared to be in episodic bursts will predictably arrest disease progression and give a
of disease activity. Higher-resolution instrumen- stable long-term result. Thirty years of excellent clin-
tation would afford better data for comparison of ical research has furthered this goal but additional
treatment effect. study is needed to more precisely define the role of
The use of full-mouth means is an important each therapeutic modality. Good clinical judgment
method of data analysis. It is a particularly good way and treatment individually tailored to suit the pa-
to show trends and patient effects. Full-mouth tient’s needs is the best approach based on current
means can also obscure important individual site ef- data.
fects. Frequency data, incidence (rate) of recurrence
and rate of disease progression are methods of
analysis that will identify site specific effects. Thus, Indications for periodontal surgery
there is a clear distinction between patient-based
and site-based data, and both types of analysis are Nonsurgical therapy is performed prior to surgical
necessary to elucidate actual treatment outcome. treatment for periodontitis. Surgery is indicated
Many of the longitudinal studies have failed to use where nonsurgical methods fail. In general, the suc-
both forms of analysis and thus have left many ques- cess of nonsurgical treatment should be assessed fol-
tions unanswered. lowing scaling and root planing but prior to the ad-
Machtei et al. reported that the rate of untreated ministration of antimicrobial agents or antibiotics.
disease progression over a 9-month period was These medications tend to reduce inflammation and

91
Wang & Greenwell

obscure sites where scaling and root planing has

root planing
Scaling and
failed to resolve disease. Pocket reduction or elimin-
Table 1. Comparison of mean attachment level change and probing depth reduction values from long-term studies of surgical periodontal therapy
ation per se is not required in sites that respond to

1.33
1.32
1.30
0.59
0.83
3.20
0.79
1.27
nonsurgical therapy and remain stable during main-
tenance. When surgery is required, however, shal-
lower probing depths may be an appropriate goal to
Modified
Widman

facilitate maintenance therapy and reduce the inci-

1.63
1.89
1.61
1.70
0.91
1.17
2.90
1.39
1.48
flap

dence of recurrence (1, 15–25). The advantages of


surgical therapy are listed in Table 2.
Preparation prior to periodontal surgery should
elimination
Probing depth reduction

include a thorough examination and diagnosis and


surgery
Pocket

a complete assessment of risk factors. All patients

1.77
0.80
1.37
1.77
1.73

3.30
1.60
1.84
should have at least 80% plaque-free surfaces and
sufficient time should be allowed for tissue re-
Currettage

sponse following scaling and root planing. A dis-


cussion of the risks and benefits of surgery is ap-
0.99
0.50
0.71
1.26
1.50

propriate, and the patient should sign an informed


consent. Medications needed for anxiety control
root planing

and endocarditis prophylaxis should be prescribed


Scaling and

if indicated.
0.45
ª0.04
0.00
0.41
0.83
0.90
0.28
0.79

Appropriate postoperative instructions should be


given to the patient including an explanation con-
cerning: 1) discomfort and potential complications;
Modified

2) all medications, especially analgesics and anti-


Widman

0.26
0.20
ª0.16
0.30
0.20
0.33
0.60
ª0.07
0.70

biotics; 3) diet modification including avoidance of


flap
elimination
Attachment level change

Table 2. Advantages of periodontal surgery


surgery
Pocket

ª0.05
0.10
ª0.73
ª0.18
ª0.31

0.30
0.05
0.45

O Improved visualization of the root surface


O More accurate determination of prognosis
Currettage

O Improved pocket reduction or elimination


O Improved regeneration of lost periodontal structures
ª0.06
0.20
ª0.52
0.04
0.03

O An improved environment for restorative dentistry


O Improved access for oral hygiene and supportive
periodontal treatment
Years

3.65
6.5
3
6
5
2
2
4

5
1
2
12 to 58
21 to 59

10 to 17
10 to 17

Table 3. Postsurgical management


32

90
15

16
16
82

Analgesics, cold packs, moist gauze locally


n

Day 1:
as needed, total avoidance of wound
disturbance
Reference

After day 1: Pain, swelling, bleeding should


diminish or disappear
Begin light activity
54
51
50
10
14
21
22
25
28
31

Warm packs as needed


Chemical plaque control recommended
After 5–10 Remove dressing and sutures
Pihlstrom et al.
Pihlstrom et al.

days: Professionally de-plaque supragingivally


Ramfjord et al.
Ramfjord et al.
Ramfjord et al.

Kaldahl et al.

Begin light oral hygiene


Lindhe et al.

Becker et al.
Isidor et al.

After 4 to 6 Weekly or biweekly visits for professional


Hill et al.

weeks: de-plaqing and oral hygiene instruction


Mean
Author

The dentogingival junction should not be probed or


instrumented for 6 to 8 weeks following surgery

92
Surgical periodontal therapy

Fig. 1. A gingivectomy and gingivoplasty was used to cor- based upon aesthetic profile ratio. C. Gingivoplasty.
rect gingival aberrations. A. Preoperative. B. Gingivectomy D. 8 weeks postsurgically.

hot or spicy food and liquids; 4) smoking reduction, tal wedges, especially distal to second molars are
especially during the healing period; 5) home care often referred for the same reasons. The following
instructions; and 6) where to call if adverse events surgical techniques are appropriate for use in gen-
occur or questions arise. A brief discussion of post- eral practice:
surgical management is listed in Table 3.
Gingivectomy (Fig. 1)
Role of the general practitioner This procedure is used to excise suprabony pockets
if there is sufficient attached gingiva, to reduce gingi-
The general dentist plays a prominent role in peri- val overgrowth/hyperplasia, and for aesthetic crown
odontal diagnosis and therapy. Most periodontitis is lengthening in certain situations. Generally, this pro-
initially diagnosed in the general dental office. cedure should not be used when: 1) infrabony
Whether or not the patient is referred depends on pockets/defects are present; 2) osseous surgery is re-
numerous factors including the patient’s wishes and quired; 3) there is inadequate attached gingiva; 4)
the dentist’s inclination to treat or refer. Scaling and frena/muscle attachments interfere; and 5) long clin-
root planing and surgical treatment is appropriate ical crowns will compromise aesthetics.
in general practices. Many general practitioners limit
surgical treatment to areas of horizontal bone loss
Modified Widman flap (Fig. 2)
where probing depths are less than 5 millimeters.
Vertical osseous defects and furcation involvements This procedure, introduced by Ramfjord & Nissle,
of class II or greater are often referred to the peri- was designed to remove the inflamed pocket wall,
odontist due to the wide array of treatment options provide access for root debridement, and preserve
and the difficulty associated with some of these sur- the maximum amount of periodontal tissue (53). It
gical procedures used to treat these conditions. Dis- is indicated where aesthetics is a primary concern,

93
Wang & Greenwell

94
Surgical periodontal therapy

Fig. 2. A modified Widman flap was used to reduce peri- tion. G, H. Suture. I, J. 1 week of healing. K, L. 8 weeks’
odontal pockets around teeth .12–15 (buccal and palatal follow-up.
view). A, B. Preoperative. C, D. Incision. E, F. Flap reflec-

especially in the maxillary anterior sextant. The Crown lengthening (Fig. 3 and 4)
drawbacks include the inability to achieve pocket
elimination and healing with a long junctional epi- Surgical crown lengthening is an appropriate pro-
thelium. cedure to: 1) facilitate caries removal; 2) provide ad-
ditional restorative retention; 3) establish biological
width; 4) improve aesthetics in cases of altered pass-
Open flap debridement
ive eruption. This procedure should only be con-
The objectives of this technique are to provide ac- sidered when the remaining root is supported by a
cess for root debridement, to achieve pocket reduc- healthy periodontium and the post-surgery crown/
tion, and to permit maximum flap coverage of de- root ratio will be favorable.
vices used for regenerative procedures. A sulcular in-
cision is used instead of an inverse bevel incision.
Lateral pedicle flap for one tooth
This procedure was developed to cover exposed
Apically positioned flap without osseous
roots, prevent root sensitivity and root caries. It
recontouring
should be performed when there is: 1) isolated re-
The objectives of this procedure are to reduce cession; 2) an adequate band of keratinized gingiva
pockets by repositioning the flap apically, to provide on the adjacent donor tooth; and 3) adequate ves-
access for root preparation, and to preserve or in- tibular depth. Areas with multiple adjacent recession
crease the zone of attached gingiva. An inverse bevel sites or secondary frenal pull at the donor site should
incision is used. be avoided.

95
Wang & Greenwell

Fig. 3. A crown-lengthening procedure (an apically posi-


tioned flap with osseous recontouring) was used to estab-
lish biological width and increase the retention for the
fractured tooth .3 palatal side. A. Presurgically. B. In-
cision. C. After osseous. D. Suture. E. 8 weeks of healing.

Histological studies have shown the flap pro- the goals of surgery are to: 1) gain access for root
cedures described above tend to heal with a long preparation when nonsurgical methods are ineffec-
junctional epithelium and not a new connective tive; 2) establish favorable gingival contours; 3) fa-
tissue attachment. Long junctional epithelium, how- cilitate oral hygiene; 4) lengthen the clinical crown
ever, has been shown to provide a stable therapeutic to facilitating adequate restorative procedures; and
outcome (6, 7, 57, 61). 5) regain lost periodontium using regenerative ap-
proaches. To ensure proper healing atraumatic surgi-
cal principles should be followed including: 1) ade-
Principles of periodontal surgery quate anesthesia; 2) surface disinfection; 3) sharp in-
strumentation; 4) minimal, atraumatic tissue
Historically the aims of periodontal surgery were to handling; 5) short operating time; 6) preventing un-
remove the soft tissue pocket wall and infected bone necessary contamination; and 7) proper suturing
and to eliminate the periodontal pocket. Currently, and dressing, if indicated.

96
Surgical periodontal therapy

Fig. 4. A crown-lengthening procedure, utilizing the prin- ments. A–D. Surgical procedure. E. 4 weeks of postopera-
ciple of apically positioned flap, was performed from .7 tive healing. F. Final restoration.
to 10 to facilitate crown placement and aesthetic require-

Postsurgical complications ations performed without antibiotics, while 1 infec-


tion was noted in 43 operations with antibiotic
The risks of surgery include pain, swelling, blood coverage. Curtis et al. also compared the incidence
loss, reaction to medications, and infection. Other and severity of postoperative complications and
potential risks include root sensitivity, flap slough- pain among flap surgery, osseous surgery and muco-
ing, root resorption or ankylosis, some loss of al- gingival surgery (9). They reported only 5.5% of 304
veolar crest, flap perforation, abscess formation, and treated cases had experienced moderate to severe
irregular gingival contours. The incidence of these pain. Moreover, they showed that osseous surgery
complications is low (1%) as reported by Pack & was three times more likely to cause bleeding, infec-
Haber (46). They found only 8 infections in 884 oper- tion, swelling or adverse tissue changes than mucog-

97
Wang & Greenwell

ingival surgery. Mucogingival surgery was 3.5 times gression rate index for the diagnosis and monitoring of un-
treated periodontitis. Thesis. Louisville, KY: University of
more likely to cause pain than osseous surgery and
Louisville, 1996.
six times more likely than soft tissue surgery. If post- 9. Curtis JW, McLain JB, Hutchinson RA. The incidence and
operative complications occur, they should be man- severity of complications and pain following periodontal
aged by prompt and appropriate treatment, which surgery. J Periodontol 1985: 56: 597–601.
may include control of bleeding, adequate anal- 10. Hill RW, Ramfjord SP, Morrison EC, Appleberry EA, Caffesse
RG, Kerry GJ, Nissle RR. Four types of periodontal treat-
gesics or antibiotics.
ment compared over two years. J Periodontol 1981: 52:
655–662.
11. Isidor F, Attström R, Karring T. Regeneration of alveolar
Future trends in periodontal surgery bone following surgical and nonsurgical periodontal treat-
ment. J Clin Periodontol 1985: 12: 687–696.
12. Isidor F, Karring T. Long term effect of surgical and nonsur-
Periodontal therapy has evolved from the days of
gical periodontal treatment. A 5 year clinical study. J Peri-
scaling and root planing and/or gingivectomy to cur- odontal Res 1986: 21: 462–472.
rently include a wide array of sophisticated plastic 13. Isidor F, Karring T, Attström R. The effect of root planing as
and regenerative procedures. Regeneration of oss- compared to that of surgical treatment. J Clin Periodontol
eous and furcation defects became possible with the 1984: 11: 669–681.
14. Jeffcoat M, Reddy M. Progression of probing attachment
advent of guided tissue regeneration techniques but
loss in adult periodontitis. J Periodontol 1991: 62: 185–189.
have not yet become predictable. As growth factor 15. Kaldahl WB, Johnson GK, Patil KD, Kalkwarf KL. Levels of
therapy develops, regeneration will become predict- cigarette consumption and response to periodontal ther-
able, and resection will likely disappear as a mode of apy. J Periodontol 1996: 67: 675–681.
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studies that compared periodontal therapies. J Periodontol
20 years ago, is now routine. The development of
1993: 64: 243–253.
new materials to eliminate the need for palatal do- 17. Kaldahl WB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE Jr.
nor tissue will increase the frequency of these pro- Evaluation of four modalities of periodontal therapy. J Peri-
cedures and reduce the prevalence of recession in odontol 1988: 59: 783–793.
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of four tooth and site groupings to periodontal therapy. J
Periodontol 1990: 61: 173–179.
20. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP. Relationship
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