Jan Lindhe. Clinical Periodontology

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PERIODONTAL SURGERY: ACCESS THERAPY • 545

sion. In the posterior tooth region, an apical position-

ing should be the standard.

Independent of flap positioning the goal should be

to achieve complete soft tissue coverage of the alveolar

bone, not only at buccal /lingual sites but also in proxi

mal sites. It is therefore of utmost importance to

care-

fully plan the incisions in such a way that this

goal can

be achieved at the termination of the surgical

interven

tion.

Hard tissue pockets

During conventional periodontal surgery one would

usually opt for the conversion of an intrabony defect

into a suprabony defect, which then is eliminated by

an apical repositioning of the soft tissues. Osseous

recontouring of angular bony defects and craters in-

volves excisional techniques which should be used

with caution and discrimination. However, the thera-

pist is often faced with the dilemma of deciding

whether or not to eliminate an angular bony defect.

There are a number of factors that should be consid-

ered in the treatment decision, such as:

•

esthetics

•

tooth/tooth site involved

•

defect morphology

•

amount of remaining periodontium

Since alveolar bone supports the soft tissue, an altered

bone level through recontouring will result in reces-

sion of the soft tissue margin. For esthetic reasons one

may therefore be conservative in eliminating proximal

bony defects in the anterior tooth region. For example,

in the case of an approximal crater it may often be

sufficient to reduce/eliminate the bone wall on the

lingual side of the crater, thereby maintaining the bone

support for the soft tissue on the facial aspect (Fig.

25-40). In favor of esthetics one may even have to

compromise the amount of bone removal and accept

that some pocket depth will remain in certain situ-

ations. In addition to esthetics, the presence of furca-

tions may limit the extent to which bone recontouring

can be performed.

Defect morphology is a variable of significance for

repair/regeneration during healing (Rosling et al.

1976a, Cortellini et al. 1993, 1995a). While two and,

especially, three-wall defects may show great poten-

tial for repair/regeneration, one-wall defects and ap-

proximal craters will rarely result in such a healing.

Further, the removal of intrabony connective tissue/

granulation tissue during a surgical procedure will

always lead to crestal resorption of bone, especially in

sites with thin bony walls. This results in reduction of

the vertical dimensions of the bone tissue at the site

(

Fig. 25-53). Thus, the potential for bone fill following

compromise in regard to osseous surgery is greater

areas with thick, non-supporting bone.

The various treatment options available for the

hard tissue defect may include:

Fig. 25-53. Illustration of the amount of crestal bone re

sorption that may take place following a modified Wid

man flap procedure without bone recontouring. (a)

View of the area at time of initial surgical treatment. (b)

At the re-entry operation performed after 6 months of

healing.

•

elimination of the osseous defect by resection of

bone (osteoplasty and/or ostectomy)

•

maintenance of the area without osseous resection

(hoping for some type of periodontal repair, e.g.

bone fill leading to gain of clinical attachment),

•

compromising the amount of bone removal and

accepting that a certain pocket depth will remain

•

an attempt to improve healing through the use of a

regenerative procedure or

•

extraction of the involved tooth if the bony defect is

considered too advanced.

After careful consideration, indications for osseous

surgery in conjunction with apical repositioning of

flaps may also include subgingival caries, perfora-

tions or root fractures in the coronal third of the root

as well as inadequate retention for fixed prosthetic

restorations due to a short clinical crown (crown-

lengthening procedures). The "crown lengthening"

needed in such cases is performed by removing often

significant amounts of supporting bone and by recon-

touring. A "biologic width" of approximately 3 mm is

needed between the alveolar bone crest to be establ-

ished and the anticipated restoration margin for suc-

cessful results (Bragger et al. 1992, Herrero et al. 1995,

Pontoriero & Carnevale 2001).

Root surface instrumentation

Before incisions are made to excise or elevate the soft

tissue, a careful examination should be carried out to

identify at which tooth sites periodontal lesions re-

main. Only tooth sites with signs of pathology (bleed-

ing following pocket probing) should be subjected to

root instrumentation following surgical exposure.

Further, at these sites, root surface instrumentation

should be limited to that part of the root that will be

covered by the soft tissue following flap replacement

and suturing. This is an important consideration since

instrumentation of the supragingival portion of the

546 • CHAPTER 25

root may lead to postsurgical dentin hypersensitivity,

which in turn may impede proper oral hygiene meas-

ures. Hence, before root instrumentation is executed,

remaining granulation tissue must be removed, bone

recontouring carried out, if indicated, and the postsur

gical soft tissue level determined. If the intention is to

apically reposition the flap at the level of the bone

crest, only approximately 3 mm of the root surface

coronal to the bone crest has to be carefully scaled and

root planed, whereas if the flap is to be coronally

positioned the entire exposed root often has to be

instrumented.

The root instrumentation can be performed with

hand or ultrasonic instruments according to the op-

erator's preferences. Ultrasonic (sonic) instrumenta-

tion offers the additional benefits of improved visibil-

ity due to the irrigating effect of the cooling water. For

root instrumentation within intrabony defects, root

concavities and entrances to furcations, the use of

rotating fine-grained diamond stones may be used.

Root surface conditioning/ biomodification

An important consideration in periodontal surgery is

to make the exposed root surface biologically compat-

ible with a healthy periodontium. This so-called con-

ditioning includes removing bacteria, endotoxins and

other antigens found within the cementum-dentin of

pathologically exposed root. In addition to scaling

and

root planing, agents such as citric acid/ortho-

phosphoric acid, tetracycline and EDTA are used for

root surface conditioning. Root surface condition-

ing/biomodification by means of an etching proce-

dure may serve several purposes:

•

removal of the smear layer following mechanical

debridement

•

demineralization of the root surface (citric acid)

•

selective removal of hydroxyapatite and exposure

of the collagenous matrix of the root surface (EDTA)

•

local delivery of antimicrobial compound (tetracy-

cline HCL)

•

inhibition of collagenolytic activity (tetracycline

HCL)

•

enhancing cellular responses (migration and

attach

ment)

•

preventing epithelial down-growth

•

improving retention of different biomolecules to

exposed collagen

•

expressing a cementoblast phenotype for coloniz-

ing cells.

It should be noted that etching of a root surface with

an agent operating at a low pH, e.g. citric acid or

orthophosphoric acid, might exert immediate ne-

crotizing effects on the surrounding periodontal liga-

ment and other periodontal tissues, whereas agents

operating at a neutral pH (e.g. EDTA) do not seem to

have this negative effect (Blomlof & Lindskog

1995a,

b).

Although

in vitro

results have indicated possible

benefits of the use of root surface conditioning/bio-

modification agents through enhanced cellular re-

sponses during wound healing, the usefulness of ac-

ids as well as other chemical agents for conditioning

of root surfaces in conjunction with conventional peri

odontal surgery has been questioned (Blomlof et al.

2000). Histological evidence indicates that healing fol-

lowing root surface conditioning with acids or other

chemical agents is generally dominated by a long

junctional epithelium or connective tissue attachment

without evidence of new cementum formation. How-

ever, root surface biomodification must still be re-

garded as an important method to facilitate regenera-

tion. Thus, in this treatment the root represents one of

the wound margins and must provide an appropriate

surface for cell attachment, colonization and prolifera

tion.

Suturing

When a flap procedure has been employed it is impor

tant to ensure that, at the end of surgery, the flaps are

placed in the intended position and that the flaps are

properly adapted to each other and to the tooth sur-

faces. Preferably, full coverage of the buccal/lingual

(

palatal) and interdental alveolar bone should be ob-

tained by full (primary) closure of the soft tissue flaps.

If this can be achieved, healing by first intention re-

sults and the postoperative bone resorption becomes

minimal. Therefore, prior to suturing, the flap margins

should be trimmed to properly fit the buccal and

lingual (palatal) bone margin as well as the interproxi

mal areas; excessive soft tissue must be removed. If the

amount of flap tissue present is insufficient to cover

the interproximal bone, the flaps at the buccal or

lingual aspects of the teeth must be recontoured and,

in some cases, even coronally displaced.

Following proper trimming, the flaps are secured

the correct position by sutures. The materials most

commonly used as sutures in periodontal surgery are

fabricated of silk and various synthetic materials. The

dimensions usually preferred are 3-0 or 4-0. These

materials are non-resorbable and should be removed

after 7-14 days. If the sutures need to be maintained in

place for several weeks, Teflon® suture material is

preferable due to minimal tissue reactions to the ma-

terial.

Since the flap tissue following the final preparation

is thin, non-traumatic needles (eyeless), either curved

or straight, with a small diameter should be used.

Such needles are available as rounded (non-cutting)

or with different cutting edges.

PERIODONTAL SURGERY: ACCESS THERAPY • 547

a a

Fig. 25-54a,b.

Suturing.

Interrupted interdental suture.

Fig. 25-55a,b.

Suturing.

Modified interrupted interden-

tal suture. Note that with this suturing technique the

suture is lying on the surface of the interdental tissue

keeping the soft tissue flaps in close contact with the

underlying bone.

Fig. 25-56a-d.

Suturing.

Modified mattress suture.

Suturing technique

The three most frequently used sutures in periodontal

flap surgery are:

•

interrupted interdental sutures,

•

suspensory sutures and

•

continuous sutures.

The

interrupted interdental suture

(Fig. 25-54) provides

close interdental adaptation between the buccal and

lingual flaps with equal tension on both units. This

type

of suture is therefore not recommended when the buccal

and lingual flaps are repositioned at different

levels.

When this technique of suturing is employed,

548 • CHAPTER 25

Fig. 25-57a-c.

Suturing.

Suspensory suture.

Fig. 25-58a,b.

Suturing.

Continuous suture.

the needle is passed through the buccal flap from the

external surface, across the interdental area and

through the lingual flap from the internal surface, or

vice versa. When closing the suture, care must be

taken to avoid tearing the flap tissues.

In order to avoid having the suture material be-

tween the mucosa and the alveolar bone in the inter-

dental area, an alternative technique for the use of the

interrupted interdental suture can be used if the flaps

have not been elevated beyond the mucogingival line

(

Fig. 25-55). With the use of a curved needle the suture

is anchored in the attached tissue on the buccal aspect

of the proximal site, the suture brought to the lingual

side through the proximal sites, and anchored in the

attached tissue on the lingual side. The suture is then

brought back to the starting point and tied (Fig. 25-

55b). Hence, the suture will be lying on the surface of

the interdental tissue, keeping the soft tissue flaps in

close contact with the underlying bone.

In regenerative procedures, which usually require

coronal advancing of the flap,

a modified mattress suture

may be used to secure close flap adaptation (Fig.

25-56)

. The needle is passed through the buccal flap

from the

external surface, across the interdental area and

through the lingual flap from the internal surface.

The

suture is run back to the buccal side by passing

the

needle through the lingual and buccal flaps. There-

after, the suture is brought through the approximal site

coronally to the tissue, passed through the loop of the

suture on the lingual aspect, and then brought back to

the starting point on the buccal side and tied.

The

suspensory suture

(Fig. 25-57) is used primarily

when the surgical procedure is of limited extent and

involves only the tissue of the buccal or lingual aspect

of the teeth. It is also the suture of choice when the

buccal and lingual flaps are repositioned at different

levels. The needle is passed through the buccal flap

from its external surface at the mesial side of the tooth,

the suture placed around the lingual surface of the

tooth and the needle passed through the buccal flap

on the distal side of the tooth (Fig. 25-57a). The suture

brought back to the starting point via the lingual

surface of the tooth and tied (Fig. 25-57b,c). If a lingual

flap has been elevated as well, this is secured in the

intended position using the same technique.

The

continuous suture

(Fig. 25-58) is commonly used

when flaps involving several teeth are to be apically

repositioned. When flaps have been elevated on both

sides of the teeth, one flap at a time is secured in its

correct position. The suturing procedure is started at

the mesial/distal aspect of the buccal flap by passing

the needle through the flap and across the interdental

area. The suture is laid around the lingual surface of

the tooth and returned to the buccal side through the

next interdental space. The procedure is repeated

tooth

by tooth until the distal/mesial end of the flap

reached. Thereafter, the needle is passed through the

lingual flap (Fig. 25-58a), with the suture laid around

the buccal aspect of each tooth and through each

interproximal space. When the suturing of the lingual

flap is completed and the needle has been brought

back to the first interdental area, the positions of the

PERIODONTAL SURGERY: ACCESS THERAPY • 549

flaps are adjusted and secured in their proper posi-

tions by closing the suture (Fig. 25-58b). Thus, only

one knot is needed.

Periodontal dressings

Periodontal dressings are mainly used:

•

to protect the wound postsurgically,

•

to obtain and maintain a close adaptation of the

mucosal flaps to the underlying bone (especially

when a flap has been apically repositioned) and

•

for the comfort of the patient.

In addition, periodontal dressings can, during the

initial phase of healing, prevent postoperative bleed-

ing and, if properly placed in the operated segment

(

especially interproximally), prevent the formation of

excessive granulation tissue.

Periodontal dressings should have the following

properties:

•

The dressing should be soft, but still have enough

plasticity and flexibility to facilitate its placement in

the operated area and to allow proper adaptation.

•

The dressing should harden within a reasonable

time.

•

After setting, the dressing should be sufficiently

rigid to prevent fracture and dislocation.

•

The dressing should have a smooth surface after

setting to prevent irritation to the cheeks and lips.

•

The dressing should preferably have bactericidal

properties to prevent excessive plaque formation.

•

The dressing must not detrimentally interfere with

healing.

It has been suggested that antibacterial agents should

be incorporated in periodontal dressings to prevent

bacterial growth in the wound area during healing.

Results from clinical studies and

in vitro

evaluation of

the antibacterial properties of various periodontal

dressings, however, suggest that the antibacterial ac-

tivity of most commercial dressings probably is ex-

hausted long before the end of the 7-14-day period

during which the dressing is frequently maintained in

the operated segment (O'Neil 1975, Haugen et al.

1977).

Mouth rinsing with antibacterial agents such as

chlorhexidine does not prevent the formation

plaque

under

the dressing (Plyss et al. 1975) and

should therefore not be regarded as a means to im-

prove or shorten the period

wound healing. On the

other hand, results from clinical studies as well as

clinical experience suggest that a periodontal dressing

may often be unnecessary or even undesirable after

periodontal flap procedures and may be usefully re-

placed by rinsing with chlorhexidine only (Sanz et al.

1989, Vaughan & Garnick 1989).

A commonly used periodontal dressing is Coe-

Pak

(Coe Laboratories Inc., Chicago, IL, US), which

supplied in two tubes. One tube contains oxides of

various metals (mainly zinc-oxide) and lorothidol (a

fungicide). The second tube contains non-ionizing

carboxylic acids and chlorothymol (a bacteriostatic

agent). Equal parts from both tubes are mixed together

immediately prior to insertion. The setting time can be

prolonged by adding a retarder.

A light curing dressing, e.g. Barricaid

(Dentsply

International Inc., Milford, DE, US), is useful in the

anterior tooth region and particularly following mu-

cogingival surgery, because it has a favorable esthetic

appearence and it can be applied without dislocating

the soft tissue. However, the light curing dressing is

not the choice of dressing to be used in situations

where the flap has to be apically retained, due to its

soft state before curing.

Cyanoacrylates have also been used as periodontal

dressings with varying success. Dressings of the cy-

anoacrylate type are applied in a liquid directly onto

the wound, or sprayed over the wound surface. Al-

though the application of this kind of dressing is

simple, its properties often do not meet clinical de-

mands, which is why its use is rather limited at pre-

sent.

Application technique

•

Ensure that bleeding from the operated tissues has

ceased before the dressing material is inserted.

•

Carefully dry teeth and soft tissue before the appli-

cation for optimal adherence of the dressing.

•

Moisten the surgical gloves to avoid the material

sticking to the fingertips.

•

When using the Coe-Pak

' dressing material, the

interproximal areas are filled first. Thin rolls of the

dressing, adjusted in length to cover the entire field

of operation, are then placed against the buccal and

lingual surfaces of the teeth. The rolls are pressed

against the tooth surfaces and the dressing material

is forced into the interproximal areas. Coe-Pak

may also be applied to the wound surfaces by

means of a plastic syringe. It is important to ensure

that dressing material is never introduced between

the flap and the underlying bone or root surface.

•

The surface of the dressing is subsequently

smoothed and excess material is removed with a

suitable instrument. The dressing should not cover

more than the apical third of the tooth surfaces.

Furthermore, interferences of the dressing with mu-

cogingival structures (e.g. the vestibular fold, fre-

nula) should be carefully checked to avoid displace-

ment of the dressing during normal function.

The light curing dressing (Barricaid

) is preferably

applied with the supplied syringe, adjusted and then

550 • CHAPTER 25

cured by light. It is important to carefully dry teeth

and soft tissue before the application for optimal ad-

herence. Excess of dressing material can easily be

removed following the curing with a knife or finishing

burs in a low-speed handpiece.

Postoperative pain control

In order to minimize postoperative pain and discom-

fort for the patient, the surgical handling of the tissues

should be as atraumatic as possible. Care should be

taken during surgery to avoid unnecessary tearing of

the flaps, to keep the bone moistened and to ensure

complete soft tissue coverage of the alveolar bone at

suturing. With a carefully performed surgical proce-

dure most patients will normally experience only

minimal postoperative problems. The pain experience

is usually limited to the first days following surgery

and is of a level that in most patients can be adequately

controlled with normally used drugs for pain control.

However, it is important to recognize that the pain

threshold level is subjective and may vary between

individuals. It is also important to give the patient

information about the postsurgical sequence and that

uncomplicated healing is the common event. Further,

during the early phase of healing, the patient should

be instructed to avoid chewing in the area subjected

to surgical treatment.

Postsurgical care

Postoperative plaque control is the most important

variable in determining the long-term result of peri-

odontal surgery. Provided proper postoperative

plaque

control levels are established, most surgical treatment

techniques will result in conditions which favor the

maintenance of a healthy periodontium.

Although there are other factors

a more general

nature affecting surgical outcome (e.g. the systemic

status of the patient at time of surgery and during

healing), disease recurrence is an inevitable complica

tion, regardless of surgical technique used, in patients

not given proper postsurgical and maintenance care.

Since self-performed oral hygiene is often associ-

ated with pain and discomfort during the immediate

postsurgical phase, regularly performed professional

toothcleaning is a more effective means of mechanical

plaque control following periodontal surgery. In the

immediate postsurgical patient management self-per-

formed rinsing with a suitable antiplaque agent, e.g.

twice daily rinsing with 0.1-0.2% chlorhexidine solu-

tion, is recommended. Although an obvious disad-

vantage with the use of chlorhexidine is the staining

of teeth and tongue, this is usually not a deterrent for

compliance. Nevertheless, it is important to return to

and maintain good mechanical oral hygiene measures

as soon as possible. This is especially important since

rinsing with chlorhexidine, in contrast to properly

performed mechanical oral hygiene, is not likely to

have any influence on subgingival recolonization of

plaque.

Maintaining good postsurgical wound stability is

another important factor affecting the outcome of

some types of periodontal flap surgery. If wound sta-

bility is judged an important part of a specific proce-

dure, the procedure itself as well as the postsurgical

care must include measures to stabilize the healing

wound (e.g. adequate suturing technique, protection

from mechanical trauma to the marginal tissues dur-

ing the initial healing phase). If a mucoperiosteal flap

is replaced rather than apically repositioned, early

apical migration of gingival epithelial cells will occur

as a consequence of a break between root surface and

healing connective tissue. Hence, a maintained tight

adaptation of the flap to the root surface is essential

and one may therefore consider keeping the sutures

in place for a longer period of time than the 7-10 days

usually prescribed following standard flap surgery.

Following suture removal, the surgically treated

area is thoroughly irrigated with a dental spray and

the teeth are carefully cleaned with a rubber cup and

polishing paste. If the healing is satisfactory for start-

ing mechanical toothcleaning, the patient is instructed

in gentle brushing of the operated area using a tooth-

brush that has been softened in hot water. For cleaning

of the interdental area, toothpicks are prescribed. At

this early phase following the surgical treatment the

use of interdental brushes is abandoned due to the risk

of traumatizing the interdental tissues. Visits are

scheduled for supportive care at 2-week intervals to

closely monitor the patient's plaque control. During

this postoperative maintenance phase, adjustments of

the methods for optimal self-performed mechanical

cleaning are made depending on the healing status of

the tissues. Dictated by the patient's plaque control

standard, the time interval between visits for suppor-

tive care may gradually be increased.

OUTCOME OF SURGICAL

PERIODONTAL THERAPY

Healing following surgical pocket therapy

Gingivectomy

(Fig. 25-59): Within a few days following

excision of the inflamed gingival soft tissues coronal

to the base of the periodontal pocket, epithelial cells

start to migrate over the wound surface. The epi-

thelialization

the gingivectomy wound is usually

complete within 7 to 14 days following surgery

(

Engler et al. 1966, Stahl et al. 1968). During the follow

ing weeks a new dento-gingival unit is formed. The

fibroblasts in the supra-alveolar tissue adjacent to the

tooth surface proliferate (Waerhaug 1955) and new

connective tissue is laid down. If the wound healing

occurs in the vicinity of a plaque-free tooth surface, a

PERIODONTAL SURGERY: ACCESS THERAPY • 551

Fig. 25-59.

Gingivectomy.

Dimensional changes as a result of therapy. (a) The preoperative dimensions. The line indi

cates the location of the primary incision, i.e. the suprabony pocket is eliminated with the gingivectomy technique.

(b) Dimensions following proper healing. Minor resorption of the alveolar bone crest as well as some loss of connec

tive tissue attachment has occurred.

Fig. 25-60.

Apically repositioned flap.

Dimensional changes. (a) The preoperative dimensions. The broken line indi

cates the site from which the mucoperiosteal flap is reflected. (b) Bone recontouring has been completed and

the

flap repositioned to cover the alveolar bone. (c) Dimensions following healing. Minor resorption of the

marginal al

veolar bone has occurred as well as some loss of connective tissue attachment.

free gingival unit will form which has all the charac-

teristics of a normal free gingiva (Hamp et al. 1975).

The height of the newly formed free gingival unit may

vary not only between different parts of the dentition

but also from one tooth surface to another due to

primarily anatomical factors.

The re-establishment of a new, free gingival unit by

coronal regrowth of tissue from the line of the

gingivectomy" incision implies that sites with so-

called "zero pockets" only occasionally occur follow-

ing gingivectomy. Complete healing of the gingivec-

tomy wound takes 4-5 weeks, although the surface of

the gingiva may appear by clinical inspection to be

healed already after approximately 14 days (Ramfjord

et al. 1966). Minor remodeling of the alveolar bone

crest may also occur postoperatively.

The apically repositioned flap

(Fig. 25-60): Following

osseous surgery for elimination of bony defects and

the establishment of "physiologic contours" and repo-

sitioning of the soft tissue flaps to the level of the

alveolar bone, healing will occur primarily by first

intention, especially in areas where proper soft tissue

coverage of the alveolar bone has been obtained. Dur

ing the initial phase of healing, bone resorption of

varying degrees almost always occurs in the crestal

area of the alveolar bone (Ramfjord & Costich 1968).

The extent of the reduction of the alveolar bone height

resulting from this resorption is related to the thick-

ness of the bone in each specific site (Wood et al. 1972,

Karring et al. 1975).

During the phase of tissue regeneration and matu-

ration a new dento-gingival unit will form by coronal

growth of the connective tissue. This regrowth occurs

in a manner similar to that which characterized heal-

ing following gingivectomy.

The modified Widman flap

(Fig. 25-61): If a "modified

552 • CHAPTER 25

Fig. 25-61.

Modified Widman flap.

Dimensional changes. (a) The preoperative dimensions. The broken line indicates

the site from which the mucoperiosteal flap is reflected. (b) Surgery (including curettage of the angular bone de

fect) is completed with the mucoperiosteal flap repositioned as close as possible to its presurgical position. (c) Di

mensions following healing. Osseous repair as well as some crestal bone resorption can be expected during

healing

with the establishment of a "long" junctional epithelium interposed between the regenerated bone tissue

and the

root surface. An apical displacement of the soft tissue margin has occurred.

Widman flap" is carried out in an area with a deep

infrabony lesion, bone repair may occur within the

boundaries of the lesion (Rosling et al. 1976a, Poison

& Heijl 1978). However, crestal bone resorption is also

seen. The amount of bone fill obtained is dependent

upon (1) the anatomy of the osseous defect (e.g. a

three-walled infrabony defect often provides a better

mould for bone repair than two-walled or one-walled

defects), (2) the amount of crestal bone resorption, and

(3) the extent of chronic inflammation, which may

occupy the area of healing. Interposed between the

regenerated bone tissue and the root surface, a long

junctional epithelium is always found (Caton & Zan-

der 1976, Caton et al. 1980). The apical cells of the

newly formed junctional epithelium are found at a

level on the root that closely coincides with the pre-

surgical attachment level.

Soft tissue recession will take place during the heal

ing phase following a modified Widman flap proce-

dure. Although the major apical shift in the position

of the soft tissue margin will occur during the first 6

months following the surgical treatment (Lindhe et al.

1987), the soft tissue recession may often continue for

more than 1 year. Among factors influencing the de-

gree of soft tissue recession, besides the period for soft

tissue remodeling, are the initial height and thickness

of the supracrestal flap tissue and the amount of cre-

stal bone resorption.

Clinical outcome of surgical access therapy

in comparison to non-surgical therapy

Surgical treatment of periodontal lesions mainly

serves the purpose of (1) creating accessibility for

proper professional debridement of the infected root

surfaces and (2) establishing a gingival morphology

that facilitates the patient's self-performed plaque

control, in order to enhance the long-term preserva-

tion of the dentition. Hence, the amount of tooth loss

would be the most relevant criterion in an evaluation

of the relative importance of surgical access therapy

in the overall treatment of periodontal disease. How-

ever, since the rate of tooth loss is comparatively low,

this would require studies with extremely long peri-

ods of follow-up. Other criteria, such as resolution of

gingivitis (bleeding on probing), probing pocket

depth

reduction and clinical attachment level change,

have

therefore commonly been used to evaluate the

efficacy of periodontal therapy, even if these may only

be considered as surrogate end points. An additional

variable often of concern is gingival recession, since

this outcome variable may affect the patient's overall

appreciation of the treatment result. With regard to

changes in probing attachment levels, it should be

recalled that healing following conventional surgical

access therapy consistently results in the formation of

a junctional epithelium to a level on the root that

closely coincides with the presurgical attachment

level. Hence, when evaluating the outcome of various

therapeutic approaches the magnitude of

gain

of clini-

cal attachment may be of less importance since it

mainly is a measure of "pocket closure". Instead,

maintained probing attachment levels or further loss

should be focused on as the pertinent outcome vari-

able.

Pioneering contributions to the understanding of

the relative importance of the surgical component of

periodontal therapy were generated by the classic

longitudinal studies by the Michigan group (Ramfjord

and co-workers) and the Gothenburg group (Lindhe

and co-workers). Subsequently, several other clinical

research centers contributed with important data re-

garding the efficacy of surgical access therapy in corn-

PERIODONTAL SURGERY: ACCESS THERAPY • 553

Approximal tooth surfaces

Fig. 25-62. Average

ap proximal

pocket depths at the initial exami-

nation and 6, 12 and 24 months af-

ter surgery (top) and alterations in

approximal

attachment levels from

the initial examination immediately

prior to surgery to the reex-

aminations 6, 12 and 24 months

postoperatively (bottom). Note

that

only areas with pockets which at

the initial examination had a depth

of 3 mm or more are

included in

the analysis. I = stan

dard error.

AFB = apically reposi

tioned flap

with bone recontour

ing. AF =

apically repositioned

flap. WFB =

modified Widman

flap with bone

recontouring. WF

= modified

Widman flap. G =

gingivectomy

including curettage

of bone defects. (

Data from Ny

man et al. 1977.)

Fig. 25-63. Average approximal

pocket depths at the initial exami-

nation and 6, 12 and 24 months af-

ter surgery (top), and alterations

approximal attachment levels

from

the initial examination imme

diately

prior to surgery to the re-

examinations 6, 12, and 24 months

postoperatively (bottom). Note

that

only areas with pockets which at

the initial examination

had a depth

of 3 mm or more

have been

included in the statistical analysis.

I = standard error.

AFB = apically

repositioned flap

and bone

correction. AF = apically

repositioned flap. WFB = Widman

flap and bone correction. WF =

Widman Flap. G = gingviectomy,

including curettage of the bony

defects. (Data from Rosling et al.

1976.)

parison to non-surgical periodontal therapy The topic

Plaque accumulation

has been extensively reviewed in several publications An important factor to consider in the evaluation of

(e.g. Kaldahl et al. 1993, Palcanis 1996) and some of the

the relative effect of the surgical component of peri-

general conclusions from these reviews will be high-

odontal therapy is the standard of postoperative

lighted below.

plaque control. Nyman et al. (1977) reported on a

clinical study in which the patients received only a

554 • CHAPTER 25

single episode of oral hygiene instruction before the

surgical treatment and no specific postoperative sup-

portive care. As a consequence both plaque and gin-

gival indices remained relatively high during the 2

years of postoperative follow-up. Independent of sur-

gical technique used, the patients showed a rebound

of pocket depths to more or less pretreatment levels

and further deterioration of clinical attachment levels

at both proximal and lingual tooth sites (Fig. 25-62). In

contrast, in a parallel study in which the patients

received repeated oral hygiene instructions and pro-

fessional tooth-cleaning once every 2 weeks during

the postoperative period (Rosling et al. 1976b), the

patients maintained the surgically reduced pocket

depth throughout the 2-year follow-up period and

clinical attachment level gains were observed for most

of the surgical procedures evaluated (Fig. 25-63). The

fact that the standard of postoperative oral hygiene is

decisive for the outcome of surgical pocket therapy is

further underlined by data from a 5-year longitudinal

study by Lindhe et al. (1984), which showed that

patients with a high standard of plaque control main-

tained clinical attachment levels and probing depth

reductions following treatment more consistently

than

patients with poor plaque control. On the other

hand,

professional tooth cleaning including subgingi

val

scaling every 3 months may partly compensate for

the

negative effects of variations in self-performed

plaque

control (Ramfjord et al. 1982, Isidor & Karring

1986).

Fig. 25-64. Longitudinal evalu-

ation of four treatment modalities

in three categories of initial prob-

ing depth 1-3 mm, 4-6 mm and > 7

mm. RPL = scaling and root plan-

ing.

CUR = subgingival curettage.

MWF = Modified Widman Flap.

PEL = pocket elimination surgery.

(Data from Ramfjord et al. 1987,

presented by Egelberg 1995.)