Clinical Continued »


The different surgical techniques for treatment of periodontitis (A) Access surgery (e.g. modified Widman flap, open flap debridement). These procedures are designed to allow instrumentation of the root surface under direct vision. The modified Widman flap


technique is a very conservative method where the buccal and palatal/lingual tissues are reflected only minimally (not beyond the mucogingival junction) to allow root surface debridement with better access than with conventional non- surgical therapy (Fig 1). It minimises the amount of tissue shrinkage post operatively, but where there are infrabony defects, it can often leave residual pocketing.


On the other hand, open flap debridement relies on full flap reflection to allow for maximum vision and access to the root surfaces for debridement (Figs 2 and 3). While this may make it easier to debride deep infrabony defects, open flap debridement may also leave residual deep pocketing if these defects are not recontoured with resective techniques, or grafted using regenerative techniques. Access procedures are best used in those areas where there are deep pockets, but with few infrabony defects. In particular, modified Widman techniques can be used where tissue contour changes are undesirable, but it should always be noted that any surgical therapy in the upper anterior region is likely to run the risk of unacceptable aesthetic changes, and may be best handled non-surgically if at all possible.


(B) Resective surgery


(e.g. gingivectomy, osseous surgery). These procedures are designed to


achieve maximum pocket depth reduction. They should therefore be reserved for areas that are not in an aesthetic zone. Before the advent of flap surgery


procedures for periodontal therapy, gingivectomy was the most common periodontal surgical technique. It offers considerable pocket depth reduction, but this is often at the expense of removing attached gingiva, and it doesn’t address any underlying infrabony defects, often leading to the re-development of deeper pocketing over time. It is still a useful technique, but is mostly reserved for cases of gingival hyperplasia where there is an abundance of attached gingiva and suprabony pocketing (Figs 4 and 5). Flap procedures have more or less


replaced gingivectomy now as they allow positioning of the tissues, give access to infrabony defects, and allow for recontouring of the bony tissues to allow flap adaptation and pocket reduction (osseous surgery). Osseous surgery is where infrabony defects can be recontoured using diamond and carbide surgical burs, and this allows good tissue adaptation to eliminate infrabony pocketing (albeit at the expense of longer looking teeth)(Figs 6, 7 and 8).


(C) Regenerative surgery (e.g. guided tissue regeneration – GTR). GTR can be employed to recapture missing periodontal tissues such as bone, cementum and periodontal ligament. However, certain anat- omical features need to be present to allow for regenerative procedures to be completed successfully, and often this is not the case where periodontal tissues have been severely destroyed by the disease process. In general, if a defect has an


infrabony defect of greater than 4mm in depth, with containing bony walls,


“What you first think of is probably driven by when or where you’ve graduated, or by


personal experience of some of your own patients”


then GTR may be successful. However, upper molar furcations, and F3 (‘through and through’) lower molar furcations do not exhibit positive outcomes as a rule, and are not good candidates for GTR procedures. Smoking and poor plaque control are the biggest predictors of a poor outcome with these procedures. Many materials are in use for GTR. Most are based around the use of a combined hard tissue graft and a resorbable collagen membrane, but some other single material techniques are in frequent use also (e.g. enamel matrix proteins). Bone grafting materials are usually


from animal (xenograft), human (allo- graft), self (autograft) or synthetic (e.g. calcium triphosphate) sources. Membranes are most often resorbable collagen materials of animal origin, and these have mostly replaced the non-resorbable types due to the ease of use, enhanced biocompatibility, and the avoidance of the need for a second surgery to remove the product at a later date (Figs 9 and 10).


(D) Combination procedures. Even within a quadrant, the local bony architecture can vary considerably, meaning that some areas require resective work, yet others may be candidates for GTR, all within the same surgery (Figs 11, 12 and 13). It is very often helpful to combine techniques at one surgical sitting, and this gives the most appropriate approach for each individual tooth, avoiding the ‘one size fits all’ mindset. It is often possible to predict the


areas for the various approaches by carefully scrutinising the clinical data and the radiographs. One can frequently identify the presence and magnitude of any infrabony defects in advance of the procedure, and create


Continued »


Fig 5


Two weeks after gingectomy for gingival overgrowth (child)


Fig 6 Interproximal infrabony defect to be recontoured


Fig 7 Recontouring of osseous defect with surgical burs


Ireland’s Dental magazine 23


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