Periodontal Surgery

Surgical procedures on the periodontium (periodontal apparatus) aim, on the one hand, to treat periodontal pockets under vision in order to achieve a state of periodontal health by eliminating (removing) calculus (tartar below the gums) and periodontopathogenic microorganisms. In addition, periodontal surgery (periodontal surgery) is used to correct mucogingival problems such as recession (exposed tooth necks) or frenulum. Before surgical periodontal treatment, inflammations of the periodontium are first treated conservatively, i.e. non-surgically in the form of a closed curettage. If after three to six months there are still isolated pockets with probing depths greater than six millimeters and bleeding on probing despite effective oral hygiene, surgical intervention is considered. In addition, there may be growths of the gingiva (the gums) that also cannot be eliminated by a conservative approach. In this case, periodontal surgery is also necessary. Depending on the intended treatment goal, a distinction is made between:

I. Resective periodontal surgery.

  • Gingivectomy
  • Gingivoplasty
  • Flap surgery
  • Resective furcation therapy

II. regenerative periodontal surgery

  • Guided Tissue Regeneration (GTR) – guided tissue regeneration.
  • Regenerative furcation treatment with GTR

III. mucogingival periodontal surgery

  • Recession coverage
  • Frenectomy (removal of a frenulum of the lip or tongue).

Before the procedures

  • Oral hygiene optimization
  • Professional dental cleaning (PZR)
  • Non-surgical periodontal therapy

I.1. gingivectomy

Gingivectomy (gum removal) is used to remove pathologically (pathologically) thickened gingiva with the aim of eliminating pockets while preserving the natural course of the gingiva (gums). This procedure is used only when supra-alveolar pockets (gum pockets without bone resorption) are present and the gingiva in the affected area is fibrotically (connective tissue) thickened. This technique is not applicable in intra-alveolar pockets (pockets extending into the bony tooth compartment) caused by periodontitis (inflammation of the periodontium). In the anterior region, gingivectomy may cause esthetic impairment. Indications (areas of application)

  • Elimination of gingival overgrowth
  • Reduction of supraalveolar pockets (pockets not extending into the bony tooth socket).
  • Improvement of accessibility for hygiene measures.

Contraindications

  • Intraalveolar pockets – bone pockets.
  • Maxillary anterior region, especially with narrow thin gingiva.
  • Bulging course of the alveolar bone.

Possible complications

Bone thickening carries the risk of being exposed intraoperatively (during the procedure).

I.2. gingivoplasty

Gingivoplasty (modeling of the gingiva) is used to correct small areas of the gingiva and is also not used if infrabony periodontal pockets (pockets extending into the bony tooth compartment) are present in the area to be treated. Small thickenings of the gingiva can be removed by gingivoplasty in order to achieve an esthetic and natural appearance of the gums after successful completion of periodontal treatment. Indications (areas of application)

  • Localized limited thickening of the gingiva
  • Interdental craters – common after NUG/NUP (necrotizing ulcerative gingivitis/periodontitis).

Contraindications

  • Generalized thickened gingiva – indication for gingivectomy.
  • Presence of periodontal pockets – indication for flap surgery.

I.3 Flap surgery

Flap surgeries are used to clean hard-to-reach root surfaces, bone pockets or furcations (root division sites) under visual control.For this purpose, in the areas where adequate cleaning by means of scaling and root planing (root planing) was previously not possible by means of conservative (non-surgical) periodontal treatment, the gums are mobilized (surgically detached) to a greater or lesser extent, depending on the technique, in order to completely free the root surface from calculus (tartar below the gums) and periodontopathogenic microorganisms (disease-causing periodontal germs). Indications (areas of application)

  • Residual pockets over 6 mm after conventional (non-surgical) periodontal treatment.
  • Cleaning of poorly accessible areas such as furcations (root division sites).
  • Improving the hygienic ability of poorly accessible areas for the patient.
  • Surgical crown lengthening – to increase the distance of the crown margin to the limbus alveolaris (bone edge of the tooth socket) to 2 to 3 mm before providing a crown.

Contraindications

  • Shallow supraalveolar pockets
  • Thickened, fibrous gingiva
  • Poor compliance – lack of motivation and plaque control by the patient.
  • General diseases that prohibit a surgical approach.

The procedures

Various techniques exist for the preparation of a mucogingival flap (a flap of gum and oral mucosa):

  • Open curettage
  • Curettage according to Kirkland
  • Apical displacement flap according to Nabers and Friedmann
  • Papilla preservation flap according to Takei/ modified according to Cortellini.
  • Modified Widman flap (synonym: Widman flap, paro-flap surgery) – access flap according to Ramfjord and Nissle.
  • Microsurgical flap techniques
  • Et al

The primary goal of the various techniques is pocket reduction or elimination and reparative healing of the periodontal defect previously caused by inflammation, with a satisfactory treatment result for the gingiva postoperatively, both aesthetically and functionally. The procedures differ in terms of their incision and the extent to which the mucogingival flap is mobilized, i.e. detached from the bony support. The combination with a regenerative procedure such as GTR with the insertion of a membrane requires a more extended mobilization of the flap. After the procedure

For the first week after the procedure, the patient must not use a toothbrush or interdental care aids. Instead, rinsing with 0.1 to 0.2% chlorhexidine solution is done twice a day. After about a week, the sutures are removed. For another five weeks, oral hygiene should be performed carefully with a soft toothbrush. The interdental spaces should also be cleaned. This phase can be supported with gel containing chlorhexidine to inhibit plaque. Six weeks postoperatively, a first professional dental cleaning is advisable, which is followed by close-meshed recall appointments at intervals of two to three months as a supportive maintenance therapy.

I.4 Surgical furcation therapy

I.4.1 Root amputation

Posterior teeth have two or more roots. If their furcations (division sites) are exposed after the course of periodontitis (inflammation of the periodontium with bone loss), it may be advisable to amputate part of the roots to make the remaining roots hygienic. In this way, the tooth can be preserved and a gap between the teeth can be avoided. The technique is usually applied to upper molars.

I.4.2 Hemisection

In a hemisection (from Greek hemi = half), not only half of the rootstock but also of the crown is removed. When applied to mandibular molars, a half molar comparable in size to a premolar (anterior, smaller molar) remains, which can serve as a bridge abutment, for example. The prerequisite is a successfully completed root canal treatment. Indications (areas of application)

  • Furcations grade II (up to 3 mm can be probed in the horizontal direction).
  • Furcations grade III (more than 3 mm deep horizontally soundable, but not yet continuous).
  • First and second molars

Contraindications

  • Lack of compliance – lack of cooperation and motivation of the patient.

I.4.3 Premolarization

For furcation treatment in mandibular molars, premolarization is available as an alternative.In the case of second- or third-degree furcation, the roots and the crown of the tooth are separated and both parts are reconstructed with abutments and crowns. The prerequisite for this is a sufficiently large distance between the two roots and a successfully completed root canal treatment. Indications (areas of application)

  • Furcations grade II and III
  • First molars in the lower jaw

Contraindications

  • Divergence of the roots of less than 30 °.
  • Absence of proximal bone

I.4.4.Tunneling

For tunneling, the exposed furcation (division of the roots in multi-rooted teeth) is surgically expanded to make it accessible to daily cleaning by the patient, for example, with interdental brushes (interdental brushes). The prerequisite is therefore a willingness to maintain excellent oral hygiene and regular attendance at recall (follow-up appointments). Other surgical procedures must be ruled out. Indications (areas of application)

  • Advanced furcations grade II and III.
  • First, rarely second molars in the mandible.

Contraindications

  • Divergence of the roots of less than 30 °.
  • Absence of proximal bone
  • High susceptibility to caries
  • Lack of compliance
  • Poor oral hygiene

II Regenerative periodontal surgery

II.1 Guided tissue regeneration (GTR)

To allow the damaged structures of the periodontium to reform unimpeded and restore firm support to the tooth, a membrane is inserted during regenerative treatment to keep the rapidly proliferating (growing) marginal epithelium of the periodontal pocket away from the root surface. Under the protection of the membrane as a barrier, the much slower differentiating tissues of the periodontium – alveolar bone and desmodont (root membrane) – can regenerate. Depending on the material used, the membrane may have to be removed in a second operation after a few weeks. An alternative is the introduction of enamel matrix proteins into the bone pocket, through which cementogenesis (new formation of fibrous cementum on the root surface) is generated, which establishes the connection to the newly forming alveolar bone.

II.2 Regenerative furcation treatment

In regenerative furcation treatment, furcations are also covered with a membrane according to the principle of GTR to achieve filling of the defect with alveolar bone. Alternatively, it is also possible to work with enamel matrix proteins. Indications (areas of application)

  • Buccal (to the cheek) as well as lingual (to the tongue) furcations grade II in mandibular molars.
  • Buccal furcations grade II with molars in the upper jaw.
  • Intraosseous periodontal defects – bone pockets, interdental craters (between adjacent teeth).
  • Recession coverage

Contraindications

General

  • General diseases that speak against surgery
  • Poor oral hygiene
  • Nicotine abuse – heavy smoking

Specifically

  • Horizontal bone resorption
  • Single-walled bone pockets
  • Furcations grade III
  • For maxillary molars: mesial (front) or distal (back) furcations grade II
  • Furcations on premolars (premolar teeth).
  • Furcations on wisdom teeth
  • Miller class III and IV recessions
  • Severely periodontally damaged teeth with no prospect of regeneration – e.g. greatly increased tooth mobility.

III. mucogingival surgical periodontal operations

III.1. recession coverage

Recession refers to a regression of the periodontium, i.e., the gingiva and alveolar bone covering the tooth root, without inflammatory events. It is located on the buccal or oral tooth surface (towards the cheek or oral cavity). The result is an exposed tooth neck that is sensitive to cold and osmotic stimuli (triggered by sugar or acid). In addition, there may be an esthetic impairment. The procedures

The selection of the appropriate technique follows depending on the severity of the recession, the gingival thickness and the localization in the oral cavity. Some of the procedures that can be used are:

  • Lateral displacement flap – shallow recessions, usually in maxillary anterior teeth.
  • Coronal displacement flap with free gingival graft – recessions to the area of the mucosa (mobile mucosa), in the case of flat vestibule (oral vestibule).
  • Coronal displacement flap with connective tissue graft – isolated recessions up to the mucosa area, with thin gingiva.
  • Semilunar coronal shift flap – shallow gingival recessions without mucosa involvement up to 3 mm, mostly in maxillary anterior teeth.
  • Envelope technique – flat gingival recessions without mucosa involvement, in thin gingiva.
  • Guided Tissue Regeneration (GTR) – recessions with mucosa involvement without interdental bone loss (between teeth).
  • Enamel matrix proteins

III.2. correction of irradiating lip and cheek bands

If bands attach in the area of periodontal pockets or recession, they complicate oral hygiene and force further recession of the gingiva in the recession area. Cutting or relocating the attaching ligament allows the gingival margin to adhere tightly to the affected tooth. The adhesion of plaque (bacterial plaque) can thus be counteracted. The tight pull of high-set bands that radiate into an interdental space (space between teeth) can even prevent the gap closure of adjacent teeth. After surgical removal of the affected band, gap closure occurs spontaneously or is initiated by orthodontic treatment. Indications (areas of application)

  • Recession prophylaxis
  • Before orthodontic gap closure
  • To allow a spontaneous gap closure
  • To make the accumulation of biofilm more difficult

The procedures

  • Frenotomy (removal of a frenulum of the lip or tongue).
  • Frenectomy – loosening of the frenulum with subsequent displacement in V-Y or Z-plasty (named after the incision and subsequent displacement).

After the procedure

Postoperatively, infection prophylaxis is performed with CHX rinses (chlorhexidine). Periodontal dressing is not necessary, wound healing is usually without complications.