5.5 Surgical Periodontal Therapy Overview & Maintenance Protocols

5.5 Surgical Periodontal Therapy Overview & Maintenance Protocols

NBDHE Core Concept: Surgical periodontal therapy is indicated when non-surgical periodontal therapy (NSPT) fails to resolve deep pockets (>=6 mm), severe vertical osseous defects, or mucogingival deformities. Surgery provides direct visual access for root debridement and allows resective or regenerative recontouring of periodontal tissues.

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1. Indications & Objectives of Periodontal Surgery

Periodontal surgery is an adjunctive phase of treatment performed following initial NSPT and re-evaluation.

Primary Indications

• Deep Persistent Pockets (>= 6 mm): Pockets exceeding 5 mm cannot be thoroughly instrumented with hand or ultrasonic instruments due to root concavities and furcations.
• Vertical (Infrabony) Osseous Defects: Bony craters and multi-walled vertical defects suitable for bone grafting or regeneration.
• Furcation Involvements (Class II or III): Surgical exposure allows root resection, hemisection, or GTR.
• Mucogingival Defect Correction: Inadequate attached gingiva or progressive gingival recession.

Absolute & Relative Contraindications

• Uncontrolled systemic diseases (e.g., uncontrolled diabetes mellitus, recent myocardial infarction within 6 months, active leukemia).
• Non-compliant patient oral hygiene (Plaque Index > 20%).
• Heavy tobacco smoking (severely impairs surgical wound healing and graft survival).

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2. Resective Periodontal Surgical Procedures

Resective surgery aims to reduce or eliminate deep periodontal pockets by removing or repositioning tissue margins.

Flap & Tissue Resection Classifications

• Gingivectomy: The surgical excision of the unattached soft tissue pocket wall. Indicated for gingival enlargement / hyperplasia (e.g., drug-induced via phenytoin, nifedipine, or cyclosporine) or pseudopockets. Contraindication: Must NOT be performed if attached gingiva is narrow or if osseous surgery is required.
• Modified Widman Flap (MWF): An internal bevel flap reflected just enough to gain direct visual access to root surfaces for SRP. The flap is repositioned in its original location, achieving primary closure with minimal tissue excision.
• Apically Positioned Flap (APF): The soft tissue flap is repositioned apically toward the tooth apex to eliminate deep pockets while preserving the existing zone of attached gingiva.

Osseous Surgery: Ostectomy vs. Osteoplasty

Osseous surgery modifies alveolar bone deformities caused by periodontitis to restore physiologic bone contours.

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3. Regenerative Periodontal Surgery & Bone Grafting

Regenerative procedures aim to restore lost periodontal tissue, forming new alveolar bone, cementum, and functional periodontal ligament fibers.

Guided Tissue Regeneration (GTR)

• Biological Concept: Following surgical flap elevation, epithelial cells migrate along the root surface rapidly (0.5–1.0 mm/day), much faster than connective tissue cells or osteoblasts. If unchecked, epithelial cells form a Long Junctional Epithelium (LJE).
• Mechanism: GTR places a physical barrier membrane (resorbable collagen/polylactic acid or non-resorbable ePTFE) over the osseous defect between the soft tissue flap and the tooth root. This membrane physically excludes rapidly migrating epithelial cells, creating a protected space for slower-growing PDL progenitor cells and osteoblasts to repopulate the root and reform true new attachment.

[Flap Reflection] ──► [Place Barrier Membrane Over Defect] ──► Excludes Epithelial Cells
                                                             ──► Allows PDL & Osteoblasts to Form New Attachment

Periodontal Bone Graft Material Classifications

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4. Mucogingival Surgery: FGG vs. CTG

Mucogingival procedures correct defects in the morphology, position, or amount of keratinized gingiva.

• Free Gingival Graft (FGG): A full-thickness graft (epithelium + underlying connective tissue) harvested from the hard palate and sutured to a prepared recipient bed. Primary Goal: Increase the width of attached/keratinized gingiva. Resulting tissue often appears lighter and mismatching in color.
• Subepithelial Connective Tissue Graft (CTG): A graft containing connective tissue ONLY harvested from under a palatal flap and covered by a flap at the recipient site. Primary Goal: Root coverage for localized gingival recession; achieves superior aesthetic color blending.

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5. Post-Operative Management & Periodontal Dressings

Proper post-surgical care ensures wound stability and patient comfort.

Periodontal Dressings (Coe-Pak)

• Periodontal dressings are non-eugenol pastes mixed and molded over surgical sites. They lock mechanically into interdental embrasures.
• Critical Concept: Periodontal dressings do NOT contain healing agents and do NOT accelerate wound healing. They function strictly to protect the surgical wound from trauma/debris, stabilize soft tissue flaps, and improve patient comfort.

Post-Surgical Instructions

• Prescribe 0.12% Chlorhexidine rinse twice daily; the patient must DEFER mechanical brushing at the surgical site for 14 days.
• Suture removal is performed at 7 to 14 days post-surgery.
• Avoid hot foods, hard diets, spitting, or using straws for the first 24 to 48 hours.