Periodontal surgery cezar pdf

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Periodontal
Surgery
Access Therapy
Cezar E. Lahham
Palestine / Bethlehem
ceazarlahham@hotmail.com
+970595031843

Facebook page: Dentist Cezar ‫سيزار‬ .‫د‬
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2021
Periodontal surgery:
Access Therapy
Chapter outline:
1. Introduction
2. Indications and contraindications for periodontal surgery
3. Classification of flaps
4. Techniques
5. Osseous surgeries
6. Crown lengthening procedures
7. Suturing techniques
8. Periodontal dressing
9. Conclusions from some Clinical researches
1. Introduction
• Surgical access therapy must be considered as adjunctive to cause‐related therapy,
so, it should be done in the second phase (surgical phase = corrective phase) of treatment
(after 2-3 months from the scaling and root planning).
• It is done after the initial phase to;
A. Decrease the amount of bacteria
B. Reduce the gingival inflammation (the tissues become less friable)
C. Insure that the patient follows the OHI as required.
2. Indications and contraindications for periodontal surgery
• Indications:
A. Residual pocket >5mm (Waerhaug 1978; Caffesse et al. 1986)
B. Presence of osseous defects (e.g: Craters)
C. Furcation involvement
D. To regenerate periodontal tissues
E. Gingival enlargement & asymmetry
F. Periodontal pockets adjacent to distal molars
G. To get an access to excise periapical lesion (Apicectomy)
H. Facilitate oral hygiene measures
I. Shifting of gingival margin to position coronal, apical or lateral (for functional reasons
or Aesthetic reasons).
• Contraindications:
A. Uncooperative patient (noncompliant) who do not follow the OHI during
phase I of treatment
B. When the optimum result can be obtained by non-surgical therapy.
C. Soft, edematous gingival tissue.

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D. Medically compromised patients where surgery is a risky proposition
E. Teeth with hopeless prognosis
F. When surgery is likely to result in extreme esthetic disfigurement.
G. Smoker patients (relative contraindication); less capacity to heal following surgery
3. Classification of flaps:
A. According to flap thickness: 1. Full-thickness flap (Epithelium + CT + periosteum)
2. Partial-thickness flap (Epithelium + CT)
B. According to position of flap margins following the surgery:
1. Coronally displaced flap
2. Apically displaced flap
3. Laterally displaced flap
4. Nondisplaced flap
For the management of the papilla:
1. Conventional flap: (fig 1)
(is used (1) when the interdental spaces are too narrow,
thereby precluding the possibility of preserving the
papilla, (2) when the flap is to be displaced and (3) when
there is break in continuity of the interdental papilla.)
Fig 1: Conventional flap
2. papilla preservation flap: (fig 2)
(is used when we have spacing between teeth)
Fig 2: Papilla preservation flap

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4. Techniques:
A. Gingivectomy
B. Original Widman flap
C. Neumann flap
D. Modified flap operation (Kirkland’s flap)
E. Apically positioned flap
F. Modified Widman flap
G. Papilla preservation flap
1. Gingivectomy: Surgical procedure in which we excise the soft tissue wall of the pathogenic
pocket. By Robicsek (1884)
Today was first described by Goldman 1951
Technique:
1. Local Anesthesia
2. Determine the pocket depth; When the depth of the pocket has been assessed, an equivalent
distance is delineated on the outer aspect of the gingiva. The tip of the probe is then turned
horizontally and used to produce a bleeding point at the level of the bottom of the probeable
pocket. (Fig 3)
Fig 3
Pocket marker tweezer
Crane Kaplan
3. External (Beveled incision)= The primary incision: The incision is terminated at a level 0.5-1 mm
apical to the “bottom” of the pocket and is angulated to give the cut surface a distinct bevel,
should be planned to give a thin and properly festooned margin of the remaining gingiva.
Thus, in areas where the gingiva is bulky, the incision must be placed at a more apical level
than in areas with a thin gingiva (fig 4).

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The incision may be made with a scalpel (blade No. 12B or 15; Bard– Parker®) in either a Bard–
Parker® handle or an angulated handle (e.g. a Blake’s handle) or handle #3 , or a Kirkland knife
No. 15/16.
Fig 4
4. Secondary incision to separate the interproximal soft tissue from the interdental periodontium,
using an Orban knife (No. 1 or 2) or a Waerhaug knife (No. 1 or 2; a saw‐toothed modification
of the Orban knife) or blade 11
5. The incised tissues are carefully removed with a curette or a scaler
6. Pieces of gauze packs often have to be placed in the interdental areas to control bleeding.
7. The exposed root surfaces are carefully debrided.
8. the dentogingival regions are probed again to detect any remaining pockets, and the gingival
contour is checked and, if necessary, corrected with the use of knives or rotating diamond
burs. (Gingivoplasty performed with tissue nippers and a round diamond at high speed with
abundant cooling)
9. cover the incised area by a periodontal dressing (e.g: Coe pack), to protect it during the
period of healing.

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10. Remove the dressing material after 10-14 days, then clean and polish the teeth, Check the root
surfaces carefully and remove any granulation tissues using a curette.
11. The patient is instructed to clean the area using soft toothbrush.
Postoperative instructions:
1. The pack should remain until the next appointment (after ~2 wks)
2. Avoid hot drinks/foods first 3 hours after the surgery
3. Do Not smoke
4. Do not brush the surgical site.
5. Mouth wash 0.2% CHX twice daily
Advantages:
1. Simple technique
2. Predictable morphological results
3. Complete pocket elimination
Disadvantages:
1. Limited indications
2. Postoperative discomfort
3. Healing by secondary intension
4. Risk to do bone exposure
5. Loss of attached gingiva
6. Longer teeth (may be an esthetic problem in addition to risk for dental hyper sensitivity)
7. May cause phonetic problems (if dark triangles are found)
Indications:
1. Gingival enlargement / Pseudo-pockets
2. Suprabony pockets
3. Idiopathic gingival fibromatosis
4. To increase the crown length (for a certain limit)
Contraindications:
1. Narrow width of attached gingiva (or Base of the pocket located apical to the MGJ)
2. Infrabony pockets
3. Bone recontouring is needed
4. Systemic contraindications (uncontrolled medical diseases, or specific types of drugs)
Gingivectomy is usually not considered suitable in situations where the incision will lead to the
removal of the entire zone of gingiva. This is the case when the bottom of the probeable
pocket to be excised is located at or below the mucogingival junction. As an alternative in
such a situation, an internal beveled gingivectomy may be performed.

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Internal incision gingivectomy
Types of gingivectomy:
1. Gingivectomy by blade
2. Gingivectomy by laser (less discomfort, minimal bleeding, rapid healing, but more
expensive)
3. Gingivectomy by cryosurgery
4. Gingivectomy by chemosurgery
5. Gingivectomy by electrosurgery (can be harmful to root surface / bone)
Healing after Gingivectomy:
1. Clot formation
2. Underlying tissue become acutely inflamed with some necrosis.
3. The clot is replaced by Granulation tissue.
4. After 12 to 24 hours, epithelial cells at the margins of the wound begin to migrate over the
granulation tissue, separating it from the contaminated surface layer of the clot.
5. Epithelial activity at the margins reaches a peak in 24 to 36 hours.
6. The new epithelial cells arise from the basal and deeper spinous layers of the epithelial
wound edge and migrate over the wound over a fibrin layer that is later resorbed and
replaced by a connective tissue bed.
7. After 24 hrs; the number of CT cells is increased, mainly fibroblasts and angioblasts.
8. By the third day, numerous young fibroblasts are located in the area.
9. The highly vascular granulation tissue grows coronally, creating a new free gingival margin and
sulcus. Vasodilation and vascularity begin to decrease after the fourth day of healing and
appear to be almost normal by the sixteenth day
10. Capillaries derived from PDL blood vessels migrate into the granulation tissue and within 2
weeks they connect to gingival blood vessels.
11. The epithelial cells advance by a tumbling action with the cells becoming fixed to the
substrate by hemidesmosomes and a new basement lamina. After 7 to 14 days, surface
epithelialization is generally complete.
12. During the first 4 weeks after gingivectomy, keratinization is less than it was before surgery.
13. Complete epithelial repair takes about 1 month.
14. Complete repair of the connective tissue takes about 6-8 weeks
(Complete healing of the gingivectomy wound takes 4–5 weeks)

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Original Widman flap: (by Leonard Widman in 1918)
Rarely used!
Technique:
1. Anesthesia
2. Two vertical releasing incision are done first to demarcate the area of surgery.
3. Reverse bevel incision (internal incision toward the bone crest) 1-2 mm from the gingival
margin (connect two releasing incisions together)
4. The flap is elevated by periosteal elevator (e.g. Periosteal elevator #9) until we expose 2-3
mm from the alveolar bone.
5. The collar of inflamed tissue around the neck of the teeth is removed with curettes
6. The exposed root surfaces are carefully instrumented.
7. Bone recontouring is recommended in order to achieve an ideal anatomic form of the
underlying alveolar bone
8. The buccal and lingual flaps are laid back over the alveolar bone and secured in this position
with interproximal sutures
Advantages:
1. Less discomfort for the patient (compared with gingivectomy), since healing occurred
by primary intention
2. Possible to re‐establish a proper contour of the alveolar bone in sites with angular bony
defects.
Disadvantages:
1. Often the interproximal areas are left without soft tissue coverage of the crestal bone.
2. The flap replaced in more apical position (slightly) because we do bone recontouring.

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INSTRUMENTS:-
From left to right: Kirkland, Orban, Waerhaug.
NEUMANN FLAP (1920)
Technique:
1. Anesthesia
2. Intracrevicular incision (= intrasulcular incision)
3. Two vertical releasing incisions
4. Flap elevation
5. the inside of the flap is curetted to remove the pocket epithelium and the granulation
tissue.
6. The root surfaces are subsequently carefully debrided. Any irregularities of the alveolar
bone crest are corrected.
Advantages:
More conservative surgical technique compared with gingivectomy and original Widman
flap.
MODIFIED FLAP OPERATION (KIRKLAND) 1931
Technique:
1. Anesthesia
2. Intracrevicular incision (= intrasulcular) extends on many teeth to get good access,
without any releasing incisions!
3. Flap elevation

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4. Root surface is debrided
5. No bone is removed
6. Following the elimination of the pocket epithelium and granulation tissue from the inner
surface of the flaps, these are replaced at their original position and secured with
interproximal sutures.
Advantages:
1. Existing gingiva is preserved
2. Marginal alveolar bone is exposed such that the morphology of bony defects
can be identified and the proper treatment rendered
3. Furcation areas are exposed, and the degree of involvement and the “tooth–
bone” relationship can be identified
4. Flap can be repositioned at its original level or shifted apically (but less than
original Widman and neumann), thereby making it possible to adjust the
gingival margin to the local conditions
5. Flap procedure preserves the oral epithelium and often makes the use of a
surgical dressing superfluous
6. Postoperative period is usually less unpleasant to the patient when compared
to gingivectomy.
APICAL REPOSITIONED FLAP (Friedman 1962)
(very similar to original Widman, but ARF the flap replaced more apically, and the
amount of the attached gingiva is increased here)
Technique:
1. reverse bevel incision is made using a scalpel with a Bard–Parker® blade (No. 12B or No.
15)

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2. two vertical releasing incisions extend beyond the MGJ.
3. Full-thickness Flap is elevated (the flap will be movable because it extends beyond the
MGJ)
4. Root surfaces are debrided
5. The alveolar bone crest is recontoured
6. the buccal/lingual flap is repositioned to the level of the newly recontoured alveolar bone
crest and secured in this position
7. Suturing (e.g: continuous suturing technique)
8. Periodontal dressing material (the light‐cured dressing is not the dressing of choice for
situations where the flap has to be retained apically, due to its soft state before curing.)
Advantages:
1. Minimum pocket depth postoperatively
2. If optimal soft tissue coverage of the alveolar bone is obtained, the post‐surgical bone loss is
minimal
3. Postoperative position of the gingival margin may be controlled and the entire mucogingival
complex may be maintained

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Disadvantages:
1. esthetic problems
2. root sensitivity
Lindhe and Nyman (1980) found that after an apically repositioned flap procedure, the
buccal gingival margin shifted to a more coronal position (by about 1mm) during 10–11
years of maintenance. In interdental areas denuded following surgery, van der Velden
(1982) found an up‐growth of around 4mm of gingival tissue 3 years after surgery,
while no significant change in attachment levels was observed
BEVELED FLAP: To handle periodontal pockets on the palatal aspect of the maxillary
teeth, Friedman described a modification of the “apically repositioned flap”, which he
termed the beveled flap
1. Intracrevicular 2. Flap elevation 3. Bone recontouring 4. Beveled incision
5.suturing
MODIFIED WIDMAN FLAP: Ramfjord and Nissle (1974)
Technique:
1. Anesthesia
2. Internal = reverse bevel incision (0.5-1 mm from gingival margin buccally, 1-2 mm from
gingival margin palatally), if the pocket<2 → Go inside the sulcus= intracrevicular
3. Flap elevation
4. Intracrevicular incision
5. Horizontal incision

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6. The pocket epithelium and the granulation tissues are removed by means of curettes.
7. The exposed roots are carefully scaled and planed
8. the flaps are trimmed and adjusted to the alveolar bone to obtain complete coverage of the
interproximal bone . If this adaptation cannot be achieved by soft tissue recontouring, some
bone may be removed from the outer aspects of the alveolar process to facilitate adaptation.
(bone exposure 1.5-2 mm)
9. Suturing
10. Dressing material may be placed over the area.
11. Remove sutures + Dressing material after 1 week.
Advantages:
1. • Possibility of obtaining a close adaptation of the soft tissues to the root surfaces
2. • Minimum of trauma to which the alveolar bone and the soft connective tissues are exposed
3. • Less exposure of the root surfaces (esthetic point of view)
4. No bone removal
Soft tissue recession will take place during the healing phase following a modified Widman
flap procedure. Although the major apical shift in the position of the soft tissue margin will
occur during the first 6 months following the surgical treatment, the soft tissue recession may
often continue for >1year.
Conventional Papilla preservation flap Takei et al. (1985)
Technique:
1. intrasulcular incision at the facial and proximal aspects of the teeth without making incisions
through the interdental papillae
2. intrasulcular incision is made along the lingual/ palatal aspect of the teeth with a semilunar
incision made across each interdental area.

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The semilunar incision should dip apically by at least 5mm from the line angles of the teeth,
which will allow the interdental tissue to be elevated in the facial flap.
3. A curette or interproximal knife is used to free the interdental papilla carefully from the
underlying hard tissue.
4. The detached interdental tissue is pushed through the embrasure with a blunt instrument
5. A full‐thickness flap is reflected with a periosteal elevator on both facial and lingual/palatal
surfaces.
6. The exposed root surfaces are thoroughly debrided and bone defects carefully curetted
7. While holding the reflected flap, the margins of the flap and the interdental tissue are trimmed
to remove pocket epithelium and excessive granulation tissue
8. The flaps are repositioned and sutured using cross mattress sutures
9. A surgical dressing may be placed to protect the surgical area.
10. The dressing and sutures are removed after 1 week.
Advantages
1- Healing by primary intension
2- Maximum protection of the grafting material
3- Maximum vascularity for the papillae and the graft with limited postoperative gingival
recession
4- Esthetic pleasing
5- Prevent postoperative tissue craters
Disadvantages
1. Technically difficult
2. Time consuming

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3. Granulation tissue attached to interdental papillae
4. Extended flap with long incisions and reflection
5. Require wide interproximal embrasures
Modified - Simplified Papilla preservation flap (by Cortellini et al 1995,1999)
Less invasive procedure, less patient’s discomfort
Could be used in cases of narrow interproximal embrasure
Buccal horizontal incision preserving papillae more and bring incision line more away from the
bony defect (not at the base like conventional papilla preservation technique)
Vertical releasing incisions can be placed in the interproximal spaces neighboring the
defect if coronal advancement of the flap is desired.
Please note: M-D extension of the flap is better than vertical releasing incisions (because
the blood supply will be preserved)
Technique Modified PPT Simplified PPT
By Cortellini et al 1995 Cortellini et al 1999
Incision Horizontal incision (2-4 mm
far from the gingival margin)
Oblique incision (<2mm far
from the gingival margin)
indication Wide embrasure Narrow embrasure
Minimally invasive surgery (MIS) by Harrel and Rees 1995
The flap extends one tooth mesial & one tooth distal to the defect
1- Small incisions (teeth adjacent to the defect)
2- Not contentious
3- Buccal 2 vertical releasing incisions and one horizontal (like Modified PPT)
Simplified PPT
<2mm from GM
(suitable for tight interproximal contact)
Modified PPT
2-4 mm from GM
(suitable for wide embrasure)
Simplified PPT

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Minimal invasive surgery with (Simplified papilla preservation or Modified papilla
preservation technique) by Cortellini 1999
Cortellini’s modification was in the amount of flap reflection, here he elevate the flap till the
halfway of adjacent teeth (just ½ tooth mesially, and ½ tooth distally); which called: Triangular
flap.
Modified Minimal invasive surgery (M-MIST) by Cortellini 2009
The access to the buccal defect is gained through the elevation of small buccal flap
without elevation of the interdental papilla
Indications:
1. Buccal defect does not extend to the palatal tissue
2. Accessibility can be gained from small flap (due to using special accessible instruments,
magnification, .. etc)
The soft tissue wall technique by G. Rasperini et al 2013
“Single flap approach”
This technique is useful for the regenerative treatment of non-contained infrabony defects.
Note: a minimal increase in gingival recession was reported in the literature after GTR
procedures even after using a microsurgical approach for the treatment of vertical bony
defects. Soft tissue wall techniques was used to reduce gingival recession and achieve
marginal soft tissue stability.
Single flap approach and papilla preservation could provide better outcomes than
double flap. (Barbato et al 2020)
Triangular flap

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Fig 1 The soft tissue wall technique aims to change the three-dimen-
sional morphology of an infrabony defect from non-contained (one walled)
to well contained (three walled). The defect is delimited from a bone wall
(yellow line) and palatal/lingual ap (pink shade); the third wall (green line)
is surgically created to coronally advance the buccul fap
by G. Rasperini et al 2013
We should de-epithelize the papillae two 5-0 nonresorbable e-PTFE
sling sutures were used to stabilize
the coronally displaced flap
Tension free primary closure of the
interdental papilla upon the bony defect was
achieved using a 7-0 non-resorbable e-PTFE
internal horizontal mattress suture.
The vertical releasing incisions were closed
with interrupted sutures.

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In 2014, Zucchelli et al use soft tissue wall technique, single flap approach to do
connective tissue graft with coronally advanced flap (CTG placed below CAF and used
as a buccal soft tissue wall for the bony defect treated with bone graft and/or EMD,
simplified papilla technique was adopted for interdental soft tissue preservation.
Zucchelli et al 2014
Advantages: (Zucchelli et al 2014)
1. Connective tissue graft plays a rule as a barrier (rigid enough) to limit buccal soft tissue
collapse inside the bony defect.
2. Also, CTG helps in blood clot stabilization inside the intrabony component of the defect,
Three new techniques that does not touch the papilla !
1- Entire papilla preservation technique
2- Non-incised papillae surgical approach
3- VISTA and M-VISTA
Entire papilla preservation technique (Serhat Aslan et al 2017)
1. Vertical releasing incision adjacent to papillae
2. Degranulate beneath the papilla (like a tunnel)
3. Insert the graft material
4. Suturing
Xiyan Pei 2021

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Non-incised papillae surgical approach NIPSA by Jose A Moreno Rodriguez 2018
Apical (submarginal) horizontal incision was done to preserve the papillae and the
marginal gingiva.
Intrabony defect with absence of the buccal wall is a prerequisite for access and
correct debridement. (if the defect is extended into the lingual side, you should not
do this technique)
Clinical outcomes of entire papilla
preservation EEP technique
“Aslan et al 2019”

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VISTA and M-VISTA
Vestibular incision subperiosteal tunnel access (VISTA)
Specially used to treat gingival recession
Vertical incision Periosteal tunnel preparation CTG is inserted
Modified – VISTA
1- Extending the vertical incision slightly beyound the MGJ.
2- Performing intracrevicular incision
3- Releasing the tunnel-papillae compex to facilitate the coronal traction of the whole tunnel-
papillae compex
coronally anchored
suture with
composite stops

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Key points (As a conclusion for all techniques)
1. Periodontal surgery is one of the most common surgical procedures in the oral cavity
2. It is indicated in persistent pockets, osseous defects, furcation defects, and whenever
regeneration is attempted.
3. The three basic horizontal incisions of periodontal flap are the internal bevel incision,
crevicular incision, and the interdental incision. Occasionally vertical releasing incisions are
needed.
4. Papilla preservation is indicated in esthetic zone and when bone grafts are placed
5. Routine full thickness flaps are employed.
6. Following flap reflection a thorough debridement is performed.
7. Osseous management is done either by additive or respective methods.
8. Usually a non-absorbable sutures made of either silk or EPTF are used.
9. Many types of suturing techniques are employed for different situations.
10. Periodontal dressings may or may not be placed.
11. The most common techniques for pocket reduction are modified widman flap and
undisplaced access flap (e.g Kirkland Flap).
12. Apically displaced flap in addition to pocket eradication also aids in increasing the width of
attached gingiva
13. As a general rule; By reducing the flap extension, the blood supply will be enhanced, the
micromovement will be reduced, so clot stability will be achieved, also we will reduce the need
for GTR and/or bone grafting, the risk for infection or contamination will be reduced, as a final
result the patient will be more comfort.
Distal wedge procedures
(Robinson 1966)
The most direct approach to pocket elimination in such cases in the maxillary jaw is the
gingivectomy procedure. But this procedure reduce the amount of Keratinized gingiva or remove
it at all in this area! , the bulbous tissue should be reduced in size rather than removed in toto. This
may be accomplished by the distal wedge procedure.
Advantages:
1. facilitates access to the osseous defect
2. To maintain and preserve attached gingiva.
3. To eliminate periodontal pocket.
4. To lengthen clinical crown.

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5. To create easily cleansable gingiva-alveolar form.
Technique: (Maxilla)
1. Buccal and lingual incisions are made in a vertical direction through the tuberosity or retromolar
pad to form a triangular wedge . The facial and lingual incisions should be extended in a mesial
direction along the buccal and lingual surfaces of the distal molar to facilitate flap elevation.
2. The facial and lingual walls of the tuberosity or retromolar pad are deflected and the incised
wedge of tissue is dissected and separated from the bone
3. The walls of the facial and lingual flaps are then reduced in thickness by undermining incisions
4. Loose tags of tissue are removed and the root surfaces are debrided. If necessary, the bone is
recontoured.
5. The buccal and lingual flaps are replaced over the exposed alveolar bone, and the edges
trimmed to avoid overlapping wound margins. The flaps are secured in this position with
interrupted sutures
6. Remove sutures after 1 week.
MODIFICATIONS FOR DISTAL WIDGE PROCEDURE:
1. Linear incision
2. Triangular incision (for mandible)

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3. Pedicle incision
4. Square parallel incision (for maxilla)
Mandibular molars:
TECHNIQUE:
The retromolar pad area does not usually present as much fibrous attached gingiva. The two
incisions distal to the molar should follow the area with the greatest amount of attached
gingiva. Therefore, the incisions could be directed distolingually or distofacially, depending on
which area has more attached gingiva. Before the flap is completely reflected, it is thinned with
a 15 no. blade. It is easier to thin the flap before it is completely free and mobile. After the
reflection of the flap and the removal of the redundant fibrous tissue, any necessary osseous
surgery is performed. The flaps are approximated similarly to those in the maxillary tuberosity
area.
OSSEOUS SURGERY
1. Osteoplasty (by Friedman 1955)
Removing NONSUPPORTING bone
2. Ostectomy
Removing SUPPORTING bone

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OSTEOPLASTY OSTECTOMY
CROWN LENGTHENING PROCEDUREs
A. SURGICAL
B. NONSURGICAL
A. SURGICAL CL
1. GINGIVECTOMY
2. APICALLY REPOSITIONED FLAP: As a general rule, at least 4 mm of sound tooth
structure must be exposed at the time of surgery. During healing, the supracrestal soft
tissues will proliferate coronally to cover 2–3 mm of the root, thereby leaving only 1–2 mm
of supragingivally located sound tooth structure.
3. Surgical extrusion
4. Distal widge procedures
B. Nonsurgical CL
1. Orthodontic extrusion
Suturing
The three most frequently used sutures in periodontal flap surgery are:
1. Interrupted interdental sutures
2. Suspensory sutures
3. Continuous sutures.
1. Interrupted interdental suture
buccal and lingual flaps at the same level

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Modified interrupted suturing technique (no suturing material beneath the
incision line.
In regenerative procedures, which usually require a coronal advancement of the flap, a modified
mattress suture may be used as an interdental suture to secure close flap adaptation
The suspensory suture 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 continuous suture is commonly used when flaps involving several teeth are to be repositioned
apically
Periodontal dressings
Periodontal dressings are mainly used:
1. To protect the wound post‐surgically
2. To obtain and maintain a close adaptation of the mucosal flaps to the underlying bone
(especially when a flap has been repositioned apically)

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3. For the comfort of the patient.
4. prevent postoperative bleeding during the initial phase of healing
5. prevent the formation of excessive granulation tissue
Ideal Properties:
1. Soft, but with enough plasticity and flexibility to facilitate placement in the operated area
and to allow proper adaptation
2. Hardens within a reasonable time
3. After setting, sufficiently rigid to prevent fracture and dislocation
4. Smooth surface after setting to prevent irritation of the cheeks and lips
5. Preferably, bacteriocidal properties to prevent excessive plaque formation
6. Must not detrimentally interfere with healing.
Note: Mouth rinsing with antibacterial agents such as chlorhexidine does not prevent the
formation of plaque under the dressing
a. A commonly used periodontal dressing is Coe‐ Pak =
1. One tube contains oxides of various metals (mainly zinc oxide) and lorothidol
(a fungicide).
2. The second tube contains non‐ionizing carboxylic acids and chlorothymol (a
bacteriostatic agent).
MIX 1:1
b. A light‐cured dressing, for example Barricaid
(is useful in the anterior tooth region and particularly following
mucogingival surgery, because it has a favorable esthetic appearance and
it can be applied without dislocating the soft tissue.)
c. Cyanoacrylates: have also been used as periodontal dressings with varying
success. Dressings of the cyanoacrylate type are applied in a liquid directly
onto the wound, or sprayed over the wound surface. Its use is rather
limited at present
Conclusions from some Clinical researches
• Gingivectomy is more associated with clinical attachment loss compared with other
periodontal surgery procedures.
While Modified Widman flap (without bone recontouring) is associated with the maximum attachment
gain.
“Rosling et al 1976”

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Plaque accumulation:
With regard to post‐treatment plaque accumulation, there is no evidence to suggest that differences
exist between non‐surgical or surgical treatment or between various surgical procedures. In addition,
most studies have shown that the magnitude of gingivitis resolution is not influenced by the treatment
modality
Nyman et al. (1977)
Recession :-
Most recession occurred after GINGIVECTOMY procedure (Compared with other surgical
procedures)
At the short term: Surgical procedures associated with more recession than Nonsurgical
procedures
While in the long term: insignificant (no difference)
(Kaldahl et al. 1996; Becker et al. 2001)
Coronal growth of the gingiva:-
Lindhe and Nyman (1980) found that after an apically repositioned flap procedure, the buccal gingival
margin shifted to a more coronal position (by about 1mm) during 10–11 years of maintenance. In
interdental areas denuded following surgery, van der Velden (1982) found an up‐growth of around
4mm of gingival tissue 3 years after surgery
Critical probing depth
the surgical therapy showed superior outcome only when the initial probing depth of the anterior
teeth was >6–7mm, while at molars the corresponding cut‐ off point was 4.5mm.
(Nordland et al. 1987; Loos et al. 1988)
Oral Hygiene measures + SRP
The amount of reduction of PD is more in the deeper pockets (>4.5 mm)
If the pocket is less than 5 and we do subgingival RP; the result will be ATTACHMENT LOSS!
This is called Critical probing depth (CPD)
Badersten el al 1984
Dressing material :
Studies show; less probing depth in case we use dressing material (less 1.5-2 mm)
So more attachment gain (1.5-2 mm), it is a result of indirect effect on the healing process.
“Dressing material protects the wound during healing phases”
“Sigush B et al 2005”

27
2021
In case of 2 & 3 Wall defect, single rooted
When Modified Widman Flap is done with supportive periodontal therapy SPT(every 3m)
Results were: (Attachment gain 3.5 mm, bone fill 2.8 mm, resorption margin 0.4 mm)
Whereas Without SPT: (just once per year)
The average bone loss was 0.7 mm, and the marginal resorption was 1.4mm
“Rosling et al 1976”
Oral Hygiene
With Oral hygiene: all types of flap surgery will lead to attachment gain “EXCEPT: GINGIVECTOMY”
While without OH: All of them → Attachment loss
“Nyman et al 1977”
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Dentist Cezar ‫سيزار‬ .‫د‬

Periodontal surgery cezar pdf

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