This document discusses periodontal pockets and various techniques for treating them, including gingivectomy. It defines different types of periodontal pockets and explores gingivectomy techniques like surgical gingivectomy and electro surgery gingivectomy. It also summarizes flap procedures like the modified Widman flap and apically repositioned flap. Osseous surgery principles and techniques are outlined for reshaping alveolar bone. The document concludes that surgical therapy provides greater benefit than non-surgical therapy for deeper initial periodontal disease levels.

1. SUBMITTED BY
ANURAGJB
FINAL YEAR PART A
NICDS

2.  The ultimate goal of periodontal therapy has been aimed to
restore the health and function of the periodontium.
 To achieve this goal many non surgical and surgical
techniques have been proposed to treat a variety of
periodontal conditions, most commonly-the periodontal
pocket.

3.  Periodontal pocket is defined as a pathologically
deepened gingival sulcus.it may occur by coronal
movement of gingival margin, apical displacement of
gingival attachment or a combination of above.

4. Depending up on its morphology
 Gingival pocket (pseudo pocket): This type of pocket is
formed by gingival enlargement without destruction
of the underlying periodontal tissues.
 Periodontal pocket: This type of pocket occurs with
destruction of the supporting periodontal tissues.
 Combined pocket

5. Depending up on its relationship to crestal bone.
 Suprabony pocket
 Infrabony pocket
Depending on the number of surfaces involved
 Simple pocket
 Complex pocket
 Compound pocket
Depending on the nature of soft tissue wall of the pocket
 Edematous pocket
 Fibrotic pocket
Depending up on the disease activity
 Active pocket
 Inactive pocket

6.  ENAP
 GINGIVECTOMY
 PERIODONTAL FLAP PROCEDURES
 OSSEOUS SURGERY

7.  1.After adequate anesthesia, an internal bevel incisions
ismade from the margin of the free gingiva apically to a
point below the bottom of the pocket .The incision is
carried interproximally on both the facialand the lingual
sides, attempting to retain as much inter proximal
tissue as possible. The intentions to cut the inner portion
of the soft tissue wall of thepocket, all around the tooth.
 2. Remove the excised tissue with a curette, and carefully
root plane all exposed cementum to a smooth, hard
consistency. Preserve all connective tissue fibers that
remain attached to the root surface.
 3. Approximate the wound edges; if they do not meet
passively, recontour the bone until good adaptation of the
wound edges is achieved. Place sutures and a periodontal
dressing.

9.  Gingivectomy means excision of the gingiva. By
removing the pocket wall, gingivectomy provides
visibility and accessibility for complete calculus
removal and thorough smoothing of the roots creating
a favorable environment for gingival healing and
restoration of a physiologic gingival contour.
 Types: Surgical gingivectomy
Gingivectomy by electro surgery
Laser Gingivectomy
Gingivectomy by chemosurgery

11.  Pocket marking
 Gingivectomy incision-Knives1215blade,Blake
knife,kirkland,orban.
 External bevel incision at 45degree apical to base of
pocket,continous,scalloped.
 Secondary incisions done with orbans knife.
 Tissue removal- curette / scaler.
 Root scaling and planning.
 Periodontal dressing

12. GINGIVECTOMY BY ELECTRO SURGERY
3 classes of electrode are used
1)Needle electrode-For incisions
2)Ball electrode-For hemostasis
3)Loop electrode-For relocation of frenum and muscle
attachement
ADVANTAGES
Bloodless field during surgery
DISADVANTAGES
Cemental necrosis
Bone necrosis

13.  The removal of gingival enlargements and gingivoplasty is
performed with the needle electrode, supplemented by the
small ovoid loop or the diamond-shaped electrodes for
festooning. A blended cutting and coagulating(fully
rectified) current is used. In all reshaping procedures, the
electrode is activated and moved in a concise "shaving"
motion.
 For hemostasis, the ball electrode is used. Hemorrhage
must be controlled by direct pressure (via air, compress,or
hemostat) first; then the surface is lightly touched with a
coagulating current. Electrosurgery is helpful for the
control of isolated bleeding points. Bleeding areas
locatedinterproximally are reached with a thin,
barshapedelectrode.
Frenum and muscle attachments can be relocated to
facilitate pocket elimination using a loop electrode. Forthis
purpose, the frenum or muscle is stretched and
sectionedwith the loop electrode and a coagulating
current.

14.  GINGIVECTOMY BY CHEMOSURGERY
Chemicals used are 5percent paraformaldehyde or
pottasium hydroide to remove gingiva
DISADVANTAGES
Depth of penetration cannot be controlled
Healing is delayed
 LASER GINGIVECTOMY
Most commonly used lasers are carbon dioxide and
Nd:YAG Lasers

15.  Definition:-periodontal flap is a section of gingiva
and/or mucosa surgically separated from the
underlying tissues to provide visibility of and access to
thebone and root surface.

16.  THE MODIFIED WIDMANS FLAP
 THE UNDISPLACED FLAP
 THE APICALLY DISPLACED FLAP

17.  Technique
 Step1: It is an initial internal bevel inision,0.5-1mm away
from the gingival margin, directed. to the alveolar crest
 .Step2:Gingiva is reflected with a periosteal elevator
 Step3:A crevicular incision is made
 Step4:After the flap is reflected, third incision is made in
the interdental spaces with orban knife and the gingival
collar is removed.
 Step5:Tissue tags and granulation tissue are removed with a
curette.Root surfaces are examined and scaled.
 Step5:Bone architecture is not corrected.
 Step6:Interrupted direct sutures are placed

18.  Technique:-
 Step 1. Pocket is measured with a periodontal probe
and bleeding points are produced on outer surface of
gingiva to mark pocket bottom.
 Step 2. The initial internal bevel incision is made
following the scalloping of bleeding marks on gingiva
up to a point apical to alveolar crest.
 Step 3. 2nd crevicular incision is made from bottom of
the pocket to bone to detach the connective tissue
from the tooth
 Step 4. Flap is reflected with periosteal elevator (blunt
dissection) from the internal bevel incision.

19.  Step 5. Interdental incision is made with interdental
knife, separating connective tissue from the bone.
 Step 6. The irregular wedge of tissue created by 3rd
incision is removed with a curette
 Step 7. The whole area is scaled, root planed and
debrided. After this the flap edge should rest on the
root bone junction. If it is not resting then the flap is
rescalloped and trimmed to allow the flap edge to end
at the root bone junction.
 Step 8. Continuous sling sutures is used to secure
facial and lingual flaps and covered with a periodontal
pack.

21.  1962 – Friedman proposed the term apically repositioned flap.
Technique:-
 Step 1.
Internal bevel incision is made 1mm from the crest of the gingiva
and directed toward the crest of the bone.
 Step 2.
Crevicular incisions are made followed by initial elevation of flap
and then interdental incision is performed; the wedge of tissue
containing pocket wall is removed
 Step 3.
Vertical releasing incisions are made extending beyond the
muccogingival junction and flap is elevated with a periosteal
elevator
 Step 4.
Remove all the granulation tissue,rootplaning is done and flap is
positioned apically at the tooth bone junction.
• Step5:Flaps are sutured together

22.  Principles outlined by schlugger and Goldman
 Gingival contour is dependent on the underlying bony
contour and the elimination of the soft tissue pockets
has to be combined with osseous recountering.
 To maintain
Shallow pockets
Optimal gingival contour after surgery

23.  Reshaping of alveolar bone to achieve a more
physiological form without removal of tooth
supporting bone
 INDICATIONS
Buccal/Lingual bony ledges
Intrabony defect- buccal/Lingual
Tilted molars
Interproximal defects
Furcation involvements

24.  Removal of tooth supporting bone to reshape the
deformities
INDICATIONS
Elimination of interdentalcraters
Correction of one walled defects
Other angular defects not amenable to
regeneration
Horizontal alveolar bone loss with irregular
marginal contours

25.  When the objective is reduction of probing depth
,surgical therapy provides a great benefit than non
surgical therapy for all levels of initial disease severity.
 When the objective is to increase the attachment level,
non surgical therapy provides a greater benefit for
initial disease severity levels 1-3 mm and 4-6mm and
surgical therapy for >6mm

26.  Carranza’s clinical periodontology 9th edition
 Essentials of clinical periodontology and periodontics
Shantipriya reddy