9. 1981 Erwin P. Barrington. an Overview of Periodontal Surgical Procedures

8/19/2019 9. 1981 Erwin P. Barrington. an Overview of Periodontal Surgical Procedures

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An Overview of Periodontal Surgical Procedures

Erwin P. Barrington

Over the past three decades most articles pertaining tosurgical procedures, especially those dealing with thenewer ones, have included discussions of indications andcontraindications as well as the advantages and disad-vantages of specific procedures. More recently, however,few authors have dealt directly with indications for peri-odontal surgery. Instead, there has been a tendency tolimit such references to broad comments on the time-honored matter of presence of periodontal pockets and/ or absence of bone. Certainly with the questioning whichthe profession is now conducting on the status of peri-odontal surgery, indications for these procedures shouldbe carefully reviewed.

This report will discuss the indications for specificperiodontal surgical procedures in the light of our presentknowledge of periodontal disease and therapy. It willalso evaluate the comparative studies carried out duringthe past decade on surgical techniques and the resultsreported.

Definition of Periodontal Surgical Procedures

Surgery has been defined as the act and art of treatingdiseases or injuries by manual operation.1 If this broaddefinition is used, nearly all periodontal treatment, fromhard or soft tissue curettage through osseous surgicalprocedures, falls under the heading of "periodontal sur-gery". In common usage the term "periodontal surgery"2is applied only to specific surgical manipulations ofperiodontal soft tissues and bone and not to the accom-panying debridement and root planing. These latterprocedures, however, probably play the decisive role inthe success or failure of the surgical procedures.3"13 Inthis article any manipulative procedure of the root sur-

face and soft and/or osseous tissue will be considered a

surgical procedure.One rationale for periodontal therapy is that it will

interrupt a sequence of events leading to the loss of teethwhich can disrupt and destroy complete dentitions.13'14Yet the concept of a "sequence of events which destroysdentitions" is vague because of the relative lack of infor-mation on the natural history of the disease. One reporton the natural history has been described in a longitu-dinal study of populations in Norway and Sri Lanka.15The groups had major geographical, cultural, socioeco-nomic and educational differences and represented ex-tremes with

respect to dental care. The

predominant

periodontal diseases reported in both populations werechronic gingivitis and Periodontitis. Destruction of sup-porting structures associated with chronic Periodontitiswas continuous and progressed at a relatively even ratein both groups. Annual rates of periodontal attachmentloss were significantly different, however, averaging 0.09mm in the Norwegian population and 0.25 mm in SriLankans.

Becker et al.16 used a different approach in reportingon a sample of 30 untreated patients who were followedfor various periods up to 10 years. They found a tendencytoward progressive periodontal disease as evidenced bygreater pocketing, continuing bone résorption and ulti-mately further loss of teeth. The teeth lost were thosewhich had initially greater pocket depth and highermobility scores than the teeth which were present at boththe initial and final examination. The average tooth loss

per patient was calculated to be 0.6 per year. In a follow-up study17 the authors found that every untreated patienthad progressive bone loss, greatest in the molar areas.

Further studies on the natural history of so prevalenta disease are obviously needed. In a sense every perio-dontist could contribute to such knowledge, possibly byestablishing a system similar to that of Becker et al.

Periodontists have no doubt of the efficacy of therapyin the control of periodontal disease.7"13 Recently, how-ever, questions have been raised about the need for someof the so-called "advanced" surgical approaches to ther-apy as opposed to the so-called "conservative" ap-proaches.9' 18-20 Several studies have dealt with the prob-ability of success. Oliver21 reported on a series of 442patients who were treated by various therapies and fol-lowed for 5 to 17 years, with an average post-treatment

period of 10.1 years. The average tooth loss due torecurrent periodontal disease was 0.5 tooth per patient.The results were not computed on a per year basis butsimple arithmetic shows that the average tooth loss peryear, if calculated as Becker et al. did, would be 0.05.This loss in treated patients compares quite favorablywith the Becker figure of 0.6 tooth loss per year onuntreated patients.

More recently Hirschfeld and Wasserman22 studiedthe results of treatment of 600 patients over a 15- to 50-year period. Their patients were treated with a variety ofsurgical and "nonsurgical" techniques. They dividedtheir results into three

groups based on the number of

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teeth lost after therapy. The patients classified as "well-maintained" (83% of the sample) lost an average of 0.7tooth per patient. Fifteen percent lost an average of sixteeth per patient over the same period and were classifiedas "downhill". Two percent were classified as "extremedownhill" and lost an average of II teeth per patient.This type of result, focusing in on the maintenance ofteeth, may well be considered as representing the degreeof success that can be achieved with periodontal therapy.

This concept of success makes it clear that while theinitial aim of therapy may have been the total eradicationof periodontal disease,8' 10' · 13'

14' 19' 23'24 continued main-tenance of the treated dentition, with arrest and slowedprogression of the patient's disease, may well be the mostimportant result of treatment.19'21'22

On the basis of the results of Hirschfeld and Wasser-

man, in which the maintenance of support of teeth isconsidered a major criterion of success, periodontistsmay consider themselves successful in approximately80% of cases. At this time control of the disease is being

evaluated in broader terms than just the elimination ofpockets at one period in the patient's lifetime. Mainte-nance of the treated patient is receiving more and moreemphasis. The existence of maintenance programsstrongly suggests that following treatment the patientstill needs periodic evaluation and care for control ofhis/her periodontal problems since permanent elimina-tion of the factors causing the disease is not possible atpresent.

It may then be the task of periodontics to determinewhich types of surgical procedures are least traumatic tothe patient and at the same time achieve the most

effective control of the disease, so that the

greatest partof the dentition is maintained for the longest time. Itseems logical to predict that control of periodontal dis-ease, by controlling plaque and rendering pockets inac-tive, will be one of the most important objectives in thefuture.

The techniques used in treating pockets and periodon-tal disease so as to maintain the dentition are also beingevaluated.9 The necessity of evaluating the current indi-cations for periodontal surgical procedures has beenbrought to light by the assertion that periodontal diseaseis being grossly overtreated.9 An assessment of the indi-cations for current treatment procedures is therefore inorder. Among the reasons that have been given forperforming periodontal surgery are to:4'7-131. Eliminate pockets by removing soft tissue, recon-

touring it, or by using a combination of the twoprocedures.

2. Eliminate pockets by removing osseous tissue, recon-touring it, or by using a combination of the twoprocedures.

3. Remove diseased periodontal tissue in order to createconditions favorable for new attachment or readap-tation of the soft and/or osseous tissue to the tooth.

4. Correct mucogingival deficiencies and deformities.5. Establish acceptable gingival contours to aid in per-

formance of effective hygiene.6. Improve the esthetic appearance of soft tissue in

areas of tissue enlargement.7. Create a favorable environment for necessary restor-

ative dentistry.8. Establish drainage for a gingival or periodontal ab-

scess to turn an acute periodontal problem into amore treatable state.

Periodontal Pockets as an Indicator for SurgicalProcedures

According to Ramfjord,23 all periodontal therapy his-torically has been aimed at pocket elimination. Thenecessity for this traditional objective of therapy is nowbeing questioned and challenged.918,20'24 The factorswhich have played a role in this re-evaluation of peri-odontal pockets and the ways in which their state ofactivity contributes to an assessment of the need for

surgical procedures will be reviewed.Probably the most important criterion used over time

by periodontists in determining whether periodontal sur-gery is necessary, is the depth of the pocket. The instru-ment commonly employed for measuring and evaluatingthe periodontal pocket has been the periodontal probe.Recently the art and science of probing has come undercloser scrutiny and questioning.9,20-30

The periodontal probe was reported by Orban to bethe "eyes of the operator beneath the gingival margin".26According to Listgarten,25,28 it has been rather apparentthat the probing depth measured from the gingival mar-

gin seldom corresponds to sulcus or pocket depth. Thediscrepancy is smallest in the absence of inflammatorychanges and greatest with increasing amounts of inflam-mation. In Periodontitis the probe tip will pass to a level0.3-0.5 mm apical to the termination of the junctionalepithelium.28,29 Gamick et al.27 showed an even greatervariation and depth of penetration.

These discrepancies may lead to an exaggerated mea-surement of pocket depth. An error in the oppositedirection may occur after therapy when crevicular depthmay be underestimated because the now healthy gingivalconnective tissue readapts closely to the tooth, resulting

in shallower penetration of the probe.20-28The measurement of pocket depth as a major criterionfor evaluation of therapy, both pre- and post-treatment,must therefore be re-evaluated in light of what is nowknown about discrepancies in periodontal probing. Itmay well be that periodontists have relied too much onprobing depth measurements and have overestimatedthe need for so-called "advanced" surgical techniques byinadvertently probing too deeply. When an awareness ofthese discrepancies is combined with the recognition thatthe depth of the pocket, even ifprecisely measured, doesnot determine the presence or absence of active disease,


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but merely documents the history of the disease process,9it becomes obvious that using the results of probing asthe major criterion of the need for surgery needs to bereassessed. However, if pocket depth is no longer consid-ered the major criterion to assess the activity of thedisease state, one may then ask what criteria are to beused to evaluate the progress of disease and work towardthe goal of control and maintenance.

Other Criteria Employed in Assessing PeriodontalStatus

In the clinical setting other recognized physical char-acteristics of the gingival tissue are color, size, shape,consistency, presence or absence of exúdate and propen-sity for hemorrhage. While highly subjective in nature,visualization of the color, size and shape of the tissue isimportant in evaluating its state of health. Changes inthese characteristics can lead to the conclusion that

inflammatory activity is present. This has been shown inseveral reports31"34 which employed indices evaluatinggingival status. A change in consistency from firm to softcould be an indication of inflammatory activity.

Hemorrhage from the pocket upon provocation isprobably one of the most frequent signs of inflammatoryactivity. The use of gingival bleeding indices30"38 is basedon the premise that deterioration of gingival health willbe reflected by an increase in crevicular vascularity anda decrease in the mechanical strength of the crevicularepithelium. Even light probing will therefore elicit ahemorrhagic response. Some correlation between theoverall number of blood vessels and the Gingival Indexhas been reported.38

The presence or absence of exúdate has been studiedin detail using flow rates of crevicular fluid as one of thecriteria.39"47

Several studies have demonstrated a high correlationbetween the rate of flow of crevicular fluid and the

severity of clinically assessed gingival inflammation.42"45Crevicular fluid flow can be used as an indicator of earlyas well as advanced gingival disease.43"46 Copious crevic-ular flow or exúdate is also an indicator of inflammatoryactivity in gingival tissue.46"48

The view that pocket depth should not be the onlycriterion to be used is supported by the fact that total

pocket elimination cannot be sustained

for indefinite

periods.19'20'22 In addition, the goal of gaining access andvisibility for debridement of the lesions of periodontaldisease may provide a better rationale for surgery thanpocket elimination.

A priority listing of the signs of activity of the peri-odontal disease state that could be used in monitoring itscontrol would then be: (a) Propensity for hemorrhage,(b) Crevicular fluid flow, (c) Pocket depth, (d) Color,size, shape and consistency of the gingiva. Even thoughdepth is relegated to third place on this suggested list formonitoring the patient, it remains important since one ofthe major problems in treating periodontal disease is

accessibility. The complete removal of plaque and itsproducts from root surface more than 3 mm subgingi-vally is difficult.49,50 Incomplete subgingival plaque con-trol is usually equal to no plaque control at all.50 In manycases it may even be worse because both the patient andclinician may be led to believe that the treatment takenhas been successful. This fact led Waerhaug to believethat surgical elimination of pathologic pockets deeper

than 3 mm is the most predictable method for attainingadequate subgingival health.49,50The major purpose of the foregoing section has been

to suggest a reordering of the criteria used for diseasecontrol and thereby bring into focus the concept ofdisease elimination and control as a goal, rather thanpocket elimination by itself.

Once the need for therapy has been established, var-ious techniques can be utilized. These will be discussedin the following sections.

Scaling, Root Planing and Subgingival Curettage

The combined techniques of scaling, root planing andsubgingival curettage have long been the cornerstone ofperiodontal therapy.3,4'51 Scaling and root planing referto the removal of calculus, bacteria and their productsfrom the root surface, or lying free in the pocket, and theremoval of all contaminated cementum and dentin.

Thorough root surface preparation can be accomplishedthrough both physical and chemical means.5'52"56 Subgin-gival curettage refers to scraping of the inner surface ofthe gingival wall of the periodontal pocket to clean out,separate and remove diseased soft tissue.2,57

Although most textbooks separate the description and

definition of the two procedures, they may be done atthe same time in the overall sequence of therapy. Sometherapists will separate the procedures by doing scalingand root planing and waiting several weeks for resolutionof inflammation before doing subgingival curettage. Therationale for this is puzzling as subgingival curettage asa treatment procedure per se is almost fruitless. It wouldseem that because of the importance of root surfacepreparation,0,6,52"56 the subgingival curettage could bedone at the same time, as an adjunctive procedure, andthus not subject the patient to two separate treatments.Most periodontists approach treatment by using this

technique as a combined

procedure and it will be dis-

cussed that way in this report.Over the years many indications and uses for scaling,

root planing and subgingival curettage have been pro-posed. More recently the uses have narrowed to thefollowing situations: (a) Pocket Reduction (Disease Con-trol) Therapy, (b) Presurgical Preparation of Tissues, (c)Treatment of "Compromise" Situations, (d) Mainte-nance of Treated Patients.

a. Pocket Reduction (Disease Control) TherapyIn gingivitis and Periodontitis the combined approach

of removing plaque and calculus and maintaining proper


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plaque control measures can effectively reduce and eveneliminate gingivitis and incipient Periodontitis.4 The de-gree of tissue shrinkage and pocket depth reduction willdepend on the original depth of the pocket, the amountof edematous fluid in the tissue, the amounts of fibrousconnective tissue and the thoroughness of root prepara-tion.55"58

If the tissue is edematous, the pocket depth is minimal

(2-4 mm) to

moderate (4-7 mm), and the

pocket wall is

not fibrotic, then scaling, root planing and subgingivalcurettage can reduce pocket depth to such an extent thatit can be maintained by the patient. In this event scaling,root planing and subgingival curettage can be called adefinitive procedure.4,18-20

Pocket shrinkage following scaling, root planing andcurettage occurs through a combination of tissue re-sponses. Sufficient shrinkage may occur with resolutionof the edema, while remodeling of the connective tissuemay go on for months, even years.18,20 Further changesin the tissue occur through new attachment by a long

junctional epithelium and/or

readaptation of the

gingi-val connective tissue to the root surface.6,58-62In a series of studies, a group headed by Ramfjord and

Knowles have reported18,20,60,62"66 on both the short andlong-term gains in attachment and tissue reduction ob-tained by using subgingival curettage. Subgingival cu-rettage was most effective in cases with minimal pock-eting (1-3 mm). In moderately deep pockets (4-6 mm)it was not as effective in pocket reduction as othersurgical techniques. Attachment was greatest during thefirst year and later tended to stay the same or decrease

slightly.20Thus, in summary, in looking at scaling, root planing

and subgingival curettage as a definite pocket reduction(disease control) procedure, a combination of tissue re-sponses can take place to bring about the results. Theseresponses and changes consist of shrinkage of the tissuethrough loss of edema, return of the connective tissue tohealth, establishment of a long junctional epithelium,and the previously mentioned phenomenon of thechange in probing depth that takes place between in-flamed and noninflamed gingival tissues.

b. Presurgical Preparation of Tissues

The International Conference on Research in the Bi-

ology of Periodontal Disease concluded that "the differ-ence between using curettage as a definitive procedureor as a presurgical procedure seemed to be based on thedepth of the pockets at the start of treatment, as well asthe quality and quantity of tissue involved in the subgin-gival curettage procedure".4

If more extensive surgical techniques or proceduresare to be utilized, presurgical p'reparation of the tissuemay render the tissues easier to handle during thesesurgical procedures. Scaling and subgingival curettagehave been found to be of value in this respect, althoughnot universally so.67-72 Zamet72 reported using scaling

and curettage in conjunction with a good oral hygieneprogram to prepare patients for surgery. He found thatthis protocol resulted in an appreciable degree of tissueshrinkage and resolution of inflammation.

c. Treatment of Compromise Situations

It is not always possible to carry out the indicatedprocedure in treating patients with periodontal disease.A treatment

plan may have to be

changed to fit the needs

of a particular patient.Although scaling, root planing and subgingival curet-

tage are surgical procedures, they do not tend to arousethe patient's anxiety as much as some otherprocedures.67,73 Some patients are psychologically un-willing or unable to accept surgical manipulations oftheir tissues, and scaling, root planing and subgingivalcurettage may have to be used in these situations.8,13'67'71

Other patients, because of systemic and medical prob-lems, may not be able to undergo more extensive pro-cedures. Scaling, root planing and subgingival curettagecan be used in these

patients with minimal risk.67,73

A third situation in which scaling, root planing andsubgingival curettage may be a treatment compromiseoccurs when they are intended as presurgical proceduresbut after their execution the patient and/or therapistdecides to discontinue treatment. In this situation these

procedures serve as the definitive treatment. In manyinstances, scaling, root planing and subgingival curettagecan help minimize disease activity.

d. Maintenance of the Treated Patient

Extensive periodontal surgical procedures may effecta primary cure for the disease, but the curette serves topreserve this cure.67 In many instances the surgicallytreated periodontal case may not be maintained in healthby periodic prophylaxis alone. Repeated scaling, rootplaning and soft tissue curettage may be necessary toprevent a recurrence of disease in previously treatedareas.59,67

Comment

Scaling, root planing and subgingival curettage can bean effective approach to shallow and moderately deepperiodontal pockets, can help reduce tissue inflammationprior to other surgical procedures, can be effective in

certain "compromise" situations aiid can help to main-tain the treated patient. Without proper root surfacepreparation, subgingival curettage is not truly an effec-tive surgical procedure.

Excisional New Attachment Procedure

While scaling, root planing and subgingival curettageare well established procedures, the Excisional New At-tachment Procedure (ENAP) is relatively new. Forerun-ners of the ENAP appeared in the literature in 1931when Kirkland,74 described a modified flap operationfor treating periodontal disease and in 1939 when Bar-


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kann75 described a conservative surgical approach totreat periodontal pockets. Barkann's procedure closelyapproximates the ENAP technique reported on by Yu-kna et al.6'76-79 The ENAP is essentially subgingval cu-rettage performed with a knife. The objectives are topermit thorough soft tissue preparation and to securebetter access to the root surface. Among its stated advan-tages over traditional subgingival curettage is the defin-

itive, clean excision of the

junctional epithelium and the

subjacent tissue with a greater probability of new clinicalattachment.6'76

The ENAP is restricted to suprabony pockets whoseapical extent lies within the keratinized gingiva. It is notadvocated for pockets that extend beyond the mucogin-gival junction or for treatment of osseous defects. Verti-cal or relaxing incisions are not utilized, since positioningof the tissues at their original level is intended and isessential.6,76

Clinical improvement was reported at 1- and 3-yearevaluations following the procedure but probing depthsincreased

slightly and the amount of

newly gained at-

tachment decreased slightly at each postoperative eval-uation from 1 to 5 years.76'79 However, an overall gain of1.5 mm in clinical attachment was still evident 5 yearsafter treatment.79

Studies by Yukna and associates suggest a trend to-ward a relapse somewhere around the 5-year mark.79Since no clinically significant tissue loss occurs with thistechnique, retreatment by the ENAP procedure every 5years or so may well preserve the maximum amount ofattachment for the longest possible time.6

Histologie studies show that the ENAP heals with along, thin junctional epithelium and a minimal amountof connective tissue attachment. These results do notfulfill the histologie criteria for new attachment; however,the relative absence of inflammatory cells in the subja-cent connective tissue suggests a picture of periodontalhealth.77

Both subgingival curettage and ENAP have the ad-vantage of minimizing postsurgical recession and rootsensitivity because the free gingival margin is kept vir-tually intact and tissue elevation is not a part of theseprocedures.6Comment

The ENAP procedure can be used in rather specificcircumstances and therefore is limited in its scope. Theinitial gain of clinical attachment, which is the majorpremise of the technique, seems to be lost over time.Because it does "conserve" tissue, the technique can berepeated to re-establish tissue attachment after an inter-val of several years.

Gingivectomy and Gingivoplasty

The gingivectomy was one of the foremost surgicalprocedures in periodontal therapy from the 1930's

through the early 1960's.M G. V. Black, around 1900,may have been one of the first to practice it in thiscountry.80 It was reported on extensively by Crane andKaplan,81 Ward82 and Kirkland,80 who is considered the"Father of the Gingivectomy".

The gingivectomy derives its effectiveness from thefact that it removes the diseased pocket wall whichobscures the tooth surface.8'10,11 It creates visibility and

accessibility for the

complete removal of irritants from

the root surface. This is particularly advantageous inview of today's knowledge concerning the importance ofroot surface preparation. In addition, it is considered tobe a relatively fast and simple procedure.

A perusal of the modern textbooks in Periodontologydiscloses the indications and contraindications for gin-givectomy.7-13 The indications generally agreed upon areelimination of suprabony pockets whose depth is greaterthan is accessible for root preparation without tissueremoval; elimination of suprabony pockets whose tissueis firm and fibrotic, and therefore will not shrink after

scaling, root planing and subgingival curettage; and elim-ination of gingival enlargements. The contraindicationsgenerally agreed upon are situations when there is a needto gain access to osseous tissue, when the base of thepocket is apical to the mucogingival junction, and whena zone of keratinized gingiva will not be present afterexcision of the tissue.

Glickman83 in 1956 reported on 250 cases treated withgingivectomy which were followed for 3 months to 7years. He used an "unembellished" gingivectomy tech-nique which did not include preoperative scaling androot planing to reduce inflammation in the tissue priorto the surgical procedure. In addition, the technique didnot employ drugs, medicaments or adjunctive mechani-cal aids84-87 to augment the tissue removal or healingresponse. Although evaluated only clinically, Glickmanmade a convincing case for the use of the unembellishedgingivectomy.

Several biometrie studies have been done over the

years to evaluate the gingivectomy as a usable technique.Gingivectomy has been shown to be a better method

for shallow (up to 4 mm) pocket elimination than curet-tage even though loss of attachment has been reportedwith gingivectomy that did not occur with curettage.88-92Since pocket elimination per se is not considered the

primary objective of periodontal therapy, it is doubtfulthat gingivectomy would be the treatment of choice inpockets as shallow as 4 mm. Deeper pockets (greaterthan 6 mm) are reported to be treated better by curettageand other procedures, as they may result in a gain ofattachment,6' 18' 19'65'66 while gingivectomy results in a lossof attachment.

Probably the major disadvantage of the gingivectomyis its limited applicability. It cannot be used when mu-cogingival problems or osseous deformities exist.8,13'93-95In such areas it has not been proven as effective as the


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flap approach or the flap approach with osseous con-touring.94,95

Gingivoplasty is a term sometimes used synonymouslywith gingivectomy and is done in the absence of pocketswith the sole purpose of recontouring the gin-giva.8,10,13,86,87,96 The true gingivoplasty may be doneafter other surgical procedures that have resulted inunacceptable tissue form, such as rolled margins, cratersand bulbous interdental papillae. The gingiva is fes-tooned and scalloped by hand or rotary instruments tocreate interdental grooves and sluiceways. Most perio-dontists are of the opinion that gingivectomy and gingi-voplasty are similar terms but generally use the term"gingivoplasty" to refer to a thinning of the tissues ratherthan a removal of the pocket wall.

Comment

The gingivectomy-gingivoplasty technique remains auseful technique. The indications advanced for it byearlier therapists still hold true but to a lesser extent. Thecontraindications hold true but to a much greater extent.

Probably the greatest factor in the decreased use of thegingivectomy has been the understanding of the impor-tance of accessibility and treatment of osseous deformi-ties in the elimination and control of disease activity.

Periodontal Flap Procedures

Scaling, root planing, subgingival curettage, ENAPand gingivectomy are all procedures done without ele-vating the underlying periosteum and exposing the bone.Procedures which require elevation and reflection of thesoft tissues from the surface of the bone are referred toas flap procedures. Broadly stated, the main reasons for

doing flap procedures are:6-81012101,105-107 (l) To secureaccess for root planing and to the underlying osseoustissue. (2) To facilitate removal of lining epithelium andgranulation tissue that may interfere with healing. (3) Tofacilitate attempts to reestablish tissue health by newattachment and/or close adaptation of the connectivetissue to the root.

The Modified Widman Flap

In 1916 Leonard Widman reported on the use of thereverse beveled incision in obtaining access to the un-derlying tissues with a mucoperiosteal flap.100 The mod-ified Widman

Flap101 described in detail

by Ramfjordand Nissle in 1974 is considered more conservative thanthat originally described by Widman.6,19,101,102 Less boneis exposed with the modified technique than with theoriginal procedure and more attention is paid to closeinterproximal adaptation. Also in contrast to the originalprocedure, sharp knives rather than curettes are used toseparate the collar of tissue around the necks of the teeth.Whereas the original procedure included the surgicalremoval of osseous defects, the modified technique seeksto maintain bony pocket walls.

The primary objective of the procedure is not pocketelimination per se, but maximum healing of periodontalpockets with minimum loss of tissues during and afterthe procedure.101 Periodontal support and health aremaintained by means of a long junctional epithelialattachment and close connective tissue adaptation, withor without new attachment of connective tissue and with

or without regeneration of bone. One key to its successseems to be the prevention of subgingival plaque exten-

sion, thus permitting optimal healing.102The initial internal bevel incision is begun 0.5 to 1.0mm from the free gingival margin, aimed at the alveolarcrest, and followed by reflection of a full-thickness flapthat exposes 1 to 2 mm of the alveolar bone. A secondvertical incision is made from the bottom of the pocketto the alveolar crest. Another horizontal incision alongthe alveolar crest then severs the supracrestal tissue,permitting its removal. Following root planing and cu-rettement of any bony defects, the flaps are closelyadapted interproximally and to the teeth and securedwith interrupted sutures. Primary wound closure is an

essential objective of the modified Widman procedureand the removal of bone is undertaken only when nec-essary to achieve this objective.101

The incision design and full thickness flap reflectionallow better access to deeper areas of disease than eitherthe ENAP or subgingival curettage and, in addition,provide access to bony defects. The close adaptation ofgingival tissues to the tooth surfaces is thought to pro-mote the formation of a new epithelial attachment whichseals off the more apical areas between the tooth and thesurrounding tissues. If the healing connective tissueadapts closely to the tooth surface, reattachment with

formation ofnew

cementum may develop gradually fromthe apical aspect of the lesion.101,102The stated advantages of the modified Widman Flap

are that it optimizes access to the root surface and allowsintimate postsurgical adaptation of healthy connectivetissue and epithelium to the root surface, thereby en-hancing the potential for new attachment. In addition, itallows optimal soft tissue coverage of root surfaces, thusproviding a result which is both esthetically desirableand amenable to oral hygiene procedures, with poten-tially less root sensitivity and fewer root caries prob-lems.101,102

Disadvantages of the modified Widman

flap include

the fact that its flap design is technically exacting, espe-cially interproximally. Moreover, interproximal tissuearchitecture is poor immediately following removal ofthe dressing and sutures, especially in areas of interprox-imal bony craters. However, if meticulous oral hygieneis maintained, the interdental tissues regenerate over afew months with a gain rather than loss ofattachment.101,102

Histologie evaluation of the modified Widman flapdemonstrates healing by means of a long, thin junctional


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epithelium to the depth of the surgical wound, with nogain in connective tissue attachment and no increase increstal bone height.61'103 Repair of this nature may be adisadvantage because it is probably more prone to break-down and pocket reformation than a true connectivetissue attachment; however, longitudinal studies suggestthat this epithelial adherence may be maintaina-ble.19' 60'62 Filling in of osseous defects occurs to varyingextents.95

The modified Widman flap has been evaluated forseveral years as part of the University of Michiganlongitudinal study begun in 1971 by Ramfjord and co-workers.19'20'60'62-66' 102 In general, the latest results20'104indicate that traditional methods for surgical eliminationof periodontal pockets do not have any advantage overeither subgingival curettage or the modified Widmanflap procedure. When moderate to severe periodontalpockets are considered, these three techniques all reducepocket depth, with subgingival curettage being least ef-fective. In moderately deep pockets (4-6 mm), all threetechniques produce a gain in attachment level, the great-est being obtained with the modified Widman flap.When deep pockets (7-12 mm) are treated, the modifiedWidman flap produces a significantly better gain thaneither of the other two techniques. These results havebeen maintained almost without variation over 8 yearsof observation. When shallow pockets (1-3 mm) aretreated by any of these methods, they become deeperand lose attachment during the 1st year and thesechanges also persist through the years. The changes inpocket depth and level of attachment as a response totherapy do not seem to be related to tooth type.104Comment

Modified Widman flap surgery may be utilized when-ever reattachment with minimal gingival recession isdesired. It may be the preferred procedure in treatingmoderately deep pockets or moderate furcation involve-ment, and in patients with a high caries rate and rootsensitivity problems. Studies have shown that the modi-fied Widman procedure is as effective in maintainingclinical levels of attachment as co-called traditional sur-

gical procedures such as those involving ostectomy. Re-pair of the modified Widman procedure by means of along junctional epithelium, not by new attachment ofconnective tissue, may be a disadvantage in that the area

may be prone to new pocket formation and reinstitutionof disease activity.

Open Flap Curettage

Open flap curettage as a treatment procedure has beenadvocated to permit accessibility, visibility, and debride-ment; and to promote repair with relative patient com-fort.8, 105-107 Although flap curettage is similar in manyways to the modified Widman flap, it is generally a moreextensive procedure which usually includes elevation ofthe mucoperiosteum past the mucogingival junction.

The indications for open flap curettage are summa-rized by Ammons and Smith106 and Ammons et al.107 asfollows: (1) in patients with advanced periodontal dis-ease, where osseous procedures may jeopardize the at-tachment apparatus; (2) in disease states where the mor-phology of anatomic defects may be favorable for regen-eration; (3) when preservation of tissue is importantbecause of esthetics, particularly in the anterior part ofthe mouth; and (4) as part of initial preparation of the

patient to secure total debridement of a lesion, e.g., priorto orthodontic therapy, or as an exploratory procedurein a deep defect, e.g., in evaluation of a furcation.

The technique employs an inverse bevel incision,placed approximately 1 mm lateral to the free gingivalmargin which follows the contours of the teeth andextends apically to the alveolar crest. A mucoperiostealflap is reflected to completely expose the involved area.After thorough debridement, the flap is placed back inposition and secured with sutures. This technique thusallows optimal accessibility and tissue coverage.

There is a paucity of biometrie data on the effects of

open flap curettage. The studies which have been doneare generally of relatively short duration.106'107 They haveshown a return to periodontal health; a net reduction inplaque and gingival inflammation; a net gain of attach-ment, particularly in deeper pockets; but no real induce-ment of bone regeneration. After treatment, probingdepths increased over the study periods but did notreturn to the original levels.

Remodeling of osseous tissue has been shown to takeplace with open flap curettage, especially in intraosseousdefects.108"110

Comment

Open flap curettage provides access to the diseasedarea for root debridement and permits visualization andpossible treatment of osseous tissue. It provides for op-timal tissue coverage where tissue preservation is impor-tant for esthetic reasons. It seems to be an effectivemethod of eliminating periodontal disease activity.

Osseous Surgery

Osseous surgery is often considered a recent addition

to periodontal surgical procedures, but its use dates backto the late 19th century. Robicsek described a procedurewhich allowed access to the bone for

smoothing and

reshaping.111 Zentler, Zemsky and Neuman, in the pre-1920's, reported that access to bone was necessary toremove, reduce and reshape infected or necroticbone.112113

Schluger114 was dissatisfied with the pattern of behav-ior of the soft tissue after gingivectomy and curettageprocedures, and in 1949 published a report on the re-shaping of osseous tissues. He stated that the form of theunderlying bone dictated soft tissue results and that thedifferences between the levels and shapes of osseoustissue and the soft tissue caused recurrent pocketing and


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recurrent periodontal disease. Thus, he attributed thefailure of the other techniques to their inability to correctirregularities in the bone such as ledges, reverse architec-ture, craters and thick bony margins. The principlesunderlying bone reshaping are fairly simple. The goal isto create a form to the bone that resembles or closelyapproximates an idealistic architectural form.

When achieving this goal by performing osseous con-

touring, the therapist would establish a physiologic ar-chitecture to the bone, which is then followed by theoverlying gingiva. In cases where furcations would beexposed or excessive bone support would be sacrificed,Schluger advised accepting residual pockets.

The tenets of osseous recontouring have been rede-fined over the years and have been based on a numberof clinical reports of successfully treated cases.115"123

The technique of osseous contouring has been criti-cized however, because of the possibly excessive amountof osseous tissue which sometimes must be removed toachieve a physiologic contour consistent with a precon-

ceived ideal. Therapists became concerned about remov-ing good, healthy supporting bone and possibly sacrific-ing attachment needed for survival of the dentition.124'125

In response to this, Selipsky122 claimed that reshapingof ledges and thickened margins does not reduce anyportion of the attachment apparatus and therefore doesnot contribute to loss of supporting bone. He said thatthe technique removes very little actual attachment, av-eraging 0.6 mm on the interproximal and 1 mm in themidfacial, midlingual and midpalatal areas. He pointedout that most of the supporting bone for the tooth is inthe broad interproximal area and not on the facial,

lingual and palatal surfaces.Another concern has to do with increase in mobilityafter osseous resective procedures. Studies on mobilitypatterns showed that there is a definite increase in thefirst few weeks after the procedure, but a return topresurgical levels in about 6 months.107,122

Several studies comparing techniques have tested theefficacy of osseous recontouring in periodontal therapy.One problem with the studies is that the protocol foreach study is different. While it is difficult to find acommon thread to tie them together, some interestingconclusions can be drawn.

There is

greater loss of bone after osseous

recontouringthan after flap curettage alone.107 In addition, there is agreater potential for securing an increase in periodontalattachment if bone is not recontoured and is completelycovered by the soft tissue flap.95

In one long-term study (8 years)62 surgical pocketelimination did not enhance the prognosis for mainte-nance of periodontal support in either moderate or ad-vanced periodontal lesions when osseous recontouringwas compared with the modified Widman or subgingivalcurettage techniques.62

Osseous recontouring has been significantly more suc-cessful than the gingivectomy procedure in eliminating

pockets and creating physiologic contours in cases asso-ciated with osseous defects. However, it has not seemedto make any difference in the plaque-control abilities ofthe patients studied.94'107Ochsenbein123 recently summarized the current status

of osseous contouring and listed indications and con-traindications. Among the indications were thick ledges,tori and other such aberrations; furcation invasions; fur-

cation invasions which may require root amputations orhemisections; and shallow craters and minor angulardefects. Contraindications included were three-walled

intrabony defects, especially those with a wide orifice;bony defects on the buccal aspect of mandibular molarsassociated with the external oblique ridge; moderate todeep circumferential defects; and advanced periodontallesions or isolated deep craters. These indications andcontraindications can act only as guidelines. Conceptsand skills in bone surgery vary considerably betweendifferent schools of therapy and different periodontists,and there is no general agreement on the role and

limitations of ostectomy and osteoplasty in periodontaltherapy.4'124Because there appears to be a general tendency to-

wards techniques which foster tissue conservation, it hasbeen suggested that ostectomy procedures have no placein the treatment of patients with early bone destructionand are of questionable value in areas of moderate tosevere bone loss.124 Where then, does osseous recontour-

ing have its place in therapy? There is no question thatthe indications of Ochsenbein have merit.123 Osseouscontouring may therefore be a definite aid in the naturalprocess of bone remodelling that takes place after a flap

approach with debridement and root surface

prepara-tion.108"110 The resultant healing process can help elimi-nate many discrepancies in tissue contour and allow forbetter access for patient and therapist to maintain thetreated area.

Comment

Osseous contouring will eliminate discrepancies inbdhy architecture resulting from periodontal disease andalong with the natural process of bone remodelling willcreate tissue contours which allow for a more maintain-

able periodontal environment. However, concepts, skillsand

philosophies in bone surgery vary considerably be-

tween periodontists, and at this time there is no generalagreement on the role of osseous contouring in peri-odontal therapy.

CONCLUDING REMARKS

It is obvious from the foregoing that there are manytechnical approaches to periodontal surgery. The merepresence of a periodontal pocket of a cerain depth as themajor indicator for surgery is not as steadfast as oncebelieved. Other criteria such as hemorrhage and exúdatemust also be used in evaluating the need for surgery. Thedecision on which approach to use remains with the


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526 Barrington J. Periodontol.

September, 1981

therapist and the individual situation with which he/sheis faced.

However, in the past decade it has become increasinglyclear that the need for so-called more advanced surgicalprocedures is not as important to the control of peri-odontal diseases as was once thought. Regardless, it isalso clear that some form of surgical intervention, asdefined by this paper, is still necessary to interrupt thesequence of events that make up the pathogenesis ofperiodontal disease that leads to eventual tooth loss. Thispaper has reviewed and evaluated some of the current

procedures available to the therapist in the surgicalapproach to therapy.

ACKNOWLEDGMENT

The author wishes to thank Dr. Michelle Zmick for her many hoursof work in helping to compile and write this paper.

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http://www.joponline.org/action/showLinks?crossref=10.1111%2Fj.1600-051X.1980.tb01947.xhttp://www.joponline.org/action/showLinks?crossref=10.1111%2Fj.1600-051X.1980.tb01947.xhttp://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1974.45.9.672http://www.joponline.org/action/showLinks?system-d=10.1902%2Fjop.1966.37.6.447http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1974.45.2.107http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1974.45.2.107http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1977.48.3.136http://www.joponline.org/action/showLinks?pmid=5224011http://www.joponline.org/action/showLinks?pmid=5224011http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1973.44.2.66http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1973.44.2.66http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1974.45.8.2.601http://www.joponline.org/action/showLinks?system-d=10.1902%2Fjop.1965.36.2.96http://www.joponline.org/action/showLinks?pmid=282813http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1975.46.9.522http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1971.42.9.571http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1976.47.10.586http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1979.50.7.345http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1979.50.7.345http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1977.48.3.131http://www.joponline.org/action/showLinks?crossref=10.1016%2F0030-4220%2855%2990377-7http://www.joponline.org/action/showLinks?crossref=10.1111%2Fj.1600-051X.1976.tb00042.xhttp://www.joponline.org/action/showLinks?pmid=4244946http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1978.49.7.337http://www.joponline.org/action/showLinks?pmid=161784&crossref=10.1111%2Fj.1600-0765.1979.tb00240.xhttp://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1978.49.3.142http://www.joponline.org/action/showLinks?crossref=10.1016%2F0030-4220%2850%2990143-5http://www.joponline.org/action/showLinks?pmid=1094036&crossref=10.1111%2Fj.1600-051X.1975.tb01729.xhttp://www.joponline.org/action/showLinks?system-d=10.1902%2Fjop.1961.32.4.301http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1975.46.11.646http://www.joponline.org/action/showLinks?system-d=10.1902%2Fjop.1961.32.4.301http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1976.47.12.701http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1976.47.12.701http://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1975.46.11.639http://www.joponline.org/action/showLinks?crossref=10.1111%2Fj.1600-051X.1980.tb01965.xhttp://www.joponline.org/action/showLinks?pmid=787013&crossref=10.1111%2Fj.1600-051X.1976.tb01865.xhttp://www.joponline.org/action/showLinks?system=10.1902%2Fjop.1976.47.12.696http://www.joponline.org/action/showLinks?pmid=787013&crossref=10.1111%2Fj.1600-051X.1976.tb01865.xhttp://www.joponline.org/action/showLinks?crossref=10.1111%2Fj.1600-051X.1980.tb01964.x


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September, 1981

104. Ramfjord, S. P., Knowles, J. W., Morrison, E. C, Burgett, F.G., and Nissle, R. R.: Results of periodontal therapy related to toothtype. J Periodontol 51: 270, 1980.

105. Klavan, B.: The replaced graft. J Periodontol 41: 406, 1970.106. Ammons, W., and Smith, D.: Flap curettage: Rationale, tech-

nique and expectations. Dent Clin North Am 20: 215, 1976.107. Smith, D., Ammons, W., and Van Belle, G.: A longitudinal

study of periodontal status comparing osseous recontouring with flapcurettage. J Periodontol 51: 367, 1980.

108. Patur, B., and Glickman, I.: Clinical and roentgenographicevaluation of post-treatment healing of intrabony pockets. J Periodon-tol 33: 164, 1962.

109. Donnenfeld, O. W., Hoag, P. M., and Weissman, D. P.: Aclinical study in the effects of osteoplasty. J Periodontol 41: 131, 1970.

110. Patur, B.: Osseous defects: Evaluation of diagnostic and treat-ment methods. J Periodontol 45: 523, 1974.

111. Stern, I. B., Everett, F., and Robicsek, K.: S. Robicsek—a

pioneer in the surgical treatment of periodontal disease. J Periodontol36: 265, 1965.

112. Zentler, .: Suppurative gingivitis with alveolar involvement.A new surgical procedure. J Am Med Assoc 71: 1918.

113. Zemsky, J. L.: Surgical treatment of periodontal disease. DentCosmos 68: 465, 1926.

114. Schluger, S.: Osseous resection: A basic principle in periodon-tal

surgery. Oral

Surg 2:

316, 1949.

115. Friedman, N.: Periodontal osseous surgery: Osteoplasty andostectomy. J Periodontol 26: 257, 1955.

116. Ochsenbein, C: Osseous resection in periodontal surgery. JPeriodontol 29: 15, 1958.

117. Ochsenbein, C, and Bohannon, Pl.: The palatal approach toosseous surgery. J Periodontol 35: 37, 1964.

118. Ochsenbein, C, and Ross, S.: A re-evaluation of osseous

surgery. Dent Clin North Am 13: 87, 1969.119. Barrington, E. P., O'Bannon, J. Y., Ochsenbein, C, and Stal-

lard, R. E.: In our opinion: To what extent do you remove or recontourbone in periodontal therapy? J Periodontol 43: 184, 1972.

120. Johnson, R. L.: Principles in periodontal osseous resection.Dent Clin North Am 20: 35, 1976.

121. Tibbetts, Jr., L. S., Ochsenbein, C, and Loughlin, D. M.:

Rationale for lingual approach to mandibular osseous surgery. DentClin North Am 20: 61, 1976.

122. Selipsky, H.: Osseous surgery—how much need we compro-mise. Dent Clin North Am 20: 79, 1976.

123. Ochsenbein, C: Current status of osseous surgery. J Periodon-tol 45: 577, 1977.

124. Flores-de-Jacoby, L., and Fesseler, .: The efficacy of osseoussurgery. Efficacy of Treatment Procedures in Periodontics (Workshop),Shanley, D. B. (ed), Chicago, Quintessence Pubi., 1980.

125. Knoell, A. C, and Vogan, W. I.: A mathematical investigationof the biomechanical effects of simulated periodontal surgery. / Per-iodont Res 12: 290, 1977.

Send reprint requests to: Dr. Erwin P. Barrington, Department ofPeriodontics, University of Illinois, College of Dentistry, 801 S PaulinaSt, Chicago, IL 60612.

Announcements

BOSTON UNIVERSITY GOLDMAN SCHOOL OF GRADUATEDENTISTRY

Boston University Goldman School of Graduate Dentistry an-nounces the following Continuing Education courses:Title: Dental ImplantsDate: September 23, 1981Faculty: Morton Perel, D.D.S.

Title: Minor Tooth MovementDate: October 14, 1981Faculty: Anthony Gianelly, D.M.D., Ph.D., M.D.

Title: Selected Procedures in Periodontal Surgery: Gingival Re-construction

Date: October 15-16, 1981Faculty: Hyman Smukler, D.M.D., H.D.D.; Gerald A. Isenberg,

D.D.S.; Alan M. Shuman, D.M.D.

Title: Practical Periodontal SurgeryDate: November 19-20, 1981Faculty: Department of Periodontology

For further information contact: Division of Continuing Education,Boston University School of Gradaute Dentistry, 100 East NewtonStreet, Boston, Mass. 02118

TEMPLE UNIVERSITY SCHOOL OF DENTISTRY

Temple University School of Dentistry announces the followingContinuing Education Courses:Treatment Planning The Difficult Cases In Perioprosthesis, Dr. R.

Schoor, Dr. A. Rinaldi; September 16, 17, 1981.This is a seminar course designed to help the restorative dentist

develop a diagnosis, treatment plan and a prognosis for the complexmoderate and advanced periodontal patient. Cases will be presentedfor group discussion. Periodontal prognosis of key abutment teeth,designs of the prosthesis and acceptable clinical compromise will bediscussed in depth.

Clinical Periodontal Surgery; Dr. D. Litwack, Dr. M. Salkin, Dr.R. Schoor; September 23, 24, 25, 1981.The purpose of this clinical technique course is to present the

current biological concepts of up-to-date periodontal surgery. Theinfluence of all surgical modalitites on present day dental practice willbe analyzed and discussed.

For further information contact: Division of Continuing Education,Temple University School of Dentistry, 3223 North Broad Street,Philadelphia, PA 19140.
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9. 1981 Erwin P. Barrington. an Overview of Periodontal Surgical Procedures

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