SURGICAL PERIODONTAL

THERAPY
(Phase II Periodontal Therapy)
 General Principles
• Carefully planned
• Patient prepare (medically, psychological, all
aspects)
• Complication that may occurs during or
after surgery
 Patient Preparation
• Reevaluation after phase 1 therapy (reprobing)
• Premedication (compromice, prophylactic
antibiotic)
• Smoking (stop min. 3-4 weeks post op)
• Informed consent
• Emergency equipment
• Prevent transmission of infection
• Sedation and anesthesia
• Tissue management (sharp of instrument)
• Scaling and root planing (bifurcation)
• Hemostatis
• Periodontal dressing
• Patienst instruction
Objectives of Surgical Periodontal
Therapy
 Controlling/ eliminating periodontal
disease
 Correcting anatomic conditions :
 May favour periodontal disease
 May impair esthetic
 For prosthetic purpose
 Implant placement
 The advantages of surgical
Therapy
• Improved visualization
• More acurate determination of prgonosis
• Pocket reduction/ elimination
• Regenaration of lost periodontal structures
• Improved environment for restorative dentistry
• Access for oral hygiene and supp. Perio. Treat.
 Gingival Curettage
• Scraping of the gingival wall of periodontal pocket
to remove inflammed soft tissues
• Eliminate bacteria and diseased tissue
• Inadvertant curettage/ performed when SRP
 Indications
• Deep infrabony pockets/ closes surgery
• Reduce inflammation prior pocket elimination
• If Surgical technique are contra indicated
• Shrinkage of localized areas of gingiva (bulbous)
• Maintenance for areas of recurrent inf.
 Contra Indications
• Acute infection
• Fibrous ephitelial enlargement (phenytoin
hyperplasia)
• Frenal pull of MG
• Extention of base of pocket apical to MJ
 PROCEDURE
• Basic technique-curette is selected so that the cutting edge
will be against the tissue.
• Instrument is inserted so as to engage the inner lining of
pocket wall and is carried along the soft tissue
• Pocket wall maybe supported by gentle finger pressure on
the external surface.
 OTHER TECHNIQUES
Excisional new attachment procedure (ENAP):
Definitive subgingival curettage procedure.
• ENAP was an attempt to overcome some of the
limitations of closed gingival curettage.
Ultrasonic curettage
• Ultrasonic vibrations disrupt tissue continuity,
• Effective for debriding the epithelial lining of
periodontal pockets.
• It results in a narrow band of necrotic tissue
(microcauterisation) which strips off the inner
lining of the pocket
 Lasers
• Laser curettage in suprabony pockets where
osseous surgery is not required
• considerably less invasive than traditional
flap surgery
• good candidate for gingival curettage (small
size tip diameter)
 TISSUE RESPONSE TO
CURETTAGE
• Reversal of all signs of gingival inflammation.
• Shrinkage, resolution of oedema and exudation.
• Morphologic features in gingiva and mucosa are
delineated more clearly after inflammation has
been resolved.
• Exuberant granulation tissue rarely present
postoperatively.
• Gingiva is firm to the scalpel and is of good texture
to be beveled or split as required.
 Gingivectomy
• Excise suprabony pocket (sufficent attached
gingiva)
• Reduce gingival enlargement
• Esthetic crownlengthening (certain situations)
 Contraindications
• Indrabony pocket
• Need ossesous surgery
• Inadequate attached gingiva
• Interfe with frena/ muscle
• long clinical crowns will compromise aesthetics.
A. Preoperative. B. Gingivectomy based upon aesthetic
profile ratio. C. Gingivoplasty. D. 8 weeks postsurgically.
 Periodontal Flap
A periodontal flap is a section of gingiva and/or mucosa
surgically separated from the underlying tissues to provide
visibility and access to the bone and root surface.
 INDICATIONS
• Irregular bony contours
• Deep craters
• Pockets on teeth in which a complete removal
of root irritants is not clinically possible
• Grade II or III furcation involvement
• Root resection / hemisection
• Intrabony pockets on distal areas of last molars
• Persistent inflammation in areas with moderate
to deep pockets.
 CONTRAINDICATIONS
• Uncontrolled medical conditions such as
• Poor plaque control
• High caries rate
• Unrealistic patient expectations or desires
 Classified basedon
Bone exposure after flap reflection
• Full thickness (mucoperiosteal)
• Partial thickness (mucosal)
Placement of the flap after surgery
• Udisplaced flaps
• Displaced flaps
Management of the papilla
• Conventional flaps
• Papilla preservation flaps
 PARTIAL THICKNESS FLAP
• Split thickness flap.
• Periosteum covers the bone.
• Indicated when the flap has to be positioned apically.
• When the operator does not desire to expose the
bone.
 FULL THICKNESS
Periosteum is reflected toFLAP
expose the
underlying bone. Indicated in resective
osseous surgery

Contraindications:
• Thin periodontal tissue with probable osseous
dehiscence and osseous fenestration.
• Area where alveolar bone isthin.
Nondisplaced Flap
Apically Displaced Flap
Coronally Displaced Flap
Laterally Displaced Flap