Chapter 14. Surgical Methods of Treatment of Periodontal Pathology

Periodontal diseases are among the commonest diseases of mankind. Investigation of their biological basis and treatment remain issues that demand further scientific research, as the etiology and pathogenesis of these diseases comprise genetic, environmental, microbiological, social factors, being connected in both directions with systemic health. Thus, effective management of periodontal diseases requires an integrated and individual approach to treatment planning for each patient. The use of surgical methods at one of the stages of complex treatment of periodontal diseases is an important factor in achieving sustainable positive results.

There are several classifications of surgical methods for treating periodontal diseases.

Depending on the clinical situation, surgical periodontal care can be provided:

• In terms of urgent dental care.
• In a planned manner, after the obligatory comprehensive hygienic and anti-inflammatory preparation (Fig. 14.1).

Fig. 14.1. Chronic periodontitis: a - scheme; b - intraoral clinical view

Urgent care is indicated during the period of exacerbation of the inflammatory process, during the formation of periodontal abscesses.

Methods of urgent care, used for special indications at the time of exacerbation of the inflammatory process in the periodontal tissues, are as follows:

• tooth extraction;
• incision and drainage of abscesses.

Planned surgical interventions are carried out after a full course of preoperative preparation, including:

• teaching and motivation for supragingival plaque control;
• removal of dental plaque;
• local anti-inflammatory therapy;
• treatment of inflammatory diseases of the teeth and oral cavity;
• production of temporary prosthetic structures;
• training in oral hygiene;
• functional selective grinding;
• splinting of mobile teeth while maintaining mobility.

From a practical point of view, all periodontal interventions can be divided into three groups.

• The first group includes interventions aimed at eliminating an inflammatory process in periodontal tissues including curettage, flap surgery, gingivectomy, periodontal abscess drainage.
  • The goal of all types of interventions in this group is to eliminate periodontal pockets or pseudopockets, which become reservoirs of microbial accumulations and their waste products.
  • The prerequisites for performing these interventions are the normal width of the attached gingiva and the absence of pathological cords or disturbance of frenum, normal depth of the vestibule of the oral cavity.
• The second group of interventions is referred to as mucogingival and pre-prosthetic surgery.
  • The surgical treatment that is included in this group is aimed at eliminating disorders in the structure of periodontal soft tissues or bone tissue of the vestibule and the oral cavity. These disorders not only impair the conditions for future prosthetic treatment or aggravate the course of the inflammatory process in the periodontium, but in some cases become the causes of specific inflammatory lesions on their own.
  • The interventions include the plastic surgery of frenum of the upper and lower lip, the tongue, pathological cords, vestibuloplasty, gingival recession closure, gummy smile treatment, soft tissue augmentation in peri-implant area, surgical crown lengthening.
• The third group of interventions deals with the excision of tumors and tumor-like lesions that arise from the periodontal tissues.
  • These operations are associated with the necessity to close the defects of tissues by different techniques.
  • Histological examination of the excised tissues is obligatory.

Surgical methods for the treatment of periodontitis depending on the tissue recovery type are divided as follows:

• resective methods: gingivectomy, apically displaced flap, amputation, and resection of the roots of the teeth, surgical crown lengthening;
• reparative methods: curettage, open curettage, flap surgery;
• mucogingival methods: plastic surgery of the labial frenum, connective tissue cords and the vestibule of the oral cavity and the tongue, gummy smile treatment, augmentation of the attached keratinized gingiva (AKG) or attached keratinized mucosa (AKM) zone, gingival recession closure;
• regenerative methods: directed tissue regeneration.

Before starting any periodontal treatment, it is necessary to collect a detailed history.