King Salman International University

Faculty of Dentistry
Periodontics-2

I-Fundamentals of Periodontal Surgery

Introduction
Periodontal surgery is an essential component of advanced periodontal therapy. It involves surgical
interventions to treat periodontal disease, regenerate lost structures, and create favorable conditions for
oral health maintenance. This document covers the fundamentals of periodontal surgery, including its
goals, indications, contraindications, classifications, techniques, patient preparation, intraoperative
considerations, and post-surgical care.

Goals of Periodontal Surgery

Periodontal surgery aims to achieve the following objectives:

1. Improving Accessibility for Scaling and Root Planing (SRP): Deep periodontal pockets (≥6
mm) and furcation involvement make non-surgical treatment less effective. Surgery provides
direct access for proper instrumentation.
2. Regenerating the Periodontal Apparatus: Periodontal disease can destroy the supporting
tissues, including bone and periodontal ligament. Surgical interventions aim to restore these
structures.
3. Correcting Abnormal Gingival and Bone Morphology: Conditions such as gingival overgrowth
and uneven alveolar bone can complicate oral hygiene and contribute to disease progression.
Surgical correction improves accessibility for plaque control.
4. Enhancing Esthetics: Procedures like root coverage and papilla reconstruction improve the
appearance of the gums, especially for patients concerned about gingival recession or black
triangles.
5. Preprosthetic Preparation: Periodontal surgery prepares the periodontium for restorative and
prosthetic treatments by ensuring adequate space and contour, such as in crown lengthening and
ridge augmentation.
6. Managing Mucogingival Defects: Correcting mucogingival problems, such as inadequate
attached gingiva and high frenum attachment, enhances long-term periodontal health.
7. Facilitating Implant Placement: Bone augmentation techniques and guided bone regeneration
improve the foundation for dental implants.

Indications for Periodontal Surgery

Surgical intervention is recommended when:

1. Periodontal pockets are too deep for effective non-surgical treatment.

2. Tissue destruction requires regenerative techniques.
3. Bone morphology needs correction for functional or esthetic purposes.
4. Mucogingival issues hinder proper oral hygiene or prosthetic work.

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 King Salman International University
Faculty of Dentistry
Periodontics-2

5. Preprosthetic procedures are needed to support restorations or implants.

6. Esthetic concerns such as gingival recession require soft tissue grafting.

Contraindications for Periodontal Surgery

Periodontal surgery is not suitable for all patients. Some contraindications include:

1. Uncooperative Patients: Poor motivation and lack of commitment to oral hygiene can lead to
surgical failure.
2. Severe Systemic Diseases: Patients with conditions such as malignancy, uncontrolled diabetes,
severe cardiovascular disease, renal disease, or blood disorders may require medical clearance
before surgery.
3. Hopeless Teeth: When a tooth has severe bone loss and cannot be saved, extraction may be the
preferred option.
4. Acute Infections: Surgery should be postponed if an active infection is present to prevent
complications.
5. Poor Esthetic Outcomes: If surgery results in unfavorable aesthetics, alternative treatments
should be considered.

Classification of Periodontal Surgical Therapy

Periodontal surgery is classified into the following categories based on the treatment objectives:

1. Pocket Reduction Surgery

• Gingivectomy: Removes excessive gingival tissue to eliminate pockets.

• Flap Surgery: Provides direct access for deep cleaning and bone reshaping.

2. Regenerative Periodontal Surgery

• Guided Tissue Regeneration (GTR): Uses barrier membranes to promote selective tissue
regrowth.
• Bone Grafting: Replaces lost bone using autografts, allografts, xenografts, or synthetic materials.
• Enamel Matrix Derivatives (EMD) and Growth Factors: Stimulate periodontal tissue
regeneration.

3. Mucogingival and Soft Tissue Surgery

• Root Coverage Procedures:

o Laterally positioned flap
o Double papilla flap
o Subepithelial connective tissue graft
o Coronally positioned flap
o Semilunar flap
• Gingival Augmentation:
o Free gingival grafts for increasing attached gingiva.

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 King Salman International University
Faculty of Dentistry
Periodontics-2

• Frenectomy and Frenotomy: Correction of aberrant frenum attachment.

4. Preprosthetic Periodontal Surgery

• Crown Lengthening: Increases clinical crown height for prosthetic restorations.

• Ridge Augmentation: Improves bone volume for prosthetic support.

5. Implant-Related Periodontal Surgery

• Implant Placement Surgery: Includes single-stage or two-stage implant placement.

• Sinus Lifting: Increases bone height in the maxillary sinus region for implant support.
• Peri-implantitis Treatment: Surgical intervention to manage infections around implants.

Patient Preparation and Pre-Surgical Considerations

1. Phase I Therapy Before Surgery

Before performing periodontal surgery, Phase I therapy (non-surgical periodontal therapy) is essential to
optimize conditions for healing and improve surgical outcomes. This phase includes:

• Scaling and Root Planing (SRP) to reduce bacterial load and inflammation.
• Plaque Control Instruction: Patients should demonstrate good oral hygiene practices before
surgery.
• Correction of Contributing Factors such as occlusal trauma, poorly fitting restorations, or
smoking cessation counseling.
• Antibiotic Prophylaxis for patients at risk of infection (e.g., immunocompromised patients or
those with systemic conditions requiring coverage).

2. Pre-Surgical Evaluation and Re-Evaluation (4-6 Weeks Post-Phase I Therapy)

The patient is reassessed to determine whether surgical intervention is necessary. Key assessments
include:
• Pocket Depth Measurement: Evaluate whether critical probing depths indicate a need for
surgery.
• Assess pocket depth, clinical attachment level, gingival inflammation, tooth mobility, plaque
control, and microbiological status.
• Evaluate the Critical Probing Depth (CPD):
➢ Non-surgical therapy:
▪ CPD = 2.9 – 5.4 mm: Below this range, clinical attachment loss occurs; above this,
attachment gain is possible.
➢ Surgical therapy:
▪ CPD = 4.2 – 6.2 mm: Below this range, clinical attachment loss occurs; above this,
attachment gain is expected.
• Clinical Attachment Level: Ensure that attachment loss progression is monitored.
• Gingival Inflammation: Persistent inflammation despite non-surgical therapy justifies surgery.
• Tooth Mobility Assessment: Identify teeth requiring additional stabilization.
• Microbiological Testing (if indicated) to assess the bacterial profile.

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 King Salman International University
Faculty of Dentistry
Periodontics-2

3. Medical and Systemic Considerations

• Review of Medical History: Ensure systemic conditions (e.g., diabetes, cardiovascular diseases)
are controlled.
• Medication Adjustment: Coordinate with the patient’s physician if anticoagulants,
immunosuppressants, or other medications require modification.
• Allergy Screening: Check for allergies to anesthetics, antibiotics, or periodontal dressing
materials.

4. Preoperative Instructions for the Patient

• Dietary Restrictions: Avoid food intake 2 hours before surgery if sedation is planned.
• Oral Hygiene Maintenance: Brush and floss thoroughly before the appointment.
• Medication Adherence: Take prescribed medications, including antibiotics if indicated.
• Smoking and Alcohol Abstinence: Avoid smoking and alcohol at least 24-48 hours before
surgery to promote healing.
• Transportation Arrangements: If sedation is involved, arrange for someone to drive the patient
home.

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