Periodontal Surgical Therapy
Periodontal Surgical Therapy
Tested here: flap design selection, resective versus regenerative intent, and the contraindications that matter more than the technique.
Core rules
- Flap access: modified Widman (tissue conservation, open debridement), papilla-preservation incisions (best for regeneration and esthetics), apically positioned flap (pocket elimination plus keratinized tissue), distal wedge (terminal molars).
- Osseous resective surgery creates positive architecture; it suits suprabony defects and shallow craters and is contraindicated in deep vertical defects or where it would remove support from adjacent teeth.
- Gingivectomy is limited to suprabony pockets with adequate attached gingiva; never where attachment loss or a shallow vestibule exists.
- Crown lengthening: bone must sit about 3 mm from the final margin (2 mm supracrestal attached tissues + 1 mm sulcus) - plan it before, not after, the restoration.
- Hemostasis, atraumatic handling, tension-free suturing, and 1–2 weeks of healing before probing.
Worked example
A maxillary premolar has a 6 mm pocket, 1 mm keratinized tissue and a 2 mm ferrule deficit for a planned crown. Gingivectomy is contraindicated (inadequate keratinized tissue, attachment loss). Choose a full-thickness flap with apically positioned closure plus ostectomy to gain both pocket elimination and 3 mm from bone to future margin.
Traps
Resecting bone in a vertical defect; performing osseous surgery on a tooth slated for extraction; forgetting that crown lengthening of adjacent teeth alters their support; probing immediately after surgery; leaving unsupported papillae and blaming the patient for the black triangle.