Congrès IAHD 2000

Evolution of Periodontal Surgery Techniques in this Century

Assistant Professor, Periodontology Department, Faculty of Dentistry, University Camilo Castelo Branco, São Paulo, Brazil.
Professor and Chairman, Periodontology Department, Faculty of Dentistry, University Camilo Castelo Branco, São Paulo, Brazil.

In the beginning of the century, the surgical treatment was not attractive to clinicians, not well-accepted by the patients, and we had unpredictability of good results.

In the beginning of the century, we also didn't know much about the etiologic agent of "alveolar pyorrhea".

In 1884, the researcher and clinician Robicsek, was the first to describe the radical technique of gingivectomy with bone exposure. Firstly, he measured the pocket depth to determinate the line where the gingival tissue would be excised. After this procedure, and using a semicircular incision on each tooth, he incised the tissue to be removed on the labial and lingual surfaces of the surgical area. Using a sharp instrument, the interdental gingiva was excised and the remaining tissue was removed with curettes. The removal of the soft tissue was considered the first phase of the surgery. The following surgical phase consisted on removing the bone tissue with surgical drills. The surgical field should be stained with iodine dye and the patient instructed to mouthwash with an antiseptic solution (Stern IB; Everett FG; Robicsek K,  S. Robicsek - a pioneer in the surgical treatment of periodontal disease. J Periodontol 1965; 36:265-268).

According to Stern et al. (1965), S. Robicsek had some remarkable insights about the periodontal disease treatment. These insights, usually, influenced the development of surgical periodontal techniques in the world. The nature of his contribution is neither the flap, nor the gingivectomy as we know, but rather the radical gingivectomy which is an excision of the gingiva, exposing the marginal and interseptal alveolar bone in order to remove granulation tissue and change the shape of this bone by a proper instrumentation (Stern IB; Everett FG; Robicsek K,  S. Robicsek - a pioneer in the surgical treatment of periodontal disease. J Periodontol 1965; 36:265-268).

GOLDMAN (1950) introduced the concept on the development and importance of physiologic contours of the tissues. The elimination of periodontal pockets, the control of gingival inflammation and the re-establishment of physiologic function of periodontal tissues are essential requirements for the success of periodontal treatment. So, the conquest of an excellent bacterial plaque mechanic control performed by the patient, constitutes a relevant aspect for the maintenance of the obtained results (Goldman HM  The development of physiologic gingival contours by gingivoplasty.  Oral Surg Oral Med Oral Pathol 1950; 3:879-888).

The gingivectomy procedure as it is used today was described in 1951 by Henry M Goldman. In gingivectomy technique the gingival tissue which faces the tooth is excised down to the base of the pocket in order to include the junctional epithelium, leaving part of the connective tissue above the alveolar crest.

In 1916, Leonard Widman in the entitled monograph "The Operative Treatment of Pyorrhea Alveolaris" was one of the first researchers to describe in detail the use of flaps to eliminate periodontal pockets.

A mucoperiosteal flap is lifted exposing the involved bone and soft tissue; a complete removal of granulation reaction should be performed. A bone reshaping should be performed for two reasons: 1) to eliminate of sharp tips of bone tissue, and 2) to eliminate necrotic bone - the apically displaced flap is first mentioned (Everett F; Waerhaug J; Widman A  Leonard Widman: surgical treatment of pyorrhea alveolaris. J Periodontol 1971; 42:571-579).

According to Wennström et al. (1997), in 1931, KIRKLAND published a surgical procedure to be used in the treatment of "periodontal pus pockets". The procedure was called the modified flap operation, and it was basically an access flap for proper root debridement by intracrevicular incisions through the bottom of the pocket on both the labial and lingual aspects of interdental area (Wennström J; Heijl L; Lindhe J  Periodontal surgery: access therapy. In: Lindhe J; Karring T; Lang NP  Clinical periodontology and implant dentistry. 3ed Copenhagen: Munksgaard  1997, p.508-549).

Historically, osseous surgery was performed for the primary purpose of eliminating necrotic or infected bone (Cohen ES Atlas of cosmetic & reconstructive periodontal surgery. 2ed Malvern: Lea Febiger, 1994, p.259).

In 1935, Kronfeld, in the research "Condition of the Bone Tissue of the Alveolar Process below the Periodontal Pockets", demonstrated scientifically, through histological studies that the bone tissue of alveolar process adjacent to the periodontal pockets did not present characteristics of necrotic bone (Kronfeld R J Periodontol 1935; 6:22).

HIRSCHFELD (1952) proposed the technique of subgingival curettage in order to eliminate or to reduce pocket depths through a reduction of the inflammatory process in the tissues and subsequent healing. The procedure was executed under local anesthesia and the tissue was scrapped in order to remove the ulcerated epithelium of the pocket (Hirschfeld L Subgingival curettage in periodontal treatment. J Amer Dent Ass 1952; 44:301-314).

According to ROBINSON (1966), the periodontal pockets adjacent to distal root surfaces of the second and third molars are aspects of the periodontal therapy of difficult solution and they have been denied frequently for many periodontists. The periodontal pocket on the distal surface of molars can be extremely deep due to the anatomy of this area. When the pocket becomes deeper, that depth is larger than in other areas and the inaccessibility of the area leads to the inability in the mechanical control of bacterial plaque executed by the patient. Regarding to these aspects, he developed the Distal Wedge procedure in order to treat periodontal pockets adjacent to the distal surfaces of the molars. This technique uses internal bevel incisions and it has as objectives: to obtain access to the bone tissue, to preserve attached gingiva, to eliminate periodontal pockets, to reduce the healing period and to minimize the postoperative pain (Robinson RE  The distal wedge. Periodontics 1966; 4:256-264).

RAMFJORD; NISSLE (1974), concerned about bone tissue preserving, obtaining a perfect closure of the flaps with minimal root exposure and facilitating the oral hygiene executed by the patient, they modified the technique initially described by Widman, in 1916, turning it into a conservative procedure. The changes were: primer incision is an inverse beveled, partial-thickness, thinning incision held parallel to the long axis of the tooth and directed toward the crest of bone, and intra-sulcular (secondary) incision was performed around the dental surfaces. After raising the flaps the loosened collar of tissue was removed at the alveolar crest. These modifications try to maintain the height of the gum, preserve the aesthetics, guarantee the repairing through long juncional epithelium, besides facilitate the mechanical control of bacterial plaque executed by the patient (Ramfjord SP; Nissle RR  The modified Widman operation. J Periodontol 1974: 45:601-607).

According to TAKEI et al. (1985), the most common postoperative problem associated with grafting procedures is the immediate, partial or complete exfoliation of the implant materials. This is most often due to a surgical technique that results in incomplete tissue coverage of the graft material in the interproximal areas. Even if there is an apparent tissue approximation at the time of surgical closure, the tissue shrinkage associated with wound healing will often expose the graft material during the postoperative period. Because of the observed difficulties, they developed the papilla preservation technique for use in conjunction with bone grafts and synthetic materials in periodontal osseous defects (Takei HH; Han TJ; Carranza Jr FA; Kenney EB Flap technique for periodontal bone implants. J Periodontol, 1985; 56:204-210).

In 1949, SCHLUGER was one of the first researchers that described the principles of resective osseous surgery related, basically, with remained bone where it could be established the physiologic contours without attachment loss, elimination of interdental craters and intrabony defects with the objective of eliminating periodontal pockets and reaching a physiologic gingival and osseous architecture after surgical procedures (Schluger S A basic principle in periodontal surgery. Oral Surg Oral Med Oral Pathol 1949; 2:316-325).

FRIEDMAN (1955) introduced the terms "osteoplasty" and "ostectomy", designed to define the reduction and removal of no supporting and/or supporting bone, respectively (Friedman N Osteoplasty and ostectomy. J Periodontol 1955; 26:257-269).

For GOLDMAN; COHEN (1958), a classification of bone defects is necessary not only for academic purposes but also as a rational base for selection of treatment methods. Based on these aspects, they suggested a classification of bone defects based on the location and in the number of remaining bone walls. These can be classified in defects of three, two or one bone walls and combinations. This classification serves as a base to establishment of the periodontal therapy (Goldman HM, Cohen  DW The infrabony pocket: classification and treatment. J Periodontol  1958; 29:272-291).

In 1958, GLICKMAN with the objective to facilitate and to select the proper treatment to be performed, proposed a classification for furcation problems. In the horizontal aspect, qualified it in: Grade I - incipient lesion; Grade II - partial destruction of the supporting structures of the furcation area; Grade III - total destruction of the supporting structures of the furcation area, allowing the insertion of a periodontal probe without the clinical exposure of the furca; Grade IV - the same as Grade III plus the clinical exposure of the furcation area (Glickman I  El periodontium en la salud y la enfermedad. Reconocimiento de la enfermedad periodontal en la práctica de la odontología general. 2ed Trad. Fermin A Carranza Jr, Buenos Aires: Mundi 1961 p.532-540).

The existence of intrabony defect cases with potential to be reconstituted, stimulated the appearance and development of new techniques that used bone grafts with inductor potential capable to stimulate the osteogenesis, cementogenesis and formation of new fibers of periodontal ligament. In 1965, NABERS; O'LEARY, developed the technique of autogenous bone graft to treat three walls bone defects. The grafting materials are easy-obtained, compatible with the receiving tissues and with inductive perspectives (Nabers CL; O'leary TJ Autogenous bone transplants in the treatment of osseous defects. J Periodontol  1965; 36:5-14).

EWEN (1965) presented the bone swaging technique. It is necessary the existence of a prosthetic space adjacent to the angular bone defect. The bone tissue adjacent to the defect is moved and pressed towards the root surface without been fractured entirely, with the use of a chisel. This technique is indicated for the treatment of bone saliencies, bifurcations and bone defects of three walls (Ewen SJ Bone swaging. J Periodontol  1965; 36:57-36).

Due to the difficulties when using autogenous bone grafts in relation to the occurrence of bone sequestrations when large bone graft particles are used and the difficulty of obtaining bone marrow and adequate quantities of cancellous bone intraorally, ROBINSON, in 1969, developed the osseous coagulum technique for bone induction, using small particles of cortical bone with some cancellous bone, obtained by cutting it with drill in the donor site. The bone tissue obtained is mixed with blood and its becomes an bone coagulum. It is now collected, transported and transplanted into the interior of a bone defect (Robinson, RE Osseous coagulum for bone induction. J Periodontol 1969; 40:503-510).

According to SCHALLHORN et al. (1970), efforts have been made to regenerate the portions of lost bone tissue during the progress of periodontal diseases. While favorable results have been reached with several types of bone grafts, there are growing evidences that autogenous hematopoietic marrow bone (from the iliac crest) is best material available for bone graft purposes (Schallhorn RG; Hiatt, WH; Boyce, W  Iliac transplants in periodontal therapy. J Periodontol  1970; 41:566-580).

According to DIEM et al. (1972), the biggest objective of the periodontal therapy has been the development of new techniques that induce the regeneration of periodontal lost tissues. A big number of researchers has been relating an apparent osteogenic and cementogenic response with mineralized dental fragments and particles of bone tissue. They developed a technique to reduce bone fragments of cortical and medular bone to smaller particles, produced by trituration for 60 seconds in mechanical amalgamator (Diem CR; Bowers GM; Moffitt WC  Bone blending - a technique for osseous implants. J Periodontol  1972; 43:295-297).

HIATT; SCHALLHORN (1973), published an article demonstrating, clinically, that the tuberosity, edentulous area and healing extraction alveolus constitute excellent sources for obtaining medular bone grafts for filling bone defects (Hiatt WH, Schallhorn RG  Intraoral transplants of cancellous bone and marrow in periodontal lesions. J Periodontol  1973; 44:194-208).

From the 1980's on, we can found in the literature the first studies using the GTR techniques. I will describe some of these studies, according to its importance.

YOUNGER (1902) was one of the first clinical researchers to describe a surgical technique to restore the lost parts of the periodontium. The procedure consisted in scaling the root surfaces to remove dental calculus, treat it with lactic acid, dry the surface as much as possible with an alcoholic solution, place on the root and bone defect a piece of Japanese paper soaked in celluloid liquid, suture and tie it around the tooth, preventing all possibilities of the paper getting out of position and, finally, suture the flaps of the surgical wound (Younger WJ The american dental club the Paris. Dental Cosmos 1904; 46:39).

In 1982, NYMAN et al., tested the hypothesis that new connective tissue attachment could be obtained on a previously periodontitis involved root surface through cells originating from the periodontal ligament. They demonstrated by histological studies a presence of new cementum with inserting principal fibers formed on the previously diseased root surface when a periodontal surgery technique was performed with a Millipore filter (which during the wound healing did not allow the dentogingival epithelium and the gingival connective tissue from reaching contact with the prepared root surface)(Nyman S; Lindhe J; Karring T; Rylander H New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982; 9:290-295).

GOLDMAN, in 1953, affirmed that there are three specific problems that involve the interrelation between the gingiva and the alveolar mucosa. The first consists of periodontal pockets that extend beyond the attached gingiva reaching the alveolar mucosa. The second, an abnormal traction of frenulum that can transmit tension for the gingival margins and cause recessions. The third, the functional condition of a shallow vestibule that promotes a decrease of attached gingiva levels (Goldman HM Periodontia. 3ed St Louis: CV Mosby 1953).

In 1964, OORN developed a technique for repositioning the frenum in periodontal problems (Corn H Cirurgia mucogengival reconstrutiva. In: Goldman HM; Cohen W Periodontia 6ed Trad. José Luiz Freire de Andrade, Rio de Janeiro: Guanabara Koogan, 1983 p.732-873).

According to NABERS (1954), when the apical point of periodontal pocket migrates apically beyond the mucogingival line, this condition is capable to create difficulties during the periodontal treatment due to the structural differences between the attached gingiva and the alveolar mucosa. Based on these aspects, the author was one of the first authors to relate the necessity of preserving the strip of attached gingiva, developing a surgical technique for repositioning the attached gingiva in relation to the bone crest of the alveolar process. A flap is reflected and moved away, the reaction of existent granulation in the area is eliminated, the flap is now apically repositioned along the margins of the bone tissue about 2mm below the original position and, finally, sutured (Nabers CL Repositioning the attached gingiva. J Periodontol 1954; 25:38-39).

ARIAUDO; TYRRELL (1957), modified the NABER's technique (1954), introducing the concept of the two vertical incisions. The presented technique allows to preserve or to increase the strip of attached gingiva although the periodontal pocket is apically positioned to the mucogingival junction, because a new band of attached gingiva is formed coronally to the replaced attached gingiva (Ariaudo AA; Tyrrell HA Repositioning and increasing the zone of attached gingiva. J Periodontol 1957; 28:106-110).

FRIEDMAN (1962) Proposed the term "apically repositioned flap", instead of the term "attached gingiva repositioning", initially proposed by NABERS, in 1954 (Friedman N Mucogingival surgery: the apically repositioned flap. J Periodontol  1962; 33:328-340).

GRUPE; WARREN Jr (1956), developed a technique for lateral sliding of the flap with the objective of correcting the gingival recessions. Initially, the root surfaces should be scalled and smoothed. The incisions were made, firstly, outlining the inflamed gingival tissue for its complete removal. Another incision was made far from the recession preserving the papilla adjacent to the defect, and extending towards the alveolar mucosa. The full-thickness flap it should be sufficiently wide to cover the gingival recession. Finally, it is was moved laterally to cover the gingival recession and, then, sutured (Grupe HE; Warren Jr RF Repair of gingival defects by a sliding flap operation. J Periodontol 1956; 27:92-95).

CORN (1964b) and GRUPE (1966), proposed different modifications in the technique of lateral sliding of the flap.

- cutback incision (Corn H  Periodontics 1964b; 2:229).

- submarginal incision (Grupe HE, Modified technique for the sliding flap operation. J  Periodontol  1966; 37:491-494).

For COHEN; ROSS (1968), the lateral sliding of the flap and the flap moved laterally from edentulous areas are techniques that need an adjacent donor area. These displacement techniques require a band of attached gingiva equal or lightly larger than the necessary tissue in the receptor site. Frequently, an insufficient or absent band of attached gingiva in the adjacent tooth reduces the predictability of the technique. Based on these aspects, they developed the technique of double papilla laterally positioned flaps. The flap is formed by suturing the two flaps adjacent to the area to be covered (Cohen DW; Ross SE The double papillae repositioned-flap in periodontal therapy. J Periodontol 1968; 39:65-70).

NORBERG in 1926 was the first to report the coronally repositioned flap in order to cover root surfaces. In 1975, BERNIMOULIN et al. designed a technique with the same goal but combining the use of a free gingival graft 2 months prior to the coronally repositioned flap technique which was performed through two vertical parallel incisions leaving reaching the alveolar mucosa, obtaining a enlarged band of attached gingiva (Bernimoulin JP; Lüscher B; Mühlemann HR Coronally repositioned periodontal flap: clinical evaluation after one year. J Clin Periodontol 1975; 2:1-13).

In 1963, BJÖRN, described a free transplantation of gingiva. In 1966, NABERS developed a technique with free gingival grafts of masticatory mucosa membrane in periodontal surgical procedures that aimed to create bands of attached gingiva, enlarge them and change the extension of vestibular fornix (Nabers JM Extension of the vestibular fornix utilizing a gingival graft. Periodontics 1966; 4:77).

RAETZKE, in 1985, developed a new method for covering localized areas of root exposure with free connective tissue grafts using connective tissue obtained from the depth of the hard palate, leaving only a narrow surface defect at the donor site. The graft is positioned directly over the exposed root, but its major part is placed in an "envelope" previously created by an undermining partial thickness incision in the tissues surrounding the defect (Raetzke PB Covering localized areas of root exposure employing the "envelope" technique. J Periodontol 1985; 56:397-402).

LANGER; LANGER (1985), published an article in which they introduce new concepts, indications and procedures with the objective of covering root surfaces and enlarge bands of attached gingiva combining a partial-thickness flap coronally positioned with a subepithelial connective tissue graft (Langer B; Langer L Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985; 56:715-720).

Langer Technique
(Courtesy of Dr. Claudio Júlio Lopes, UNICASTELO)

TARNOW(1986) described the technique of a semilunar flap coronally moved and designated primarily to cover root surfaces with gingival recessions of 2 or 3mm. The technique involves a semilunar incision made parallel to the free gingival margin of the facial tissue, and coronally positioning this tissue over the denuded root (Tarnow DP Semilunar coronally repositioned flap. J Periodontol 1986; 13:182-185).

In 1992, HARRIS proposed a technique root coverage as follow: double papilla incisions, partial-thickness flap completed by sharp dissection, periosteal bed prepared, connective tissue suturing, and double papilla flap sutured over the graft (HARRIS RJ J Periodontol 1992; 63:477).

In 1994, SHANELEC; TIBBETTS, published an article referring about periodontal microsurgery. The microsurgery refers to a refinement in surgical technique by which normal vision is enhanced through magnification and the techniques are each time less traumatic and the results present more predictability and quality of healing (Shanelec DA; Tibbetts LS  A perspective on the future of periodontal microsurgery. Periodontology 2000  1996; 11: 58-68).

According to MILLER Jr; ALLEN (1996) the periodontal plastic surgery encompasses a much broader range of treatment and address treatment of the following defects: the shallow vestibule (vestibular deepening); the aberrant frenum (frenectomy); marginal tissue recession (soft tissue grafting); excessive gingival display (crown lengthening); deficient ridges (ridge augumentation); ridge collapse folowing extraction of periodontally involved teeth (grafting extraction sites); loss of interdental papillae (papilla reconstruction); unerupted teeth requiring orthodontic movement (surgical exposure); aesthetic defects around dental implants (bone and/or soft tissue augmentantion (Miller Jr PD; Allen EP The development of periodontal plastic surgery. Periodontology 2000  1996; 11:7-28).




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