An Overview of Periodontal

Erwin P.

Barrington

Over the past three decades most articles pertaining to

surgical procedures, especially those dealing with the
newer ones, have included discussions of indications and
contraindications as well as the advantages and disadvantages of specific procedures. More recently, however,
few authors have dealt directly with indications for periodontal surgery. Instead, there has been a tendency to
limit such references to broad comments on the timehonored matter of presence of periodontal pockets and/
or absence of bone. Certainly with the questioning which
the profession is now conducting on the status of periodontal surgery, indications for these procedures should
be carefully reviewed.
This report will discuss the indications for specific
periodontal surgical procedures in the light of our present
knowledge of periodontal disease and therapy. It will
also evaluate the comparative studies carried out during
the past decade on surgical techniques and the results

periodontal diseases reported in both populations were

gingivitis and Periodontitis. Destruction of supporting structures associated with chronic Periodontitis
was continuous and progressed at a relatively even rate
in both groups. Annual rates of periodontal attachment
loss were significantly different, however, averaging 0.09
mm in the Norwegian population and 0.25 mm in Sri
chronic

Lankans.
Becker et al.16 used a different approach in reporting
on a sample of 30 untreated patients who were followed
for various periods up to 10 years. They found a tendency
toward progressive periodontal disease as evidenced by
greater pocketing, continuing bone rsorption and ultimately further loss of teeth. The teeth lost were those
which had initially greater pocket depth and higher
mobility scores than the teeth which were present at both
the initial and final examination. The average tooth loss
per patient was calculated to be 0.6 per year. In a followup study17 the authors found that every untreated patient
had progressive bone loss, greatest in the molar areas.
Further studies on the natural history of so prevalent
a disease are obviously needed. In a sense every periodontist could contribute to such knowledge, possibly by
establishing a system similar to that of Becker et al.
Periodontists have no doubt of the efficacy of therapy
in the control of periodontal disease.7"13 Recently, however, questions have been raised about the need for some
of the so-called "advanced" surgical approaches to therapy as opposed to the so-called "conservative" approaches.9' 18-20 Several studies have dealt with the probability of success. Oliver21 reported on a series of 442
patients who were treated by various therapies and followed for 5 to 17 years, with an average post-treatment
period of 10.1 years. The average tooth loss due to
recurrent periodontal disease was 0.5 tooth per patient.
The results were not computed on a per year basis but
simple arithmetic shows that the average tooth loss per
year, if calculated as Becker et al. did, would be 0.05.
This loss in treated patients compares quite favorably
with the Becker figure of 0.6 tooth loss per year on
untreated patients.
More recently Hirschfeld and Wasserman22 studied
the results of treatment of 600 patients over a 15- to 50year period. Their patients were treated with a variety of
surgical and "nonsurgical" techniques. They divided
their results into three groups based on the number of

reported.

Definition of Periodontal

Surgical Procedures

Surgery has been defined as the act and art of treating

diseases or injuries by manual operation.1 If this broad
definition is used, nearly all periodontal treatment, from
hard or soft tissue curettage through osseous surgical
procedures, falls under the heading of "periodontal surgery". In common usage the term "periodontal surgery"2
is applied only to specific surgical manipulations of
periodontal soft tissues and bone and not to the accompanying debridement and root planing. These latter
procedures, however, probably play the decisive role in
the success or failure of the surgical procedures.3"13 In
this article any manipulative procedure of the root surface and soft and/or

osseous

tissue will be considered

Surgical Procedures

surgical procedure.

periodontal therapy is that it will

interrupt a sequence of events leading to the loss of teeth
which can disrupt and destroy complete dentitions.13'14
Yet the concept of a "sequence of events which destroys
One rationale for

dentitions" is vague because of the relative lack of information on the natural history of the disease. One report
on the natural history has been described in a longitudinal study of populations in Norway and Sri Lanka.15
The groups had major geographical, cultural, socioeconomic and educational differences and represented extremes with respect to dental care. The predominant

518

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Periodontal

Number 9

teeth lost after therapy. The patients classified as "wellmaintained" (83% of the sample) lost an average of 0.7
tooth per patient. Fifteen percent lost an average of six
teeth per patient over the same period and were classified
as "downhill". Two percent were classified as "extreme
downhill" and lost an average of II teeth per patient.
This type of result, focusing in on the maintenance of
teeth, may well be considered as representing the degree
of success that can be achieved with periodontal therapy.
This concept of success makes it clear that while the
initial aim of therapy may have been the total eradication
of periodontal disease,8' 10' 13' 14' 19' 23'24 continued maintenance of the treated dentition, with arrest and slowed
progression of the patient's disease, may well be the most
important result of treatment.19'21'22
On the basis of the results of Hirschfeld and Wasserman, in which the maintenance of support of teeth is
considered a major criterion of success, periodontists
may consider themselves successful in approximately
80% of cases. At this time control of the disease is being
evaluated in broader terms than just the elimination of
pockets at one period in the patient's lifetime. Maintenance of the treated patient is receiving more and more
emphasis. The existence of maintenance programs
strongly suggests that following treatment the patient
still needs periodic evaluation and care for control of
his/her periodontal problems since permanent elimination of the factors causing the disease is not possible at

present.

It may then be the task of periodontics to determine

which types of surgical procedures are least traumatic to
the patient and at the same time achieve the most
effective control of the disease, so that the greatest part
of the dentition is maintained for the longest time. It
seems logical to predict that control of periodontal disease, by controlling plaque and rendering pockets inactive, will be one of the most important objectives in the
future.
The techniques used in treating pockets and periodontal disease so as to maintain the dentition are also being
evaluated.9 The necessity of evaluating the current indications for periodontal surgical procedures has been
brought to light by the assertion that periodontal disease
is being grossly overtreated.9 An assessment of the indications for current treatment procedures is therefore in
order. Among the reasons that have been given for

performing periodontal surgery are to:4'7-13

1. Eliminate pockets by removing soft tissue, recontouring it, or by using a combination of the two
procedures.
2. Eliminate pockets by removing osseous tissue, recontouring it, or by using a combination of the two
procedures.
3. Remove diseased periodontal tissue in order to create
conditions favorable for new attachment or readaptation of the soft and/or

osseous

tissue

to

the tooth.

Surgical Procedures

519

4. Correct mucogingival deficiencies and deformities.

5. Establish acceptable gingival contours to aid in performance of effective hygiene.
6. Improve the esthetic appearance of soft tissue in
areas of tissue enlargement.
7. Create a favorable environment for necessary restorative dentistry.
8. Establish drainage for a gingival or periodontal abscess to turn an acute periodontal problem into a
more treatable state.
Periodontal Pockets as an Indicator for
Procedures

Surgical

According to Ramfjord,23 all periodontal therapy historically has been aimed at pocket elimination. The
necessity for this traditional objective of therapy is now
being questioned and challenged.918,20'24 The factors
which have played a role in this re-evaluation of periodontal pockets and the ways in which their state of
activity contributes to an assessment of the need for
surgical procedures will be reviewed.
Probably the most important criterion used over time
by periodontists in determining whether periodontal surgery is necessary, is the depth of the pocket. The instrument commonly employed for measuring and evaluating
the periodontal pocket has been the periodontal probe.
Recently the art and science of probing has come under
closer scrutiny and questioning.9,20-30
The periodontal probe was reported by Orban to be
the "eyes of the operator beneath the gingival margin".26
According to Listgarten,25,28 it has been rather apparent
that the probing depth measured from the gingival margin seldom corresponds to sulcus or pocket depth. The
discrepancy is smallest in the absence of inflammatory
changes and greatest with increasing amounts of inflammation. In Periodontitis the probe tip will pass to a level
0.3-0.5 mm apical to the termination of the junctional

epithelium.28,29 Gamick et al.27 showed an even greater

variation and depth of penetration.

These discrepancies may lead to an exaggerated measurement of pocket depth. An error in the opposite
direction may occur after therapy when crevicular depth
may be underestimated because the now healthy gingival
connective tissue readapts closely to the tooth, resulting
in shallower penetration of the
The measurement of pocket depth as a major criterion
for evaluation of therapy, both pre- and post-treatment,
must therefore be re-evaluated in light of what is now
known about discrepancies in periodontal probing. It
may well be that periodontists have relied too much on
probing depth measurements and have overestimated
the need for so-called "advanced" surgical techniques by
inadvertently probing too deeply. When an awareness of
these discrepancies is combined with the recognition that
the depth of the pocket, even if precisely measured, does
not determine the presence or absence of active disease,

probe.20-28

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J. Periodontol.
1981

Barrington

September,

but merely documents the history of the disease process,9

it becomes obvious that using the results of probing as
the major criterion of the need for surgery needs to be
reassessed. However, if pocket depth is no longer considered the major criterion to assess the activity of the
disease state, one may then ask what criteria are to be
used to evaluate the progress of disease and work toward
the goal of control and maintenance.
Other Criteria Employed in

Assessing Periodontal

Status
In the clinical setting other recognized physical characteristics of the gingival tissue are color, size, shape,
consistency, presence or absence of exdate and propensity for hemorrhage. While highly subjective in nature,
visualization of the color, size and shape of the tissue is
important in evaluating its state of health. Changes in
these characteristics can lead to the conclusion that
inflammatory activity is present. This has been shown in
which employed indices evaluating
several
gingival status. A change in consistency from firm to soft
could be an indication of inflammatory activity.
Hemorrhage from the pocket upon provocation is
probably one of the most frequent signs of inflammatory
activity. The use of gingival bleeding indices30"38 is based
on the
premise that deterioration of gingival health will
be reflected by an increase in crevicular vascularity and
a decrease in the mechanical strength of the crevicular
epithelium. Even light probing will therefore elicit a
hemorrhagic response. Some correlation between the
overall number of blood vessels and the Gingival Index
has been
The presence or absence of exdate has been studied
in detail using flow rates of crevicular fluid as one of the

reports31"34

reported.38

criteria.39"47

Several studies have demonstrated a high correlation

between the rate of flow of crevicular fluid and the
severity of clinically assessed gingival inflammation.42"45
Crevicular fluid flow can be used as an indicator of early
as well as advanced gingival disease.43"46 Copious crevicular flow or exdate is also an indicator of inflammatory
activity in gingival tissue.46"48
The view that pocket depth should not be the only
criterion to be used is supported by the fact that total
pocket elimination cannot be sustained for indefinite
In addition, the goal of gaining access and
debridement
of the lesions of periodontal
for
visibility
disease may provide a better rationale for surgery than
pocket elimination.
A priority listing of the signs of activity of the periodontal disease state that could be used in monitoring its
control would then be: (a) Propensity for hemorrhage,
(b) Crevicular fluid flow, (c) Pocket depth, (d) Color,
size, shape and consistency of the gingiva. Even though
depth is relegated to third place on this suggested list for
monitoring the patient, it remains important since one of
the major problems in treating periodontal disease is

periods.19'20'22

accessibility. The complete removal of plaque and its

products from root surface more than 3 mm subgingivally is difficult.49,50 Incomplete subgingival plaque control is usually equal to no plaque control at all.50 In many

it may even be worse because both the patient and

clinician may be led to believe that the treatment taken
has been successful. This fact led Waerhaug to believe
that surgical elimination of pathologic pockets deeper
than 3 mm is the most predictable method for attaining
cases

adequate subgingival health.49,50

The major purpose of the foregoing section has been
to suggest a reordering of the criteria used for disease
control and thereby bring into focus the concept of
disease elimination and control as a goal, rather than
pocket elimination by itself.
Once the need for therapy has been established, various techniques can be utilized. These will be discussed
in the following sections.
Scaling, Root Planing and Subgingival Curettage

techniques of scaling, root planing and

subgingival curettage have long been the cornerstone of
periodontal therapy.3,4'51 Scaling and root planing refer
to the removal of calculus, bacteria and their products
from the root surface, or lying free in the pocket, and the
The combined

removal of all contaminated cementum and dentin.

Thorough root surface preparation can be accomplished
through both physical and chemical means.5'52"56 Subgingival curettage refers to scraping of the inner surface of
the gingival wall of the periodontal pocket to clean out,
separate and remove diseased soft tissue.2,57
Although most textbooks separate the description and
definition of the two procedures, they may be done at
the same time in the overall sequence of therapy. Some
therapists will separate the procedures by doing scaling
and root planing and waiting several weeks for resolution
of inflammation before doing subgingival curettage. The
rationale for this is puzzling as subgingival curettage as
a treatment procedure per se is almost fruitless. It would
seem that because of the importance of root surface
preparation,0,6,52"56 the subgingival curettage could be
done at the same time, as an adjunctive procedure, and
thus not subject the patient to two separate treatments.
Most periodontists approach treatment by using this
technique as a combined procedure and it will be discussed that way in this report.
Over the years many indications and uses for scaling,
root planing and subgingival curettage have been proposed. More recently the uses have narrowed to the
following situations: (a) Pocket Reduction (Disease Control) Therapy, (b) Presurgical Preparation of Tissues, (c)
Treatment of "Compromise" Situations, (d) Maintenance of Treated Patients.
a.

Pocket Reduction (Disease

Control) Therapy

In gingivitis and Periodontitis the combined approach

of removing plaque and calculus and maintaining proper

Volume 52
Number 9

plaque control measures can effectively reduce and even

eliminate gingivitis and incipient Periodontitis.4 The degree of tissue shrinkage and pocket depth reduction will
depend on the original depth of the pocket, the amount
of edematous fluid in the tissue, the amounts of fibrous
connective tissue and the thoroughness of root prepara-

tion.55"58

pocket depth is minimal

and the pocket wall is
not fibrotic, then scaling, root planing and subgingival
curettage can reduce pocket depth to such an extent that
it can be maintained by the patient. In this event scaling,
root planing and subgingival curettage can be called a
If the tissue is edematous, the

(2-4 mm) to moderate (4-7 mm),

definitive procedure.4,18-20
Pocket shrinkage following scaling, root planing and
curettage occurs through a combination of tissue responses. Sufficient shrinkage may occur with resolution
of the edema, while remodeling of the connective tissue
may go on for months, even years.18,20 Further changes
in the tissue occur through new attachment by a long
junctional epithelium and/or readaptation of the gingival connective tissue to the root surface.6,58-62
In a series of studies, a group headed by Ramfjord and
Knowles have reported18,20,60,62"66 on both the short and
long-term gains in attachment and tissue reduction obtained by using subgingival curettage. Subgingival curettage was most effective in cases with minimal pock-

eting (1-3 mm).

In

moderately deep pockets (4-6 mm)

effective in pocket reduction as other

surgical techniques. Attachment was greatest during the
first year and later tended to stay the same or decrease

it

was not as

slightly.20

Thus, in summary, in looking at scaling, root planing

and subgingival curettage as a definite pocket reduction

(disease control) procedure,

combination of tissue responses can take place to bring about the results. These
responses and changes consist of shrinkage of the tissue
through loss of edema, return of the connective tissue to
health, establishment of a long junctional epithelium,
and the previously mentioned phenomenon of the
change in probing depth that takes place between inflamed and noninflamed gingival tissues.
b.

Surgical Procedures 521

and curettage in conjunction with a good oral hygiene
program to prepare patients for surgery. He found that
this protocol resulted in an appreciable degree of tissue
shrinkage and resolution of inflammation.
Periodontal

Presurgical Preparation of Tissues

The International Conference

on

Research in the Bi-

ology of Periodontal Disease concluded that "the difference between using curettage as a definitive procedure
or as a presurgical procedure seemed to be based on the
depth of the pockets at the start of treatment, as well as
the quality and quantity of tissue involved in the subgingival curettage procedure".4
If more extensive surgical techniques or procedures
are to be utilized, presurgical p'reparation of the tissue
may render the tissues easier to handle during these
surgical procedures. Scaling and subgingival curettage
have been found to be of value in this respect, although
not universally so.67-72 Zamet72 reported using scaling

c.

Treatment of

Compromise Situations

always possible to carry out the indicated

procedure treating patients with periodontal disease.
A treatment plan may have to be changed to fit the needs
of a particular patient.
Although scaling, root planing and subgingival curettage are surgical procedures, they do not tend to arouse
the patient's anxiety as much as some other
procedures.67,73 Some patients are psychologically unwilling or unable to accept surgical manipulations of
their tissues, and scaling, root planing and subgingival
It is

not

in

curettage may have to be used in these situations.8,13'67'71

Other patients, because of systemic and medical problems, may not be able to undergo more extensive procedures. Scaling, root planing and subgingival curettage
can be used in these patients with minimal risk.67,73
A third situation in which scaling, root planing and
subgingival curettage may be a treatment compromise
occurs when they are intended as presurgical procedures
but after their execution the patient and/or therapist
decides to discontinue treatment. In this situation these
procedures serve as the definitive treatment. In many
instances, scaling, root planing and subgingival curettage
can help minimize disease activity.
d. Maintenance of the Treated Patient

Extensive periodontal surgical procedures may effect

primary cure for the disease, but the curette serves to
preserve this cure.67 In many instances the surgically

treated periodontal case may not be maintained in health

by periodic prophylaxis alone. Repeated scaling, root
planing and soft tissue curettage may be necessary to
prevent a recurrence of disease in previously treated

areas.59,67

Comment

Scaling, root planing and subgingival curettage can be

an effective approach to shallow and moderately deep
periodontal pockets, can help reduce tissue inflammation
prior to other surgical procedures, can be effective in
certain "compromise" situations aiid can help to maintain the treated patient. Without proper root surface
preparation, subgingival curettage is not truly an effective surgical procedure.
Excisional New Attachment Procedure

While scaling, root planing and subgingival curettage

well established procedures, the Excisional New Attachment Procedure (ENAP) is relatively new. Forerunners of the ENAP appeared in the literature in 1931
when Kirkland,74 described a modified flap operation
for treating periodontal disease and in 1939 when Bar-

are

522

3. Periodontol.
1981

Barrington

kann75 described

September,

conservative surgical approach to

treat periodontal pockets. Barkann's procedure closely
approximates the ENAP technique reported on by Yukna et al.6'76-79 The ENAP is essentially subgingval curettage performed with a knife. The objectives are to
permit thorough soft tissue preparation and to secure
better access to the root surface. Among its stated advantages over traditional subgingival curettage is the definitive, clean excision of the junctional epithelium and the
subjacent tissue with a greater probability of new clinical
a

attachment.6'76

The ENAP is restricted to suprabony pockets whose

apical extent lies within the keratinized gingiva. It is not
advocated for pockets that extend beyond the mucogingival junction or for treatment of osseous defects. Vertical or relaxing incisions are not utilized, since positioning
of the tissues at their original level is intended and is

essential.6,76

Clinical improvement was reported at 1- and 3-year

evaluations following the procedure but probing depths
increased slightly and the amount of newly gained attachment decreased slightly at each postoperative evaluation from 1 to 5 years.76'79 However, an overall gain of
1.5 mm in clinical attachment was still evident 5 years
after treatment.79
Studies by Yukna and associates suggest a trend toward a relapse somewhere around the 5-year mark.79
Since no clinically significant tissue loss occurs with this
technique, retreatment by the ENAP procedure every 5
years or so may well preserve the maximum amount of
attachment for the longest possible time.6
Histologie studies show that the ENAP heals with a
long, thin junctional epithelium and a minimal amount
of connective tissue attachment. These results do not
fulfill the histologie criteria for new attachment; however,
the relative absence of inflammatory cells in the subjacent connective tissue suggests a picture of periodontal

health.77

subgingival curettage and ENAP have the advantage of minimizing postsurgical recession and root
sensitivity because the free gingival margin is kept virtually intact and tissue elevation is not a part of these
Both

procedures.6

Comment
The ENAP procedure can be used in rather specific
circumstances and therefore is limited in its scope. The
initial gain of clinical attachment, which is the major
premise of the technique, seems to be lost over time.
Because it does "conserve" tissue, the technique can be
repeated to re-establish tissue attachment after an interval of several years.

Gingivectomy and Gingivoplasty

The gingivectomy was one of the
procedures in periodontal therapy

foremost surgical
from the 1930's

the early 1960's.M G. V. Black, around 1900,

have
been one of the first to practice it in this
may
It
country.80 was reported on extensively by Crane and
Kaplan,81 Ward82 and Kirkland,80 who is considered the
"Father of the Gingivectomy".
The gingivectomy derives its effectiveness from the
fact that it removes the diseased pocket wall which
obscures the tooth surface.8'10,11 It creates visibility and
accessibility for the complete removal of irritants from
the root surface. This is particularly advantageous in
view of today's knowledge concerning the importance of
root surface preparation. In addition, it is considered to
be a relatively fast and simple procedure.
A perusal of the modern textbooks in Periodontology
discloses the indications and contraindications for gingivectomy.7-13 The indications generally agreed upon are
elimination of suprabony pockets whose depth is greater
than is accessible for root preparation without tissue
removal; elimination of suprabony pockets whose tissue
is firm and fibrotic, and therefore will not shrink after
scaling, root planing and subgingival curettage; and elimination of gingival enlargements. The contraindications
generally agreed upon are situations when there is a need
to gain access to osseous tissue, when the base of the
pocket is apical to the mucogingival junction, and when
a zone of keratinized gingiva will not be present after
excision of the tissue.
Glickman83 in 1956 reported on 250 cases treated with
gingivectomy which were followed for 3 months to 7
years. He used an "unembellished" gingivectomy technique which did not include preoperative scaling and
root planing to reduce inflammation in the tissue prior
to the surgical procedure. In addition, the technique did
not employ drugs, medicaments or adjunctive mechanical aids84-87 to augment the tissue removal or healing
response. Although evaluated only clinically, Glickman
made a convincing case for the use of the unembellished

through

gingivectomy.

Several biometrie studies have been done over the

years to evaluate the gingivectomy as a usable technique.
Gingivectomy has been shown to be a better method
for shallow (up to 4 mm) pocket elimination than curettage even though loss of attachment has been reported
with gingivectomy that did not occur with curettage.88-92
Since pocket elimination per se is not considered the
primary objective of periodontal therapy, it is doubtful
that gingivectomy would be the treatment of choice in
pockets as shallow as 4 mm. Deeper pockets (greater
than 6 mm) are reported to be treated better by curettage
and other procedures, as they may result in a gain of
attachment,6' 18' 19'65'66 while gingivectomy results in a loss
of attachment.
Probably the major disadvantage of the gingivectomy
is its limited applicability. It cannot be used when mucogingival problems or osseous deformities exist.8,13'93-95
In such areas it has not been proven as effective as the

Volume 52
Number 9

Surgical Procedures 523

The primary objective of the procedure is not pocket
elimination per se, but maximum healing of periodontal
pockets with minimum loss of tissues during and after
Periodontal

flap approach

or

the

touring.94,95

flap approach

with

osseous con-

Gingivoplasty is a term sometimes used synonymously

with gingivectomy and is done in the absence of pockets
with the sole purpose of recontouring the gingiva.8,10,13,86,87,96 The true gingivoplasty may be done
after other surgical procedures that have resulted in
unacceptable tissue form, such as rolled margins, craters
and bulbous interdental papillae. The gingiva is festooned and scalloped by hand or rotary instruments to
create interdental grooves and sluiceways. Most periodontists are of the opinion that gingivectomy and gingivoplasty are similar terms but generally use the term
"gingivoplasty" to refer to a thinning of the tissues rather
than a removal of the pocket wall.
Comment

The gingivectomy-gingivoplasty technique remains a

useful technique. The indications advanced for it by
earlier therapists still hold true but to a lesser extent. The
contraindications hold true but to a much greater extent.
Probably the greatest factor in the decreased use of the
gingivectomy has been the understanding of the importance of accessibility and treatment of osseous deformities in the elimination and control of disease activity.
Periodontal Flap Procedures

Scaling, root planing, subgingival curettage, ENAP

gingivectomy are all procedures done without elevating the underlying periosteum and exposing the bone.
Procedures which require elevation and reflection of the

and

soft tissues from the surface of the bone are referred to

flap procedures. Broadly stated, the main reasons for

as

doing flap procedures are:6-81012101,105-107 (l) To secure

access for root planing and to the underlying osseous
tissue. (2) To facilitate removal of lining epithelium and
granulation tissue that may interfere with healing. (3) To
facilitate attempts to reestablish tissue health by new
attachment and/or close adaptation of the connective
tissue to the root.
The Modified Widman Flap
In 1916 Leonard Widman reported on the use of the
reverse beveled incision in obtaining access to the unThe modderlying tissues with a mucoperiosteal
described in detail by Ramfjord
ified Widman
and Nissle in 1974 is considered more conservative than
that originally described by Widman.6,19,101,102 Less bone
is exposed with the modified technique than with the
original procedure and more attention is paid to close
interproximal adaptation. Also in contrast to the original
procedure, sharp knives rather than curettes are used to
separate the collar of tissue around the necks of the teeth.
Whereas the original procedure included the surgical
removal of osseous defects, the modified technique seeks
to maintain bony pocket walls.

Flap101

flap.100

the procedure.101 Periodontal support and health are

maintained by means of a long junctional epithelial
attachment and close connective tissue adaptation, with
or without new attachment of connective tissue and with
or without regeneration of bone. One key to its success
seems to be the prevention of subgingival plaque extension, thus permitting optimal healing.102
The initial internal bevel incision is begun 0.5 to 1.0
mm from the free gingival margin, aimed at the alveolar
crest, and followed by reflection of a full-thickness flap
that exposes 1 to 2 mm of the alveolar bone. A second
vertical incision is made from the bottom of the pocket
to the alveolar crest. Another horizontal incision along
the alveolar crest then severs the supracrestal tissue,
permitting its removal. Following root planing and curettement of any bony defects, the flaps are closely
adapted interproximally and to the teeth and secured
with interrupted sutures. Primary wound closure is an
essential objective of the modified Widman procedure
and the removal of bone is undertaken only when necessary to achieve this objective.101
The incision design and full thickness flap reflection
allow better access to deeper areas of disease than either
the ENAP or subgingival curettage and, in addition,
provide access to bony defects. The close adaptation of
gingival tissues to the tooth surfaces is thought to promote the formation of a new epithelial attachment which
seals off the more apical areas between the tooth and the
surrounding tissues. If the healing connective tissue
adapts closely to the tooth surface, reattachment with
formation of new cementum may develop gradually from
the apical aspect of the lesion.101,102
The stated advantages of the modified Widman Flap
are that it optimizes access to the root surface and allows
intimate postsurgical adaptation of healthy connective
tissue and epithelium to the root surface, thereby enhancing the potential for new attachment. In addition, it
allows optimal soft tissue coverage of root surfaces, thus
providing a result which is both esthetically desirable
and amenable to oral hygiene procedures, with potentially less root sensitivity and fewer root caries prob-

lems.101,102

Disadvantages of the modified Widman flap include

flap design is technically exacting, especially interproximally. Moreover, interproximal tissue
architecture is poor immediately following removal of
the dressing and sutures, especially in areas of interproximal bony craters. However, if meticulous oral hygiene
the fact that its

is maintained, the interdental tissues regenerate over a

few months with a gain rather than loss of

attachment.101,102

Histologie evaluation of the modified Widman flap

demonstrates healing by means of a long, thin junctional

J. Periodontol.

Barrington
epithelium to the depth of the surgical wound, with no
gain in connective tissue attachment and no increase in

September,

524

crestal bone

height.61'103 Repair of this nature may be a

disadvantage because it is probably more prone to breakdown and pocket reformation than a true connective
tissue attachment; however, longitudinal studies suggest
that this epithelial adherence may be maintainable.19' 60'62 Filling in of osseous defects occurs to varying
extents.95

The modified Widman flap has been evaluated for

several years as part of the University of Michigan
longitudinal study begun in 1971 by Ramfjord and coworkers.19'20'60'62-66' 102 In general, the latest results20'104
indicate that traditional methods for surgical elimination
of periodontal pockets do not have any advantage over
either subgingival curettage or the modified Widman
flap procedure. When moderate to severe periodontal
pockets are considered, these three techniques all reduce
pocket depth, with subgingival curettage being least effective. In moderately deep pockets (4-6 mm), all three
techniques produce a gain in attachment level, the greatest being obtained with the modified Widman flap.
When deep pockets (7-12 mm) are treated, the modified
Widman flap produces a significantly better gain than
either of the other two techniques. These results have
been maintained almost without variation over 8 years
of observation. When shallow pockets (1-3 mm) are
treated by any of these methods, they become deeper
and lose attachment during the 1st year and these
changes also persist through the years. The changes in
pocket depth and level of attachment as a response to
therapy do not seem to be related to tooth type.104

1981

The indications for open flap curettage are summarized by Ammons and Smith106 and Ammons et al.107 as
follows: (1) in patients with advanced periodontal disease, where osseous procedures may jeopardize the attachment apparatus; (2) in disease states where the morphology of anatomic defects may be favorable for regeneration; (3) when preservation of tissue is important
because of esthetics, particularly in the anterior part of
the mouth; and (4) as part of initial preparation of the
patient to secure total debridement of a lesion, e.g., prior
to orthodontic therapy, or as an exploratory procedure
in a deep defect, e.g., in evaluation of a furcation.
The technique employs an inverse bevel incision,
placed approximately 1 mm lateral to the free gingival
margin which follows the contours of the teeth and
extends apically to the alveolar crest. A mucoperiosteal
flap is reflected to completely expose the involved area.
After thorough debridement, the flap is placed back in
position and secured with sutures. This technique thus
allows optimal accessibility and tissue coverage.
There is a paucity of biometrie data on the effects of
open flap curettage. The studies which have been done
are generally of relatively short duration.106'107 They have
shown a return to periodontal health; a net reduction in
plaque and gingival inflammation; a net gain of attachment, particularly in deeper pockets; but no real inducement of bone regeneration. After treatment, probing
depths increased over the study periods but did not
return to the original levels.
Remodeling of osseous tissue has been shown to take
place with open flap curettage, especially in intraosseous

defects.108"110

Comment

Comment

Modified Widman flap surgery may be utilized whenever reattachment with minimal gingival recession is
desired. It may be the preferred procedure in treating
moderately deep pockets or moderate furcation involvement, and in patients with a high caries rate and root
sensitivity problems. Studies have shown that the modified Widman procedure is as effective in maintaining
clinical levels of attachment as co-called traditional surgical procedures such as those involving ostectomy. Repair of the modified Widman procedure by means of a
long junctional epithelium, not by new attachment of
connective tissue, may be a disadvantage in that the area
may be prone to new pocket formation and reinstitution
of disease activity.

Open flap curettage provides access to the diseased

area for root debridement and permits visualization and
possible treatment of osseous tissue. It provides for optimal tissue coverage where tissue preservation is impor-

Open Flap Curettage

procedure has been

Open flap curettage
advocated to permit accessibility, visibility, and debridement; and to promote repair with relative patient comfort.8, 105-107 Although flap curettage is similar in many
ways to the modified Widman flap, it is generally a more
extensive procedure which usually includes elevation of
the mucoperiosteum past the mucogingival junction.
as a

treatment

esthetic reasons. It seems to be an effective

method of eliminating periodontal disease activity.

tant for

Osseous

Surgery

Osseous surgery is often considered a recent addition

periodontal surgical procedures, but its use dates back
the late 19th century. Robicsek described a procedure
which allowed access to the bone for smoothing and
reshaping.111 Zentler, Zemsky and Neuman, in the pre1920's, reported that access to bone was necessary to
remove, reduce and reshape infected or necrotic

to
to

bone.112113

Schluger114 was dissatisfied with the pattern of behavior of the soft tissue after gingivectomy and curettage
procedures, and in 1949 published a report on the reshaping of osseous tissues. He stated that the form of the
underlying bone dictated soft tissue results and that the
differences between the levels and shapes of osseous
tissue and the soft tissue caused recurrent pocketing and

Volume 52
Number 9

Periodontal

recurrent periodontal disease. Thus, he attributed the

failure of the other techniques to their inability to correct
irregularities in the bone such as ledges, reverse architecture, craters and thick bony margins. The principles
underlying bone reshaping are fairly simple. The goal is
to create a form to the bone that resembles or closely
approximates an idealistic architectural form.
When achieving this goal by performing osseous contouring, the therapist would establish a physiologic architecture to the bone, which is then followed by the
overlying gingiva. In cases where furcations would be
exposed or excessive bone support would be sacrificed,
Schluger advised accepting residual pockets.
The tenets of osseous recontouring have been redefined over the years and have been based on a number
of clinical reports of successfully treated cases.115"123
The technique of osseous contouring has been criticized however, because of the possibly excessive amount
of osseous tissue which sometimes must be removed to
achieve a physiologic contour consistent with a preconceived ideal. Therapists became concerned about removing good, healthy supporting bone and possibly sacrificing attachment needed for survival of the dentition.124'125
In response to this, Selipsky122 claimed that reshaping
of ledges and thickened margins does not reduce any
portion of the attachment apparatus and therefore does
not contribute to loss of supporting bone. He said that
the technique removes very little actual attachment, averaging 0.6 mm on the interproximal and 1 mm in the
midfacial, midlingual and midpalatal areas. He pointed
out that most of the supporting bone for the tooth is in
the broad interproximal area and not on the facial,
lingual and palatal surfaces.
Another concern has to do with increase in mobility
after osseous resective procedures. Studies on mobility
patterns showed that there is a definite increase in the
first few weeks after the procedure, but a return to
presurgical levels in about 6 months.107,122
Several studies comparing techniques have tested the
efficacy of osseous recontouring in periodontal therapy.
One problem with the studies is that the protocol for
each study is different. While it is difficult to find a
common thread to tie them together, some interesting
conclusions can be drawn.
There is greater loss of bone after osseous recontouring
than after flap curettage alone.107 In addition, there is a
greater potential for securing an increase in periodontal
attachment if bone is not recontoured and is completely
covered by the soft tissue flap.95
In one long-term study (8 years)62 surgical pocket
elimination did not enhance the prognosis for maintenance of periodontal support in either moderate or advanced periodontal lesions when osseous recontouring
was compared with the modified Widman or subgingival

curettage techniques.62

Osseous recontouring has been

cessful than the

significantly more sucgingivectomy procedure in eliminating

Surgical Procedures

525

pockets and creating physiologic contours in cases asso-

ciated with osseous defects. However, it has not seemed

make any difference in the plaque-control abilities of
the patients studied.94'107
Ochsenbein123 recently summarized the current status
of osseous contouring and listed indications and contraindications. Among the indications were thick ledges,
tori and other such aberrations; furcation invasions; furcation invasions which may require root amputations or
hemisections; and shallow craters and minor angular
defects. Contraindications included were three-walled
intrabony defects, especially those with a wide orifice;
bony defects on the buccal aspect of mandibular molars
associated with the external oblique ridge; moderate to
deep circumferential defects; and advanced periodontal
lesions or isolated deep craters. These indications and
contraindications can act only as guidelines. Concepts
and skills in bone surgery vary considerably between
different schools of therapy and different periodontists,
and there is no general agreement on the role and
limitations of ostectomy and osteoplasty in periodontal
to

therapy.4'124

Because there appears to be a general tendency towards techniques which foster tissue conservation, it has
been suggested that ostectomy procedures have no place
in the treatment of patients with early bone destruction
and are of questionable value in areas of moderate to
severe bone loss.124 Where then, does osseous recontouring have its place in therapy? There is no question that
the indications of Ochsenbein have merit.123 Osseous
contouring may therefore be a definite aid in the natural
process of bone remodelling that takes place after a flap
approach with debridement and root surface preparation.108"110 The resultant healing process can help eliminate many discrepancies in tissue contour and allow for
better access for patient and therapist to maintain the
treated area.
Comment
Osseous contouring will eliminate discrepancies in
bdhy architecture resulting from periodontal disease and
along with the natural process of bone remodelling will
create tissue contours which allow for a more maintainable periodontal environment. However, concepts, skills
and philosophies in bone surgery vary considerably between periodontists, and at this time there is no general
agreement on the role of osseous contouring in peri-

odontal

therapy.

CONCLUDING REMARKS
It is obvious from the foregoing that there are many
technical approaches to periodontal surgery. The mere
presence of a periodontal pocket of a cerain depth as the
major indicator for surgery is not as steadfast as once
believed. Other criteria such as hemorrhage and exdate
must also be used in evaluating the need for surgery. The
decision on which approach to use remains with the

Barrington
therapist and the individual situation with which he/she

J. Periodontol.
1981

526

is faced.

However, in the past decade it has become increasingly

clear that the need for so-called more advanced surgical
procedures is not as important to the control of periodontal diseases as was once thought. Regardless, it is
also clear that some form of surgical intervention, as
defined by this paper, is still necessary to interrupt the
sequence of events that make up the pathogenesis of
periodontal disease that leads to eventual tooth loss. This
paper has reviewed and evaluated some of the current
procedures available to the therapist in the surgical

approach to therapy.

ACKNOWLEDGMENT
The author wishes to thank Dr. Michelle Zmick for her many hours
of work in helping to compile and write this paper.

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surgery. Efficacy of Treatment Procedures in Periodontics (Workshop),
Shanley, D. B. (ed), Chicago, Quintessence Pubi., 1980.
125. Knoell, A. C, and Vogan, W. I.: A mathematical investigation
of the biomechanical effects of simulated periodontal surgery. / Periodont Res 12: 290, 1977.

Send reprint requests to: Dr. Erwin P. Barrington, Department of

Periodontics, University of Illinois, College of Dentistry, 801 S Paulina
St, Chicago, IL 60612.

Announcements
BOSTON UNIVERSITY GOLDMAN SCHOOL OF GRADUATE
DENTISTRY

TEMPLE UNIVERSITY SCHOOL OF DENTISTRY

Title:
Date:
Faculty:
Title:

Temple University School of Dentistry announces the following

Continuing Education Courses:
Treatment Planning The Difficult Cases In Perioprosthesis, Dr. R.
Schoor, Dr. A. Rinaldi; September 16, 17, 1981.
This is a seminar course designed to help the restorative dentist
develop a diagnosis, treatment plan and a prognosis for the complex
moderate and advanced periodontal patient. Cases will be presented
for group discussion. Periodontal prognosis of key abutment teeth,
designs of the prosthesis and acceptable clinical compromise will be
discussed in depth.

Practical Periodontal Surgery

Title:
Date:
November 19-20, 1981
Faculty: Department of Periodontology
For further information contact: Division of Continuing Education,
Boston University School of Gradaute Dentistry, 100 East Newton
Street, Boston, Mass. 02118

Clinical Periodontal Surgery; Dr. D. Litwack, Dr. M. Salkin, Dr.

R. Schoor; September 23, 24, 25, 1981.
The purpose of this clinical technique course is to present the
current biological concepts of up-to-date periodontal surgery. The
influence of all surgical modalitites on present day dental practice will
be analyzed and discussed.
For further information contact: Division of Continuing Education,
Temple University School of Dentistry, 3223 North Broad Street,
Philadelphia, PA 19140.

Boston University Goldman School of Graduate

nounces the following Continuing Education courses:
Dental Implants
Title:
Date:
September 23, 1981
Faculty: Morton Perel, D.D.S.

Dentistry

an-

Minor Tooth Movement

October 14, 1981
Anthony Gianelly, D.M.D., Ph.D., M.D.
Selected Procedures in Periodontal Surgery: Gingival Reconstruction
October 15-16, 1981
Date:
Faculty: Hyman Smukler, D.M.D., H.D.D.; Gerald A. Isenberg,
D.D.S.; Alan M. Shuman, D.M.D.