Surgical Methods of Treatment of

Chronic Periodontitis

By Mahdi Faour

PlanAims of surgical treatmentInstrumentsAnesthesiaMethods of surgical treatment of chronic

periodontitisResection of root apex (apicoectomy)HemisectionRoot Amputation

Aim of surgical methods of treatment of chronic forms of periodontitisSurgical treatment of chronic periodontitis

permits visualization and access to the root surface and thus has clear advantages over a nonsurgical approach for the manipulation and cleaning of root areas and surfaces. Therefore surgical approach of treatment aims at:

Providing better access for removal of etiological factors

Reducing deep probing depthsRegenerate or reconstruct lost periodontal

tissues

Instruments used in periodontal surgery• Incision and excision (periodontal knives)• Deflection and readaptation of mucosal flaps

(periosteal elevators)• Removal of adherent fibrous and granulomatous

tissue (soft tissue rongeurs and tissue scissors)• Scaling and root planing (scalers and curettes)• Removal of bone tissue (bone rongeurs, chisels and

files)• Root sectioning (burs)• Suturing (sutures and needle holders, suture

scissors)• Application of wound dressing (plastic instruments)

Examples of double-ended sickle scalers and curettes useful for root debridement in conjunction with periodontal surgery.

Set of burs which may be useful in periodontal surgery. The rotating fine-grained diamond stones may be used for debridement of infraosteal defects. The round burs are used for bone recontouring.

Examples of instruments used for bone recontouring. Bone chisels Ochsenbein and Schluger curved filem

Local anesthesia in the mandibleAs a rule, analgesia of the teeth and the soft and hard

tissues of the mandible should be obtained by a mandibular block and/or a mental block. In the anterior region of the mandible, canines and incisors can often be anesthetized by infiltration, but there are often anastomoses over the midline. These anastomoses must be anesthetized by bilateral infiltration, or by bilateral mental blocks.

The buccal soft tissues of the mandible are anesthetized by local infiltration or by blocking the buccal nerve. Local infiltration, performed as a series of injections in the buccal fold of the treatment area.

The lingual periodontal tissues must also be anesthetized. This is accomplished by blocking the lingual nerve and/or by infiltration in the floor of the mouth close to the site of operation.

Supplementary injections may be made in the interdental papillae (intraseptal injections).

Local anesthesia in the maxillaLocal anesthesia of the teeth and buccal periodontal tissues

of the maxilla can easily be obtained by injections in the mucogingival fold of the treatment area. If larger areas of the maxillary dentition are scheduled for surgery, repeated injections (in the mucogingival fold) have to be performed.

In the posterior maxillary region a tuberosity injection can be used to block the superior alveolar branches of the maxillary nerve.(Risk of hematoma in the veous plexus nearby, therefore rarely used)

Palatal nerves are most easily anesthetized by injections made at right angles to the mucosa and placed around 10 mm apical to the gingival margin adjacent to teeth included in the operation

Sometimes blocks of the nasopalatine nerves and/or the greater palatine nerves can be applied (especially when periodontal surgery involves molars).

Method of surgical treatmentResection of root apex (apicoectomy)

HemisectionRoot AmputationReplantationImplantation

Resection of root Apex

Apicoectomy is the surgical resection of the root tip of a tooth and its

removal together with the pathological periapical tissues.

Indications for Apicoectomy 1. Teeth with active periapical inflammation, despite the presence of a satisfactory

endodontic therapy.

2. Teeth with periapical inflammation and unsatisfactory endodontic therapy, which cannot be repeated because of:

– Completely calcified root canal. – Severely curved root canals. – Presence of posts or cores in root canal. – Breakage of small instrument in root canal or the presence of irretrievable

filling material.

3. Teeth with periapical inflammation, where completion of endodontic therapy is impossible due to:

– Foreign bodies driven into periapical tissues. – Perforation of inferior wall of pulp chamber. – Perforation of root. – Fracture at apical third of tooth. – Dental anomalies (dens in dente).

Contraindications for apicoectomyAll conditions that could be considered contraindications for oral

surgery concerning the age of the patient and general health problems, such as severe cardiovascular diseases, leukemia, tuberculosis, etc.

Teeth with severe resorption of periodontal tissues (deep periodontal pockets, great bone destruction).

Teeth with short root length.

Teeth whose apices have a close relationship with anatomic structures (such as maxillary sinus, mandibular canal, mental foramen, incisive and greater palatine foramen) and if causing injury to these during the surgical procedure is considered probable.

Resection TechniqueThe procedure for apicoectomy includes the

following steps:1. Designing of flap.2. Localization of apex, exposure of the

periapical area and removal of pathological tissue.

3. Resection of apex of tooth.4. Retrograde filling.5. Wound cleansing and suturing.

1-Designing of flapFlap design depends on various factors, which mainly include

position of the tooth, presence of a periodontal pocket, presence of a prosthetic restoration, and the extent of the periapical lesion.

There are three types of flaps principally used for apicoectomy: Semilunar: indicated for surgical procedures of limited extent

and is usually created at the anterior region of the maxilla.

Triangular: If there is an extensive bony defect, especially towards the alveolar crest.

Trapezoidal: When the apicoectomy is performed at the anterior region (e.g., maxillary lateral incisor) and there is an extensive bony defect near the alveolar crest.

2-Localization and Exposure of ApexWhen the periapical lesion has perforated the buccal bone, localization

and exposure of the root tip is easy, after removing the pathological tissues with a curette.

If the buccal bone covering the lesion has not been completely destroyed, but is very thin, then its surface is detected with an explorer or dental curette, whereupon, due to decreased bone density, the underlying bone is easily removed and the apex localized.

When the buccal bone remains completely intact, then the root tip may be located with a radiograph.

Exposure: With a round bur and a steady stream of saline solution, the bone covering the root tip is removed peripherally, creating an osseous window until the apex of the tooth is exposed. A curette is then used to remove pathological tissue and every foreign body or filling material.

3-Resection of Apex of Tooth.The apex is resected (2–3 mm of the total

root length) with a narrow fissure bur and inclined at a 45° angle to the long axis of the tooth.

After this procedure, the cavity is inspected and all pathological tissue is meticulously removed by curettage, especially in the area behind the apex of the tooth.

4-Retrograde fillingHaemostasis must be established (gauze

impregnated with adrenaline to minimize bleeding is placed in the bony defect)

Final Preparation of the cavityWashing and applying antiseptic

5-Wound Cleansing and Suturing of FlapThe flap is repositioned and interrupted

sutures are placed.Healing of the periapical area is checked

every 6–12months radiographically, until ossification of the cavity is ascertained. In order to evaluate the result, a preoperative radiograph is necessary, which will be compared to the postoperative radiographs later.

Short Video of Apicoectomy

Complications of apicoectomy Damage to the anatomic structures in case of penetration of the nasal

cavity, maxillary sinus and mandibular canal with the bur. Bleeding from the greater palatine artery during apicoectomy of palatal

root. Splattering of amalgam at the operation site, due to inadequate apical

isolation and improper manipulations for removal of excess filling material. Staining of mucosa due to amalgam that remained at the surgical field

(amalgam tattoo) Healing disturbances, if the semilunar incision is made over the bony deficit

or if the flap, after reapproximation, is not positioned on healthy bone. Dislodged filling material due to superficial placement, as a result of

insufficient preparation of apical cavity. Incomplete root resection, due to insufficient access or visualization and

misjudged length of root. As a result, the apical portion of the root remains in position and the retrograde filling is placed improperly, with all the resulting consequences.

Hemisection of a tooth

Hemisection is a procedure done on multi root teeth where the tooth is

cut in half between the roots and the infected half of the tooth is removed

whereas the remaining part is treated as a single root tooth.

Indications for HemisectionPeriodontal Indications:1. Severe vertical bone loss involving only one root of multi-rooted teeth.2. Bifurcation’s destruction.3. Unfavorable proximity of roots of adjacent teeth, preventing adequate hygiene maintenance in

proximal areas.4. Severe root exposure and deep periodontal pockets.

Endodontic and Restorative Indications1. Endodontic failure: Hemisection is useful in cases in which there is perforation through the floor of

the pulp chamber, or pulp canal of one of the roots of an endodontically involved tooth which cannot be instrumented.

2. Prosthetic failure of abutments within a splint: If a single or multirooted tooth is periodontally involved within a fixed bridge, instead of removing the entire bridge, if the remaining abutment support is sufficient, the root of the involved tooth is extracted.

3. Vertical fracture of one root: The prognosis of vertical fracture is hopeless. If vertical fracture traverses one root while the other roots are unaffected, the offending root may be amputed.

4. Severe destructive process: This may occur as a result of furcation or subgingival caries, traumatic injury, and large root perforation during endodontic therapy.

Contraindications for Hemisection

1. Strong adjacent teeth available for bridge abutments as alternatives to Hemisection.

2. Inoperable canals in root to be retained.

3. Root fusion-making separation impossible.

Procedure of HemisectionMake a small cut in the gum to expose the

roots. Once the roots are exposed, the dentist will

cut the tooth in half, between the roots. Then remove any decay and parts of the

tooth and roots that can't be saved. Rinse with sterile salt water. If necessary, stitches may be used to close

the wounds.

Root Amputation

Root amputation is the surgical procedure of removing the infected root of multi-

root tooth. The crown part of the tooth is not removed, but sealed with the filling

material at the amputation side.Indications and Contraindications are the

same as hemisection